Guest Post: Tits Up

It doesn’t always go as planned, or even remotely close. Sometimes you have to cope with turns you never could have imagined. Tierney offered to write her story to share with you, in case your birth and feeding journey don’t go the way you planned. You are resilient! So is this beautiful family.

Their sweet baby Nola arrived on the day after Christmas, and they coped with many unexpected, and pretty severe, turns of events. As Tierney likes to say, her birth and feeding experience went “tits up.” 

Read her story below.  – Kristina


I went in with a plan. Don’t we all? I was going to give birth naturally at a birthing center away from all the buzzing and blinking of a hospital room because that is what women can do. Everyone would relax and enjoy while I gave birth in a lovely room with a sweet jacuzzi tub, snacks and sweet tunes. Birds would freaking tweet and a burst of light would randomly appear from above. After my super natural birth, my baby would latch effortlessly and I would breastfeed like the wonder goddess I am because obviously that is the next step. My hair would also magically grow 5 feet with flowers everywhere. I would basically be the cover of natural mama-hood. That was the PLAN. Right? Wrong.

            At 30 weeks I went to Labor & Delivery because I was spotting. I had been spotting my whole pregnancy so my anxiety was starting to peak. It was at this visit point that they determined via ultrasound that my cervix was close to my placenta and this distance ruled me out of having my previously planned midwifery care. Essentially, it put me at a level of risk for bleeding heavily during birth. So it was better to give birth at the hospital because obviously emergency intervention if needed can really put a damper on things. I saw my plan start to disintegrate.

            Shifting gears, now I was giving birth in the hospital. It was the smart move. It was the necessary plan. It was not what I wanted, but it is what we had to do and for our baby. I went in ready to keep it natural. No drugs, no way. Yea. About that. We tried to labor naturally. However my contractions never became consistent and we had to use pitocin to move forward. After 18 hours contractions that were 2 minutes long and an incorrect measurement of how dilated I was by a poor intern who learned a valuable work lesson, I broke down and got the epidural. Damn did it feel good. I will not pretend that my 3 hour nap post epidural was not the best break of the event. Another plan out the window, I wanted an unmediated birth and here I was, pumped full of epidural juice. But hey, sometimes a change of plans can be a good thing.

            Thankfully with the help of my wonderfully amazing doulas I was able to push my kiddo out without any further unplanned interventions. I enjoyed the sweet tunes of Elton John, my sweet doula/nurse tribe and my husbands jokes to get me through those last bits. Upon her arrival, we began to navigate the process of her latching to feed that I just knew would be a seamless journey, because that is how I planned it. Another plan out the window.

            I started to wonder if my body was failing me and my baby. That had to be the reason none of my plans were sticking so far. Maybe I waited too long to have a baby. Maybe I slept too much on my back during my last trimester. Maybe it was that sushi I ate. Maybe it was all the podcasts I made her listen to in utero Maybe, maybe, maybe…

            The day we were discharged from the hospital the lactation consultant had me and 22 other parents to send home. While the consultant worked with the time she had it wasn’t enough and it wasn’t in depth. Despite what I thought, it is not as simple as I have nipples and she has hunger. Off we went home and it went down from there. I couldn’t get the latch to work. I couldn’t tell the difference between this is uncomfortable and this is painful. I wasn’t sure what it should feel like and so I assumed all the feelings were how it was until we got a hang of it. Six days after our daughter was born she slept straight through the night. We woke her to feed multiple times, but she wasn’t having it. No way. There was no way we had a miracle baby that peacefully slept through the night at a week. We got worried. I called the lactation consultants at the hospital but they are closed on weekends. I called our doula and she immediately directed me to someone. This wonderful person came over within 2 hours of our call with a scale, donor milk and the knowledge to help. My plan to breastfeed my child and rely solely on “instinct” or “intuition” …well, that too was a plan not fulfilled. I needed help. What I received then, was more than I ever could’ve asked for.

            Turns out our kiddo was hibernating. She hadn’t been getting enough food due to our latching issues and shut down to conserve energy. She went into power save mode. I mean come on. If it wasn’t the most heartbreaking thing I had heard to date I would have acknowledged how freaking cool it was that humans can do that. Especially little humans. Armed with donor milk and new information we forged ahead ready for the upswing into breastfeeding bliss. Right? Negative ghost rider. Enter nipple torture. Let me break this down. My child ate my nipples. Ate. My. Nipples. I mean seriously I give you life and you give me open wound injuries? The lactation consultant at my doctors office, after my 3rd visit about the same issue, prescribed me a triple ointment to help my 3rd and 4th degree wounds because they kept going. You know the term rubbing salt on the wound? Try rubbing $56 ointment on the nips because that is a gut check for sure.

            Ok, I’ve got the info. I’ve got the ointment. I’ve got the will power. Ready for breastfeeding bliss to start. Anytime now. Actually, lets get some blocked milk ducts going. Well, the kiddo wasn’t pulling all the milk out. Why? Combination of latching, knowledge, and a sweet tongue and lip tie in her mouth preventing proper latching. Right. That checks. So little miss needs a frenectomy. I need to have a pediatric dentist laser parts of her tiny baby mouth so she can better attach to me. Because breastfeeding bliss, right? How much worse can it get? Well, the blocked ducts did not go away. One week, two weeks, almost three weeks. We try massaging, heat, showers, vibration, gravity, pumping, wishful thinking, sunflower lecithin, my husband literally trying to pull it out himself (no quicker way to bond with your partner in hysterically uncomfortable laughter than this). End of third week I go in to my doctor and ask specifically for the mastitis antibiotics. I do not have a fever, flu symptoms or anything else. I only have blocked ducts and some light redness. I ask for it regardless.

