Ask Rachelle, the childbirth expert

Vol IX: A reader shares: "My Hospital vs Homebirth Experience," and Rachelle responds.

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October 1, 2005 12:19
Ask Rachelle, the childbirth expert

baby 88. (photo credit: )

 
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Rachelle Oseran is a Lamaze Certified Childbirth Educator with 21 years of experience working with pregnant and postpartum women. She is also a fitness professional certified by ACE (The American Council on Exercise) and a certified prenatal and postnatal exercise instructor. She co-directs Great Shape Exercise Studio at the Jerusalem YMCA. * * * Vol IX A reader shares her homebirth experience My first child was born at a hospital in the Tel Aviv/Central area. I made it clear that I wanted natural childbirth. I came with a written birth plan and also a friend who is a midwife/doula, but acted as a "friend" because for some silly reason such a person is not allowed in the labor/delivery room with you. Despite my wishes for natural childbirth, the doctor must have come into the room at least 4 times and said "are you ready for your epidural now?" Of course at times I was tempted to say yes as I was experiencing the pains of labor, but thank g-d my husband and doula/friend helped me move and breath and massaged me to get thru the contractions. I kept getting the feeling from the hospital that they would have been much happier if I were strapped down to the bed with an IV and monitor and epidural, rather than moving thru my contractions and standing in the shower. When I felt the need to push the midwife insisted I lay on my back on the bed. Not how I imagined I would be giving birth. Thank g-d after three easy pushes, my beautiful daughter was born. After about an hour I wanted to get out of bed, but the nurses were extremely firm with me that I am not to get out of bed for 12 hours. This is after a completely natural birth with no tearing (thanks to the epi-no). They took my baby from me and brought me to the ward. I asked to see/have my baby (it was around midnight), but they said not until the morning, after the doctor checks her!!! I was absolutely devastated. I had just given birth to my first baby and she was being kept separated from me! I also had to use the toilet. This was now 6 hours after I had given birth… yet the nurse insisted on giving me a bedpan, as hospital policy is not to get out of bed for 12 hours following a birth. Additionally, I wanted to only breastfeed. The breastfeeding was not going so good (hey, it was my first time and my daughter's first time). I am sure it also didn't help that we were separated for 12 hours. The nurse told me my baby is screaming because she is hungry and I am not producing enough milk. I replied that I thought the milk doesn't always come in right away. She said again that I am starving my baby. She then took my baby from my arms and weighed her on the scale. She said after I breastfeed her she will weigh her again. If the weight doesn't go up, I have to give her formula. I thought this was crazy…my baby was 24 hours old! Of course the weight didn't go up, and I felt like the biggest failure in the entire world. I had been a Mommy for 24 hours and already I was "starving" my baby. So they gave her formula. I was a mess and cried and cried. (Of course now I know how completely wrong the nurses were!!!) Later in the evening they asked me to bring the baby to the nursery for a checkup from the doctor. When I went to pick up my baby after, I saw that she was sleeping peacefully, sucking on a bottle nipple stuffed with a cloth (!!Yes, they used the bottle nipple as a pacifier/dummy!!) I asked the nurse what was going on and she said "Oh, your baby was hysterically crying and we are very very busy here and I didn't have time to call you and she was hungry, so I gave her formula. She kept crying so I gave her something to suck on". Again I was devastated. This was 3.5 years ago, and to this day I still get a sinking feeling in my stomach when I think about those 12 hours being separated from my daughter, not being allowed to get out of bed, and the experiences I had at the hospital. It's something that will stay with me forever, and something I will never get over. I am a super easygoing person - I never expected something like this. I cry as I write this. Fast-forward now two years. I was pregnant again. Every time I thought of going to the hospital to give birth I got sick to my stomach. My previous experience was so traumatic. While my husband supported natural childbirth, he was not for a homebirth. I understood and respected his opinion. He was worried about me. We decided on a hospital with a 'natural birthing room', however I was still very uneasy. What happened next is truly a gift from g-d. My contractions started around 6am. I didn't wake my husband because I knew I would be needing his assistance throughout the labor and birth. I called my midwife/doula friend and asked her to come over. The plan was that she would come to the hospital with us again as a "friend". Around 7:30am my contractions got stronger and I woke up my husband. My midwife/doula friend called to say she would be over in 20 minutes. I decided to go sit in our jaccuzi-bathtub. At 7:50 the doorbell rang. I walked down the steps by myself and