CPMC St. Luke's May Be A Slam Dunk If You Want To Have A Natural Hospital Birth

St. Luke's Hospital Labor & Delivery

St. Luke's Hospital Labor & Delivery

Yesterday, I went on a tour of what has been argued for years by homebirth midwives to be the best hospital in San Francisco to have a natural birth. Not having had occasion to transfer there myself, I was curious to learn about their facility and policies. This is what I learned...

One of the nurses guided myself and 3 pregnant couples on our 45 minute tour at 5pm on a Tuesday evening. She started by explaining that in labor, patients should come in through the main entrance, unless it is the weekend or after 8pm, in which case patients should enter through the emergency department off of San Jose Ave. There is a cafeteria on the 2nd floor that is open Monday through Friday from 6:30am to 6:30pm where guests can get hot food and snacks. 

Labor and delivery is on the 3rd floor. There are 3 delivery rooms and 3 triage rooms. The delivery rooms are smaller than the rooms at some of the newer hospitals like UCSF Mission Bay. The triage rooms are very small, and are used for patients who are not yet in active labor. Both the labor and the delivery rooms have attached bathrooms - although none of them have bathtubs, and only the delivery rooms have showers. 

All rooms, according to our guide, have telemetry units, also known as wireless fetal monitoring. This allows for monitoring of the baby without requiring that you be hooked up to a static machine at the bed. The monitor hangs around your neck so you can move about. 

The nurse estimated that St. Luke's does about 80 deliveries a month. On the evening of our visit, all 3 delivery rooms were occupied, and 2 out of 3 of the triage rooms were occupied. For that reason, we were not able to see an actual delivery room, just one of the smaller triage rooms. Our tour guide assured us, however, that it is very rare for them to be so full as to have to deliver patients in the triage rooms or reroute patients to another CPMC campus. 

One of the triage rooms at St. Luke's. 

One of the triage rooms at St. Luke's. 

Next, we went up to level 5 to the postpartum unit. The postpartum rooms are also small and uninspired. There is a hospital bed, a television, a fold out chair for partners, and a small sink area. They also have a connected bathroom with toilet and shower. The typical stay for a vaginal delivery is 2 days, and for a Cesarean section, 4 days. 

Postpartum room

Postpartum room

PROS

  • Midwives are the primary providers at all low-risk deliveries. There is a midwife and a physician in the labor and delivery unit 24 hours a day, 365 days a year. The physician attends deliveries only when it is deemed medically necessary.
  • Intermittent fetal monitoring is an option and wireless monitors are available in all rooms.
  • Group prenatal appointments are available in cohorts of 10 families per group. The program is modeled after the Centering Pregnancy model, but was developed by CPMC. In this model, prenatal appointments and pregnancy/childbirth education are blended into bimonthly group appointments. Afternoon and evening meeting times are available. The groups fill up months in advance, so sign up early.
  • The hospital started allowing VBACs in October of 2017. I do not have any more information on the requirements for a VBAC, policies, or rates of successful VBAC at St. Luke's.
  • Laboring patients are allowed to move freely during labor and to push in positions other than flat on their back in bed. In fact, our guide assured me that babies at St. Luke's do not have to be born in the hospital bed - that babies are born on the birth stool, in a squat, on hands and knees, and in a variety of positions. This is a BIG DEAL. I don't know of any other hospital in the Bay Area that will let you deliver your baby anywhere other than in the hospital bed.
  • Baby rooms in with mom.
  • A lactation consultant and social worker are available on the postpartum floor Monday through Friday.
  • There is no restriction on the number of visitors you can have in labor and delivery or postpartum.

CONS

  • The facility is old and the rooms are small.
  • There are no bathtubs in any of the rooms, and only the delivery rooms have showers. 
Ensuite bathroom for one of the postpartum rooms

Ensuite bathroom for one of the postpartum rooms

Unfortunately, our guide didn't have a very good grasp of the actual hospital policies or practices around things like GBS, VBAC, induction, eating in labor, C-section, or pain management options.

