I am always interested in homebirth birth plans. I’d like to think I cover most of the issues during pregnancy, but am sure some things are going to be missed. I absolutely want clients to ask anything instead of worry about something or assume one thing when another is what might happen.
So, when I came across a woman’s thinking aloud about her upcoming birth in December, I thought it was a great springboard to answer some of these common (and great!) questions. Of course, the answers will be individual depending on the woman, the midwife and the baby’s well-being, but I’m going to answer them as if she were asking me. I like to think I am pretty typical for a midwife, but could be way off base. If you are a midwife with different thoughts, please share them! If you are a woman with different experiences, share those, too, please. As Monica’s commenters said, they were very surprised by some midwives’ standard procedures.
Women! Ask anything!
I assume I will be free to walk around during labor.
Absolutely! The only time I might restrict movement is if the baby needs you to stay in one certain position. Other than that, your labor is your own.
I assume I will be able to move around and change position at will throughout labor.
Absolutely. A given.
I assume I will be able to eat and drink during labor.
Absolutely! And it is encouraged. If you don’t feel like eating or drinking (which happens more times than you can imagine), you could start feeling really nauseous and even vomit from hypoglycemia. Even a midwife who is pretty hands-off will strongly “encourage”/entice a mom to eat and drink something, even if it is simply honey on a spoon until the nausea passes and food can be taken. I don't force women to eat unless it becomes a safety issue.
Will we be prechoosing music to play during labor?
Most people do this… make labor playlists… so that during labor you aren’t (or your partner isn’t!) hanging out at the cd rack trying to figure out what to play. It’s great to have a few different mixes… soft and hypnotic (good for later stages), strong and powerful (wonderful for the early excitement parts) and even music that fits inbetween… Michael Buble, Josh Groban, (for me) Disney love songs, etc. I find that women dislike music with words the deeper they go into labor, but you might be the opposite. Singing through labor is a great way to open that cervix! An open throat and mouth = an opening cervix.
Do we care about the noise level?
Some women do, some don’t. Women who are used to a dozen hollering kids in the house might not even notice the setting up of equipment that happens when the midwives arrive. Other women are extremely sensitive to the sounds of others in labor. “Shut up!” or “Stop talking” have been heard from them and is often directed to folks who are laughing or talking about idle crap in the midst of the hard work of labor. Disrespectful! I like the moms to lead the way, but if they get morose, I will lighten the energy a tad so she can stay in the moment as well as remember there is a baby in there and she’s birthing a baby, not just having contraction after contraction.
Do we care about the light level?
Some women do. Some women love the cave-like feeling and cocoon in their homes. Others, like me, love the light and keep as many curtains open as possible – or lights on during the night. Having mood lighting available allows you to choose what you want when you want it. I have found many women like to have more light during pushing, not a huge spotlight on their perineum like in the hospital, but more light to “wake them up” for the birth.
When do the midwives like to do vaginal exams?
This is a broad question and can be answered in a vague term: depends. It depends on how you are doing, how the baby is doing and how labor is progressing. Most midwives are pretty adept at figuring out where women are in labor without a vaginal exam; the exam simply verifies the guess.
Most midwives want to do an exam when they arrive and many when their clients say they want to push.
I tend to do them for more… distinct reasons. I’ll want to do one if progress doesn’t seem to be happening… have you been pushing for an hour and there is no change? That warrants an exam to see what position the baby is in and see if the cervix is over the baby’s head. An exam is important if the baby’s heartbeat is doing funky things so we can see if the baby is close to being born or if there is time to do a transport… or to make sure the cord isn’t trying to sneak out with the baby’s head. In labor, if a mom is having more pain than we would expect, an exam can help explain what might be happening… is she in transition? Is the baby’s head (and body) posterior? Might there be a hand coming out with the head?
Vaginal exams should be few and far between anyway, but if the membranes are ruptured, they should be for very, very good reasons – and if mom is GBS positive, they REALLY should be rare. And all exams should be with sterile gloves (in my opinion), but not all midwives think that way.
I do not want an IV.