opened the door. As soon as I saw my midwife/doula friend I felt the urge to push. The next thing I know I dropped down on my knees in our salon. I leaned on my husband and my midwife/doula friend was behind me. I gave two easy pushes, and my beautiful son was born before 8am! Just like that. At home. It was amazing. I sat back on the floor and leaned against my sofa. I took my new baby in my arms and held him tightly against my body. Immediately he went for my breast and began to breastfeed and suck. (And my milk really didn't come in for 3 days, yet my baby never starved or cried from hunger…..) It was like a dream. I delivered the placenta without a problem and just sat there, skin to skin with my baby as he nursed. An experience I didn't have at the hospital. I felt amazing! My midwife/doula friend also does homebirths, and luckily she had her 'homebirth' kit in her car. She was able to take my blood pressure and check that everything was OK with myself and the baby. After about 45 minutes, I felt like I wanted to stand up, clean up a bit and use the bathroom. With the help of my husband, I walked upstairs to the bathroom. (At the hospital I was confined to bed for 12 hours. At home I walked up the steps after 45 minutes.) I sat on the side of the jaccuzi/tub and was there for about 30 minutes, letting the water run over me. Honestly, I was in shock! I could not believe I just had my baby so quickly, and at home! I must have thanked g-d a million times during those 30 minutes. I got dressed and walked downstairs myself. My husband was holding our new son. It was a dream. Soon after our midwife/doula friend left. My husband made me something to eat, and I cuddled with my baby. Finally at around 2pm (6 hours after the birth) we went to the hospital to get myself and the baby examined. It was very funny, I walked right into the labor and delivery area with my baby. I felt great, and was walking fine. No one could believe I had given birth at home. The midwife checked me quickly in the labor/delivery room and said everything was fine, no tears or rips (again, I swear by the epi-no). They then said to take my baby to the nursery for him to be examined by a doctor. I said "OK, but I am not leaving his side." They said that was fine. They asked if I wanted a wheelchair, but I said I could walk just fine. My baby was checked, and he was perfect. I then signed a form that I was leaving the hospital 'against medical advise' and we went home. (I had to bring him back the next day for the PKU test, which was fine.) I felt amazing, my baby was amazing. We were both so calm and relaxed. We were never separated, and there were no nursing issues. I had a completely medical-free birth, completely natural. I walked down the steps in my house 10 minutes before my baby was born, and I walked up the steps 45 minutes after he was born. It was so natural… so wonderful. Of course my idea of a dream childbirth is not for everyone. And of course I have full respect for women who want an epidural and want to only formula feed. But for me…the homebirth of my son is what childbirth was meant to be for me. Rachelle responds: To the woman who wrote "My hospital vs. homebirth experience," thank you for taking the time to write about your 2 birth experiences. I was saddened by the story of your first birth but the description of your second birth was heartwarming. I'm afraid to say that I hear stories like your first birth on a daily basis. Even when mother and baby are healthy, sometimes the medical personnel don't realize that a woman's birth experience can have long-term emotional effects. The attitude that labor needs to be dealt with as a potential medical catastrophe is, unfortunately, a worldwide attitude. I just returned from an international convention in Boston of CIMS - the Coalition for Improving Maternity Services (see their website www.motherfriendly.org). The convention was entitled: "Mother-Friendly Childbirth: Closing the Gap between Research and Practice." CIMS is developing a document on "Evidence Basis for the Ten Steps of the Mother-Friendly Childbirth Initiative," which is a systematic review of the research dealing with the rights of a woman in labor. In other words, there will soon be a document with a systematic review of the research on why a woman in labor should have the right to choose who can be with her during labor, common medical procedures that shouldn't be administered routinely such as an IV drip, continuous electronic fetal monitoring, etc., allowing a woman to eat or drink in labor and choosing the position that works best for her for delivery (see the 10 steps on the motherfriendly website). CIMS' Ten Steps of the Mother-Friendly Childbirth Initiative include the following recommendations for encouraging breastfeeding, which have been ratified by the World Health Organization: Hospitals and birthing centers should.... Have a written breastfeeding policy that is routinely communicated to all health care staff; Train all health care staff in skills necessary to implement this policy; Inform all pregnant women about the benefits and management of breastfeeding; Help mothers initiate breastfeeding within a half-hour of birth; Show mothers how to breast-feed and how to maintain lactation even if they should be separated from their infants; Give newborn infants no food or drink