            The next evening I am in the ER. It hurts. So bad. I cannot take much more of it and the last place I want to be with my 5 week old on a Saturday night is the local ER, but I do not know what else to do. They run tests, pull blood and check every thing they can. Nothing is coming up alarming so they send me home with instructions to keep on the antibiotics and take morphine if it gets too bad. But I cannot nurse on morphine, so beware.

            Fast forward to Wednesday night. My best friends fly in for a visit. We are going to hang out, see the sights, eat the foods. Nope. I show my friend that is a mom my breasts for her opinion. Consensus is that they shouldn’t look like that while breastfeeding. We call my doctor the very next morning and ask for immediate…. literally anything. He schedules an ultrasound at 1pm and off we go. I get my ultrasound. I also get a nurse and doctor using the phrase “biggest I have ever seen”. Biggest what you ask? Well it certainly isn’t biggest rack or biggest personality. It is biggest abscesses. Score.

            I cannot leave the hospital. I am immediately sent to the ER to be admitted for surgery. Here I am thinking I am going to spend a wonderful week with my friends of 10+ years and our beautiful kiddo. Instead I am informing them I need them to babysit while I had emergency surgery.

            What does this kind of surgery look like? Well, they cut into your breast to drain out the infected pus that is making you sick. They then stuff it with gauze and start pumping heavy antibiotics and pain meds. Hello Law and Order on heavy narcotics!!! New perspective I tell you. During this time they also find that I have developed sepsis, but don’t tell me. In retrospect I wonder if they had told me, but I was watching L&O high so I don’t recall it. I am oddly grateful for that as I was anxious enough to go into major surgery and my poor husband was simply trying to keep his head above water with a wife in the hospital, a newborn and the epic snow storm that was hitting our city. We are thankful for our friends being here as there was no one better to be there than them. Back to the surgical fun. An abscess has to heal from the inside out. So it is not as simple as stitch and go. You have to daily change out gauze from an incredibly sensitive part of your body a during an incredibly sensitive time of your life. Allowing it to slowly heal, millimeter by millimeter.

            Fast forward 6 weeks and here I am. My breasts look like I have been shot on the right and slashed on the left. Basically a sweet bar fight where I came out victor. Doctor said it was either give me scars or lose my life. I still leak every now and then. My body seems to be trying to hold onto the memories I have of breastfeeding my daughter.

             I am still trying to sort out how I feel about it all. I tell the fantastical story of my journey at gatherings and give my token joke line of “Have a kid they said! It’ll be fun they said!”. However, I mourn my experience. It wasn’t my plan. It wasn’t what I said I could do.  I question my body and my plans. Whether I was stubborn and caused my own pain or just naive and didn’t seek answers quickly enough. I should be sitting here writing about how magical bonding time with my daughter while feeding her from me. Instead my husband and I feed her via bottles of donated breast milk or formula. We clean those bottles 2 to 1000 times a day and endure the smell that is extra spit up everywhere. No I mean everywhere. Everywhere.

            But the truth is we did it. I am still here and while healing from that surgery is the single worst physical pain I have ever dealt with I have a beautiful kid. It is the furthest thing from how I planned it, but it is how it went. I want women to know that your journey may not even remotely resemble the way you planned it, but that doesn’t mean you cannot do it. You may be experiencing something and thinking you must be the only one. No one else has told you these things and so that means it is you. It is not you. It is real and you are not the only one. I promise. It does not mean you didn’t give birth or feed your child. That looks different for everyone. This may never happen to you, but still know that just because it was not the plan does not mean you cannot handle it.

            Just say to yourself I am a freaking unicorn. Unplanned, but unicorn nonetheless. See me sparkle.

But what if I poop?! (What does pooping teach us about birth?)

In our culture, it’s usually only people with whom we are very intimate, or who are taking care of us medically, who ever see us in elimination mode.  Some families have an open door-while-pooping rule, some families don’t get a choice because those little kiddos won’t be denied access to their parent, and some are more inclined to lock that door no matter what’s happening on the other side.

The key thing to notice is, “What allows me to feel un-self conscious, so that I can relax enough to go?” Most often, it’s people (if they must be present) who you feel safe with in that space with you, and an environment where you can relax. Imagine trying to poop with strangers yelling at you and bright lights pointed at your back end! You could do it if you had to, but is it ideal? I’m going to wager that for most people, probably not. The great thing about what we know about our comfort level in pooping, is we can directly connect it to birth. What environment do you imagine for your birth? Does it make a kind of sense with how you feel about your ideal environment for using the bathroom? A relaxed environment, where you feel safe and unself-conscious, where you can ask for help if you need it, and all the tools you need to feel prepared are present, and where things can move along in their own time? ( Have you ever thought so much about your pooping environment before? )

Poop can also be an early indicator of labor. Some people feel ‘flu-ish’, with some loose stools and nausea, in early labor. Unfortunately we can’t know for sure you’re not getting a virus, until you start to feel more indicators of labor, but if you are suddenly feeling like you’re passing a lot of loose poops and this is unusual for you, notice if you’re feeling some uterine contractions as well.

The other aspect where poop and birth come together is in the labor space. Some people feel very concerned that they may pass stool while pushing. There aren’t many experiences in life where we get excited about pooping right in front of a room full of people… but this is one! As you progress from transition into pushing, your body presses the baby’s head down through the pelvis. In your pelvis is not only your uterus and vagina, but also your bladder and rectum. Your rectum is located between the baby (in the uterus), and the sacrum, or back of your pelvis, so as baby is moving down and you are pushing, you’re also bearing down and creating pressure, causing whatever is in the chute, to come right out.

What does it mean if you poop in labor? Here’s the great news- it means you’re using the right muscles and pressure, and most likely, moving your baby down!  (Try sitting on the toilet and holding your breath to poop. Does it work as well as relaxing and focusing on the muscles you need to open and relax?) Experienced birth professionals are hoping to see some stool, as it’s a reassurance that things are moving  (heh, punny!) in the right direction. Doulas will notice and eye-hi-five the nurse, and then we usually get more impassioned in our statements to you that you’re indeed, moving your baby down. We can see it! Could the pressure from pushing just cause the stool to come out with no descent of baby? Yes, of course, but they generally come together.