I was able to glean some information about St. Luke's C-section rate from online. According to the California Hospital Assessment and Reporting Taskforce, CPMC St. Luke's had a NTSV C-section rate of 21.7% in 2014. For reference, the statewide rate for that year was 26%. The NTSV C-section rate includes only first-time moth­ers giv­ing birth around their due date, hav­ing a single baby that’s po­si­tioned head down.

Without knowing much more about key procedures or policies, all of the obvious cons are related to the facility. And guess what - there's good news here. CPMC is currently in the process of building a new campus for St. Luke's. The new campus will be right next door to the current one, and is on track to open towards the end of August 2018. That's in 8 months, folks! So many of you reading this will benefit from the new facility, which is certain to be leaps and bounds better than this one. I'm told there will be bathtubs :-)

If you are healthy and are having a healthy pregnancy, then having your baby at home or in a freestanding birth center is the best option if you want to avoid a C-section or other restrictive or invasive procedures. That being said, if you are absolutely set on a hospital delivery, you should seriously consider St. Luke's for your care if you are desiring a natural birth. Having a midwife as primary provider and being able to deliver in the position of choice makes St. Luke's much closer to a mother-baby friendly model of care than most other hospitals in the Bay Area. I wouldn't be surprised if many of their other protocols are similarly progressive. 

In my opinion, once St. Luke's is in the new facility, it'll be a slam dunk for Best Hospital in the Bay Area for a Natural Delivery.

Addendum: Shortly after I published this post, the lead midwife at St. Luke's reached out to me by email to clarify some aspects of the facility that my tour guide hadn't been completely accurate about. Those updates have already been made in the body of this post. She also emphasized that along with the move to the new facility, St. Luke's was working to implement changes to make the midwifery-centered approach even stronger. This is really fantastic to hear. While a nice facility can certainly make your experience more pleasant, there is nothing more important than the values of the team that is providing your care. 

All About Birth Centers

 
Many birth centers offer the option of delivering your baby in the water, also called water birth. Very few, if any, hospitals allow water birth.

Many birth centers offer the option of delivering your baby in the water, also called water birth. Very few, if any, hospitals allow water birth.

 

What is a freestanding birth center?
A birth center is a freestanding building, not connected to a hospital, where women go to receive maternity care (prenatal and postpartum) and give birth. Birth centers cater to women desiring a natural birth, without medications or medical interventions. Birth centers only care for healthy mothers and babies. High-risk pregnancies are not appropriate for birth center care.

The American Association of Birth Centers has more info.

What is the difference between a hospital and a freestanding birth center?

A freestanding birth center is a home-like environment. Many birth centers have luxurious queen beds, dimmable lighting, and a warm and cozy interior. At a birth center, you are free to move around, to eat and drink in labor, and to birth in whatever position feels right to you. Medical equipment is often hidden in cupboards, easily accessible, but out of sight, so it doesn't detract from the environment. Intermittent monitoring of the baby's heart rate is done with a handheld doppler, as opposed to a continuous fetal monitor. Interruptions and medical interventions are kept to a minimum so as not to disturb the laboring person and the natural process of birth.

But not only do birth centers offer a different kind of environment, they offer a completely different kind of care than hospitals.

Monty Python’s The Meaning of Life illustrates the problem birth centers solve in a typically comical and dramatic fashion…

 
 

Birth centers, in contrast, provide care according to what’s called the “Midwifery Model of Care.” In the Midwifery Model, care is delivered by midwives, not doctors. Here’s what a family can expect at a birth center:

  • Personal attention
  • Time with their care provider
  • In-depth education around pregnancy, birth, nutrition, tests, options, etc.
  • Individualized care tailored to their specific needs
  • A care provider who will stay with them throughout their labor and birth
  • They will know who will be at their birth
  • The freedom to move, eat, make noise, and do as they choose in labor
  • A peaceful, private environment in which to give birth
  • Overall, high-touch, low-tech care

Here’s more about the Midwifery Model of Care.

98.8% of women using a freestanding birth center would recommend it to a friend and/or return to the birth center for a subsequent birth.

If birth centers are so great, why aren’t more women choosing them?

Good question — because there aren’t enough of them.

