Waterbirth – What’s the Big Deal?

While attending the American College of Nurse Midwives (ACNM) Michigan Affiliate conference in January of this year, I had the pleasure of hearing Joanne Bailey, PhD, CNM, speak on “Hydrotherapy and Waterbirth: Evidence, Outcomes and Challenges.”

According to Dr. Bailey, the first documented waterbirth occurred in France in 1803. It wasn’t until the 1970’s and 1980’s that waterbirth started to become more popular in Europe and Russia. In 1983, Michel Odent described 100 stories of waterbirth, mostly positive. In 1989, Barbara Harper, who had studied waterbirth in Russia, held the first waterbirth conference in the U.S. She later went on to found Waterbirth International.

Despite such a long, successful history, there are only three options for someone who wishes to have a waterbirth in West Michigan today. The first is to deliver at home. Those choosing a homebirth may rent or purchase a pool that can be set-up in their home and in which they may labor and/or give birth in. The second option is to choose to give birth in a free-standing birth center. The Simply Born Birth House, in Grand Rapids, has deep tubs to labor and birth comfortably in. The third option is for rebels. If a provider is knowledgeable about how to safely manage a waterbirth, the birthing person may refuse to get out of a hospital tub and deliver underwater.

Why is waterbirth so difficult to access within a hospital? Rebecca Dekker of Evidence Based Birth asked herself that same question while delving into the research and case studies that led to the 2014 joint ACOG (American Congress of Obstetricians and Gynecologists) and AAP (American Academy of Pediatrics) statement against waterbirth. Her conclusion was that they based their decision on limited, isolated cases and not on the larger body of evidence suggesting that waterbirth is safe.

While all West Michigan hospitals have policies against waterbirth, this is not the case everywhere. In fact, Dr. Bailey tells the story of how the first waterbirths occurred at University of Michigan Health System in 1996 as the result of a consumer-driven effort. Currently, 16.4% of the births there occur underwater.

How about you? Did you have a waterbirth and if so, how did you achieve it? Please share your story!

Can CNMs attend VBAC deliveries in West Michigan hospitals? The answer is: it depends!

As a birth advocate, supporting the rights of women who plan a vaginal birth after cesarean (VBAC) will likely keep me busy for the duration of my career.  My heart goes out to women who have to navigate their healthcare options for childbirth after a cesarean one facility, practice and provider at a time. At the end of their inquiries, many find that their options are limited by their individual histories, provider decisions, hospital policies, insurance reimbursement and even politics.

Since October, I’ve been working through the West Michigan Better Birth Network, the local chapter of the non-profit, Birth Network National, to address the official VBAC ban at Spectrum Health Gerber Memorial. We have collected stories of women who have had VBACs there in order to stress to administrators that, despite being counseled that the main hospital campus, Spectrum Health Butterworth in Grand Rapids, is the safest place to labor and deliver, they have legitimate reasons for choosing a community hospital setting. [Link to a sample letter from Rebekah Thompson of New Life Doula Services. Link to my own letter from the perspective of a Substance Abuse Prevention Specialist.]

I was recently attending an event at Amanda Holbert’s yoga studio, Renew Mama. While discussing the work of the WMBBN, Amanda brought up the “ban” on CNMs attending VBACs in West Michigan hospitals. Amanda inspired me to look into this restriction further. Why could CNMs attend VBACs in some hospitals, like Borgess in Kalamazoo, but not at Spectrum Health Butterworth (the only hospital in West Michigan that both allows VBACs and has CNMs who deliver there)?

I called Spectrum Health to ask about their policy on CNMs attending VBAC deliveries and was referred to Charmaine Kyle, Clinical Nurse Specialist in Women and Infant Services. Right away, she informed me that the hospital does not have an explicit policy banning CNMs from attending VBAC deliveries. I checked in with Jen Kamel of VBACfacts, an advocate for greater access to VBACs nationwide, who suspected internal politics to be the culprit.

Before hearing back from Charmaine with a definitive answer, I attended the American College of Nurse Midwives (ACNM) Michigan Affiliate conference in Kalamazoo.  There, I met midwives from across the state, most of whom are supported in attending VBACs at the hospitals where they work. Meeting these midwives made me even more determined to find out what is causing the restriction and advocate for overcoming it – West Michigan women deserve all possible options!

This past Wednesday, I received a reply: “a midwife is available through the residency clinic and would be able to establish care with a patient antepartum.  When it comes time for delivery the midwife would partner with an obstetrician and co-manage the care during labor.  The only problem right now is we don’t have enough midwives to provide 24/7 coverage.  Our hospitalist (core faculty) obstetricians would manage the care during the night and on weekends.” In other words, a woman could see a midwife for prenatal care, but could only have one in attendance at her birth if she happens to deliver during normal business hours.