other than breast milk unless medically indicated; Practice rooming in: allow mothers and infants to remain together 24 hours a day; Encourage breastfeeding on demand; Give no artificial teat or pacifiers (also called dummies or soothers) to breastfeeding infants; Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics. In addition, in February 2005, the American Academy of Pediatrics (AAP) issued new recommendations promoting and supporting breastfeeding. The policy recommends exclusive breastfeeding (defined as human milk with no water, no juice, no nonhuman milk, or no foods) for six months. It also states that "breastfeeding should be continued for at least the first year of life and beyond" and that "there is no upper limit to the duration of breastfeeding." Documenting extensive research for the "compelling" advantage of breastfeeding, specific recommendations were given including: * Minimizing medications for the birthing mother that may adversely affect the baby. * Avoiding unnecessary suctioning of the newborn. * Placing a healthy newborn skin-to-skin with its mother until the first breastfeeding happens. * Performing the initial assessment while the newborn is with the mother. The policy states: "The mother is an optimal heat source for the infant." * Encouraging mothers to offer the breast whenever an infant shows early signs of hunger: increased alertness, physical activity, mouthing or rooting (crying is a late indicator of hunger). * Having mother and infant sleep in proximity to each other to facilitate breastfeeding. Pediatrics. 115:2:496-502 If your hospital had adhered to either of these policies you wouldn't have had the traumatic experience you reported. Now the question is, "How do we get our local hospitals to adopt these principles as official policy?" I think that new mothers have enormous power as consumers, which is largely untapped. While the woman is in the hospital, she has hopefully been made aware, either by childbirth preparation classes or by reading, of the implications of these different issues. She should also know that the Knesset passed the Patient's Rights Law in 1996, which gives her the right to receive a full explanation of the advantages and disadvantages of any procedure, as well as the right to refuse a procedure. This is, however, often difficult when the woman is in labor and feeling very vulnerable. The best recourse is a follow-up letter to the hospital about her experience. I strongly recommend that women write letters to the department head with a copy to the head of the hospital administration giving feedback - both positive and negative. Imagine how wonderful a midwife, for example, would feel if she was named in a letter as a caregiver who contributed to the woman's positive childbirth experience. However, the opposite is also extremely effective. If a woman has a bad experience, this should be outlined in a letter to the hospital. If the hospital receives many letters from unhappy women with a detailed description of what caused the distress, the hospital will be more inclined to take a closer look at their policies. I hope more women will take the time and trouble in the hectic days and weeks following the birth of their babies to give the hospitals feedback. * * * Vol VIII Q: Hi, I'm a Canadian considering aliya. We had our two babies here b'h with a midwife at home, and both were wonderful experiences. Since you know the data and evidence you'll also know that homebirth is at least as safe as a hospital for a low risk birth. Can you tell me how hard it will be to have a homebirth in Israel, if we should have another child there? Thanks. A: I'm glad to hear you had such wonderful experiences with your first two births. According to the Cochrane Database, "Home birth offers a safe and acceptable alternative to hospital confinement for selected pregnant women, and reduces the incidence of medical interventions." There are about 12 midwives in Israel who do home births. They have an organization and are working on a website but it isn't up yet. They carefully screen pregnant women and accept only low-risk pregnant women for home births. While some doctors frown on births outside of a hospital, there are many other doctors who openly support the work of these midwives. Obstetricians are available for questions if they arise and pediatricians are available for follow up visits if that is necessary. These midwives prefer that the birth takes place within a 1/2 hour distance from the hospital, in case there is a need to transfer the woman to a hospital. Financially, home births are not covered by any Israeli health insurance, i.e. they are private. In addition, a woman who gives birth at home is not entitled to the stipend from National Insurance that women who deliver in hospitals receive. If you wish to make contact with a home birth midwife in Israel, I am happy to give you the names of several native English-speaking midwives who do home birth deliveries. * * * Vol VII Reader's comment #11: I went to the Cochrane database and found it to be a very interesting source of information in all medical matters, although definitely more for the medical community than layman. I looked up risks/benefits on EFM as suggested by the columnist, and was surprised to see the following statement:' The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures.' This