 
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But why would women desire a birth without medication and/or interventions?

Pregnancy and birth happen by a complex chain of events triggered by hormonal and other physiological changes. Every time we introduce something, like a medication or another type of intervention, we run the risk of upsetting this very fragile biological process. When the process of labor is interrupted, it causes problems which necessitate other interventions to stay on track and keep everyone safe. This phenomenon is called the “Cascade of Interventions.” It can be thought of like a snowball — one intervention leads to another, and then another, and another. The ultimate intervention, where the baby is removed by surgery to the abdomen, is called a Cesarean Section. In the US, 1 in 3 women is having a C-section. This is SO HIGH! And it has grown considerably over the last several years.

The World Health Organization believes we should aim for a maximum of 10–15% of women receiving C-sections. The US is currently at about 32.4%. Most women don’t want a C-section and one of the best ways to avoid getting one is to have your baby at home or at a birth center. Out-of-hospital births end up with a transfer to the hospital and a C-section rate of only 5.2%.

More Than Half Of C-Sections Performed In U.S. Aren’t ‘Medically Necessary’
Pregnant American women give birth via caesarean section at more than double the rate the World Health Organization…www.huffingtonpost.com

What’s so bad about C-Sections?

“Like any other major surgery, c-sections can have complications, like damage to other organs, internal bleeding, blood clots or infection. Recovery after a c-section is typically longer than that of a vaginal birth. Moms who have c-sections may experience as much as six weeks of post-operation pain and bleeding, versus bleeding and vaginal discharge for two to four weeks after a vaginal birth. Finally, women who have a c-section for their first baby will face risks for subsequent pregnancies, like a higher chance of the placenta implanting or growing abnormally, or uterine rupture along the site of the scar.” Huffington Post

There is also substantial lifelong risk to the baby, as found by a recent study published in the British Medical Journal and reported by CBS News (among others).

What about pain?

Birth centers specialize in unmedicated birth. They educate women and their families prenatally about what to expect in labor and how to cope with the intensity of birth. Most women do just fine. I have heard women say that labor was not nearly as painful as expected, and that having a spider bite incised was far more painful!

That is not everyone’s experience, however. So birth centers do offer tools like massage, hydrotherapy (water is very relaxing in labor), TENS units (electro-stimulation), and other natural measures to help women cope.

That being said, there are some pain medications that pose minimal risk and can be used safely in a birth center. Those medications are nitrous oxide (laughing gas) and some types of narcotics.

How much does birth center care cost?

Not only do birth centers provide more personalized, attentive care with fewer interventions, but they are also far less expensive than hospitals. The New York Times did a great job of summing up the incredible costs of having a baby in their 2013 article, American Way of Birth, Costliest in the World. Here’s an excerpt:

“When she became pregnant, Ms. Martin called her local hospital inquiring about the price of maternity care; the finance office at first said it did not know, and then gave her a range of $4,000 to $45,000. “It was unreal,” Ms. Martin said. “I was like, How could you not know this? You’re a hospital.”

[…] Add up the bills, and the total is startling. “We’ve created incentives that encourage more expensive care, rather than care that is good for the mother,” said Maureen Corry, the executive director of Childbirth Connection.”

American Way of Birth, Costliest in the World
LACONIA, N.H. — Seven months pregnant, at a time when most expectant couples are stockpiling diapers and choosing car…www.nytimes.com

By comparison, cost of care in a birth center is usually a flat fee and varies by cost of living in that part of the country. Ranges are from about $4000 in Austin, TX to $9000 in the San Francisco Bay Area.

Does health insurance cover birth center care?

YES! Most PPO plans cover some portion of birth center and midwifery care. The amount varies considerably by plan, but many plans cover between 1/3 to the full amount of the fees.

Are birth centers licensed?

In California, licensing of birth centers is optional, and there are a number of reasons a birth center might choose to forego licensure. All midwives, however, are licensed. Licensed midwives are licensed by the Medical Board of California. Many other states also have legislation for licensing midwives and birth centers.

Is birth center care safe?