After speaking with a CNM in private practice who delivers at Spectrum Health Butterworth, I learned they are in a similar situation. The hospital’s laborist (salaried staff Ob/Gyn) will not cover them in the event a cesarean becomes necessary, so an obstetrician from their practice has to both be available and willing to stay at the hospital until the mom delivers without being paid to do so. Since they cannot guarantee that this requirement will be met, the midwives who practice at the hospital cannot advertise their ability to take on pregnant women planning VBACs.

Several changes could move West Michigan toward increased access to CNM-attended VBAC births in hospitals. First, Spectrum Health Butterworth could hire more midwives so that those working in their residency clinic could be paid to cover births occurring 24-hours a day. Secondly, the hospital could further find creative solutions to overcome the liability fears of the laborist which lead to the unwillingness to cover the midwives working in private practice. Thirdly, other hospitals that allow VBACs could hire midwives.  Finally, smaller community hospitals who already have midwives delivering there could remove their VBAC bans.

Are CNMs able to attend VBACs in hospitals in your area? What worked to increase access in your community? Do you wish you had this option?  I want to hear from you!

Honoring Women’s Childbirth Choices

freedom

I’d like to honor women who make childbirth choices that make them vulnerable to judgment in their social circles, like planning a repeat cesarean or a home birth.  While no one is obligated to defend any of their family’s personal healthcare decisions, I’d like to open the conversation about the complexity and diversity of individual situations that create the context for such an important decision as how to give birth to one’s child.

1.)           Support: While it may be easy for an outsider to say, “Screw your family member or provider,” most people rely on support within their relationships long after the birth of their children.  For some women, it may be worth it to avoid conflict around their birth decisions knowing that they will not have to heal wounds in the future.  Relationships are complicated and based on a history that predates this event.

2.)           Timing: Babies arrive on their own schedule, paving the way for the unpredictability of parenthood.  Unfortunately, modern life is not always so flexible and accommodating.  Wanting to schedule the birth of a child around the availability of the one person you cannot imagine not having by your side at the moment of birth or in the weeks to follow is rational.

3.)           Tradition: Some choices are normalized in a family.  Other times, we seek to not fall into the footsteps of our foremothers.  Carrying on or rebelling against a historical family pattern are both common and natural reactions.

4.)           Economics: What a family can afford is often the driving factor behind their reproductive decisions.  When the top choice is not feasible, compromises are inevitable.

5.)           Experiences: Our individual experiences with birth are unique.  Negative past memories, whether personally or vicariously lived, sometimes impact us more than facts.

6.)           Values: What each parent holds dear will influence their decisions around birth.  Filtering our options through our values helps us move from knee-jerk to more conscious decision-making.

From the outside, someone’s choices may seem completely irrational or even self destructive, but under the surface lays the foundation for their actions.  For example, many people will judge someone who chooses to stay in an abusive relationship without trusting them to best know how to stay safe in the face of adversity. Imposing strong opinions or even facts that dispute another’s choices does not honor our diversity. Instead, we can strive for confidence in our own decisions while respecting the choices of others.

Have you every felt frustrated by the choices or judgement of others?  What helped you reach a greater understanding?

North Ottawa Community Hospital

Questions and Answers from NOCH Hospital Tour with Laura on 2-24-14 

Classes and Other Support Services

Does the hospital offer classes in childbirth education? Newborn care? Breastfeeding? Postpartum adjustment?

Laura teaches childbirth preparation. She is trained through Prepared Childbirth Educators.  She teaches a 3 class (2 ½ hours per class – 7 ½ hours total) series and an all day (9 AM – 4 PM) Saturday class.  They have a breastfeeding support group that meets 2x/mo.  They also have infant/child CPR, Postpartum adjustment group, a refresher class, and a sibling class.  They do not have any IBCLCs, but Laurie McCabe is their certified breastfeeding counselor who teaches their breastfeeding preparation and breastfeeding and beyond classes.

Care During labor and birth – Organization of Care

Is there a birth center in the hospital? How does care in the birth center differ from “regular” hospital labor and delivery care?

 There is a separate area within the hospital that is for labor and delivery. It was private and when I was there at least, very quiet.  The nurses do work 12-hr shifts, so you may have the same nurse for your entire stay (depending on how long you are there).  They also strive for one-on-one care, when possible, so moms get a lot of personalized attention.

Would I labor and give birth in one room, or would I be required to move just before the birth? Would I stay in the same room after I give birth?

Women deliver and recover in the same room. There is an operating room on the unit just for c-sections.