is in direct contradiction to what is stated in this column 'it has been SCIENTIFICALLY PROVEN that routine continuous EFM provides no benefit for babies'. And this is supposedly from the same source. Answer: I'm glad you found the Cochrane database interesting. As you can see from my column, I quoted two sources for that statement. The statement, "Routine continuous EFM provides no benefit for babies and increases the risk of cesarean for mothers" is from Enkin, M., et al (2000) A Guide to Effective Care in Pregnancy and Childbirth. New York: Oxford University Press, chapter 30. The cesarean increase is attributed to the Cochrane database (as well as Enkin's book). * * * Vol VI Reader's comment #5: Do you run or do you know of any lamaze classes in Jerusalem? Also, do you know of any childbirth preparation classes being given in Jerusalem in English? At what point in my pregnancy should I start attending classes? Thank you. Rachelle replies: Dear Sophie, Yes, I teach Lamaze classes in English in Jerusalem. You can reach me through Great Shape/YMCA, 02-6258436. For a full listing of Lamaze Certified Childbirth Educators in Israel go to www.lamaze.org and click on For expectant and new parents, then click on Find a Lamaze educator. Only type in the Country - Israel (ignore all the rest). It's generally recommended to take the classes in your 7th month, though you should sign up in your 5th month as they fill up fast. Reader's comment #6: This column should be called ask the *natural* childbirth expert, not simply childbirth expert. Unsuspecting parents may believe that they are getting sound medical advice and information. Natural childbirth is for those who would usually avoid contemporary medicine and go for complementary or holistic medicine. Aside for giving information on natural childbirth, experts like these pull every study ever done, regardless of whether the results were scientifically proven, to put down conventional methods and try to 'prove' their ineffectiveness or lack of safety. While they may claim to simply be keeping parents informed so that they can make informed choices, in reality the information given over is chosen carefully. Rather than simply give information, natural childbirth educators give over information that will persuade parents that a natural childbirth is the one they want, and any medical intervention is bad. Readers should be aware of the source of the advice given here. Rachelle replies: Dear Rachel, Thank you for your comment. The issue you are addressing is at the heart of what is called "evidence-based medical care," that is, when medical caregivers practise (or don't) according to scientifically proven research. Every single fact that I quoted in my previous article (on epidurals) is based on scientifically proven studies. I encourage you to look them up on the Cochrane database or in Dr. Enkin's book, "A Guide to Effective Care in Pregnancy and Childbirth", New York: Oxford University Press. Medical care and technology save lives - both of mothers and babies. However, when medical procedures are used ROUTINELY - even when the labor is progressing normally (as it does in at least 85% of labors), such procedures can often cause more harm than good and this isn't just my opinion. Let me give an example. Many midwives and doctors want their patients to have continuous electronic fetal monitoring (EFM). In fact, as recently as 3 weeks ago, I asked a prominent midwife from a large Jerusalem hospital if they always use continuous EFM. She replied, "Yes, unless the woman requests otherwise." If it were medically important, then why would the midwife be flexible? How would the woman know to ask for "intermittent" monitoring if she didn't know about the pros and cons of monitoring (which she learns about from childbirth educators)? Our society often has more respect for technology than for our own bodies, which frequently leads people to believe that the baby will be safer if it is "watched" all the time. However, it has been SCIENTIFICALLY PROVEN that routine continuous EFM provides no benefit for babies and increases the risk of cesarean births for mothers (The Cochrane Database and Dr. Enkin's book). The World Health Organization (WHO) encourages intermittent manual listening and warns that EFM is often used inappropriately. The Society of Obstetricians and Gynecologists of Canada states, "The preferred method of fetal health surveillance for low risk women during labor is (to listen intermittently) with a hand-held ultrasound Doppler." So why do many medical caregivers ignore this advice? (rhetorical question). A woman in labor MUST have continuous EFM if her labor is induced or augmented with Pitocin, if she has an epidural, if there is any change in her baby's heart rate or if she or her baby has a health problem. This is for her and her baby's safety and should not be negotiated. In childbirth classes, women learn how to avoid UNNECESSARY, ROUTINE use of EFM: the woman should remember that ROUTINE use of continuous EFM doesn't make labor safer for her baby; she should find a caregiver (or hospital) who doesn't use continuous EFM routinely; she should talk to her caregiver about intermittent fetal monitoring. In childbirth preparation classes, women also learn how to keep labor as normal as possible if they need