It’s really rare that a homebirthing woman would get an IV. Some reasons a woman might have one include when she wants antibiotics for GBS (the IV is run in about 20 minute increments every 4 hours), if she can’t keep any food down and must have nourishment (with D5LR) or if she is hemorrhaging and is going to be transported to the hospital. IVs allow a MUCH faster route to get the pitocin in the system (within seconds compared to the 3-5 minutes when given intramuscularly) and that can be life-saving or health-saving for hemorrhaging women.
While choosing an IV is always an option, I ask my clients to let me make the choice to start one in an emergency.
I assume I will wear my glasses or not as I feel comfortable.
Of course! I find it sad that you might even ask that question. That’s a hospital birth plan question (one of the old ones and irrelevant in this day and age).
This is a HOMEbirth and YOU are the queen of the castle… everyone else is a guest. Your midwife/midwives are there because you hired them to do a job – to keep you and the baby safe. Everything outside of that realm should be a non-issue.
All that said, I do know one woman who wasn’t given her glasses when she asked for them during pushing and it was very distressing for her. If it is a concern of yours, assign someone the job of keeping them near you. That can help you feel more in control of your surroundings.
I assume that all procedures and options will be discussed before decisions are made.
I hope so… and many of those decisions are made before labor begins.
There are some things like giving pitocin for a hemorrhage that should have implicit permission. If you haven’t discussed implicit scenarios, now is the time. “What procedures are handled without discussion during labor?” Options need to be talked about beforehand as well.
For my clients, my listening with a fetoscope in labor isn’t an option; listening with a doppler is required. (I not only need my assistant to hear what is going on, it helps to have the family know what the baby is doing – reassuring or alarming. If it is alarmingly low or high, moms have a much easier time with the next series of instructions than if they didn’t know why they were being asked to change positions or allow me to do a vaginal exam.)
During my apprentice’s last birth, she experienced a shoulder dystocia and I needed to help her baby be born. I don’t remember, but on the video you can hear me saying, “May I help?” and “I’m going to help her” and “I’m going to give her oxygen, okay?” Permission seems to be so ingrained in me that even in an emergency, I ask it. I don’t think all midwives do this (or have to do this!), but it seems to be a quirk of mine.
When do the midwives like to do doppler checks?
Some midwives are constrained to the law and will do exactly what the rules require. Standard times seem to be every hour during the earlier stages, every half hour as labor picks up (4-6 centimeters) and every 15 minutes during transition (from 7-10). During pushing, some rules say after each contraction with periodic listening before, during and after a contraction. Other standards say every other contraction is adequate.
If the baby’s heart rate does anything odd, midwives will listen much more often and/or for longer periods of time. Getting a gauge on the rhythm and pattern can help distinguish what is going on with the baby.
So, the answer is “it depends.”
I assume there will be no AROM
It’s rare, rare, rare that AROM would be done in my world. I have done AROM once? twice? in the 3.5 years of my homebirth practice. The one I remember most clearly was a woman who was 41 weeks 6+ days who was going to transfer herself to the hospital at midnight of her 42nd week. She was 5-6 cm. dilated, we’d tried every other thing possible and AROM was THE last resort before heading to the hospital. If labor didn’t begin, we were going in anyway. And cord prolapse would have been extremely unlikely since the baby was at a +1 - +2 station.
When I broke her water, she began labor within minutes and delivered an over-ten pound baby 3 hours later, before her midnight deadline.
For this woman, AROM was appropriate.
I think the only other time I have taken an amniohook to membranes was for a woman whose water had already broken, but whose labor was off and on funky. I’ve learned that when the membranes are laying over the baby’s head, once removed, labor often picks up nicely. This is exactly what happened to this client. I used the hook to break apart the membranes (no water released) and pulled the membranes off the baby’s head. The labor pattern picked up quickly and she birthed a few hours later.
When do the midwives recommend labor augmentation? What do they usually recommend?
Augmentation? Remember, augmentation means having labor pick itself up once it has already begun. Like my removing the membranes from the baby’s head, that’s augmenting labor. Doing nipple stimulation to make stronger contractions would also be augmenting labor.
If labor is piddly, for example, a labor pattern that’s merely annoying, but pretty obvious it isn’t productive (probably from an asynclitic or posterior baby), having a mom do pelvic rocks, hip circles or turning from side to side can help the baby move into a better position and help labor become more productive.
