Sometimes a cesarean is necessary and a family knows this before labor begins. This gives them a chance to prepare in ways they may not have thought of during a regular labor-turned-cesarean birth.  ​

​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. 

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!

​I worked with somebody once that had a definite “bubble” of personal space. It was kinda fun to subtly test the limits of those boundaries. I finally determined, through months of occasional observation and experimentation, that the space was 3 feet. Step, even 1-inch, into that invisible 3-foot force-field, and my subject would move away to reestablish the 3-foot bubble.   

I, too, have a bubble.  When it comes to supporting a woman in childbirth, I temporarily deflate my bubble to support my client AND the rest of her support team. Conversely, I understand that my client may also have that bubble.  So, how does that work in such a short amount of time and in such an intimate setting?

​Simply being Probably the most important. The care team for my client become protective. We hold the space, her privacy, her concentration, her focus, her rhythm, her ritual, HER ever-evolving strategy for bringing forth her infant into this world. In the early stages of labor, a knock on the door is a welcome distraction. In the final stages, a knock on the door is met with looks of annoyance and protective aggression.  

Birth is a short, intense, intimate journey. Some are “mush longer den udders.” Sleep deprivation joke, get it?!? Guffaw, snort! Emotional support begins long before labor begins. Physical intrusion into the bubble is typically a gradual process, becoming more involved as the intensity of labor calls for more support and the temporary removal of the bubble. Informational support never ends. Doulas aren’t medical experts, but we are quite familiar with the key terms to know in the chapter of life called the Journey to Parenthood.

​“Why are you still working?! Your due date is next week, what if your water breaks while you’re at work?”

“Oh that’s not going to happen to me, they do that in movies for dramatic effect. In real life, the water breaking in a gush only happens to about 8% of women, that won’t happen to me, I will be fine”

This was a conversation between myself and my good friend Jammie one week before my October 13th due date with my first child. I had an easy pregnancy, no morning sickness or vomiting, and I had not taken a single day of work off the entire nine months. I manage an office, it’s not physical work and since I had felt fine, I felt no reason to stop working even with my due date right around the corner. I wanted to maximize my time off after the baby arrived. Little did I know, I was about to be one of those 8%...

On the morning of October 14th, one day overdue, I awoke to my dog barking. She doesn’t usually bark at night unless she needs to be let out to answer the call of nature. I groaned internally. “Ugh, it’s 2:30 a.m., I don’t want to get up and let her out,” I complained internally. Then I thought, well I probably have to pee anyway, it’s only been an hour since last time I peed and everyone knows how often pregnant ladies need to pee. I heaved my big, pregnant belly up and began walking to the bathroom. "Oh, I guess I really had to go," I thought, as I felt fluid trickle. By the time I got to the bathroom, there was a gush and a lot of fluid. Apparently my water had broken, signaling that the arrival of my baby was imminent. I called to my husband and told him to get up and let the dogs out while I cleaned up.

The first call I made was to our doula. I had made the decision to hire a doula fairly early in my pregnancy, and she came highly recommended from a mother of 6 that I have known my whole life. I hired a doula because I was afraid of having a hospital birth, I was afraid of being forced into taking unnecessary medical interventions during labor, and afraid of being bowled over by a medical team that had never met me, knew nothing about me or my baby, and didn’t know what I wanted from my birthing experience. I envisioned an intervention-free birth, preferably at home, with a midwife. My husband, rightly concerned with my health and that of our unborn baby, objected to my home birth plan and preferred a hospital setting. The compromise came in the form of our doula, who I wanted to help me through an intervention-free hospital birth.

“My water just broke, should I go to the hospital?”

“How do you feel? Have your contractions started yet?”

“I feel fine, I am not in pain and having no contractions yet.”

“It’s up to you whether or not you’re ready to go to the hospital. However, it can take some time for the contractions to catch up once the water breaks. Since your water is broken, if you do go to the hospital, it's likely they won’t allow you to leave once you’re there.”

“Ok, well I don’t want to go too early, I think I will wait a while and go later. I should not go to work though, right?”

“NO!!! Do not go to work, and keep me updated.”