EFM: continue to move as much as you feel you need to in positions that you feel are right for you, both in and out of bed,e.g. sitting on a birth ball (while still attached to the monitor); ask the staff to turn off the monitor's sound (the graph paper will continue to be fed through the machine); ask the staff to turn the monitor away from you and your helpers so that it doesn't distract you; remind your helpers that YOU are the one in labor, not the machine (adapted from "The Official Lamaze Guide: Giving Birth with Confidence" by Judith Lothian RN, PhD., Charlotte DeVries, Meadowbrook Press, 2005, available at www.lamaze.org). As the renowned French obstetrician, Dr. Michel Odent, who visited Israel last month said, "One cannot help an involuntary process. The point is not to disturb it." Vol V Comment: Your description of epidural anesthesia is understandably quite one sided. The actual medical evidence does not support most of your contentions. In particular, there is NO increase in the rate of induction (use of oxytocin) among women who choose an epidural. Of the thousands of epidurals given every year at a Toronto Hospital I have only seen a few cases of post-epidural headache and NONE of the horror scenarios you have outlined. While claiming that all interventions are "unnatural" in fashion, as a physician and someone who works for the WHO, I know that NATURAL childbirth kills at least one out of every 100 mothers. Medical interventions should be limited to appropriate indications, but a philosophy unilaterally against them needlessly scares future mothers. Epidurals allow women to experience minimal pain during childbirth and more importantly in my experience, decreases the pain so that mothers can actually "be there" and remember the experience of birth. A: Thank you for your comment in response to my answer to a question on epidurals. My role as a Childbirth Educator is to provide women with accurate information so that they are able to make educated choices concerning their bodies and their labors. Every potential side effect of epidurals that I listed is backed up by medical research [see The Cochrane Database of Systematic Reviews and Enkin, M., et al (2000) "A Guide to Effective Care in Pregnancy and Childbirth" Oxford University Press]. Many medical caregivers believe that labor pain has no benefit and that epidurals have no risks. This is a clear reflection of our culture's attitude towards labor, pain, medical management and technology but has been scientifically proven to be untrue. The perception of pain leads to the production of oxytocin, which facilitates more dilation. The pain of labor is also a guide to encourage the woman to assume positions and activities that promote good progress and that help move the baby into the ideal position for birth. As the pain of labor increases, the body releases endorphins which help the woman manage her labor. Endorphin levels remain high after delivery and cause the feelings of elation that unmedicated women experience. You state that "there is NO increase in the rate of induction (use of oxytocin) among women who choose an epidural." An analysis of data from four random-assigned trials found that epidurals increased the use of oxytocin by 450% (Howell CJ, "Epidural vs. non-epidural analgesia in labor. In: Neilson JP et al., eds. Pregnancy and Childbirth Module of the Cochrane Database of Systematic Reviews) as reported in "The Thinking Woman's Guide to a Better Birth" by Henci Goer (Perigee, 1999). I am also wondering if you, personally, reviewed the medical records of each of the women who received epidurals at the Toronto Hospital where you worked. Your statement that "NATURAL childbirth kills at least one out of every 100 mothers" seems to imply that women who don't opt for pain relief or other types of medical intervention have a one in a hundred chance of dying. That is simply untrue. The more accurate use of this statistic is in cultures where women have no access to medical care and develop obstetric complications. Birth is a normal, physiologic part of life and should be treated as such. Between 85% and 95% of births are completely normal and therefore should not involve unnecessary medical intervention. As far as a woman's emotional attitude to birth, The Cochrane Database reports that epidurals do not improve women's satisfaction with birth. I encourage you to speak to women who have had natural births to hear their experiences of empowerment and euphoria that result from an unmedicated birth. The fact that a woman has overcome the challenges of labor with emotional support from her loved ones and medical caregivers results in feelings of self-actualization (women's descriptions) and exhilaration that empower her for other challenges of parenting and life in general. While women who opt for natural childbirth but end up taking epidurals because of long, difficult labors or lack of support from caregivers should never be made to feel guilty or to feel like failures, encouraging women to take pain relief would deprive them of experiencing one of life's most challenging and rewarding events. * * * Vol IV Q: My daughter heard about a device called epi-no, which stretches the perenium in order to avoid tearing or an episiotomy. Do you have any experience with this device? Would you recommend it? A: The epi-no is