It’s important to not have a labor piddly for hours on end because moms can run out of steam – as can labors. It is always a red flag when a cranking labor winds down… not towards second stage, but in the middle of first stage. Sure, some labors quiet down so moms can sleep, but something is most likely amiss if labor just peters out.
This was the case with my mom that had the brow presentation baby. Fabulous labor and then over the course of an hour, labor just stopped. Resting, eating, drinking, nipple stimulation, squatting, lunging, visualizing (all ways to augment a labor – in addition, you can do herbs, homeopathy and acupuncture), pushing and crying didn’t change anything; contractions were just gone. Once we transferred to the hospital, the doctor prescribed an epidural and then she tried the vacuum to no avail. The cesarean showed the baby had been in an acynclitic brow presentation – a valid something-was-wrong reason for labor to peter out.
If, on the other hand, you are asking about inducing labor, that's absolutely an issue to bring up with your midwife. I work within the safety of post-dates testing (beginning testing at 41 weeks and every 2-3 days afterwards) and informed consent. As long as the baby is doing well, I'm okay hanging out. I definitely get - agitated? antsy? concerned? - at 42 weeks and would really, really want a baby born before then. I would also want to know what the cervix was doing. Is the mom's cervix long, hard and closed? Or soft and gooshy, opening? If she is 42 weeks with a tightly closed cervix, I won't be too inclined to wait much longer.
Ways to encourage a cervix to soften/ripen include loads of sex, nipple stimulation, putting Evening Primrose Oil on the cervix (with clean hands) and homeopathics. If the cervix is soft and gooshy, a hefty dose of castor oil can kick-start women into labor. Or how about a good ol' soapsuds enema? They both do the same thing: irritate the heck out of the bowels, and subsequently, the uterus.
Some midwives use blue and black cohosh... others won't touch blue cohosh anymore. I'm still on the fence.
It is common to strip membranes when trying to kick-start a labor, but I have recently read a study that showed it doesn't do a lot - and it hasn't in my experience, either.
The last resort, as I said, is Artificial Rupture of Membranes. And it is the last resort before heading in.
When and how do the midwives 'guide' pushing?
When a woman doesn’t seem to be getting the hang of it and is pushing so ineffectively that she’s just going to get a sore throat and pooped out would be one example of why I might help a woman with pushing. If she needed to push HARD because the baby was struggling inside, that would be another. Otherwise, I tend to leave women alone because they, almost always, know where and how to push.
(Oh, women who have an epidural also tend to need help with pushing.)
I can’t imagine the counting-to-ten-for-a-client Val Salva “purple” pushing, but, in my history of assisting, have certainly done that, too. Now? Not so much.
I usually help a woman by demonstration. I will have her watch for a few moments, show her how to breathe in and then where to push down… deep inside, right where she feels the most pressure/pain.
(Pushing is painful for a few women and they can pull back from causing that pain… they need to be encouraged to push through it, past it… once they push right into it, the pain disappears as the baby moves down.)
Believe it or not, some women love having fingers in the vagina to show them where to push. Once I stopped doing this routinely (as I was taught to do and watched happen every time in hospitals), I learned that some women really do appreciate the sensation/guidance of having fingers in the vagina, on the pelvic floor, pressing downward to give them a direction to push. Most women don’t need it or want it – some despise it – but as a midwife, one of our responsibilities is to know all the options so we can pull them out of our hats when the individuality of a client requires it.
Will they suggest positions for pushing?
Generally, no. I allow/encourage women to find their own positions. It is a fluid transition from first stage to second, the mom swaying and rocking during contractions one minute and then she hangs on to the foot of the bed and slides down into a squat the next. No one says, “Oh, you’re pushing now. Find whatever position you want.” It’s a given.
(And when I say “allow” I do not mean that I am giving her permission. I mean I am not forbidding her as happens in hospitals. English can be challenging sometimes. I operate from a position of deference, not authority [except in safety matters].)
If a woman has been pushing in a position for awhile and there isn’t progress, I might suggest a position change. Has she been standing holding onto the wall for an hour? Perhaps squatting with her arms over her partner’s legs as he sits on a chair is in order. Has she been in the bed (rare!) for awhile? Let’s get up and walk to the toilet to sit there for awhile. (The toilet is a great place to push! Bearing down inhibitions vanish.)