After getting off of the phone, I called my mother and told her the news. I told her I wasn’t going to the hospital yet and I didn’t expect the baby to arrive for several hours, probably not until late evening. I expected a long labor, everything I had heard and read said that most first time mommies have a long labor so I was prepared for a marathon. With this in mind, I decided to go to work. This decision was made because I knew I couldn’t get someone to cover me, I work at 4:30 am, and I just planned to go briefly to give a quick morning meeting and inform my staff that I would be out until the end of my maternity leave. My husband got dressed and drove me to work, and I was there for half an hour before we left and drove through McDonald’s for breakfast to be fueled up for all the work ahead of me!

At home around 6:30 am we both laid down, I wanted us both to try to get some rest for the long day ahead. I was having minor contractions at this point, 15-30 seconds long and 5 or so minutes apart. At about 9 am I sent my husband to drop our dogs off at a friend’s house. My contractions had increased in frequency and length but I was still not ready to go to the hospital. I was texting our doula and asked how long I could safely wait to go to the hospital? She said it was up to me how long I felt safe staying home, and she advised me to contact my doctor for an appointment to check my progress. If I had progressed enough, I could go directly to the hospital, but if I wanted to go back home, I could do that too. That sounded ideal to me, my doctor’s office was located in the parking lot of the hospital I would deliver at.

This is why I wanted a doula and why I decided to go with our doula specifically; she listened to me, asked me how I felt, and asked what decision I thought was best for me. Essentially, she helped me to decide for myself instead of just telling me what to do or what she thought was best. From our prenatal courses, she knew my concerns about having a hospital birth and advised me with that in mind. Our doula knew that I was concerned about going to the hospital too early in labor, and that I was concerned about having my movement in labor restricted by monitors and hospital rules.

The most important thing that I learned from our doula was that I had choices for this process. I could be in charge. There were productive ways to communicate with hospital staff to facilitate the birth that I wanted, and decisions that I could make to affect my birth, like the decision to stay home and labor for a while instead of going straight to the hospital when my water broke. I didn’t have to be merely a participant in my labor, I had choices and a voice. In our prenatal courses, we had talked extensively about my birth plan, making 2 or 3 drafts before we were satisfied with it. I also made a gift basket for the nurses and doctors in the hospital, to thank them for their hard work, and partly to schmooze just a little bit! The birth plan would help to communicate what I wanted in the heat of labor, and the gift basket would help them to remember me in a positive light.

​I called my doctor’s office. When I told them my water was broken, they told me to go straight to the hospital. I explained that I wasn’t ready yet and that I wanted my doctor to check me first. Fortunately my doctor was working and agreed to see me at 11:15 am. I took a shower, which was the best shower I have ever taken in my life, so relaxing! And my husband and I departed for the doctor. We pulled into the parking lot shortly after 11 am and I knew in my heart that we weren’t going home. My pain level had increased significantly since 9 am, but I was still unsure whether or not to go straight to the hospital. In my mind, I was clinging to the 4-1-1 rule (contractions every 4 minutes, 1 minute in length, happening for at least 1 hour) and I wasn’t there yet! My contractions were only about 30-45 seconds long, and I didn’t think they were long enough for me to go to the hospital.

Once in the doctor’s office, I had trouble disrobing from the waist down and getting up onto the exam table. When my doctor arrived and checked me, we were both surprised to find that I had already dilated to 5! It was time! I was going to the hospital! I was put in a wheelchair to go across the parking lot. I texted our doula: “I am at 0 station and 5 centimeters dilated, I need you here ASAP!” “I’ll be there as soon as I can!” My husband accompanied me to the room and I sent him back out to the car for the hospital bag. The desk nurse gave me a hospital gown and asked for a urine sample. I got into the gown but the urine sample wasn’t going to happen. I was in too much pain, and I curled up on the hospital bed in the fetal position instead.

When my husband got back from the car, I was crying. “I need an epidural, I can’t do this, I’m going to die!” Cue the theatrics! He went for help. The nurse checked me and immediately ordered a birth kit; baby was coming faster than any of us anticipated. I asked for an epidural. My husband asked if I was sure, and in that moment, I certainly was! The nurses told me it would be at least an hour before I could get one; in retrospect I am sure they knew there simply wasn’t going to be time. The baby was going to be there before the anesthesiologist anyway! Our doula arrived around noon I believe, and everything became a blur. I was very lucky that my doctor was on duty and was there for the birth. Between her, our doula, my husband, and the nurses, everything seemed to happen at lightning pace. Almost immediately, they had me pushing, I had plenty of help and support. My dear husband, who had pledged to stay by my head during labor to avoid the potentially traumatizing show, found himself holding one of my legs up while I pushed, after a nurse said “here, help her." Before I knew it, baby was crowning. My doctor asked if I wanted to touch the head? “No! What are you talking about?! We are wasting time, let’s get her out of there!”

