​One of the most crucial things we do as doulas is help parents make decisions. It's not as glamorous or often discussed as giving massages, squeezing aching hips, or whispering words of comfort and encouragement (not that any of those things are particularly glamorous). But it's one of the most important things we do.

Decision-making happens frequently during pregnancy. Choosing a care provider, a place to birth, which breast pump to buy through your insurance, what kind of birth preparation class to take, what sorts of things to register for, and so on...the decisions to be made sometimes feel endless.

But during labor, things are different. No longer is there a stretch of weeks or even months before baby is on the way - things are happening right now. Add to the urgency of time the fact that most laboring families are not necessarily calm, cool, and collected the way they might like to be when making decisions. Parents often don't even understand the implications of the options their care team is presenting.

That's where we come in.

In our prenatal visits and birth classes, we often use a tool well-known in the birth world. In fact, it's a tool now used by many who encourage healthcare literacy as a helpful way to approach decision-making with care providers. This tool comes in handy no matter where you're birthing, but we find it's often especially helpful for clients who are having their babies in a hospital setting.

The tool is an acronym: BRAIN. When a question comes up in labor, or a procedure or medication is suggested as the next step, our first suggestion is always to stop and take a breath. Sometimes these situations can be nerve-wracking in labor. So give yourself a moment rather than responding quickly and impulsively.

Once you've gotten a nice breath or two under your belt, take some time to go through the acronym letter by letter and ask some questions. 

B: Benefits The first question to ask is what the benefits of the suggested procedure, medication, or change to the situation would be. Remember to consider benefits both for you and for your baby. We've found that usually care providers answer this question even before you have to ask it, because their suggestion is made with the intention of giving you and/or your baby a certain benefit. But if you have any additional questions about the benefits, ask them!

R: Risks Next to ask is, what are the possible risks to you? To your baby? Usually in a medical setting the answer to this question reads more like the side effects listed on a drug label. While this is good information to know, there are other indirect considerations to think about which sometimes fall outside the realm of the care provider's role in that moment.

For example, sometimes our clients ask their nurse or anesthesiologist about the risks of an epidural. Usually we hear care providers mention things like the possibility of a drop in blood pressure, headaches, nausea, itching, etc. 

However, I've never heard a care provider mention the increased risk of a longer pushing phase, the increased use of medication to augment a labor slowed by epidural (pitocin), or the increased difficulty of breastfeeding after births involving an epidural (probably due to the IV fluids that accompany the administration of an epidural). These are things we discuss with our clients if they're considering an epidural, along with the benefits including "therapeutic rest" if labor has been long and hard. 

If you ask about the risks of your care provider's suggestion and receive information from the drug label, also ask if there are any other indirect risks they know of. (And check in with your doula too, to see if they have any other information that might help you as you make your decision.)

A: Alternatives Ask your care provider if there are any other alternatives that can be tried first before proceeding to the suggested procedure or medication. There may be something less invasive or more temporary that might help address the issue at hand. 

​Often care providers and medical staff are much more comfortable with medications and medical technology in birth than parents are - primarily because they're around those things all the time. They see highly medicalized care help families every day. But most expecting parents aren't in that boat. Our clients are often surprised that their care providers suggested something more invasive when there was a less invasive alternative. Understanding where your care provider is coming from can be really helpful in this case. And of course, if your care provider suggests an alternative or two, make sure to use your BRAIN when exploring those options as well.

I: Intuition What does your gut say about this? How are you feeling about the situation at hand and the proposed next steps? Studies have actually shown that the intuitive, ancient part of our brains (the part that gives us those gut feelings) often works faster than the more analytical part of our brains. Here is a fascinating article on the subject.

It's important not to discount the sensations in your body we refer to as a gut feeling because what it can mean is that some part of you already knows the answer. It may just take a while for the rest of your mind to catch up and figure out the "why." Pregnancy, birth, and parenting involve a LOT of intuition. Don't leave your intuition at the door when you enter the birth room.

N: Nothing Also known as, "What if we wait an hour?" This question can help you determine whether your care provider feels the situation is an emergency or not. If the answer to "Can we wait an hour?" is "Sure, I'll come check in later," you know you have time to think things over. But if the answer is, "Waiting isn't an option - we need to make a decision now," obviously that gives you a different picture.