I assume that the baby will be on me immediately after birth
Surely! Even if I have to resuscitate, the baby is either on the mom or right there next to her so she can touch and talk to her baby. Unless the baby had to go to the hospital in a crucial emergency, the baby and mom stay together.
Who will 'catch'?
Who do you want to catch? Sometimes it is left to unfold… if mom is closest, she does. If dad/partner is there because mom is on hands and knees, then s/he can catch. If dad is holding mom and she isn’t in a position (either mentally or physically) to catch, then the midwife would step in. If you have a strong need/desire for someone in particular to catch, then the midwife will be the reminder of that person getting in position.
Who will cut the cord?
Who do you want to cut the cord? I have only had to cut the cord twice before the baby was born because it was so tight around the neck the baby couldn’t advance. Otherwise, it is standard for me to not even cut the cord until the placenta is born. I don’t even think of cutting the cord before that unless it is very short and mom can’t get the baby up to see her/him. And still, we always ask and always wait until it has stopped pulsating (which doesn’t take more than a couple of minutes in most cases).
I assume the cord will have finished pulsating before we cut it.
What do we want to do with the placenta?
What do you want to do with the placenta? Some families bury it, usually under a fruit tree that becomes the baby’s tree… fruit feeding the child as s/he grows. Those who live in apartments or condos can bury it under a ficus tree in a huge pot that can be carried around from place to place as needed.
Some women will dry their placenta and put it in capsules to ingest it as a precaution/remedy for postpartum depression, depression and hormonal issues. Others make tinctures – they do the same thing as the capsules.
A few women choose to eat or drink their placentas, but that’s a whole ‘nother post.
Plenty of people throw their placentas away in the trash. And still others will donate their placentas to their midwives who often use them as educational tools for apprentices and students.
The hospital uses and sells them for a variety of things including helping surgical patients or making cosmetics.
I assume that the baby will not be taken away from me after birth--all exams done at bedside
Absolutely! Absolutely. The baby is still connected to you via the invisible umbilical cord. My clients rarely relinquish their babies even to family members, sometimes for a couple of weeks – and that is as it should be.
I have this belief that babies are so pure and holy, it is why people want to touch and hold them so badly… so they can “tap into” the holiness, taking some of it for themselves.
(Same as people being drawn to touching pregnant bellies… some folks can “see” the holy glow and want to take some of it for themselves, so touching the belly allows them to have some of the baby’s aura.)
I encourage families to allow the baby to keep his/her aura white and gold as long as possible, without the “contamination” of others who might not love or appreciate the holiness of the baby as much as they do. Especially strangers. It’s one reason I adore slings; keep those babies close!
Babies and mothers are so open to the energies of others, so vulnerable, that it is crucial to keep the gates closed to the negative feelings, wishes, beliefs of others. I ask that they don’t watch the news, read the paper or walk in the mall for awhile (as long as milk is getting established and the mom is bleeding) because there is so much sadness and pain wandering around segments of our world. Be judicious who you invite into your psychic and spiritual space when you are newly postpartum. You and your baby deserve holy peace and light.
I assume that the baby will not be washed
I can’t remember the last time I bathed a baby. It had to have been at Casa de Nacimiento and only then because a mother asked me to. I really have no recollection of washing a baby in the last 15 years.
I assume that there will be no pitocin after the birth
There won’t be any routine pitocin. However, if you are bleeding too much, then pitocin it will be. This is one of those implicit agreements and examples of permission being granted for a specific reason. Believe me, you would much rather have pitocin postpartum than end up in the hospital with all the accoutrements they have to offer hemorrhaging women, including pitocin and blood transfusions. And the ambulance ride. And doctors. And separation from your baby. Not fun.
So, I always have pitocin drawn up. I don’t want to waste time finding it and drawing it up when there is an emergency. I keep it hidden in a toothbrush holder and you will, most likely, never see the syringe. If I have to use it, I will say, “I’m going to give you a shot of pit, okay?” And the answer is always, “Okay” because you hired me to be the judge of an emergency and if I believe you need it, it isn’t for a frivolous reason and you and I have created a place of trust throughout the pregnancy; we trust each other, especially when it comes down to the nitty gritty of life and health. Right?