So, know that pooping has a purpose before birth, as a teacher to prepare our birth space, choice of location, who is present and what that space looks like, and also to indicate that labor is coming, and that pushing is likely going well. Every time you poop, you’re practicing pushing! Well done. ?

Things you can say besides “no.”

no-artLet’s be clear. “No,” is a perfectly acceptable answer to any recommendation that you aren’t on board with. Birth professionals often remind parents that they can decline anything they want, and that “‘No’ is a complete sentence.” It’s true! You aren’t obligated to explain yourself, when declining something. At the same time, sometimes this approach can set up a tension between you and the people caring for you, that might be undesirable.

It’s your provider’s responsibility to make sure that you understand why an intervention is being recommended, the benefits and risks of that intervention, and to ensure all of your questions have been answered about it, before you consent to it. Saying “no” is legitimate, and.. what if you just need more time? What about when you need time to develop your questions, so that you can make a more informed choice? You might need more tools.

Get the information you need so you can decide with confidence. What else can you say besides “no”?

I would like more time.

Asking for more time can offer you several things, depending on how you use it. Perhaps you need more time to think about what’s being recommended, or time to talk with your partner about it. Maybe you just need time to catch your breath, as the change of course raises emotions that require (and deserve!) space to be felt, before you can think through the choice in front of you.

Barring a true emergency, you can almost always ask for more time. Sometimes a provider will recommend a change in plan while they are making rounds, or checking on patients during their lunch hour, so their time is limited. You may have to decide quickly if you want to catch that window, and you could also decide that you’d rather wait a few more hours for them to return in the evening before going forward. It’s up to you to weigh the information and make a choice based on your understanding, and goals at the time.

Use your B.R.A.I.N.

This is a great mnemonic that can help you drive deeper into the information and help uncover information that can help you decide. This tool is great in labor, in parenting, with your mechanic… it never expires in its usefulness!

  • What are the Benefits of this recommendation/intervention?
  • What are the Risks?
  • What are my Alternative options?
  • What does my Intuition say? What is my gut reaction?
  • What if I do Nothing?

I’d like everyone to step out so that my partner and I can chat.

I haven’t yet met a provider (which isn’t saying that they don’t exist) who doesn’t want you to be really clear and consenting to their recommendations. Asking for more time is your right, and it’s a small request that can make a world of difference for you.

Processing your feelings is oftentimes the first step toward determining what you need to do next. A little privacy to process the change in course can help you say yes, when, if you hadn’t had that time, you might have said no (or vice versa). Perhaps it’s difficult to determine your questions with everyone staring you down,  and you’d benefit from a moment to think it through and use your B.R.A.I.N, to develop your questions before deciding.

I’m not convinced that this intervention is right for me.

Sometimes recommendations can feel a little impersonal, and more one-size-fits-all. Asking the provider to help you understand why this is intervention makes sense for you is a great way to help them to get more connected with you, and to to think past the problem that needs solving.

Give your provider the opportunity to approach their explanation from another direction if the information they’ve provided thus far doesn’t lead you to a clear decision.

What options are we not exploring?

Sometimes the birth space will have people with other expertise, whose voices haven’t been heard in context to the issue at hand. Maybe there’s a friend in the room who confronted this very choice. Perhaps you have a doula who is also a chiropractor, or your midwife is in attendance and she has a physical therapy background. There could be a wealth of other perspectives in the room, don’t miss out on hearing those voices as well!

Sharing ideas is not the same as giving advice. Remember- you are responsible for the things you consent to, just as your provider is responsible to make sure you are clear on what you are agreeing to do. Other folks in the room are not responsible for the outcomes, and should not necessarily make recommendations, but can offer another lens from which to view the decision at hand. Perhaps your labor has stalled and your friend the acupuncturist has some ideas on acupressure points to try before you agree to a medical option, for example.

What do I need to know in order to say yes to this?

We already know that if we simply don’t want to do something, we can say no. We don’t need a reason, we just.. say no. Saying yes can be more challenging, so being able to identify what things you would need to know in order to say yes can help clarify the questions you might have.

I often ask this question of clients after providers have left the room, to help them focus on what the obstacles are between them, and the clarity of their decision, either way. Sometimes there is absolutely nothing they need to know- they are very clear on how they feel about the recommendation. Sometimes they are unsure, they feel they should say yes but aren’t sure why they are reluctant. Thinking through what those obstacles might be can help you decide if they need addressing.

New ACOG Guidelines for Kitsap families

The American College of Obstetricians and Gynecologists (ACOG), is a membership organization for obstetricians and gynecologists, and is dedicated to the improvement of women’s health. ACOG regularly releases statements on trends in birth practices that generally aim toward reducing the rates of unnecessary intervention and cesareans.

Last month, ACOG has released an opinion, Approaches to Limit Intervention During Labor, that might impact your experience for your hospital birth – for the better! Seattle childbirth educator Sharon Muza breaks down what she feels are the top six points relevant to birthing clients and doulas, in this article, Six New Care Recommendations that Every Birth Doula Should Share with Their ClientsBelow, I explore her points and explain them in context to our birth climate here in Kitsap County.

1. Hospitals encourage laboring at home until active labor

Both Naval Hospital Bremerton (NHB) and Harrison Memorial Hospital in Silverdale recognize that having pregnant patients wandering the halls at 2cm isn’t good for anyone. The earlier you arrive at the hospital, the higher your risk of increased interventions, which thus, increases your risk of cesarean. Recognizing this, these facilities encourage patients to wait until they are in active labor (measuring this at 6cm), or their water is broken. How will you know if you’re 6cm if no one checks your cervix? You won’t, but your doula can help you interpret your external signs of progress and help you figure out when it might be a good time to head in to the hospital, helping to ensure you don’t go too soon.