At 1:13 pm, Tegan Janine arrived. 7 pounds, 3 ounces and 18.5 inches of pure, healthy perfection. I remember seeing her for the first time, her arms outstretched. As they laid her on my chest, I was overwhelmed with emotion and disbelief. She had arrived so quickly, I was caught off guard and burst into tears, “I’m just so happy." Delivering the placenta was slightly problematic, it didn’t want to dislodge itself. The doctor massaged away at my abdomen for 20-30 minutes, and I cursed loudly…but it was eventually delivered. I was given a shot of Pitocin in my thigh because I was bleeding a little more than they would have liked, but otherwise everything was fine.
​ 
All of the preparation and planning were worth it. The decision to hire a doula and educate myself on my choices and decisions was crucial. I am extremely fortunate that I had an easy pregnancy and a fast labor, many mothers aren’t as lucky as I was. I recognize that genetics and pure good luck played a huge part in me having a positive labor experience. I hope that by sharing a positive story of birth, other mothers can feel more confident. There are so many terrifying stories of labors gone wrong, I feel that women need to hear that labor can be a positive experience.

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. 

Recently for the Bakersfield BirthNetwork, I was presenting on comfort measures for birth. Expectant families, as well as doulas, come to these gatherings, and I love being able to offer information that is not only helpful to parents, but also information other professionals can take to their clients! As a Lamaze-certified Childbirth Educator, I am always putting together ideas in an unusual way to help make learning about birth fun!

The inspiration for this started when I had a few ideas I wanted to squish together into an activity:
1. Update the stages of labor to reflect an additional pre-labor phase at the onset of the first stage
2. Scaffold the stages/phases of labor by choosing and practicing supports meant to intertwine with the key emotional and physical events occurring
3. Provide a handout which not only helps visualize the opening of first stage, but also serves as a cheat sheet to labor happenings, timing, and ways to cope

What I came up with, I call the "Spinning Circles of Womb." Just kidding, I don't. But I think it works, and it's pretty simple, and that's all that counts -- no frilly title needed. Basically, here are the supplies: 

• items/ideas that comfort
• items that encourage art
• non-negotiable for this activity are 4 circles measuring 3cm, 6cm, 8cm, and 10cm, tacked together with a metal fastener 

I can't remember a time when I sat participants at a table, but for this activity we did, indeed, sit at a table. Surrounded by Mr. Sketch Markers, paper circles, and stickers, I began to share the stages of labor by tacking three sheets of (laminated) paper onto the wall. There is relief when an expectant parent realizes there are only three stages of labor (I did have a dad once who suggested there were 14, but that was his lucky number, and I asked him to take a guess!).

Three. That's not hard to remember, right?

​Then I tack up two more papers, which you can see below, right. I share how some genius decided to break the first stage of labor up into phases, which is another word for, let's just insert more stages into this stage and call it good. 

On the front of the circles we write things like average length of that phase, approximate cervical dilation achieved, contraction action, and more (note: I don't show all of that in the picture). The pinnacle of this is affixing the face sticker to the appropriate phase​, as a handy visual reminder of what a laboring person might be feeling in that moment. 

While we are moving through the phases with markers and stickers, we are also brainstorming what comfort measures might be beneficial at what time, and those are added to the back of that circle. We practice these comfort measures as we go. If we expect people to feel comfortable with different physical ways to counter the strong sensations of labor, we can't expect them to get there from a picture alone! Would you step into a ballroom, ready to dance in front of judges, simply from pictures you saw in a book? We need to actually show families what these positions and movements look like, how they feel, and when they help -- or they are of no help at all.

​At the close of this activity, families walk away with their concentric circles of information, a piece of pool noodle, and an information sheet which shows about 20 different physical positions of a laboring person and partner working together.

Not a bad way to merge my three goals! A handy takeaway that can be utilized easily during birth.