​If the care provider's response to waiting an hour is positive, sometimes parents are surprised they were being asked to make a decision earlier than necessary. It's important to keep in mind that care providers are often on a schedule and juggling multiple patients at once. Sometimes the timing of things has more to do with their patient load than with your particular situation, which is another reason why it's important for parents to be asking these questions. This question is especially powerful for parents who want to minimize medications and medical technology in their births. 

You should be able to take your time in making your decision unless there is a medical emergency at hand.

After you've had a chance to ask your questions, request a few minutes alone without your care providers in the room to consider your options. (If you have a doula, it could be beneficial to have them in the room with you as you talk things over. But if for any reason you'd be more comfortable having the conversation alone, by all means let your doula know.)

Once you're ready, let your care providers know you've considered your options and made a decision. If you are choosing to accept your care provider's recom-mendation, often the conversation will be fairly straightforward. But if you're choosing instead to try an alternative or wait a while before trying anything else, sometimes care providers can feel that their expertise is being undermined or that someone is convincing you not to accept their recommendation. This is a very human reaction!

To help diffuse any tension if this happens, speak from your HEART when communicating your decision to your support team.

H: Hear "I hear what you're saying and I understand why you recommended this..."

E: Empathize "...and I know you want the best for me and my baby..."

A: Affirm/Assert "...but I intend to wait a while longer before considering x, y, or z." OR "...I would rather try this alternative instead."

R: Reassure "I will let you know if anything changes."

T: Thanks "Thank you so much for your time and for taking good care of us."

These kinds of conversations can be difficult, especially if any medical concerns are present. These tools will give you an anchoring point when making decisions in labor and beyond.

​Remember to use your BRAIN and HEART!

​Megan has been serving growing families since 2014. She is an Advanced Birthing From Within Mentor and doula based in Orange County, CA. She is passionate about providing holistic guidance for her clients, helping them cultivate resilience and openness on their journeys to parenthood. In addition to offering birth doula support, she also teaches birth and parenting preparation classes. Megan practices in partnership with her wife, Marlee, who is also a birth and postpartum doula, childbirth educator, and lactation counselor. Together they serve families of all shapes and sizes with respect and compassion. Find out more about her by visiting Hero Birth Services, or her Facebook page. 

Recently I was watching The Labyrinth, that incredible movie of my early teenhood. I watched that VHS tape so much it started to warp. I know just about every line, I sing every song, and I am ALWAYS ready for it to have a different ending, even though I know that never really happens.

I was struck by the opening credits -- when the words "It's only forever," play. This one day, when we birth our babies, stays with us forever. Shouldn't we do all we can to improve our experiences so the memories bring us happiness instead of disappointment? Enter, the Labyrinth...

The basic premise: Sarah is an imaginative girl who loves to dress up and pretend play. She has to baby-sit her half-brother, Toby, and she dreams her story to be that of having a wicked stepmother and she being forced to work and have no life. Her brother begins to cry from his crib. She accidentally sends Toby off to the Goblin King, Jareth. She then has to rescue him, through the maze of a huge labyrinth, or he will be lost to her forever. Ultimately she has a few choices -- live in her pretend world forever and forget about Toby, become Jareth's queen and live happily ever after with him, or fight to get Toby back -- and of course, that's what she does. 

​But did I mention who Jareth is? 

Um, yeah -- that's why I was always Team Jareth...but I digress.

Often labor starts out so small, we work up confidence and think, like Sarah after making a good choice, "this is a piece of cake!" That's right before she falls into a hole with nothing to stop her except a bunch of "helping hands."

While early labor is often something we can handle on our own -- occupying our minds, resting, bouncing on a ball, relaxing in a tub or shower -- as things progress, our bodies will demand more from us. Instead of worrying that this is  a predictor of how hard labor may be (at some point in the future -- I call this 'catastrophysing,' and in real life, I am pretty good at it), we need to enlist support from those around us. This is where partners, doulas, midwives, mothers, nurses -- whoever is there to fill that role, come in. 

Labor WILL get more intense -- that's the nature of the process. With support, we can be lifted up by those caring people on our birth team, those helping hands. 

There is an average amount of time women will labor. For first time pregnant people that is 12ish-24ish hours. Be mindful of that when you start telling people you are in labor, people forget birth is a marathon, not a sprint. It may only be an hour of time that has passed and well-meaning friends and family can start to ask if your baby has been born yet! 