2. Active and Expectant Management of PROM are both equally good choices.

Generally, if you are one of the 10% of people whose water breaks before the start of contractions (premature rupture of membranes, (PROM)), providers will begin to be concerned about infection risk, and thus a ‘clock’ is placed on your labor. ACOG’s statement argues that in low risk patients, expectant management (waiting for you to start contractions on your own), or active management (intervening with medications to cause contractions), are both safe and acceptable.

Expectant management is definitely not the norm in Kitsap with our obstetricians – however, it is more so with midwives. The time that a provider is comfortable waiting for your contractions to begin can vary by provider, even within the same practice. Infection risks can be mitigated in several ways, and if you feel strongly about expectant management, it might be worth bringing the ACOG statement to your provider to talk with them about this in more depth.

3. Intermittent Fetal Heart Monitoring is Appropriate for Low Risk Labors

I have seen a resurgence with some of our local obstetricians requiring that all patients have continuous monitoring (belts and monitors around your belly the entirety of the labor), versus intermittent monitoring (20 minutes of monitoring out of every hour, generally.) Intermittent auscultation is offered by midwives at NHB, and by out of hospital midwives. This involves holding a doppler to your belly periodically through your labor to listen to baby’s heart tones, rather than having belts around your belly that need frequent adjustment.

Interestingly, one OB I work with said, “The longer you listen (monitor), the more issues you will find, and that doesn’t mean they’re a problem, but it does force us to intervene more often.”

We know that there is evidence that says that continuous monitoring does not improve outcomes, and does increase cesarean risk by 1.7 times! Talk with your providers about their comfort level with intermittent monitoring so that you know their position, and then do your own research. ACOG’s statement is reassuring that you can argue for intermittent monitoring if you are low-risk.

4. Artificial Rupture of Membranes is not Necessary

Rupturing amniotic sac, or “breaking the water”, is a common intervention that many folks don’t think a lot about. When the amniotic sac is broken, this usually causes the baby to drop deeper into the pelvis, and is usually intended to help speed up a slow moving labor. If baby is not in a good position for birth at the time of the procedure, the fluid cushion that gives them space to move is now gone, and this can become problematic. Having your water broken also puts you on a clock where providers expect a certain speed of progress in a certain amount of time (see point #2 above!)

Talk with your provider about the times they are most likely to rupture membranes, and what kind of informed consent you should expect at that time. Every intervention comes with risks – be sure to ask your provider about those potential risks during your prenatal visits so that you can plan accordingly. Midwives are generally less likely to augment labor by breaking your water than obstetricians, and generally are willing to wait much longer for your labor to pick up speed before suggesting interventions.

5. Eat, Drink and Labor On!

It’s been customary in hospitals to limit food at some point during the labor. Both Harrison and NHB generally limit food after clients have augmentation or pain medication in place, and definitely if a cesarean is anticipated. Depending on the nurse you have when you are in labor, you might be refused access to food once you appear to be in active labor as well. Out of hospital birth midwives encouraging eating through the entirety of your labor, at your comfort level.

Both hospitals require a saline-lock which provides IV access in the event that intravenous medications or fluids are needed at some point during your labor, or there is an emergency. It’s important for families to note that there is a growing awareness that IV fluids during the birth can impact the baby’s weight loss after the birth, thus leading to interventions for feeding issues that might not actually be problematic.

Out of hospital midwives usually recommend eating and drinking throughout the labor in order to keep your strength up, and the climate for food access during labor is changing very slowly in the hospital. Talk with your provider about their expectations with regard to food, and then plan accordingly to bring food for yourself and your birth team so that you can eat at your comfort level.

6. Labor Down and Push Spontaneously with the Urge to Push

In unmedicated, hospital birth it’s very common for providers to check your cervix, find that you have reached 10cm dilation (or are ‘complete’), and ask you to begin pushing. This can be challenging if your baby is still rather high in your pelvis and your uterus hasn’t had the time to bring your baby down a little further, giving you that urge to push. Early pushing can also extend the time you spend bringing your baby down, burning up the time allotted for pushing (which varies by provider, and your situation.)

Talk with your provider about laboring down- letting your uterus do more of the work to help your baby descend, without your active help, before beginning to push. Unmedicated births outside the hospital generally follow the birthing person’s urges to push, and as long as you are comfortable in your efforts and there aren’t signs there is dilation yet still to do, you will lead the way. With good communication in the hospital, the nurses can help you ascertain the best time to start pushing so as to get the most bang for your buck, and not extend that pushing time unnecessarily.

In Summary

Make sure to give Sharon’s article a read, and click the links I’ve posted here for more information. You don’t have to remember everything and become an encyclopedia of birth, just be informed and have a great doula who can help you strategize in the moment.

Happy birthing!

Third Party Reimbursement for Doula Care

One of the significant benefits of having a doula at your birth works out great- not necessarily for you. Doulas reduce the amount of interventions that are implemented at births, overall, and increase resiliency and satisfaction with the birth experience. Who sees the benefit of this savings? Your insurance company!

Doulas have been working for years to be recognized by the insurance companies as a service worth paying for. The presence of a doula reduces the need for pain medication, allows laboring clients to go into the hospital later in labor, reducing the need for labor augmentation, and provide breastfeeding support during the recovery period, and so much more. It seems like a no-brainer that insurance would provide reimbursement for our services, and make it more accessible to families.

Reimbursement is spotty at best, but worth attempting. Parents can go through the process and find that they are fully reimbursed, partially reimbursed, or not reimbursed at all, and there’s no formula for us to know in advance what will happen.

