Location of Birth
In the United States, hospitals are the most common place to give birth. Increasingly, hospitals try to transform their birthing units into comfortable, home-like settings with potentially necessary medical equipment hidden behind closet doors and picture frames.
Terhune discusses situations when hospital births are most appropriate : "The main advantages are for women with medical conditions�that increase the risk of fetal death, postpartum hemorrhage, seizures..." These medical conditions include multiples, malpresentation (breech), premature labor, very late labors, and labors where the membranes have been ruptured for long periods.
She adds that "there are borderline positions. We meet [the three midwives comprising Midwives Care, Inc.] once a month and we look at individual cases, and we have to decide for ourselves."
Terhune is realistic, though, about the disadvantages and risks of typical, modern medicalized birth. For starters, she asserts, "A woman instantly faces a one-in-four chance of having a c-section by walking into a hospital to have a baby." She further notes that separation of mom and baby is more likely in a hospital, which can influence bonding and the ability to breastfeed.
In many cases, doctor or CNM (more commonly true of physicians) will not be with the patient at the hospital for the majority of labor, and will be only arriving just before the birth. Hospitals vary widely in their acceptance of individual preferences, their familiarity with unmedicated childbirth, and their willingness to allow mothers to control the care of their newborns. Furthermore, adds Karen Crick, "it's unclear whether mothers and babies are in touch with their normal hormonal instincts and responses when they are in a strange environment."
When a risk of complications is present, a hospital is the best place to give birth. When risks are normal and low, a free-standing birth center or prepared home are safe and beautiful places to bear a child. Birth centers vary as to how much and which technology is available to women. Giving birth at home almost always means very little medical technology available, although CNMs will generally carry resuscitation equipment and the necessary drugs to slow or stop postpartum hemorrhaging and other minor complications.
Timing of Departure for Hospital or Birth Center
If a woman feels threatened or even slightly unfamiliar, labor may slow or stop. For this reason some mothers choose to remain at home throughout early labor and some of active labor. Others choose, or are instructed by their caregivers, to come earlier. Some wish to avoid a car ride while in heavy labor. This is a negotiable decision that need not be firmly made in advance. Simply know the advantages and disadvantages of arriving early and later.
Testing, IVs and Monitoring
Procedures vary, but nearly every hospital does some or all of the following. A blood sample may be drawn to check for many things. In most cases, the information gained by drawing blood during labor can also be gained by getting a blood sample in very late pregnancy (within a few days of labor is ideal). An IV may be started and fluids given. An external fetal monitor may be used to obtain a baseline reading of the baby's heartrate and movement. Usually further monitoring sessions will be required at regular intervals. Some women choose to have the blood drawn and the fetal monitor used for a brief period, and compromise with only a "heparin lock" instead of an IV. This involves the insertion of the needle and small connection for an IV tube, but the connection is not actually attached to the tubing and IV bag. A woman with a heparin lock can then move about freely as soon as the fetal monitor is removed. If fluids or other medications become necessary, the tube need only be inserted into the connection that has already been injected into the vein.
Each of these procedures can be very difficult to endure when labor is underway. An IV or heparin lock and blood draw can be time consuming, painful and requires that the mother be still. The fetal monitoring requires being still and often reclined numerous times for at least 10 minutes, usually 20. This is often an extremely uncomfortable position (not to mention counterproductive to cervical dilation) for laboring mothers. The use of each of these procedures is the decision of the patient. Hospital staff may refer to them as hospital policy and consider them mandatory; nevertheless, the laboring woman may refuse any of them. As with all items on a birth plan, each woman should consider the reasons for each of these and discuss your preferences with your OB or midwife.
Clothing, Eating and Drinking
Some women prefer to wear their own clothing during labor. Others prefer the hospital gowns because they are loose and can be soiled, discarded and replaced with ease. Many women find that any clothing at all is a nuisance. Eating and drinking during labor can be very important, particularly if labor is long. Fatigue can cause labor to slow and the laboring woman to give up. Regular nourishment prevents this. Hospital staff don't like women to eat during labor because they could need general anesthetic during an emergency c-section. Under general anesthesia, there is a small chance of the woman vomiting and aspirating the vomit, which can lead to serious complications. One must weigh the risks associated with the unlikely chance of an emergency c-section (assuming a normally healthy pregnancy) against those associated with hunger and fatigue. Indeed, "failure to progress" in labor can lead to c-sections, and such "failure" can often be partially due to fatigue. Most hospitals will allow water or ice chips for hydration, but if blood sugar is low and energy is required, IV fluids with glucose are likely to be preferred over food by the staff. In this case, consider that being attached to an IV restricts movement and positioning, a vital factor in encouraging labor to progress and the baby to descend into the pelvis. Usually a woman will not feel like eating much during labor, so just a nibble of bread or a sip of juice can often suffice to boost her energy enough to cope with a long labor.
Who is in Attendance?
When deciding who to invite, it can be helpful to let these people know that the invitation is tentative, and that as labor progresses people will be called on an as-needed basis. Some women prefer solitude during labor, while others benefit from many or a few family members and friends. Increasingly women are discovering a type of hired support person called a doula. Doulas are people educated in pregnancy, birth and postpartum issues (such as breastfeeding ) who provide informational, emotional and physical support throughout pregnancy, labor, childbirth and the early postpartum period.
According to Crick, "The doula is the woman who mothers the mother. For her there is no other agenda than providing support for the laboring woman," in whatever form that might take. "Statistically, mothers hiring doulas have a 25% reduction in the length of labor, have a 50% reduced risk of C-section, are 60% less likely to request an epidural, have a 30% reduced risk of forceps use, and have a 40% reduced risk of pitocin use. Women with doulas have improved success with breastfeeding and mother-infant bonding."
Many families believe in having siblings present at birth. This can be very beautiful. Young children (and older children that have been properly prepared) do not have the same fearful associations with blood and pain that adults have learned. A frankly informed toddler or preschooler who has a supportive adult in her presence is usually excited and proud to be there when her sibling is born. Some mothers, however, feel certain that the presence of their older child would inhibit them from concentrating on labor. Many mothers decide to play it by ear, having their older children nearby but not in the same room throughout labor, and available to be called in before or just after the birth. Most hospitals permit siblings at birth if they are free of colds or other illnesses and have attended a preparation course.
Pain Relief
Women can rely on many very effective, non-pharmacological means of pain relief. Non-narcotic pain relief is preferable because the narcotics in injections and epidurals reach the baby, and because babies born with such drugs in their system are more likely to have various difficulties (trouble nursing, extreme sleepiness, delayed bonding. Receiving an epidural can be painful and means being automatically "catheterized," given an IV, constant use of an external fetal monitor, and being restricted to bed. Epidurals usually slow labor, and can even stop it, leading to the use of pitocin. Many women continue to feel back pain for months or years after an epidural. It is a decision that should be made with awareness of the risks. Some non-analgesic and non-anesthetic pain relief methods are massage, heat, counter-pressure,hydrotherapy, aromatherapy, positioning, visualization, TENS (Transcutaneous Electrical Nerve Stimulation), and acupressure. For more information on these techniques, see the "For Further Information" section at the close of this article or consult a childbirth educator, a midwife or a doula. Some obstetricians are knowledgeable in these techniques, but most are not.
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