(If you think you might question your midwife in a crisis, I HIGHLY encourage you to discuss these things, including the trust issue, with her NOW. In the middle of an emergency isn’t the appropriate time to have a crisis of belief. If you don’t trust your care provider, FIND ANOTHER ONE! If there isn’t trust, there isn’t safety… physical, emotional or spiritual.)
I assume we will breastfeed as soon as possible.
Of course! But, it is good to remember that some babies don’t nurse for awhile and that is perfectly fine. Nuzzling and being close to the nipple (and mom!) is glorious in and of itself. Offering the nipple whenever you feel so led, but please don’t be offended if the baby just isn’t ready.
We will make decisions on stitches based on the situation.
If your midwife thinks you need to be sutured, GET SUTURED! I know, I know… some women would rather just keep their legs together for 6 weeks and heal that way, but why when you can be sutured and get on with your life in a couple of days. Too many women have postpartum (and further) problems not being sutured. It hurts! (first and foremost) It can get infected. It can transform the terrain in not the most sanitary way (pockets can form and debris can get caught in it). Suturing can cause issues, too, I agree, but if your midwife is even somewhat adept at suturing, get your perineum and vaginal floor put back together.
I do not want eye medication for my child.
Not a problem. If women want it, not a problem either. I have been known to leave the ointment for families that are on the fence, they can put it in themselves if they choose to do so. I encourage having the ointment if there has been any infidelity/outside-the-relationship partners in the somewhat recent past. There will be no questions asked if someone wants it… just like no questions asked if you don’t.
Vit K injection decision will be made based on the situation.
Great idea! It’s what I recommend as well. If there is bruising, was a shoulder dystocia, a difficult birth, or molding/caput on the baby’s head, then Vitamin K is a good idea. For some, having the Vitamin K is a given and I don’t have any issue with that, either. Babies rarely cry when we give the injection. Personally, I don’t offer the oral Vitamin K because it has to be given over a course of three doses and if the baby needs the coagulation properties, the baby will need them fast; the injection is more efficient.
I also recommend Vitamin K if the baby is going to the hospital and will be getting IVs or any poking done… bleeding too much can be an issue there. Also, if the baby is a boy that is going to be circumcised before the 8th day, it is a good idea as well.
I do not want Hep B vaccine for my child.
I don’t know any homebirth midwives that give immunizations, so for me, that is a moot point.
I assume newborn screening will be done a few days after the birth.
We do that at the 3 day home visit. The baby needs to ingest a decent amount of protein before the test is accurate, so doing it on the first day postpartum (our first visit after the birth) isn’t a good idea.
What do we want to do with Ben during labor? During the birth? After the birth?
I’m assuming Ben is your other child? I strongly encourage you to have a doula for Ben… someone whom he knows well, won’t be scared of and to whom he can go if he is scared or bored. The children’s doulas cannot be married to the idea of attending the birth in case a child needs them in another room at that time. The kids’ doula is there for the kids, not the mom. (If mom wants her own doula, that is a different topic.)
Kids do great at births. They are rarely scared, even of the noises, sights and smells. Blood doesn’t seem to bother them too much – most of the things we worry about with our kids actually concern grandparents a whole lot more. I believe the energy we present to the child carries over to how they perceive things. If we are happy and positive about the upcoming birth, the child looks forward to it. If we spend an inordinate amount of time discussing the blood and gore (is there gore?), then we can understand why a child might dread the labor and birth.
Kids are most often bored during the hypnotic long periods of first stage. They will need to go to the park or store if labor is during the day and if it is at night, it’s really important to try and keep them asleep if at all possible. There is nothing worse than a cranky kid in the middle of your labor.
I know that moms are often worried about their child needing only them when they are trying to birth the next baby. It is really, really important to understand that you will not be in a mothering place – as much as you want to think you will be. I am very aware of the pull between the older child and the baby to come, but the baby being birthed needs your full attention… even if your older child is having a cow about needing you. Someone needs to remove the child from the area so you can labor without worrying about your older child. I have seen, more than once, labors completely stop when mom becomes the caretaker of the older child. Your older baby is about to share you with the new baby for the rest of their lives; time to start sharing now.
Kids become a delightful part of the family after the birth… bringing mom something to drink or eat, touching the baby, telling the birth story in their own words or gestures… it really is a tender time to have your toddler or older child in your bed with the new baby. No worries on the toddler bouncing around, the baby is more than used to it from being on the inside and the playground for your older child. As long as the older child isn’t left alone with the baby and learns to not bang him/her on the head or poke the eyes, the child should be permitted to explore the new baby much as you do.