First, know if your insurance company has provided reimbursement in the past. These companies have been known to reimburse for doula services at some level. It would be best for you to check with your insurance company, find out of they have reimbursed for doula care in the past and if not, how you might approach attempting it. The list below was gathered by

  • Aetna Healthcare
  • AltPro
  • Baylor Health Care System/WEB TPA
  • Blue Cross/Blue Shield
  • Blue Cross/Blue Sheild PPO
  • Cigna
  • Degussa, a German Chemical Company
  • Elmcare, LLC, c/o North American Medical Management
  • Foundation for Medical Care
  • Fortis Insurance
  • Glencare Managed Health, Inc.
  • Great-West Life & Annuity Ins. Co.
  • HNTB (Peoria, IL)
  • Houston New England Financial, Employee Benefits (Fort Scott, KS)
  • Humana Employer’s Health
  • Lutheran General Physician’s Organization
  • Maritime Life
  • Medical Mutual
  • Oschner HMO (Louisiana)
  • Professional Benefits Administrators
  • Prudential Healthcare
  • Qualchoice
  • Summit Management Services, Inc.
  • Traveler’s
  • United HealthCare of Georgia
  • United Health POS
  • Wausau Benefits

Second, it’s best if your doula is certified, and has a National Provider Identifier (Kristina does!), and you will need the CPT code to write on your reimbursement request. There is now a CPT code for both birth doula (99499), and postpartum doula services (99501 and/or 99502), respectively.

Third, it helps to have some personal statement about the benefits (to the insurance company) that having a doula brought to your birth. Did you have a vaginal birth? Perhaps having a doula helped you avoid a costly cesarean! Think about what will move the insurance company (hint… $$$), and speak to that. If your birth was complicated and by all rights, expensive, think about the benefits that doulas bring to births in general. Insurance companies want to save money and one client won’t be as impactful as how a service might a) benefit most clients, and b) save money at the same time.

Got all that? Certified doula with an NPI, the appropriate CPT codes for your paperwork, and the appropriate forms, and you have a chance of having some of your doula fees reimbursed by your insurance company.

We’ve made it easy with the Taproot Reimbursement Client Packet,  the tools you’ll need to request reimbursement. Even if you think there’s no chance, the more requests insurance companies receive, the more likely they might approve it in the future.

Best of luck!

When is it time to go?

One of the things that come up for our clients most often is the question about when it’s time to go to the birth space, or call their birth team in. 4-1-1 is a tool that many providers give their patients as a way to time contractions and ascertain whether they’re in active labor, usually the ideal time to head to the birth space. It’s a little trickier than that- let’s save you some fruitless, early runs to the hospital!

Signs you might be in labor

There are several signs that labor could be imminent. Oftentimes these signs are not recognizable as early labor signs, until after the birth when the parents look back over the birth story. “Oh, that funny feeling in my hips was probably contractions!” Looking back retroactively can answer a lot of questions. Here are just a few early signs that could be labor, or could be something else:

  • Contractions – I know you don’t want to hear that, but not all contractions are labor contractions. How to know if they’re worth noting? Notice over time if they are getting regular, longer, stronger, and closer together. Irregular contractions can indicate early, or practice (known in other circles as ‘false’) labor.
  • Loose and frequent bowel movements – Is it that potluck pasta salad, or is it labor? It’s hard to say. This is a common sign that labor could be starting, or it could legitimately be that flu that’s going around or something funky you ate. Notice it, but don’t let this get you anxious.
  • Loss of mucus plug – This interesting substance can make itself known any time in the last weeks of pregnancy. It’s constantly regenerating, so you can lose it, and then lose it again! It indicates that your cervix has started to change a bit, but does not indicate significant change all by itself. You can lose your plug before birth, or during your labor.

Other possible signs of labor can include: lightening, or the feeling that you baby has dropped, back ache, cramps, a feeling that something is different/off.

Signs that you are most likely in labor

You’ve moved through those nebulous possible signs, and now things seem a little more certain. Here are a few ways you can identify that you are indeed in early labor:

  • Regular contractions that are increasing in intensity and length, over time. It’s time to bust out that app you’ve been using to time the Braxton Hicks contractions you’ve been having, and put it to work! Measure contractions for an hour and then try to forget about it for a while. Measuring every contraction and symptom will just drive you crazy and won’t speed things up. Contractions shouldn’t go away no matter how you change your activity.
  • Rupture of membranes, or your water breaks. This is a definite sign that things are happening- but not a sign that you will definitely get contractions or birth quickly. Notice the color of the amniotic fluid; if it has a brown or greenish tinge, check with your provider, as this can mean that your baby has passed a bowel movement, which can indicate some stress. Having your water break is usually followed by contractions, or an increase in their intensity if you’re already having them.
  • Bloody show – Your cervix has to change from the consistency of the tip of your nose, to that of your lips, to the inside of your cheek. This means as it starts to soften and open, some of the blood vessels within it will break, and there will be blood tinged mucus released. It’s a good sign that your cervix is getting the labor message!

Some other signs that you are most likely in labor might be cramping, back pain, contractions becoming more painful, a sense of inner focus with contractions, dilation of cervix noted upon vaginal exam.

So, when is it time to go?

These symptoms can paint a nice picture of what might happen- and, the start of  your labor might not look anything like this. Maybe, like one of our clients, your contractions never get closer than 10 minutes apart the entire labor. Like another client, perhaps you don’t see bloody show until you’re near the end of your labor. It can be different for everyone, so try to notice what is happening, rather than what you expect to be happening.

Providers most often want their patients to arrive in the birth space right around the beginning of active labor. This video shows a nice progression of a woman who is in early labor, and then at the end, into transition (NSWF, breasts). Generally, providers recommend you to monitor their contractions and notice when they are four minutes apart, lasting a minute, for at least an hour, or 4-1-1.

The difficulty is that you might check all of these boxes, but still look like the laboring women at the beginning of the video. It’s still too soon to go, most likely. When your labor starts to look and feel more like the woman in the middle of the video, along with the regularity of contractions that are increasing in intensity and growing closer together, this is a better time to head to your birth space.

