Today on Science & Sensibility, Laurie Levy, LMP, MA, CD(DONA, PALS), CBE, shares her experiences as a childbirth educator and doula recently relocated to a new state. Her exposures to a new birth culture and method of doing things has taken her breath away, as she settles in to supporting families in her new home. Learn more about Laurie's experiences below. Have you moved around the country and been surprised at the differences in practice you found? Why do you think there is this difference? Please discuss with us in the comments section. - Sharon Muza, Community Manager, Science & Sensibility

I moved from Seattle to Northern California this past September. In Seattle, I was privileged to train and teach with leaders in the birth community for many years. Couple this with the 1998 passage of the WA Every Category of Health Care Provider Statute which compelled insurance agencies in WA state to cover licensed midwives and you can see why I would use the word 'spoiled' to describe my experience with birth in Seattle.

At a meeting with some of my new colleagues, I joked that I sound like I am saying, 'And one time, at band camp' - when I talk about typical Seattle birth practices. In the seven hospitals in the metro Seattle area, it was common to see moms moving about the halls with telemetry units. Occasionally you would even see a woman out of bed and moving with an epidural in place. Vaginal exams were limited after the amniotic sac had ruptured. Babies were not routinely separated from their mothers. The NICU came to the birth room if needed in most cases. Mothers were encouraged to hand express colostrum to help a baby with unstable blood sugar. Babies were born directly on to their mother's chest in some cesarean births. Hospitals competed for patient's maternity care dollar offering ever improving birth suites with each remodel. Tubs, showers, mood lighting and comfortable spaces for partners to rest were expected in birth spaces. VBACs were encouraged. Mother-baby friendly hospitals were the rule not the exception.

Births in my new community

I recently attended my first series of births near my new home and, while these experiences are only a thumbnail of a much bigger picture, I found the differences in environment to be very stark indeed. In fact, few of the practices I saw lined up with Lamaze International's Six Healthy Birth Practices. I am not a Pollyanna. I know that Archie Cochrane awarded obstetrics the 'wooden spoon' in 1979 for being the least evidence based medical speciality. I have talked with nurses from other states who tell stories about mothers being confined to bed after their water breaks for fear of a cord injury or other such superstitious practices. Still I was surprised at what I saw and have been thinking about the challenges that will face me here as I start teaching childbirth education in my new home.

My intent is not to malign any of the practitioners who I met. In fact, I found that virtually every staff member that I observed wanted the best for their clients and were trying to make the best of a less-than-ideal situation. To protect confidentiality, I have combined information from several births and changed insignificant details, though I have not fictionalized any of the practices.

Healthy Birth Practice 1: Let labor begin on its own & Healthy Birth Practice 4: Avoid interventions that are not medically necessary

My client had some complications and I believe most practitioners would agree that the benefits of an induction outweighed the potential drawbacks. While I have no issue with that, I question why a provider would offer to break a mother's amniotic sac when she was only 3cm and clearly not in labor. There was no discussion of possible complications, no discussion that this practice sometimes slows labor or does nothing rather than speeds it up (Smith, et al 2013.) AROM did nothing to progress my client's labor and after 9 hours and 5 vaginal exams, she spiked a fever. This led to antibiotics, Tylenol and a spiral of other outcomes that I will address later.

Healthy Birth Practice 2: Walk, move around and change positions throughout labor

My client wanted to move around in labor but was being continuously monitored. Her window-less room measured 10' by 8'. She and her family spent a full 24 hours in this room. No one offered a telemetry unit which would allow her greater mobility and when she asked, was told that the L&D floor had one telemetry unit, but the cord to connect the device to the EFM machine was missing. My client requested to shower, and the only shower on the floor was down the hall, none of the rooms had their own. Showers were also not allowed when Pitocin was being used.

Healthy Birth Practice 3: Bring a loved one, friend or doula for continuous support

I have to say on this point the facility did pretty well. Like most hospitals, they had a practice of only allowing one support person in the room when an epidural is being administered and during cesarean birth. My client had her epidural reinserted repeatedly. I was only asked to leave the room once and was allowed into the surgery after much pleading and crying by the mom.

Healthy Birth Practice 5: Avoid giving birth on your back and follow your body's urges to push

My client was asked to do a 'pushing trial' to see if the physician could reduce the anterior lip that seemed to be holding up progress. She pushed on her back as that was the only position her provider was comfortable with and, as you will see below, she was unable to support herself in other positions.

After 24 hours, we did end up in a room that had its own toilet. Few other rooms did. None of the rooms had a tub and clients were not allowed to bring one in. The standard was communal bathrooms for women in labor, one shower for the entire unit and no refrigerators anywhere to store patient food for use during labor.

It was my client's intention to hold off on pain medications until after six centimeters (active labor.) We were creative but a 24 inch movement radius, lack of access to a tub or shower and continuous pitocin led to an epidural earlier than planned. There were some complications with the block and it needed to be replaced several times, and the final medication level was so significant that the mother had absolutely no ability to move her legs on her own at at all.