a device used during pregnancy to stretch the perineum. As its name implies, the goal of the device is to prevent an episiotomy, which is the surgical widening of the vaginal opening during birth. The epi-no has been in existence for many years and has several functions. It provides excellent biofeedback to the woman during pelvic floor muscle exercises, which are essential exercises for pelvic floor muscle tone for all women. Its other use is to stretch the perineum to prevent tearing during delivery or the need for an episiotomy. While studies have shown the device to be very effective in achieving this goal, some pelvic floor specialists are concerned about the device possibly causing long-term urinary stress incontinence as this has not yet been scientifically studied. A researcher in Australia has recently begun studying this issue but will not have results for at least 2 years. Other than that potential disadvantage, it is safe but can occasionally burst inside the vagina. While this won't cause any physical harm, it can be painful and it could be emotionally distressing to the woman. Many midwives in Israel swear by the success of the epi-no in preventing tearing and the need for an episiotomy. Other midwives prefer that the woman use the technique of perineal massage to stretch the perineum. For more information, see the website: www.epi-no.com. Q: Any idea where to get an Epi-No in the Jerusalem area? I have a friend who highly recommended using it. What do you think of it? A: You can order the Epi-no from a midwife who sells them in Jerusalem. You can reach her at 08-9231719 - she will mail it to you in Jerusalem. I personally will only feel comfortable recommending them once I know the results of the research that is studying the potential effect on long-term urinary stress incontinence. In the meantime, I recommend prenatal perineal massage. * * * Vol III Q: Several of my friends have had epidural anesthesia during their labors and were very happy with their choice. Is it safe and what are the reasons for choosing not to have one? A: Just as you will have many decisions to make regarding parenting your child, one of your biggest decisions is choosing how your baby will begin his/her life. While epidural anesthetic offers the most effective form of pain relief during childbirth, it can also strongly disrupt the birth process. The pain of labor is designed to provide women with sensory feedback and, as the woman feels pain, her body secretes oxytocin, the hormone that causes contractions. When the pain is taken away, oxytocin frequently needs to be given intravenously using the synthetic drug, Pitocin. Because contractions with Pitocin can decrease the oxygen supply to the baby, causing fetal distress, the woman will be confined to bed and will need to have continuous electronic fetal monitoring (EFM). Research has shown that continuous EFM increases the incidence of cesarean section without benefit to the babies. Another advantage of the pain of labor is that it signals the woman to respond by changing positions, which helps her baby descend through the pelvis. If the woman doesn't feel pain, she doesn't know how to respond to help her baby descend and she is also unable to be very active because of the epidural and EFM. The baby's descent is also accomplished by the resistance of the pelvic muscles. When these muscles are relaxed as a result of an epidural, they don't provide the resistance needed to help the baby rotate and descend with the contractions. This increases the likelihood of forceps, vacuum or a cesarean because of the failure of the baby to rotate into the optimal anterior position. Epidurals increase the incidence of deep vaginal tears that extend into the rectum because of the increased use of episiotomy and forceps that epidurals often necessitate. These tears may be painful, take a long time to heal, cause fecal incontinence and cause chronic pain during intercourse. Epidurals often cause a drastic drop in the mother's blood pressure, causing serious fetal distress because of decreased oxygen circulation. While it is routine to give intravenous fluids to prevent this problem, it is not always preventable. Epidurals numb the woman's bladder, so she will not have the feeling to urinate. Urinary catheters are frequently inserted when epidurals are used, increasing the likelihood of urinary tract infections. Research has shown a 700 percent increase in urinary incontinence 3 months after epidurals and a 200 percent increase one year later, compared to in non-epidural mothers. Many women develop "epidural fever", i.e. an increase in body temperature as a result of the epidural. Among women who receive an epidural, one in four will develop a fever after 4 hours and half will develop a fever after 8 hours. After birth, the babies of moms who had an epidural fever will need to be tested to rule out other serious causes of the fever (e.g. meningitis) and, in extreme cases, these tests can be quite invasive (e.g. spinal tap to the baby). The baby will be given antibiotics to treat any possible infection, even though the epidural, and not an infection, was the cause of the fever. Research has also demonstrated that epidurals can have neurobehavioral effects. These babies often cry longer and are more difficult to comfort. In addition, epidurals can affect