What do the midwives bring to a home birth?
I have four big bags and one small bag of stuff that comes into a birth space. 2 of the bags are oxygen tanks (one for mom and one for baby), the (purple) birth kit stuff, my med kit and my prenatal bag.
Inside the O2 tanks’ bags, I have IV stuff and resuscitation goodies for the baby and mom. I also have the heating pads to use to heat the baby’s blankets and hats as well as extension cords.
In my big purple bag, I have my caddy that carries all the immediately-needed birth supplies… gloves, sterile gel, pit-in-the-toothbrush-holder, sterile gauze, straws (for mom to use when drinking water/juice) and my little red emergency bag that has more pit in it, Methergine and syringes in case I need those. The caddy follows the mom around the house; wherever she goes, so, too, does the caddy.
Inside the purple bag I also have my suture kit and my blood draw kit. I carry catheters, DeLees, extra gloves, gauze, goopy stuff (sterile and non-sterile gel), band-aids, batteries and a plethora of self-care items like deodorant and a toothbrush with toothpaste. I also carry two rebozos/slings to help shift an acynclitic baby’s head.
In the med kit, I have a slew of homeopathics, herbs and medications, including the meds for mom and baby we’ve discussed above. I also have some aromatherapy vials. It was a challenge to keep the homeopathics and smelly-goods away from each other, but I have them in hyper-sealed containers so they don’t “pollute”/inactivate each other. I carry loads of needles and syringes, too.
In my prenatal bag, I have my doppler, fetoscope, baby pokie things (for newborn screens), Glucometer, Hemoglobinometer, stethoscope, urine sticks, baby scale, gloves and nitrazine paper (to check for ruptured membranes).
Women in labor don’t see most of these things… the family rarely does, either. We unpack some stuff and the rest that we don’t need stays hidden in the packs that we push away from view.
Oh, I also have a resuscitation board I bring… a board that fits inside a flannel pillowcase that I have in case I ever need to do CPR. To do CPR (chest compressions) properly, you need a firm surface and I bring mine along so I can lay it on the bed next to mom while I work on the baby. I have a routine with the board.
I lay the board down on the ground, lay a waterproof warming pad open flat on it, lay one of the heating pads on that, lay some of the blankets, washcloths and a couple of hats on top of that, put another heating pad on top and then wrap the warming pad over the whole shebang. I put my baby stethoscope on top of that, turn the heating pads on high and then keep that board next to me during the birth.
If I have the stuff, I pray I won’t need it. But, it’s there if I do.
What breastfeeding help do they offer?
Mostly whatever you need. Unless something gets really technically/physically complicated, I am able to assist. If I can’t figure something out, my apprentice is the next (and often, first!) line of defense. I was a La Leche League leader for 10 years and my apprentice is one now (although we don’t advertise that), plus both of us have successfully breastfed a dozen kids between us. – she 8, me 4. We’ve also helped hundreds and hundreds of women nurse their babies. We know what we can do – and we know when to refer to a Lactation Consultant.
How many people would come to our house?
How many are you inviting? wink With me, right now, it is my apprentice and I. I had another junior apprentice that I was bringing to births, but she needed to be with her family more than being a midwife at the moment, so we’re down to two again.
How long after the birth will they stay?
We usually stay 3-4 hours after the birth. We don’t go until you are nursing successfully, have eaten, usually showered (some women are so tired they wait to shower until they get up the next morning) and both mother and baby are stable and resting well. We try to leave the house looking like it did when we got there (or better), removing all trash, usually starting at least one load of laundry, tucking the placenta into your fridge (it needs to stay there a week in case the baby has to go to the hospital for any reason… the lab will examine it for clues) and taking all our goodies back out to my car. The one thing we don’t do is empty the tub… we leave that for dads to do.
...do you guys have any suggestions of things I am forgetting that we need to know our preferences on?
I think you asked great questions! They, and my answers, sure will be helpful to my clients. I appreciate your taking the time to ask such great questions.
Can you all think of anything she’s missing?
I hope this helps my own clients, too. I think I’ll add this to my FAQ!