Healthy Birth Practice 6: Keep mother and baby together - It's best for mother, baby and breastfeeding

I already gave away the ending - this mother gave birth by cesarean section. The operating suite was a fairly good size and I was allowed in the operating room as a doula. Baby was born immediately yelling and pinking up. Mom got to see her newborn over the blue screen but baby was immediately brought to the warmer. I heard the pediatrician say 'This baby looks so great I am going to leave!' Even with all of that, routine procedure was for baby to be recovered in a separate room. Staff would give baby all of her injections, weigh and measure her and bathe the baby before returning the baby to mom's recovery room. Standard procedure. Baby was away from her for a full hour before they had any more than a cursory hello.

After the birth, my client asked that I let her family know that she and the baby were healthy. The extended family seemed very calm when I told them the good news. They were unconcerned because they had already seen the baby. I turned around to see into the nursery where one of the grandmothers was cuddling the baby in a rocking chair. The extended family was holding the baby before the mother.

Thoughts for the future

Upon leaving, the attending physician told my client, 'There is no reason for you not to have a vaginal birth next time. Just not here.' Apparently, there has been no change in policy about VBACs even with the recent change to the ACOG guidelines (ACOG, 2010). This hospital has a VBAC ban.

I am not trying to demonize the health care providers or nurses. I don't believe that anyone enters maternity work with the idea of oppressing women. I do believe they were doing the best they could within this system. This hospital does have plans to address the facility issues but those will take quite some time and hundreds more women will labor and birth before those changes are made. Probably more important, I wonder how long it will take for a cultural shift even with floor plan improvements.

Jerome Groopman, M.D. in his book How Doctors Think discusses at length how medical providers ' and really all of us ' make the same errors of logic and repeat them over and over. So, while I am all for cheerleading and encouraging parents to advocate for themselves, ask for change in the system, understand the evidence for various practices, I also know that most people have a hard time hanging onto their personal power in a medical setting having been socialized to defer (see another Jerome Groopman book, Your Medical Mind) to their provider.

I am much more interested in preparing parents with real world expectations about what practices actually take place in their local birth community. The childbirth classes that I teach here will by necessity be different from what I taught in Seattle. Best practices are just that, but navigating the realities of what is and still having a positive birth experience vary from locale to locale.

To truly prepare parents, it is imperative that I include curriculum about what really makes up informed consent. Research may tell us one thing, but choice of provider, provider's preferences and the personal values of the birthing woman all figure into what makes up this slippery thing called 'informed consent.' I have found that many expecting parents have never made a health care decision together and have never discussed their values around health care. Exploring values and how they relate to medical decision making must also be included in childbirth classes to adequately prepare parents. This self-knowledge is not limited to the labor as it will serve parents well as together they navigate future medical decisions for their child.

And finally, parents need concrete tools and classroom practice talking to providers about their wants and desires. 'What the brain fires it wires,' neuroscience tells us. By tools, I mean a concrete list of conversation starters. For example, 'I hear what you are suggesting. I would like to tell you a bit more about where we are coming from. We would like delayed cord cutting because we value an unrushed separation)' (James, et al, 2012). The role play speaking values and truth in a safe classroom environment can help make parents more likely to actually do this during the stress of prenatal visits and labor ( Arrien, 1993).

I am so grateful that I get to work as both a doula and a childbirth educator. I gain so much information from each role that helps improve my work when I am wearing the other hat. I know that not every childbirth educator can attend births but I would encourage educators who can, to do so, and also to work in concert with doulas and other childbirth professionals to find out what is really happening in their area. Additionally, surveying past students to find out if our presented curriculum addressed the real needs of parents as they progressed through labor can help educators to adapt what we teach to meet those needs.

I am confident that the families that I work with both as a childbirth educator and a doula will benefit from my experiences of what is possible and together we can encourage change to practices that are more in line with best practices in obstetrical care.

References

Arrien, A. (1993). The four-fold way: walking the paths of the warrior, teacher, healer, and visionary. New York, NY: Harper.

James, K., Levy, L. (2012, October). Doubters, believers and choices, oh my. Concurrent session presented at the Lamaze International Annual Conference, Nashville, TN.

Smyth RMD, Markham C, Dowswell T. Amniotomy for shortening spontaneous labour. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD006167. DOI: 10.1002/14651858.CD006167.pub4.

Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:450'63.

About Laurie Levy

Laurie Levy, LMP, MA, CD(DONA), CD(PALS), CBE is a licensed massage practitioner, birth doula and childbirth educator, human anatomy and physiology instructor, and mother of three rambunctious boys. Laurie has presented at the 2011 Lamaze InternationalConference and hopes to sit for the LCCE exam in 2014. She can be reached through her website, laurielevy.net

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