newborn behaviors such as hand to mouth movements and sucking, which can affect breastfeeding. In short, an epidural may initiate the "cascade of interventions" that has been described above. My suggestion is that you not make any decision in advance of your labor, as you don't know how long your labor will last or how you will feel with the pain. Women who cannot overcome their fear of the pain or women who have very long labors and are exhausted would benefit from epidurals. If you do decide to take an epidural during labor, you might want to get less epidural medication, take the epidural later in labor and let it wear off before pushing. All these options can reduce the risks of epidurals. I encourage you to take childbirth preparation classes to learn effective comfort measures to help you work with your body during labor. I also suggest that you try to be as active as possible in labor and consider hiring a professional labor coach to help you work actively with your labor. * * * Vol II Q: My wife and I are expecting our first child in April. We are living in Beersheva and we have done our best to access the system for proper prenatal care. I am a physician and she is in medical school so we know what should be "done" at each stage of pregnancy but the four Ob/Gyn and two primary care doctors we have seen don't even measure blood pressure and weight, let alone all the other important tests. It all seems very haphazard and disorganized. Is this just Beersheva or is this par for the course in Israeli health care? Do we need to go to Jerusalem for appropriate care? A: I can understand your frustration with your wife's prenatal check-ups. If it's any consolation, it's basically the same in Jerusalem. While some private Ob/Gyns do more thorough prenatal examinations, it's not clear whether this is because the woman is paying privately for the care (it shouldn't be the case) or, more likely, these doctors feel that these tests are important during pregnancy. My suggestion to you is, especially as you know what tests are normally done, BE ASSERTIVE. You may get a response such as (to checking your wife's blood pressure), that high blood pressure usually occurs in the third trimester (not always the case). Tell the doctor that you would like her blood pressure checked each time. About checking your wife's weight, you may be given the response that, if she was a normal weight at the beinning of the pregnancy (not underweight or overweight) and if she hasn't had excessive nausea/vomiting and is eating nutritious food, then it's unnecessary. Again, say that it's important to you that her weight is checked at each prenatal visit. Other examples of differences in care include measuring fundal height to see how the baby is growing and even checking for gestational diabetes (not all doctors do this routinely). You WILL find, however, that if your doctor has ultrasound equipment in his/her office, your wife is likely to have many more than the standard three ultrasounds throughout her pregnancy. You should definitely feel comfortable asking for the tests, especially those that are non-invasive, that you would like performed. * * * Vol I Q: I can't decide where to give birth. Each friend I ask has a different story about the hospital where she delivered and it's so hard to choose. A: What's good for one woman isn't necessarily good for another. The important thing is that you register early in your pregnancy at all the hospitals you are considering. You should then take the hospital tour (some even offer tours in English) armed with a list of questions that will help you clarify the issues that are important to you. Some of the issues to consider are: With regards to labor:

  • Can I wear my own clothes during labor?
  • Can my husband stay with me while I'm being monitored in the admission room?
  • Will there be medical students attending to me or observing me in labor?
  • Can I eat or drink during labor if I wish to?
  • Will I be monitored continuously during labor or will it be intermittent monitoring?
  • Will the fetal heart rate be monitored by hand using a fetal stethoscope so that I can move around?
  • Will I have the freedom to choose positions in labor (such as walking, sitting, squatting, kneeling, using a birth ball, etc.)?
  • What is their policy regarding artificial rupture of membranes?
  • What is their policy regarding the use of the artificial hormone (oxytocin) to boost contractions or induce labor?
  • If my membranes rupture and I don't have contractions yet, after how many hours will I be induced?
  • Can I take lengthy showers for pain relief and for relaxation?
  • What percentage of women have epidurals for pain relief in labor? (e.g. if most women have epidurals, it is an indication of the hospital's attitude toward natural childbirth).
  • Do the midwives actively encourage women in labor to use pain-relieving drugs?
  • Can my husband be with me all the time?
  • Can I have an additional support person with me? With regards to the birth:
  • Can I have my husband with me during the birth?
  • Can I have an additional support person with me during the birth?
  • Can my husband be with me in the case of a Ceasarian birth?
  • Can I choose positions for pushing and for delivery?
  • Will I be able to push beyond the usual time limit if progress is being made?