My journey to becoming a doula makes plenty of sense in retrospect, but it is a winding journey. I entered college as a pre-veterinary science major, ultimately switched to a Psychology major, hated counseling but fell in love with animal behavior research, and graduated with a BA in Psychology, Biology minor, and Biology Honors. I then entered a PhD program at the University of Nebraska-Lincoln in the Biological Sciences with the intention of becoming a research professor. I actually completed my coursework for a PhD, but cut my research short to graduate with a Masters when I decided a career in academia was no longer what I wanted. After graduation, I became a homemaker and mom when our son was born 5 months later. When he was 10 months old I completed my doula training with DONA International, and attended my first doula birth one month later. Now my husband and I have three children, I am a certified birth doula with DONA International, a Hypnobabies Childbirth Hypno-Doula, co-leader of ICAN of Lincoln (International Cesarean Awareness Network), and have attended more than 55 births. I have a passion for teaching others, empowering women and families to love one another better, birth, birds, and chocolate.
 
I wanted to write a guide to other doulas and to parents-to-be on how to find, read, understand, and use primary research literature. When you have found, read, and understood the research, using the information will be a highly individual decision that only the patient themselves is able to make, based on their intuition, desires, trusted counsel, and circumstances. Yesterday, I discussed how to find and read research papers in Part 1. Here in Part 2, I walk you through a short research article and talk about how to understand the paper, and how to use that information.
 
Here is a short example of how I read a research paper. This article is a short write-up of a conference poster session. This is preliminary research, it is probably not peer-reviewed (critiqued by other scientists in the field to make sure it is done well), and though we can still gain valuable information from it, keep in mind our knowledge can change drastically with more studies, more research, and better analysis. Go read it. Really. It's quick, you'll be back in no time! Here is the paper (if you want to and have the means, print it out and grab a pen!):
 
Afshar, Y; Wang, E; Mei, J; Pisarska, M; and Gregory, K. 279: Higher odds of vaginal deliveries in women who have attended childbirth education class or have a birth plan. American Journal of Obstetrics & Gynecology, 2016;214(1):S162.
 
Since this is such a small write-up, there is no introduction or background section, simply a research objective. Do Child Birth Education classes (CBE) and/or birth plans impact the delivery mode of those women?
 
Let's look at the study design. The authors looked in the past (retrospective) at a group of women all from the same period of time with similar demographic characteristics (cohort study), and give the dates and type of birthing facility. Because birth modes can differ so much between singles and multiples, the authors only looked at singleton births. They also divided the groups into all moms, and just moms having their first birth (nulliparous). Then they divided each group into moms who attended CBE, those who had a birth plan, and those who did both.
 
Understanding statistical analysis is a whole other ball of wax, and there is no way I can explain everything here. What you need to know is when p-values are reported (p=0.01, p>0.1, p<0.0001, etc), the smaller the p-value, the greater the effect of the variable being tested. The p-value is basically the probability that any difference between the groups is due to chance, so if the p-value is small, the difference between the groups is probably due to the different variables. There is a lot more to statistics than just understanding p-values, but there's your crash course in statistics for today.
 
In this study, there were over 14,000 births that were included in the analysis (met inclusion criteria). There were differences between groups of women who did and did not attend CBE and/or have a birth plan. After adjusting for these population differences, the authors found that women who had attended CBE, had a birth plan, or both, had higher odds of a vaginal delivery compared to the group who did none of those, but there was no stronger effect of doing both. This effect was true of first-time moms as well, so the impact of CBE and/or birth plans is the same no matter which birth this is for a woman. In their original poster session, the authors likely included more figures, including their logistic regression analyses, which would help us understand the relationship between the variables and their effects, but it's a simple study and we can understand the basics with the information given here.
 
The authors conclude that attending CBE and/or having a birth plan increase the odds of a vaginal delivery, and they state that further research is needed to understand how this works. In my opinion, given my cursory understanding of this study, I think this conclusion is sound.
 
The questions I have after reading this are:

• Does the type of CBE class and/or birth plan matter?
• It seems like the number of women who had both attended CBE and used a birth plan and those who only wrote a birth plan were very close. Did most of those women who wrote a birth plan also attend a CBE, or is this an incorrect assumption?
• Does the type of class a woman took impact whether or not she writes a birth plan?
• I would have liked to know about how many scheduled and unscheduled (emergency) cesareans were in each group of moms. And the reason for the cesarean?
• How about assisted vaginal delivery (forceps or vacuum) and CBE and/or birth plan?
• I would have liked to see figures of the data, not just the study design, hopefully this research will be published in full soon.