Okay, that makes sense… but.. when is it really time to go?

First, trust your instincts, and the information you’ve been provided about emergencies. Large gushes of blood, lack of fetal movement, these types of things can be emergencies and you should observe your providers recommendations around them. Sometimes people will just get a very strong feeling that it’s time to go, – not anxious, but very decisive, instinctual feeling- and we recommend you observe that, too.

Otherwise, we recommend that you consider going to your birth space when your labor pattern is regular and increasing (frequency, length of contractions and intensity), and when your coping is looking similar to the woman in the video, toward the middle. When you have turned more inward, have developed a coping ritual, need breathing or vocalizing to help you cope, and have started to become less self-conscious, it will likely be closer to active labor, and a great time to head to your birth space.

Kitsap Birth Options – Homebirth

Here in Kitsap County we enjoy many options for low-risk, healthy clients who are looking into venues where they might like to give birth. One of these options is homebirth. Kitsap County is home to several of our own licensed, professional midwives, and we are serviced by midwives who live outside our community but attend homebirths here.

Homebirth with a licensed provider who has experience in this environment is very safe, and is on the rise in our community. While the margin of families choosing homebirth is relatively small in comparison to those choosing to birth at the hospital, the number is slowly growing over time as families discover this viable option.

Homebirth Options

Clients who are electing to have their babies at home will work with one of the midwifery practices that service Kitsap County. Some of those practices will include BirthDay Midwifery, West Sound Midwifery, Off the Grid Midwifery, Gig Harbor Midwifery, and the Gumnut Blossom Midwifery. You can find more links to local midwives on Peninsula Birth Network.

Healthy, low risk clients who desire an unmedicated birth are strongly encouraged to meet with midwives and find out more about the out-of-hospital option. Very often we hear, after the birth, “If we had known homebirth was like that, we would have chosen it,” and by then it’s too late to go back. Get your questions answered about midwifery care and make an informed decision together about what that might look like, before deciding on your venue for your unmedicated birth.

General Birth Experience

Clients will see their midwives throughout their entire prenatal, birth and postpartum period, up to six weeks. Licensed midwives can make referrals to other specialties if your care requires this, can order tests and labs and ultrasounds that are needed or that you desire, and will oversee your health and the health of your baby during your duration of care.

Midwives generally enjoy working with professional doulas who can provide more hands-on support for the clients and help keep them more comfortable at home. This allows labor to progress more comfortably and with support at home, and the midwives can arrive at an active point of labor.

When you go into labor, you will call your midwife and let them know what is happening. They will counsel you on what to do next. Most often, rest, hydration, snuggle time, and distraction are recommended so that your labor can progress before your team assembles.

Midwives will often have a student midwife, and a birth assistant in attendance with them. This might seem like many hands, but all of these people are trained and skilled in assisting the midwife if there is an emergency requiring all of those hands. The team is skilled at staying out of your space as much as you desire, and checking on your progress and welfare all along the way without being intrusive to your flow of labor. Your doula will remain with you and provide the hands-on support you need, help you develop questions you might have if a decision has to be made, and help your partner and family understand what is happening so that they can participate in the way that works for you.

When the midwives arrive, they will set up their gear, which includes medication for hemorrhage, resuscitation gear for both mother and newborn, herbs or other medications to help with the discomforts of labor, birth kit for the delivery, tools for repairing your perineum should there be a tear, and more. They are fully equipped to keep a mother and baby stable if there is an emergency, until EMS arrives and can transport you to the hospital for more advanced care.

After the birth is complete, the team will empty the birth tub and pack it away, put a load or two of laundry in, and clean up the mess left from the birth process so that you can rest comfortably. While they monitor your adjustment, they will be encouraging you to rest, eat, celebrate, and snuggle your baby, right in your bed. After a few hours of monitoring, they will provide you postpartum instructions and will let you know the next time they will come to visit and check on you, usually, about 24 hours after the birth.

The routine procedures involved with homebirth are minimal:

  • Check of vitals upon arrival (heart rate, blood pressure, temperature, fetal heart tones), and periodically after this
  • About every 30 minutes, using a hand-held doppler, listening to the baby’s heart tones
  • If you are GBS positive, you are likely to receive antibiotics administered via IV in labor, every four hours. You can strategize this and explore other options with your midwives in advance of your birth.

Most midwives encourage clients to listen to their bodies, push in the position that feels best, avoid cervical exams unless a decision needs to be made with the information, encourage partner to catch baby if they desire to, encourage breastfeeding, and do not “rush” the progress of labor with medical means. Sometimes, a little rushing is necessary, or a client changes her mind and desires pain medication, at which time, the midwife can facilitate transfer to one of the local hospitals where she will relinquish care to the provider on site.

Choosing a provider for your homebirth

When interviewing midwives, we encourage you to think about what it is that you most want to know to feel safe and comfortable in their care, just like you would with an obstetrician.

Some questions might include:

  • How many births have you attended, and what kind of emergencies have you dealt with?
  • What happens if you are at another birth when I go into labor?
  • How often do you transfer clients out of care, and what are the most common reasons for that?
  • What happens if there is an emergency at home, like a hemorrhage?
  • What is your philosophy about (allopathic medicine, natural medicine, homeopathy, herbs, etc.)?
  • What will the birth team be when I go into labor?
  • What are the expenses involved with a homebirth and how does insurance help with that?

Think about the unknowns, or concerns, you have about having your baby outside of the hospital, and bring those questions to your consultation. Knowing the answers will allow you to make an informed decision about where you would feel most safe giving birth, and what venue will bring you closest to the vision you have for the birth of your baby.

Kitsap Birth Options – Birth Center

In the previous blog post, Kitsap Birth Options – Hospitals, we explored the local options for families who plan to give birth in the hospital.