Some families consider sitting with this information for a while until there is something more exciting to report. Often the invitation (or expectation) that people will wait happily in the lobby can be a lot of pressure to the laboring person! I have been at more than one birth when a guest pops into the laboring person's room, unannounced, and either there was nothing going on, or the person had to be shooed out quickly because it was pushing time or naked time or toilet time -- this doesn't have to happen to you! You can decide where your loved ones will bide their time, and it doesn't have to be at the hospital.

Whether it comes as a loss of control, or a needed suspension of reality, staying in our left brain where logic and reason try to make sense of things isn't always productive in labor. 

As labor progresses, we need to move to our right brain and listen to what our bodies are saying. Linear flow of time, labor math, and trying to make predictions according to what we know and what has happened all need to go by the wayside. Our team should help protect this state of mind by moving with us, going at our pace, finding another place for their fears besides our ears, and knowing how to help if we are truly lost -- like getting into take-charge mode. Labor is challenging, and we are working hard enough to keep our own heads straight -- partners and others can respect this and flex to it as long as we are feeling safe and moving forward. 

We learn. We read. We immerse ourselves in information and do our best to plan for our births. But in the end, there are so many things that aren't in our control. Does this mean we shouldn't even try?

What can we really plan about birth? We'd like to think we can plan a lot -- hospital, support team, safety. But we've all seen videos of women birthing unexpectedly in their cars (as a doula I had that happen once). So what's a pregnant person to do? I'll tell you: take a comprehensive childbirth class where you'll learn your options in a nonbiased way. Understand the labor process, how to cope, and what to expect. Build your dream birth on a foundation of sound evidence-based information -- this will ensure if your Plan A becomes a Plan B, you will know exactly what your new set of choices are -- because you ALWAYS have choices. Birth, like life, may not be fair, but you can adjust the scale in your favor with knowledge and options. 

I recently had a conversation with a pregnant woman who shared: "I know no one can make me do anything I don't want to do. I can always say no or ask for other options. That's my right."

​

Not sure what your rights are? According to the American College of Obstetricians and Gynecologists (ACOG), pregnant people:

• ​have the capacity to make decisions
• have their right to refuse treatment respected
• should not be motivated into a specific clinical decision through  manipulation, coercion, duress, physical force, threats or threats of court action
• should have their experiences and beliefs valued, respected, and factored into their decision making
• should ultimately have their wishes respected, even when refusing treatment

A year ago dad was diagnosed with stage 4 cancer. His first oncologist ran him through an intense course of chemotherapy which nearly killed him. My dad's heart isn't in the best shape, and the chemotherapy was at too high of a level. At the suggestion of a good friend who was also a doctor, my dad got a second opinion. This doctor immediately told my dad to see his cardiologist to have his heart checked, stop the chemo (with two sessions remaining), and to work on getting his health back. Dr. Wong said, "I know they are giving you too much chemo, because I can see it in your face." The first oncologist made my dad feel as if he didn't have a choice -- this was what he needed to do or he would die. Faced with that choice, my dad complied without thinking twice. His second oncologist looked at the overall picture, he asked my dad what he wanted to do, he gave him choices. My dad questioned some of these choices, such as stopping the chemo early. His doctor said, "Your old doctor's ideas are to blast the cancer away -- and that was also at the expense of your quality of life and immediate health. I am the expert of this cancer, and you are the expert of your body. I am open to listening to you, offering you options, and helping to support the course of action you choose." His doctor explained there are no guaranteed outcomes, and because of that, no one can make these choices for my dad except my dad. 

This is what ACOG is laying down that many physicians aren't picking up: no one can guarantee the outcome for you and your baby -- and because of that, the choices we make during pregnancy and birth are ultimately our own. This doesn't mean you have to be contrary out of the gate, this simply means when you have researched, thought over, pondered, prayed about a decision which may differ from that of your medical provider, no one holds more power than you.

This woman had it all covered! Not only did she bring her own lighting to the hospital, she had a diffuser, and her own Tupperware rolling pin, the one you an put cold or hot water in! She was, in just about all ways, prepared. And she did it in a way that made sense to her. 

Pink was the theme! She beautified my suggested birth plan template and framed it -- setting it on the counter in her room. Every nurse that came in stopped, ooohed and awwwwed over it, and took the proffered chocolate treats sitting next to the frame. 