  • Will every effort be made to try to avoid an episiotomy?
  • May I touch my baby during delivery?
  • Does the hospital practice late cord clamping (after the pulsating stops)?
  • Will the baby be allowed to take its first breaths unassisted (no immediate suctioning, etc.)?
  • May I have skin-to-skin contact with my baby immediately after birth?
  • Does the hospital routinely give an artificial hormone injection (oxytocin) after the birth to expel the placenta?
  • Can I put my baby on my breast to stimulate the expulsion of the placenta? During the postnatal period:
  • Can my baby be with me at all times (including nights)?
  • Is there breastfeeding help available if I need it?
  • Can I be discharged early from the hospital if I wish? Childbirth preparation classes usually discuss these issues so that you have a better understanding of what your choices are. You might feel that some of these issues are very important to you, while others are not. That is why it's important that you make the right choice for you, regardless of friends' recommendations. Some women may prefer a home birth to a hospital birth. Whatever your choice, it is helpful to find out as much as possible about each hospital/home birth option so that you make the choice that will allow you to have the type of birth experience you want. Q: In the US most women hire an Ob/Gyn to be with them during labor and to deliver the baby. Should I hire a doctor privately? A: This depends on several things. First, you should think about what type of birth you want. If you want natural childbirth, you should find a doctor who shares your philosophy of birth rather than a doctor who will "manage" the birth. If you want a doctor there "in case something goes wrong," then you need to ask how your doctor handles normal labors as the majority of labors fall into this category. As Henci Goer writes in The Thinking Woman's Guide to a Better Birth (Perigee, 1999): "What happens to you depends almost entirely on your caregiver's practice style and philosophy." It's important to find out if your doctor practices any routine interventions or if he/she individualizes the care provided to the woman in labor. In Israel, most women give birth through "the system," meaning whichever midwife is on duty will be the midwife who is assigned to her (she will share the midwife with other women in labor) and she will see different midwives as the shifts change. If there is any need for intervention, the doctor on duty will be called in to supervise the intervention. In that case, too, she may see different doctors as the shifts change. Basically, the woman can choose to "go through the system" (as described above), hire a doctor privately (after clarifying his/her style of working with a woman in labor), hire a private midwife this is only an option in very few hospitals in Israel (not in Jerusalem) or in a home birth, or hire a private labor coach (doula). The doula is an added support person (usually in addition to the husband, not instead of him) and, while she is not able to perform any medical procedures, she is able to be of great assistance to the laboring woman by offering physical and emotional support. Q: All the books on pregnancy that I am reading say that I should exercise. I haven't been active until now and was wondering if starting to exercise after becoming pregnant is safe. In addition, I have heard that exercising on the back isn't safe after a certain point in the pregnancy. Is that true? A: Before beginning (or continuing) an exercise program once you are pregnant, it is imperative that you obtain your doctor's permission to exercise. After getting the go-ahead, find something that you like doing. Walking, swimming or participating in a prenatal exercise class are all great ways to maintain or develop fitness. The current guidelines of the American College of Obstetricians and Gynecologists (ACOG) encourage all women with uncomplicated pregnancies to participate in 30 minutes or more of continuous exercise on most days of the week. If you participate in a group exercise class, it is important to find an instructor who is knowledgeable about pregnancy. In addition to providing her with your doctor's permission to exercise, it's important to keep her abreast of any changes in your pregnancy that occur that might require modifying your exercise program. The current ACOG guidelines state that pregnant women should not exercise in the supine position (lying on the back) after the first trimester. This is because the weight of the uterus would compress the vena cava (a major blood vessel that returns blood from the lower body to the heart) and would therefore affect your cardiac output and the blood flow to the fetus. While many women are affected by supine hypotensive syndrome (shortness of breath, dizziness, nausea, etc.) even women who don't experience these symptoms can be affected. Studies have shown that, even though the women felt fine exercising in the supine position (even on an incline), the blood flow to their babies was compromised and caused bradycardia (an abnormally low heart rate). It's best to play it safe and follow the ACOG guidelines. A knowledgeable, experienced instructor will help you modify the exercises and help you perform them in a safe position. * * * Cafe Oleh experts have been chosen for their knowledge and reputation. Cafe Oleh does not take responsibility for any advice they offer. Send your questions for Rachelle
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