Yes, it is. Midwives that work in birth centers are fully licensed and have followed a course of study that prepares them to safely care for families in a birth center setting. Birth centers stock a variety of tools to handle potential emergencies, including medications to stop bleeding, resuscitation equipment for both the baby and the mother, and oxygen. All staff are trained in Neonatal Resuscitation, CPR and Advanced Life Support in Obstetrics. Statistics for nearly 17,000 out-of-hospital births and their outcomes can be found here.

Do birth centers carry malpractice insurance?

Yes, birth centers and the midwives who work in them are required to carry malpractice insurance.

Where can I learn more about the maternity care industry in the US?

Ricki Lake did a fantastic documentary called The Business of Being Born that gives an enlightening look at the issues surrounding maternity care in the US. Here’s the trailer…

The full version of the documentary is available for free on YouTube.

So in summary…

Birth centers…

  • are safe
  • are consumer friendly
  • have extremely high customer satisfaction
  • provide more personalized care
  • offer a peaceful, luxurious environment
  • and are cheaper than the competitor (hospitals).

Pregnancy Teas - Nourishing and Full of Nutrients

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When is it safe to start drinking pregnancy teas like Red Raspberry and Nettle Leaf?

The answer is: Pregnancy teas are safe and beneficial at any time in your pregnancy.

Below is an excerpt from Susun Weed's book Wisewoman Herbal for the Childbearing Year, 2010

Nettle Leaf Tea

Nettle leaf, or urtica dioca, is one of the finest nourishing tonics known. It is reputed to have more chlorophyll than any other herb. The list of vitamins and minerals in this herb includes nearly every one known as necessary for human health and growth.

Vitamins A, C, D, and K, calcium, potassium, phosphorus, iron and sulphur are particularly abundant in nettles. The infusion is a dark green color approaching black. The taste is deep and rich. If you are blessed with a nettle patch near you, use the fresh plant as a pot herb in the spring.

The benefits of drinking nettle infusion include:

• Aiding the kidneys. The kidneys must cleanse 150% of your normal blood supply (you have more blood in pregnancy) for most of the pregnancy. Nettle’s ability to nourish and strengthen the kidneys is of major importance. Any accumulation of minerals in the kidneys, such as gravel or stones, is gently loosened, dissolved and eliminated by the consistent use of nettle infusions.

• Increasing fertility in women and men. Nourishing mother and fetus with a multitude of vitamins and minerals. Increasing the richness and amount of breast milk.

• Diminishing pain during and after birth. The high calcium content, which is readily assimilated, helps diminish muscle pains in the uterus, in the legs and elsewhere.

• Preventing hemorrhage. Nettle is a superb source of vitamin K, and increases available hemoglobin, both of which decrease the likelihood of hemorrhage.

• Reducing hemorrhoids. Nettle’s mild astringency and general nourishing action tightens and strengthens blood vessels, helps maintain arterial elasticity and improves venous resilience.

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Red Raspberry Leaf Tea

Brewed as a tea or as an infusion, raspberry is the best known, most widely used, and safest of all uterine and pregnancy tonic herbs. Most of the benefits ascribed to regular use of Raspberry Leaf tea through pregnancy are traced to the nourishing source of vitamins and minerals found in this plant and to the strengthening power of fragrine - an alkaloid which gives tone to the muscles of the pelvic region, including the uterus itself.

Of special note are the rich concentration of vitamin C, the presence of vitamin E and the easily assimilated calcium and iron. Raspberry leaves also contain vitamins A and B complex and many minerals, including phosphorous and potassium.

The benefits of drinking a red raspberry leaf infusion include:

• Increasing fertility in both men and women. Raspberry leaf is an excellent fertility herb, especially when combined with red clover.

• Preventing miscarriage and hemorrhage. Raspberry leaf tones the uterus and helps prevent miscarriage and postpartum hemorrhage from a relaxed or atonic uterus.

• Easing of morning sickness. Many attest to raspberry leaves’ gentle relief of nausea and stomach distress throughout pregnancy.

• Reducing pain during labor and after birth. By toning the muscles used during labor and delivery, raspberry leaf eliminates many of the reasons for a painful delivery and prolonged recovery.