In this post, we will explore the option of a freestanding birth center birth experience. There are several birth centers serving Kitsap County families, but only one that resides within our community. You may choose from the Salmonberry Birth Center, located in Poulsbo and just a few minutes away from Harrison Memorial Hospital, or in Tacoma, The Birthing Inn, just blocks away from St. Joseph Medical Center. For this post, we’ll talk about our homegrown birth center, Salmonberry.

Birth Center Options

Both of these beautiful birth centers offer large tubs in which you can find pain relief during your labors, and go on to have waterbirths, should you chose to do so. Birth centers do not offer medical pain relief (narcotics, epidural, etc.) but there is soon to be nitrous oxide (laughing gas) offered at Salmonberry, which has shown a lot of success, safety and the preference of many mothers, in other communities where this is offered. Salmonberry will be the first venue in Kitsap county offering this service, starting December 1!

General Birth Experience

During your labor and birth at a birth center, your midwife will strategize with you on when to arrive at the center. Unlike hospitals which generally encourage you to arrive somewhat early so that you can be assessed, and then sent home if needed, your midwives will stay in close contact with you during early labor, so that you will arrive in active labor. You’re encouraged to spend early labor at home where you are more comfortable and can eat, sleep, toilet, have visitors, and pass the time that can often be quite lengthy, and then come to the birth center when things are more serious.

You are encouraged to move throughout your labor, or rest in the large bed in your private room. There is a large jacuzzi tub that may accommodate both you and your partner, and you may bring food and eat freely throughout your labor to keep your stamina up. The midwives will monitor your well-being by checking your vitals, tracking your labor progress, and listening to your baby’s heart rate frequently through the use of dopplers. You can push your baby out in the position you prefer, whether on the bed, or in the tub.

You will stay after the birth for up to six hours or so, and then will be released home with your baby.  The midwives will follow up with you when your baby is 24 hours old, and four days old, at your home. Your baby will be discharged to the pediatrician you’ve chosen at that time, and then will see your midwives for the last visits at 3 and 6 weeks, at which time your care with their team will be closed out. Salmonberry midwives will perform the metabolic screening, hearing tests and other newborn screens during your care with them.

At Salmonberry, your birth will be attended by one of the 3 midwives in the practice, a birth assistant, a student, and whomever you bring for your support team. While this might seem like a lot of people, the midwives are sensitive to give you, your partner, doula, and anyone else with you, space to create the birth environment you desire, to move freely, and be supported by the people closest to you, whilst watching over the progress of labor and safety of you and your baby. In an emergency, all hands are needed in order to manage a complication or work with providers at the hospital for transfer of care.

Should you transfer to the hospital, your midwife and student midwife will accompany you along with your birth team, if they are available, and you desire it. Depending on the circumstances, they may continue the postpartum care format outlined above after you are discharged from the hospital and depending on your care needs at that time.

While transfers are uncommon, most often, clients transfer from the birth center to the hospital for pain relief and for stalled labor. In other words, in need of support that the birth center can not provide, but not necessarily for emergencies. In emergencies, the midwives are very skilled at stabilizing both mother and baby until they can be transported to the hospital for more advanced care.

Choosing a midwife for your birth center birth

The state of Washington licenses midwives as clinical providers who can care for you throughout the course of your pregnancy, birth and postpartum period. Midwives bring life-saving drugs and tools to every birth they attend, whether at home or in the birth center. They can manage postpartum bleeding, resuscitate a newborn who is having trouble breathing, and more, keeping mother and baby stable until a transfer is made to the hospital for more advanced care. It’s a great system that works well for families who experience an unexpected complication, to ensure safety.

Birth centers are operated generally, by midwives. Washington state has either certified-nurse midwives, or licensed midwives. The pathways to licensure for each of these are different, and as a result, there are some differences in the ways each kind of midwife can practice in our state, but both types of midwives have demonstrated their skills and abilities to ensure the safety of both mother and baby through the pregnancy, birth and postpartum.

Salmonberry birth center has their own midwifery team, so you will work with possibly, all of the midwives in the in-house practice, and the midwife on call when you go into labor will attend your birth. Washington law prohibits birth centers from accepting patients who have had previous uterine surgery, so for clients exploring their VBAC options, unfortunately, a birth center would not be an option for you.

If you desire an unmedicated birth, consider exploring the option to birth in a freestanding birth center or at home. Both are safe options for low-risk pregnant people, and the birth centers that serve local families are beautiful venues in which to have a baby. We recommend that even if you aren’t considering birthing outside the hospital for this birth, make an “informed no” by getting your questions answered, and then deciding with knowledge.

Next we’ll be exploring the option of homebirth in Kitsap County. Stay tuned!

Kitsap Birth Options – Hospitals

Here in Kitsap County we enjoy many options for low-risk, healthy clients who are looking into venues where they might like to give birth. This post is applicable to clients with every health situation; hospital birth is where most people will give birth and it’s the safest place for high risk clients. I hope you find this information helpful!

When we work with clients who are trying to figure out their options, our first question is, “Beyond safety,  what are your birth goals?

Knowing the ultimate destination in which you are headed helps us to ascertain what options might be most helpful to you. Do you want to have an epidural at a certain point of labor? A hospital is the place for you. Would you like to have more control over your experience but don’t want to deal with having people in your home? The birth center would be a great option for you. Feel most safe and comfortable birthing at home? Midwifery led homebirth might be the option for you!

Let’s break down what those options look like here in Kitsap County.

Hospital Options

We have two hospitals serving Kitsap County, Harrison Memorial Hospital for civilians and Naval Hospital Bremerton (NHB) for military families.

Clients birthing at Harrison will choose from The Doctor’s Clinic, Women & Children,  right inside the hospital, or Kitsap OB/GYN just a few blocks away. As a patient in one of these practices you will choose the provider you wish to work with and they will attend most, if not all of your prenatal visits. The physician that is on-call during the time you deliver will be the one to attend your birth. Some of the providers will make an effort to come to your birth even if they are not on call, but you aren’t guaranteed to have your provider at your birth. Harrison does not (yet!) support midwifery care but we are crossing our fingers that this will change!

