For my follow-up to yesterday's blog, I have put together a list of the issues and factors that can and should be considered in order to make an informed decision about your own birthing plan.
1) Medical History and Complications: In any pregnancy, this must be the first thing to consider, because it influences all future options. If you have a history of complications in pregnancy, or if you have complications that have arisen during your current pregnancy such as Pregnancy Induced Hypertension, Diabetes, other chronic health problems, substance use, or multiple births (twins) then you are going to need closer medical supervision during your pregnancy and a physician and obstetrician are going to be your team of choice. The term ‘High Risk’ doesn’t mean that you can’t have a healthy, normal pregnancy, it just means that you and your health care team have to monitor a little more closely in order to produce the best outcomes for you and your baby. Many midwife groups, especially those in Alberta do not accept women categorized as ‘high risk’ because the incidence of medically indicated interventions (those which are not chosen ahead of time, but are for the sole purpose of reducing harm and injury to the mother and/or baby) in these pregnancies is so much higher. One more thing I’d like to point out here is that when first pregnancies result in a caesarean section delivery, a common myth is that all subsequent babies have to be delivered by c-section as well. In fact, the Canadian Health Services Research Foundation actually suggests that because of the unnecessary harm and expense involved in a c-section, women with a history of medically indicated c-sections who have a current healthy pregnancy can and perhaps should still try to have a vaginal delivery. Therefore, knowing your history and potential risk factors and sharing these with your doctor or midwife is incredibly important, so they can give you the best advice and care possible.
As I’ll explore a little later, sometimes the best laid plans have to be conceived (no pun intended) with flexibility in mind. I’ve seen women (and even in the documentary) with no history of complications or other risk factors develop complications during their delivery and have to switch their plan on the fly. This doesn’t happen often (about 1 in 5 pregnancies need some type of medically indicated intervention), but it can happen, so you just need to keep that in mind. In “The Business of Being Born” one individual who chose to use a midwife had to end up going to the hospital because she was delivery prematurely and so needed the right interventions in order to make sure her preterm infant had the right help and she had the right supervision during this surprise labour. Though there was disappointment about not being able to follow her plan, this lady understood why things needed to change, and my hope for you is that if you are faced with that situation you realize that it isn’t a reflection of your personal ability or a failure of your plan.
2) Finances: The facets of this issue may vary depending on where you live. For example, in Alberta, as of April 01, 2009, midwifery officially became a service covered by Alberta HealthCare, so this factored into a lot of Albertan’s decisions on whether or not to use midwives. There are currently 40 practicing midwives in Alberta, and full time midwives take care of 40 patients per year. Although I am not familiar with the models of health insurance and funding in the United States, the documentary did follow one couple struggling to get funding for midwifery through their insurance company. They also mentioned a fee for a midwife to be around $4000 (that includes all pre and postnatal visits, as well as the delivery and supplies). So financial considerations in whether you want a midwife or physician assisted birth may be limited by what your insurance company allows or is willing to compensate you for. Many insurance companies do cover the cost of an ob/gyn and hospital stay, but not the cost of midwives. However, if you do not have insurance coverage or partial insurance coverage for both obstetrician and midwife, one thing to note is that the rough cost of delivering a baby with an obstetrician in a hospital can be $40,000 (JUST for the delivery, not for the pre/post natal care- compare that to the $4000 for a midwife). Add to that the potential cost of an anaesthesiologist if you chose an epidural, and the cost of the prescription for the medication that goes in to the epidural. So where you are getting the funds to make your decision can be an important factor. Whether or not you have made your decision surrounding the delivery, it is always a good idea to contact your insurance provider and find out what their coverage is and also what potential costs might be incurred (i.e. if you require a c-section) so that you can prepare for that as needed. Again, this is referring to models other than the universal health care system we are privileged to have access to in Canada.
3) Interventions and their Benefits/Side effects: This is perhaps the most important knowledge in making an informed decision about the steps you and your partner may take to welcoming your new baby to this world. I have seen that there can be times when you are inundated with terms and interventions- nitrous oxide gas, morphine, epidural, pitocin, decelerations, vacuum, forceps, caesarean section- that come at you with such force and speed at a such a vulnerable point in your delivery that they don’t really seem like choices YOU are making at all. Without giving you a small lecture in labour interventions, I will try to give you the gist of what these things mean.