• Assisting in the production of plentiful breastmilk. The high mineral content of raspberry leaf assists in milk production, but its astringency may counter that for some women.

• Providing a safe and speedy parturition. Raspberry leaf works to encourage the uterus to let go and function without tension. It does not strengthen contractions, but does allow the contracting uterus to work more effectively and so may make the birth easier and faster.

© Susun Weed 2010

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Infusion Preparation

Measure by weight one ounce of dried herb and place in a quart jar. Fill the jar to the top with boiling water, put the lid on and let it steep for a minimum of 4 hours (up to 8 hours for the abovementioned herbs) at room temperature. Strain the herbs off and discard. Drink infusion hot or cold, and refrigerate what you don’t drink right away. Drink 2-4 cups per day of either or both Nettle or Red Raspberry Leaf infusion.

Leaves contain the potent healer chlorophyll. Long steeping extracts all the chlorophyll, as well as the vitamins, minerals and other medicinal components of the leaves. Steeping in a closed jar keeps the water-soluble vitamins from escaping in the steam. NOT ALL HERBS ARE SAFE AS INFUSIONS (STEEPING FOR LONGER PERIODS OF TIME). Nettles and Red Raspberry ARE safe and beneficial as an infusion. On the other hand, Chamomile should only be steeped for a maximum of 30 minutes. For more comprehensive information see Susun Weed’s book: Wise Woman Herbal for the Childbearing Year.

Sources for Quality Organic Herbs
Mountain Rose Herbs www.mountainroseherbs.com (Online)
The Homestead Apothecary homesteadapothecary.com (Berkeley)
Starwest Botanicals http://www.starwest-botanicals.com/ (Online)
Lhasa Karnak Herb Company www.herb-inc.com (Berkeley)

Buy 4-8 oz to start. Then, if you’d like to continue preparing and drinking infusions throughout pregnancy and postpartum, order 1 lb at a time.

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HOME BIRTH STORY: Trust, Surrender and the Magic of Home Birth with Melissa Thormahlen

Melissa Thormahlen, who had her son, Tyler, at home with us last year, shares her birth story on the Doing It At Home Podcast. Thank you Melissa for telling your beautiful story so other families can learn about home birth! <3 <3

Hear Melissa's home birth story here

Below is a written excerpt from the podcast:

Melissa Thormahlen knows how to give me “all the feels.” I knew her story would impact many when her first email to me about her birth story had me tearing up.

 
melissa and tyler
 

She experienced most of her birthing experience at home with her first baby Emmeline, before transferring to a hospital and having a beautiful birth.

For Tyler, baby number 2, she knew she wanted to go for a home birth again because she trusted her body and her amazing birth team. 

In Tyler’s birth story, Melissa explains the trust and surrender to the process. She also took time to be close and intimate with her husband, Paul in the time before active labor.

When baby Tyler was born in the bathtub after a strong surge that took everyone by surprise she exclaimed, “I DID IT!”

 We even get to hear from baby Tyler as he chimes in a couple of times. We love when the babies make little appearances, they’re the reason we’ve come together to chat after all!

BONUS! Melissa emailed me a written version of her birth story before we got into it on the podcast. So for you readers out there, you can check out a very beautiful and detailed summary of Melissa's birth story below : )

 Melissa Thormahlen's Home Birth Story

I'm sure you'll get lots of stories but I feel compelled to share mine. My little home birthed man, who is 11 weeks, is sleeping on my chest as I'm writing to you.

Tyler was born at home on October 22. I have an older daughter who is 2.5 years old and I also planned her birth to be at home but she had different plans. She was posterior and my labor with her was long and exhausting so we ended up transferring to the hospital with her at 9.5cm. When we decided to have our second I knew I could birth at home I had so much faith in my body and my team. I used the same doula but since we had moved I had a different midwife. With Tyler I got the amazing homebirth I always wanted.

I'm not sure how much of the story you wanted people to share via email but here is my birth story:

Baby Tyler

 

On Thursday October 19th at 1:30am my water broke. I was due October 26th. I got up to go to the bathroom and when I got back in bed I felt a blurb of water roll down and out. Then there was quite a bit of fluid. Not an alarming amount but enough to know I wasn't peeing myself. For about an hour after that I had contractions, but then they petered off and I feel asleep. 