Clients birthing at NHB will choose a provider and generally, work with that provider and their team throughout their pregnancy. When the time comes to deliver, your provider will make an effort to attend your birth, or the provider who is on call. This could be a certified nurse midwife, a family practice physician, or an OB/GYN, depending on what your care requires and who is available during the time you deliver.

General Birth Experience

During your labor, your nurses will attend your care and support you and your team, answer questions you have about your medical care and help you strategize, and liaise between you and your provider. Your doctor will visit once or twice during the day, and generally stays connected through updates by the nurses to what is happening during your labor. When you are pushing and the baby is crowning, the provider will come to catch your baby, take care of any bleeding or repairs, and then once again, you’ll largely be cared for by the nurses.

Each hospital has routine procedures they require of all patients birthing in their facilities. Some of these might include:

  • IV access via a saline-lock upon admission
  • Routine cervical exams at certain time intervals, and/or marked changes in your labor
  • Use of Pitocin routinely after the delivery to help prevent postpartum hemorrhage

During your stay, the staff does not remain in the room with you during your labor, they are oftentimes busy working with other patients as well. The nursing staff changes shift every 12 hours, so you will have a fresh face in the morning and late evening, every day.

Different hospitals have different amenities, from having midwives on staff or not, to things like labor tubs, peanut/yoga balls, telemetry units for mobile monitoring of your baby, even down to microwaves and refrigerators in your room, or in a common area, space for your support people to rest, etc. Both hospitals offer the gamut of pain medication options, have anesthesiologists/anesthetists on staff to serve your needs, and have operating room in case a cesarean is needed, as well as lactation staff for after the birth. Both facilities also offer childbirth classes, and may have other types of classes as well.

You will remain in the hospital for 24 hours after your uncomplicated vaginal birth, and 48 hours after your uncomplicated cesarean, and then will be discharged to go home with your baby. You may stay longer if you or the baby has a health issue. If your newborn is required to stay longer, you’ll be allowed to stay at the hospital as a “boarder”, which means you will have a room, and a stipend for one meal a day, but will not receive interaction from nursing staff as you will technically be discharged.

Neither hospital has advanced special care for your newborn; if there is an emergency that goes beyond their ability to care for your baby, they will be transferred to Mary Bridge Children’s Hospital in Tacoma, or Seattle Children’s Hospital, or Madigan Army Medical Center, respectively.

Choosing a provider for your hospital birth

All obstetricians are surgeons, and some OBs are more comfortable with unmedicated, active birth, than others. Some OB’s are more comfortable doing cesareans as an earlier intervention, than others might be. Some providers are very comfortable offering Vaginal Birth After Cesarean (VBAC) in low risk patients, or, as it’s known in the hospital, Trial of Labor After Cesarean (TOLAC), and some are less so.

If you and the provider you are working with are not a match, you have the right to change providers at any time in your pregnancy. The further along you are, the more challenging this might be as calendars fill up for due dates, so if you are feeling a disconnect or a lack of alignment in goals, don’t wait to interview other providers.

All of the providers serving families in Kitsap County, in the hospital and outside it, offer safe, licensed medical care for you and your baby. When you imagine your birth, beyond safety, what do you want that experience to feel like? How do you want to remember it? Use those questions to help guide you in your research on which provider, and which venue, is right for you.

Frequently Asked Questions

What does a doula do, exactly?

A birth doula provides information, encouragement, mentorship, and support to you and your family during the birth of your baby. If you think about learning a new skill, there will be a time of preparation, and a time to execute what you’ve learned.

What does doula care look like?

Prenatally, you have as many visits as you need to connect with your doulas and to help plan for your birth. When you go into labor, your doula will join you when you feel the time is right for more support, and will remain with you through the duration of the birth. For very long births, we might call in a back up doula so that we can rest and refresh. During the course of your birth, we might be sitting quietly near you, not speaking or touching you if that’s what works for you, or we could be playing music and dancing with you to get your baby out. Mostly, it’s a lot of well-timed and context-based information to help you make informed decisions, knowledgeably physical support that is relative to the stage of labor you are in, and emotional support for you and your partner along the way.

My partner will be at the birth, won’t a doula be in the way?

We know your partner is the expert on you! It’s our job to support your partner in supporting you, just the way you both envision. That varies from family to family, and we help fill the gaps between where your vision ends, and your partner’s vision begins.

Whether it’s providing information, demonstrating pain coping techniques, keeping watch while he rests, or working through unexpected changes, we are there to help you, help yourselves have the best birth possible. Your partner is the number one support person for your experience, and we are there to help, not get in the way or take over.

How do I choose a rate in the sliding scale?

Choose the rate that works for your family. That’s it! We give a sliding scale guideline of $800-$1300 within which you can choose, and the number is entirely up to you. Whether you decide to hire Laura or Kristina, you choose your rate, let her know what it is, and then send 50% with your contract to begin services. No haggling!

How many visits can I have with my doula before and after the birth?

Again, this is completely up to you; you are in charge. Support should feel supportive- we don’t want our clients worrying that they will ‘use up’ a visit if they need a little more attention. We will work together to decide whether your needs can be addressed by phone or email, or if a visit would benefit you more.

What is an independent childbirth class vs. a hospital class?

Hospital based classes, while free or low cost, are often-times more a primer of what to expect when you arrive at the hospital to give birth. Independent childbirth classes are aimed at informing you of all of your options without attachment to the outcome you choose (natural vs. medicated, induction, cesarean, etc.).

Independent classes not only help to inform you of the process, but also expose you to options you might not have considered. They are also many times, influenced by the needs of the parents present, rather than what can be a rigid curriculum aimed at suiting a broader audience.

There are merits to both approaches! If you’re interested to find out more about Taproot classes, click here.