Let’s start with pitocin- it’s a synthetic form of a hormone found naturally in our body called oxytocin. It is usually used in the labour room in order to induce labour, and speed up contractions. Doctors may use this if your membranes have been ruptured for a long time and labour isn’t progressing fast enough. However, one thing to note about this is that using pitocin can often start off a cascade of interventions. Because oxytocin is the hormone that naturally controls contractions during labour, administration of pitocin can cause contractions to come more frequently and with more force. The pain of the contractions thus becomes incredibly intense, and without a break between contractions as you’d normally have, the use of an epidural may be necessary. The continuous contractions could also lead to continued pressure on the baby, particularly the umbilical cord and their blood supply, leading to decelerations (drops) in the baby’s heart rate. If the decelerations are consistent enough or severe enough, the need to get the baby out may become more urgent, and this is when further interventions such as using assistance (such as vacuums or forceps) to deliver vaginally or even emergency caesarean section may become necessary for the baby. If you thought the preceding paragraph was a little fast, it kind of resembles the sequence of events that can occur.
Next, we have an epidural. Some women elect to have an epidural with their doctor before the day of delivery, and some women need to make a decision to have an epidural right in the delivery room. Sometimes it can even be too late and too far along your labour to have an epidural, even if you planned on it. The epidural needs to be given before a certain point in labour to ensure that it takes effect at the right time. If you get it too late in labour, you may be having a baby without the effects of the epidural anyways. When we say epidural, we refer to the method of drug delivery, rather than the actual drug. Epidural is when medication is delivered by an anaesthesiologist via a long thin needle in to the epidural space of your spine (that’s right- a needle in your spine, while you’re having contractions). The most common cocktail used in an epidural is an anaesthesia such as bupivicaine and a pain medication such as morphine, though every anaesthesiologist could use a different cocktail depending on the circumstances. Usually alongside an epidural, you need an intravenous access in order to have fluids administered to you, as well as a catheter for your urine because essentially after an epidural you will be on your back and immobile (the medication is very strong). The biggest side effects you need to know about: labour is slowed down because of the interaction of the drug with your body, and because you are now horizontal and not working with gravity to get the baby out; depending on your reaction to the drug (everybody metabolizes and uses drugs differently) you may become very tired, and “out of it”; your respirations slow down; when baby is born, they are likely going to experience similar side effects as well, with the most dangerous being that the epidural may slow their respirations (breathing) down way too much. Babies who have had epidurals may not feed as successfully in the first days because they are still feeling the effects of the drug. One of the greatest benefits of an epidural that I have heard is not only the pain relief but also the potential for rest it can give a woman who is already extremely exhausted from a long labour.
The most important side effects you need to know about in terms of caesareans is that they are in every sense of the word a full surgery. In addition to all the inherent risks of any surgery (infection, excessive bleeding, complications) this means that there will be a longer recovery time compared to a vaginal delivery, and this can affect your functioning when you come home after a delivery. It’s a good idea to be prepared with as much support from your partner, family and friends to make your recovery as smooth and quick as possible. In terms of what it means for baby, one of the important things is that caesarean sections can affect the respiratory system of a newborn. The labour process involves a lot of chemical and mechanical actions which activate certain systems in the newborn’s lungs and circulation, and sometimes with a c-section these processes are interrupted and the baby may have some difficulties transitioning to the world. The benefits of a caesarean can be that you have made a choice you are comfortable with, or that the caesarean had the ability to get your baby out with the speed and precision that was necessary to prevent harm.
If you’d like to know more, please talk to your doctor and/or care provider, or even let me know and I can try to direct you to some more useful information.
4) Personal Preference: After all is said and done, and given a low risk, healthy pregnancy it is ultimately up to the woman and her partner to make these decisions for their baby. I hope if I have shared anything at all here, it is that you do have the power to make decisions for your baby and you, starting now. No intervention or decision will be made without your consent, and knowledge and information will empower you to make those decisions and give that consent with power and confidence. Women have varying pain thresholds, different perceptions of home deliveries vs hospital rooms, and strong views and beliefs about physicians vs. midwifes. No matter the personal history and reasons a woman has, each is a valid one. No matter what choice you make (given that the health of your baby and you is maintained), it is YOURS to make, and you start the role of parent and guardian to your baby before they are even born. From one woman to another, may you find the power and empowerment to lead a healthy and prosperous family and life.