In the morning I called my mom to come pick up my 2.5 year old for her stay with grandma while we had the baby. Then called my midwife and doula and we we made a plan. Since my water had broken I was on a clock and I knew my labor had to start within 24-48 hours. Luckily my midwife felt comfortable waiting the 48 before going to the hospital for a medical induction. Shortly after my mom left with Emeline, Firen (my midwife) came to the house to check on baby, double check it was in fact my waters that ruptured, and bring herbs that were supposed to bring on labor. 

All that day I tried to induce labor naturally. I took a combination of cotton, black cohosh and a labor tincture every 15 minutes for about 4 hours. I also was advised to do some nipple stimulation. I only had contractions if I was laying in bed on my left side. If I got up or moved they went away. I was beginning to become hard on myself. So at some point I told Paul (my husband) I wanted to get up and go for a walk. We got up and dressed and out we went. Because it was so close to Halloween we looked at all the decorated houses and talked about how fun it will be that our son will have a birthday so close to Halloween. We live relatively close to downtown so at the end of our walk we decided to go out to dinner. We had a wonderful time just the two of us. We came home and crawled into bed. I went to sleep that night and didn't have any contractions. 

When we woke up on Friday Paul asked what I wanted to do and I said go get eggs Benedict so off we went. We had a wonderful love filled breakfast at a local restaurant, Chows. We snuggled and ate leisurely something that is harder to do with a toddler. After breakfast I figured I'd try one labor inducing activity, so I plugged in my breast pump. Besides the feeling of sore nipples and some very light contractions nothing came of it so I gave up. I decided instead that I should get my nails done so off I went. On my way into the nail salon I had my first good surge! 

After getting my nails done I went home and took care of some things around the house. Alli my amazing doula came over  around 2 and we walked to town. I was having some sort of regular contractions at this point but it still seemed like they could go away at a moments notice so it wasn't alarming. We went to The Coffee Shop and had smoothies, tea, Alli got a salad and a coffee and we sat outside and talked about random things. She was my doula with my first as well so we have a strong relationship. I had a few contractions while at the coffee shop where I needed to stop talking which meant I was making some progress. 

We walked back to the house after that and I got into the shower. It was nice to rinse off and upon getting out I had a really nice strong surge. They were still about 20 min apart, but it was a welcome feeling. Even if they stopped I had a feeling they would return. Firen came and checked me out while Alli was still there and it was perfect to have the team together. The baby was doing great and so was I so there was no reason to change our plan of heading to the hospital the next morning for the Rupture of Membrane Test unless I went into labor that night....

Once Firen left we took Alli to Walnut Creek to meet her family. When we were heading home we noticed Skipolini's  Pizza was in the area and they serve a Preggo pizza that is supposed to put you into labor. Since I was already having some contractions I figured it wouldn't hurt to try that too. We went in and had another nice meal together just Paul and I. I was having more regular surges and they felt like they were getting a bit more intense. 

We went home after the pizza to regroup. We were supposed to go to a movie but it didn't start for a while so we came home first. Then we both realized how tired we were and crawled into bed. Amy my sister arrived at 9:00 we chatted with her for a bit and around 9:30I told everyone to get some sleep. My body must have know what was coming because I feel asleep fast and slept hard for 2 hours. At 11:30 I woke up to a really strong contraction. Paul immediately jumped into gear and supported me through each contraction. He lit candles around the house and put on Enya. It was so romantic and sweet. He supported me through each surge and told me sweet things after each one. He was my rock.