Knowing her husband might need important information to be easily accessed, she put a list of must-dos on the back of the front door, so nothing would be overlooked or forgotten before leaving the house. She also had a small photo album full of ways to support her,  phone numbers, and small self-care steps he could take for himself. 

A packing list was created so all items this woman wanted would be included. Then it was broken down even more to specific location, so others would be able to find what she was needing or wanting without digging into the wrong place. 

Another photo album was filled with calming images the woman could look at during labor. 

Does this seem like a lot of work? Or does it sound like your style? You don't have to be this thorough! The key is to make your plans in a way that speaks to your own sense of organization. In labor, we can utilize comfort measures that we are familiar with and turn to during times of stress or discomfort -- we don't have to learn a lot of new-fangled coping measures that might feel unnatural or hard to remember. It works the same way when getting ready for labor and birth -- rely on an organizational strategy that feels good and works for you!

For almost two months, I have been faithfully blogging once a week. I had the opportunity to leave my doula world here in Bakersfield and visit Scottsdale with my kids -- so I took it! I had this experience, which I knew fit right in to what parents face as they create their personal plans for birth.

A family member works at WestWorld of Scottsdale. This is a huge venue where they host horse shows, rodeos, expos, and auctions. We had been invited to the Barrett Jackson Auto Auction -- we watch this on TV every year. With four boys from 3-17, this show did not disappoint! 

Our family member showed us the following video, in anticipation of our experience -- she was giddy with excitement as the boys watched with dropped jaws:

After we viewed it a few times, I had some questions for my family member. 

"Did you guys know they were going to do that?"
"Did they ask your permission?"
"If they had asked your permission, would you have allowed it?"

Even though she and her whole office couldn't stop watching this video, the answers to all three questions were, "No."

No, they had no idea this was being planned.
No, permission wasn't asked.
No, it would not have been allowed.

There are some scary scenes in this, right? The car drifts past people, past doors, around Mr. Jackson's Bugatti! Things are loud, dangerous-looking, out of the norm for the venue. But the driver has the experience of drifting, and he knows his car. He has learned how the car works, how best to throw a drift, what his car can and can't do. It is obvious he has had a lot of time behind the wheel.  

This fits into how we can craft our birth plans. 

I recently sat with a couple as they worked to put their birth preferences together. The example they were using was mighty -- like four-pages mighty! Four-pages mighty suggests you list every little thing you might even think of doing or accessing or trying. I suggest a less-is-more approach. Include 6ish of the most important choices you want. Now all the others fall under the umbrella of, we will try them if the time arises and the situation fits, generally without getting specific prior approval, but utilizing something until someone says why we can't. Do you see the parallel now? 

So you want to use a peanut ball? Bring it out when it's time -- but you don't need to take up space on your birth plan stating, "Mother will use the peanut ball we brought to optimize baby's position if Mother becomes tired or needs to stay in bed."

Do you get sick or grouchy or faint when you don't eat frequently enough? Instead of writing, "Mother has snacks available and will eat as she feels necessary in order to maintain energy for labor and birth," just pack your food and snack as you need to.

If your goal is to be active in labor, you need not put, "We wish to labor out of the bed, so we will be walking, using the shower, sitting on the ball we brought, and rocking in a chair to achieve this." You can simply show the bed isn't where you want to stay, and get up and get moving. 

Ideally, talking to your doctor ahead of time to discover what specific choices your situation warrants provides leverage. What if your doctor says no to everything you want to try? Then look for evidence. For example, in November 2015 the American Society of Anesthesiologists stated, based on evidence, that "Most healthy women could benefit from a light meal in labor." If your provider isn't keen on that, ask about this ASA recommendation -- why does it not apply to you? You can do this for many of your choices -- find the evidence and ask why you don't fit the recommendation. What is often termed as "hospital policy" can be broken down into "provider preference"; ensure you are getting accurate information.

Learn your choices. Understand how your body and your baby work together towards birth. Decide how you want to shape your experience by the options you face. And go for it.  If you aren't "allowed" to do something, assess the risks and the reasons, and move forward. Try something else. Keep asking questions. Stay busy and active. This is your machine and you know it best.

​Remember that saying: "It's easier to ask for forgiveness than to ask for permission"?

It absolutely applies here.