Finally, the authors found a statistically significant difference in delivery mode based on CBE and/or birth plan, and with a relatively small group of women! In human research, 14,000 people is really not much. That's approximately the population of downtown St. Louis, MO. To find a statistically significant effect in a small sample size suggests that either it is due to random chance, or this is a very strong effect. I am excited to see what further research shows in this area!
 
In lengthier research articles, there would be a list of references. For more information on the topic and related topics, this list is where you want to start. In lengthier research articles, there would be a list of references. For more information on this and related topics, including additional studies, this list is where you want to look.

Now, how do you use this information, either for your doula or CBE clients, or for yourself? First, you must understand that research does not, and can not predict your outcome. Research is not a crystal ball, it cannot predict with certainty, in real life, who will and will not experience which outcome. In addition, the facts, found in the scientific literature, are an important piece of any decision-making process. But your intuition, your desires, the availability of options, the counsel of trusted medical caregivers, and many more variables will come together to determine the best decision for you in your circumstances. Science tries to isolate variables, to pinpoint and quantify the exact effect of one thing, which is vital for understanding how one thing affects another. But we do not live in a laboratory. Applying those results to real-life, complicated, individual healthcare decisions is something that only the patient themselves can do.
 
I hope that now you are better equipped to find, read, understand, and use primary research articles. Happy reading!

The night after my first birth as a doula I couldn’t sleep -- I was very sad, very tired, and very quiet.
 
“My water broke, no contractions yet, the midwife told me to go to the hospital at five.” I was on a bus, busy with formalities when I received the mom’s text. I went back to my house as soon as I could, checked-in with my doula group on WhatsApp, washed my hair, got my doula bag, printed DONA certification papers, and left. Filled with excitement and adrenaline, I was happy. At last, 2 years after my first doula course, 3 months after my DONA training, a mama had trusted me to be her doula, and I was over the moon; although I knew this wasn’t the best scenario.
 
“Remember all our plans? Well, we are going to let them go.” I said that to the mom, but I was saying it to myself, too. An hour later I was in her bedroom, had turned the lights down, and understood that the couple’s choice was to go soon to the hospital. I had half an hour to time contractions. With the birth ball, rebozo in dad’s hands, and massage, a few contractions came -- shy, like someone who comes into a new place and doesn't know what to do. Respecting their decision to leave for the hospital at five (we had an hour or so of driving), I suggested we go.
 
“Wait, I have to do some stuff before -- get me the hair iron.” So there I was, with a mom about to go to the hospital not in labour -- but I was supporting with love what was important to her though it wasn't ideal to me. I took the iron, and while she was on the birth ball I did my best so she wouldn't realise I have no experience with hair irons (my hair is so straight!), and my fingers were burning. I took my time, this was important to the mom, so it was important to me. When I finished I helped the dad so he wouldn't forget anything. She put on perfume, called for a car, and we were out.
 
“It’s not a big deal, just relax yourself.” The driver had been a policeman, and he had attended three births himself. I think this man knew more about births than a lot of OBs. The energy in the car was pretty high, there was confidence and smiles, but the mom already knew that as soon as she entered the hospital, the interventions and protocols and rules would start.
 
“We’re going to try a vaginal birth, ok? But you know that at 37 weeks, your cervix is immature, and a c-section, is always a possibility, ok?” The midwife talked to the mama, but she was in another place. She sadly signed admission papers -- each form was a broken expectation given away with her street clothes and her credit card. 
 
“Everything is perfect, Clari. There’s always a bigger plan than the one we can see or understand.” The WhatsApp group of my doula-mates was strong, careful, douling the doula. The same group that replied when I asked for a photo of “Labouring in bed” by Penny Simkin. In the hospital, I learned I would not able to be with the couple in the room -- rules are rules and only one person goes with the mama. We all sat in the waiting room. I lent my doula stuff to the dad and gave him some advice and information. When the mom was finally called, she was so upset I didn’t know what to say as they walked away.
 
The waiting room was full with grandmas, aunts, sisters and expecting couples. Absolutely every birth of that afternoon/night was a cesarean birth. C-sections were so many that the OR was full all the time. I cried a little, then got calmed -- I did my best, there was nothing I could do but wait, think positively about them, pray a bit, and wait some more. We were on the 10th floor, and as I watched elevator numbers rise up, I tried to visualize it was the mom progressing to 10. I listened to sticky-sweet love songs on TV, and whenever I opened WhatsApp, my doulas were always there, supporting me.
 