My sister had slept until around 2am when things became more serious and I needed help. Mentally I was having a hard time staying on top of the contractions. We called Alli to come over and she gave me two more positions to try. I got into the shower first and it felt like one long continuous contraction. I think there was too much pressure and it didn't feel good to stand. Then I sat backward on the toilet and Paul massaged me from behind. It was ok but I was having lots of thoughts of self doubt so I made Paul call Alli back and demand she come over. She arrived at 2:45. She witnessed a few contractions, had Amy make me oatmeal and bring me drinks. After a particularly strong contraction she decided to call Firen to tell her it appeared I was already bearing down. Firen came immediately arriving at 3:50. When she arrived I was laying on the bed, Alli behind me, Paul on my front and Amy by my feet. I was so supported. Firen began setting up and checking my vitals. She listens to baby and determined everyone was happy and healthy!

I made her wait a little before checking for dilation and when she finally did I was 7cm. Which was great progress for a second time mom. They all ensured me I would progress fast but I couldn't bare down anymore. So Alli would breath, hiss and huff through each contraction with me helping me to keep from pushing. Which I have to say might very well be the hardest part for me, not pushing when your whole body is screaming to do so. At some point Paul suggested I get into the bathtub because it could help me relax and keep me from pushing. So they set it up and I got in. It was wonderful but the surges were really strong and I kept saying how I was dreaming of an epidural. This is transition! My doula handed me a small elephant figurine and I clutched onto it like my life depended on it. In my head I kept saying "if an elephant can be pregnant for 2 years then I can do this".

At this point in the tub my surges were so strong I was having a hard time fighting the urge to push and they were coupling. It was a lot. I asked how long until they could check me again and my midwife told me she'd wait 10 more contractions, 30 more minutes. I didn't want to go a second longer without being able to push, so this was hard. I sunk into the water and clutched my elephant. I powered on. After only 4 more contractions she said she'd check me but I had to turn over to the other side of the tub.

When I got up to turn over I had the strongest surge yet which was immediately followed by another one. Once I laid back down in the tub Firen checked me and announced I was 10cm. She looked at me as said, "do you want to have this baby here or..." and just then another surge came and I pushed with all my might. I reached my hands down and got in two more pushes feeling my son's head emerge. Then at the tail end of the surge I pushed once more and out came his body. My doula describes this moment as Tyler swimming up into my arms. I pulled him onto my chest and felt overwhelming rush of joy and love. "I did it" was all I said for a good 5 min.

I wanted more than anything to have a homebirth and this experience was pure magic. After Tyler was born my husband and I and baby Tyler crawled into bed where I birthed the placenta. My doula made us a delicious breakfast and we ate and rehashed the whole night. Tyler came into this world at 5:29am in the bathtub at our home surrounded but love and faith in my body. I wish everyone could experience the joy that is natural birth in a way where the woman feels completely supported.

I hope you enjoy my story! Thank you for all you're doing to normalize homebirth. And congratulations on your precious little girl. 

 
melissa family
 

A Blueprint for Waterbirth: ACNM's Practice Template

Midwife Firen Jones (Nightingale Birth founder) supporting a mother in the tub

Midwife Firen Jones (Nightingale Birth founder) supporting a mother in the tub

Water is delightfully therapeutic whether you are swimming in the ocean, taking a hot bath, icing a sore muscle or floating in a pool.  It is only sensible that women in labor can benefit from showers and submersion in a warm tub of water; it relaxes tense muscles and eases the weight of pregnancy as gravity lessens, and you are able to rest more comfortably. 

Families in the Bay Area are discovering the benefits of hydrotherapy for pain relief during labor and to help them have a natural, unmedicated birth. And while some hospitals may allow their patients to labor in the shower for a short while, they do not have birth tubs to labor in or offer waterbirth as an option.  This is one of the many reasons families are turning midwives for their care.  Using water for therapy throughout the labor process is so ingrained into the education and practice of midwives that it is offered by every home birth midwife I know.  

While most of our clients use water at some point during their labor and birth, whether they actually deliver in the water is about 50/50 and completely up to their preference in the moment.  But I can say that water is an important therapeutic option in labor; it offers a whole different environment to labor in.  

In November 2016, representatives from American Association of Birth Centers, American College of Nurse Midwives, Midwives Alliance of North America, and National Association of Certified Professional Midwives and other birth experts developed a model template for safely using hydrotherapy during labor and for water birth.  