Care during labor and birth – companions

Do you have any policies that limit the number of people who may be with me during labor and birth? Can the baby’s siblings be present?  Is there an age restriction?

I didn’t ask and it didn’t come up.

Do you have experience with trained labor support (doulas) during labor and birth? Do you encourage use of doula care?

Laura said they see a doula at a birth about every four months or so.

Care During Labor and Birth – interventions

Do you monitor the well-being of the baby during labor? Do you use occasional or continuous electronic fetal monitoring?  Is a Doppler or fetoscope an option?

It’s up to the provider and really depends on how well the baby is doing. They do use the wireless, which can pick up the heartbeat at long distances (mom can walk the perimeter of the ward without a problem) and are waterproof.

What are your usual policies and practices about:

  •  IVs in labor

I didn’t ask and it didn’t come up.

  • Freedom to be active and move about in labor

This is very much supported. They have three sizes of birth balls that Laura described using in a variety of ways.  As mentioned before, moms are encouraged to walk, as well.

  • Eating and drinking in labor

Laura said that it’s up to the provider, but they have juice, jello and other “clear fluids” on hand.

  • Positions for birth

She described many different births using the stool, squat bar and hands and knees. Hands and knees and the stool seemed to be her favorite.  She said she sees more intact perineums with the stool, too.

What is the usual care if a labor is progressing slowly?

If a mom comes in, she is monitored for two hours. If, during that time, there is no cervical change, they will send her home.  Laura encouraged labor support people or moms themselves to call the hospital to inform staff of their progress.  She said to just call straight to labor and delivery.  She said that 4-1-1 is the rule: contractions four minutes apart, lasting 1 minute each, continuing for at least an hour, but it’s usually OK to wait a little longer.

What percent of the time do women giving birth here get an episiotomy?

She had stats, but didn’t want to give them out without asking permission first.

Care during labor and birth – help with pain

How would you recommend that I prepare for managing pain during labor and birth?

I didn’t ask this question, but they do have a high percentage of parents that attend their childbirth preparation classes.

What drug-free measures for pain relief are available in this hospital?

They have birth balls, as mentioned above. For comfort, they are cool with aromatherapy and have a CD player families can use.  Their Jacuzzi can be used for pain relief, but there isn’t enough space to deliver in there.  Some of the providers are pushing for a portable birth tubs, but it is still uncertain.

What would happen if I decided that I wanted an epidural?

I didn’t ask this question.

Are other pain medications an option?

I didn’t ask this question.

Care during labor and birth – complications

What percentage of women who give birth here have cesarean sections?

She had stats, but had to ask permission before disseminating. She did say their overall c-section rate was lower than the national average and primary c-section rate was only 19%.

Are there any situations (such as cesareans or other procedures, tests, treatments) that would require me to be separated from my partner and/or doula during labor or birth?

Only 1 person is allowed to be in with the mom during a cesarean.

Postpartum and newborn care

What newborn care is routinely provided or offered if a baby is healthy?

Hep B shot, Vit K shot and Erythromycin eye drops. Baby is weighed and measured.

Would my baby be separated from me immediately or shortly after birth? For what purpose and how long?

Early skin-to-skin is encouraged. Most procedures take but a few minutes to complete.  The baby can stay with mom until she’s ready to hand him/her off and then he/she can go back to her quickly afterward.

Are there any policies regarding use of hospital nursery care by healthy newborns? Do you have a “rooming in” option, where my baby could stay in the room with me instead of being cared for in the nursery?

I didn’t ask this question.

Is there a newborn intensive care unit on site? Is there any situation in which my baby would need to be transferred to another facility?

There is no NICU on site.

What breastfeeding resources are available? Does the hospital have a lactation consultant on staff?  How would I ensure that my breastfed baby would not be given bottles of water or formula?  Do you pass out formula samples?

They have a certified breastfeeding counselor, Laurie McCabe, who serves all of their patients, but most staff nurses have some training. There are no IBCLCs on staff.

Could my partner stay with me throughout my stay after the baby is born? What accommodations are available?

The rooms have a pull out love seat that looks pretty comfortable.

Leaving the hospital

How long do women usually stay after a vaginal birth? Are shorter or longer stays acceptable to the staff?

I didn’t ask this question.

What follow-up care would you provide after I go home? Does the hospital have a nurse available for home visits?  Do you provide information or give breastfeeding or emotional support over the phone?

About 45% or more of the moms who deliver there have a positive perinatal risk assessment screen. Laura attributes this to the very personalized care she gives and the multiple contacts which build trust with moms to be honest about their experience.  They have a support group for postpartum adjustment and are dedicated to providing emotional support.