No news. I texted the dad, sending him inspirational pictures, advice, good intentions -- they knew I was there. Time passed and I thought that maybe so many scheduled c-sections (Easter holidays were coming) would give her some time to progress. Five hours later, I saw the OB, and then the midwife.
 
“The baby was born.” I never, ever wrote a message so fast. I needed them, I needed my doulas. Their experience was my support, their words, my relief. I asked the midwife if everything was fine and she said yes, “she didn’t progress and she had a c-section." She said I was able to see them now. I started to go down the stairs. I cried. I cursed. I read messages of support, of the lovely presence beyond this hospital, doula sisters. I held my tears and entered the room.
 
“You know how this works… doulas, midwifes, the more you know about it, the worse it is.” I thought the worst was over, I was wrong. There was the midwife, putting poison in mom’s mind with her words, blaming the c-section on a painful tired new mama who knew too much or had too much support, who was still dealing with anesthesia. I turned down the lights, stroked the mama, and watched a new mama with her baby -- the greatest love that exists, the one that heals everything.

La noche de mi primer acompañamiento como doula no pude dormir, estaba muy triste, muy cansada, y también muy tranquila.
 
“Rompí bolsa, estoy sin contracciones, la partera me indicó que me interne a las 5.” Estaba en un colectivo yendo a hacer trámites cuando recibo el mensaje de la mamá. Volví a mi casa lo más rápido que pude, di aviso a mi grupo de doulas, me lavé el pelo, agarré las cosas, imprimí los papeles de DONA y salí. Después de la excitación y la adrenalina inicial, disfruté. Por fin, después de 2 años de mi primer formación de doula, a 3 meses de la capacitación de DONA, una mamá había confiado en mí, y yo estaba en las nubes de la felicidad, aunque sabía que el escenario no era el mejor.
 
“¿Viste todos nuestros planes? Bueno, los vamos a soltar.” Se lo dije a la mamá pero me lo dije a mí misma. Una hora después estaba en su cuarto, había bajado las luces, y comprendido que el deseo de la pareja era llegar pronto al sanatorio. Tenía media hora para llamar a las contracciones. Con la pelota, un poco de manteo de parte del papá y masajes, fueron llegando algunas contracciones, tímidas, como quien recién llega a un lugar nuevo y no sabe bien qué hacer. Respetando el deseo de llegar puntual a la institución (teníamos una hora o más de viaje), sugerí ir saliendo.
 
“Esperá, antes tengo que hacer cosas, alcanzame la planchita.” Ahí estaba yo, con una mamá a punto de internarse sin trabajo de parto, acompañando con profundo amor lo posible, lo real, dejando de lado lo ideal. Agarré la planchita y mientras ella estaba en la pelota, hice mi mejor esfuerzo para que no se note que soy casi inexperta en el tema (mi pelo es hiper lacio) y que me quemaba los dedos. Me tomé mi tiempo, esto era importante para ella, así que fue importante para mí. Al terminar ayudé al papá a que no se olvide nada, ella se puso perfume, llamó al remís y nos fuimos.
 
“No es nada del otro mundo, solamente hay que relajarse.” El remisero había sido policía, y había atendido él mismo 3 partos en vía pública. Hoy creo que el remisero sabe más de partos que muchos médicos. La energía en el auto estaba alta, había confianza y sonrisas, pero la mamá ya sabía que apenas pise el sanatorio, empezaría el baile del protocolo institucional.
 
“Vamos a tratar de que sea por vía vaginal, ¿sí? Pero igualmente vos sabés que en semana 37 el cuello está inmaduro y que la opción de la cesárea siempre está, ¿sí?” La partera le hablaba pero ella estaba en otro lado. Firmaba los papeles de la internación con tristeza, cada formulario era una expectativa que se iba, que debía entregar junto con su ropa de calle y la tarjeta de crédito.
 
“Todo es perfecto Clari. Siempre hay un plan más grande que el que podemos ver o entender.” El grupo de whatsapp con mis compañeras doulas atento, firme, douleando a la doula. El mismo grupo que respondió de la mejor manera cuando les pedí una foto de “Trabajo de parto en la cama” de Penny Simkin. Ya me habían dicho que no podía pasar, que por normas sólo pasa una persona, que es la misma que luego entra a sala de partos. Nos sentamos a esperar la internación, le pasé mis cosas de doula al papá, le di consejos, y le reenvié la información de Penny Simkin. Cuando la vinieron a buscar, el ánimo de la mamá estaba tan bajo que no supe qué decirle.
 