Personally, I think this was a smart move by the ACNM. It provides information and direction in how to approach waterbirth for providers who are less familiar with the practice.  It also creates a standard of care (born from the midwifery model of care) that hospitals can adopt if they are considering offering waterbirth.  

Lets take a look at the basics they’ve outlined: 

Pool Rules:

  1. Baby is head down
  2. There is only one baby
  3. Pregnancy has reached term (37 weeks gestation)
  4. Baby’s heart rate has been evaluated.  Their baseline, heart rate and rhythm appear to be normal.

Golden Rules of Hydrotherapy:

  1. If she might have trouble getting herself out of the tub, maybe she shouldn’t be in there.  Basically if she has a musculoskeletal condition or reduced mobility, has taken any sedative medications, had an epidural or abnormal blood loss (hemorrhage) she may not have the strength or wherewithal to remove herself from the water.  Makes sense.
  2. Keep the water warm, but not too hot.  Use a thermometer to monitor the water temp – it really shouldn’t be over 100F.  And it is likely your client will be letting you know it's too hot.  Body temperature or a little warmer is ideal.
  3. Keep it clean.  No one wants to see a turd floating by as they are trying to relax, plus it smells and is gross.  Sure lots of people poo a little when giving birth, but one of the many magic tricks of midwives is for our clients to never realize they poo during labor. Let's keep it that way.  A disposable fish net or even using a gloved hand to remove debris works just fine. 
  4. Empty and refresh the tub.  We definitely want to avoid mini science experiments during these labors so regularly emptying, rinsing and refilling the birth tub not only provides an opportunity for your client to get out, walk around and change her position (which is good during longer labors), but it also helps avoid bacterial contamination that can result from prolonged heating of water.
  5. Slip and slides have no place in labor.  Make sure she can get in and out without slipping. Labor is hard enough and slipping on a wet floor will only make it worse.  Have able-bodied support available if she needs help, as leg-lifts are ten times more difficult in labor.
  6. Use your clinical judgment.   This probably isn’t your first rodeo with a waterbirth.  Listen to your laboring client and follow your intuition about whether she should stay in or get out.

Facilitating a Safe Waterbirth:

  1. Monitoring is as normal.  On this note, definitely get a waterproof doppler probe and keep the other end well protected from water!
  2. Support spontaneous physiologic pushing.  Since the baby will be born into the water there is no need to “catch” them so you can take a hands-off approach or help your client catch their baby. 
  3. Gently bring baby up and out of water immediately following birth.  We’ve all seen that video where the OB is allowing baby to stay submerged for several moments following birth.  Don’t do that, evidence doesn’t support that practice.  Help your client bring her baby up into the lovely fresh air.
  4. Do not submerge baby’s face once it has been exposed to air.  If just their head is born into the air (client suddenly stands up), assist your client in a supported position where baby is born avoiding re-submersion into water.  Likewise, once baby is brought to the surface of the water, support your client in holding their baby to prevent submersion of baby’s airway following birth.
  5. Maintain newborn's temperature. This is best done by drying their head and keeping them skin-to-skin.  They can stay partially submerged in the tub or covered with warm dry blankets in the immediate postpartum.
  6. Monitor third stage per normal.  This is greatly based on comfort level and experience of the midwife, but barring excessive bleeding the placenta can be delivered normally in the tub.  Just be sure to grab a bowl!

 Signs that it is time to get out of the tub:

  1. Client’s temperature is above 100.4 degrees Fahrenheit
  2. Tight nuchal cord that cannot be reduced
  3. Apparent shoulder dystocia
  4. Excessive bleeding
  5. Client loses consciousness… obviously…

This work of the ACNM and collaborators provides an evidence-based template for larger institutions to develop guidelines so birthing families can have the option for laboring and birthing in water.  Quite honestly, I am a midwife who recognizes the importance of evidence-based practice and appreciate having this kind of information available to guide my practice.  I also respect the unique needs of each birthing family and know to be judicious with how I use guidelines for each individual.

Interested in reading the full article?  Find it HERE

What are your thoughts?  How might this inform your choice to use hydrotherapy in labor or have a waterbirth?  If you are a provider, how might this inform your practice?