En la sala de espera había abuelas, tías, hermanas, parejas. Absolutamente todos los nacimientos de esa tarde/noche habían sido por cesárea, tantos que el quirófano no daba a basto. Lloré un poco y después me calmé, había dado lo mejor de mí y ya no podía hacer nada más que esperarlos afuera, pensar positivamente en ellos, rezar un poco, y esperar. Estábamos en el piso 10, miraba los números que indican en qué piso está el ascensor y visualizaba que era ella quien progresaba a 10. Escuchaba canciones melosas en la tele. Abría whatsapp, las doulas ahí, conteniendo, acompañando.
 
No hay noticias, buenas noticias. Le escribía al papá por whatsapp con imágenes inspiradoras, consejos, buenas intenciones, ellos sabían que yo estaba ahí. El tiempo pasaba, pensé que tantas cesáreas programadas (ay, los médicos, se acercaba Semana Santa) quizás le den tiempo. Cinco horas más tarde, veo pasar al obstetra, y luego sale la partera.
 
“Ya nació.” Nunca escribí tan rápido un whatsapp, las necesitaba, necesitaba a mis doulas, su experiencia era mi sostén; sus palabras, mi consuelo. Pregunto a la partera si estaba todo bien, me dice que sí, que no progresó y fue a cesárea y que podía pasar a verlos. Empiezo a bajar la escalera. Lloro, puteo. Caen mensajes de contención, de presencia amorosa incluso a la distancia, mensajes de doula. Bajo la escalera, contengo las lágrimas, espero a que salgan las enfermeras y el obstetra y paso a verlos.
 
“Viste cómo es esto, doulas, parteras, cuanto más sabés… peor es.” Pensé que había pasado lo peor, pero no, ahí estaba la partera, culpando a una mamá dolorida, cansada, aún bajo los efectos de la anestesia, poniendo veneno en el suero con sus palabras. Bajé las luces, acaricié a la mamá, y contemplé el amor más grande que existe, el que todo lo cura. 

​You have just grown a tiny person,
You are Wonder Woman,
Stand up and be proud!
 
OK, so you may or may not feel like adopting the Wonder Woman stance for your entire labour and birth, but here are 7 great benefits to being upright during labour:

 1. Do You Know the 3 Cs? Feeling Calm, Confident and in Control!  

• Mums who choose their own position during labour will rarely lie on their backs, and they report more feelings of confidence and being in control.  
• Stress hormones are lowered when adopting an upright position, allowing oxytocin and endorphins (birth hormones) to flow.  
• Women feel more a part of their birth team and less like a patient when they’re not lying in bed.

You can imagine it could be difficult to feel confident being the only person in the room on your back with no underwear on. ​

3. Less chance of Distress to your Baby!

• Getting off your back allows maximum circulation (blood flow and oxygen) between you and your baby.
• Your baby is 54% less likely to have abnormal fetal heart rate patterns.
• It reduces the risk of aorto-caval compression.  

You know how you’ve been told not to lie on your back during pregnancy?It usually gets quite uncomfortable from somewhere in your second trimester anyway. The reason is that the main abdominal artery and vein can be compressed by the uterus and the weight of the baby, limiting blood flow. This can result in low maternal blood pressure, feeling faint, sweating and dizziness, and it may also effect baby’s heart rate. It doesn’t sound like a good idea at the best of times, never mind when you’re in labour. This does not occur when a woman is in a side lying or upright position. 

More Information:
Whole, Healthy and Intact - Avoiding Perineal Trauma, by Tracy Donegan 
What is the Evidence for Pushing Positions?

References: 
​2012 Cochrane review, Gupta et al., de Jonge and Lagro-Jansenn 2004; Green and Baston 2003; Green et al. 1990. ​Lawrence et al 2013

Bernie Burke is a GentleBirth Instructor and DONA trained Birth Doula, with a background in Holisitic therapies.  Bernie found GentleBirth during her second pregnancy and fell in love with the program, it transformed how she felt about birth.  She is passionate about all things birth and she has seen first-hand the positive change in her clients and their partners while using the program.
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Bernie believes that when women and their partners feel empowered to make decisions about their birth, no matter what path it takes, they step into parenthood feeling confident and secure.  Bernie is looking forward to assisting families as a Doula in 2016.