Using the BRAIN acronym is so, so helpful when speaking with your care providers. It stands for:
B - Benefits - What are the benefits to going ahead with this decision?
R - Risks - What risks are associated with doing this procedure or making this decision?
A - Alternatives - What alternatives are available here? What alternatives are there that might not be available here but available somewhere else?
I - Intuition - What does your gut tell you?
N - Next or Nothing - What comes next if we say yes? What happens if you say no? (go through BRAIN for the no scenario if it is a legitimate option)
Delayed Cord Clamping
Epidural + Narcotics
According to Obstetric Guideline #4 of the British Columbia Perinatal Health Program, there is conflicting evidence about whether or not the use of epidurals can impact breastfeeding.
If you ARE considering the use of an epidural during your birthing time, there are a few things I’d like you to know based on my past experience with clients who’ve made this choice:
1. Your baby’s heart rate: As the Epidural Information pamphlet linked to above explains, sometimes your baby’s heart will often drop in the first 30 minutes after administering the epidural.
2. What pushing looks like: Spontaneous pushing, where you follow your body’s own urges and bear down only instinctively, is ideal. This is the type of pushing you will likely go over in your prenatal classes. It is less stressful for the mother, and more gentle on her body, reducing risks of tearing. Directed or forceful pushing, on the other hand, is associated with increased risks of “reduced oxygenation of the fetus, more frequent trauma to the birth canal, and potential injury to future pelvic floor function” (Albers et al). Pushing with an epidural typically involves directed pushing, as you will not be guided as clearly by your body’s own sensations as you would in an unmedicated birth. It is much more difficult for your body to push effectively with an epidural.
3. Waiting for pressure, the urge to push, or “labouring down”: The Royal College of Midwives of the UK has a great paper on good practice guidelines for pushing. It includes the recommendation that pushing should not be encouraged until women experience some urge or sensation to push before beginning pushing, whether or not they are using epidural anaesthesia. Although it is often common for medical professionals to encourage women to start pushing once they are fully dilated, pushing is much more effective if you wait until this pressure is felt, even if you have an epidural!
There are also other medications that are commonly used by women who want to take a pharmacological approach to birthing. These include nitronox (nitrous oxide mixed with oxygen gas), and narcotics (such as morphine and fentanyl). You can find more information on these options and their risks in the same Obstetric Guideline document I linked to above.
BC Midwives GBS Protocol
Homebirth Reference Site - UK Although based in the UK this website contains some information that is also useful to those planning homebirth in Canada.
Research on Homebirth:
Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician
The College of Midwives of BC information booklet on home birth.
The College of Midwives of BC statement on home birth. There are a lot of references for further reading included in this statement.
CBC news story “Home birth with midwife safe as hospital”.
Canadian Women’s Health Network information on home birth.
Canadian study on home birth by Janssen et al, September, 2009: Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician.
Vedam S, Schummers L, Stoll K, Fulton C: Home birth: an annotated guide to the literature.
Induction + Interventions
According to Perinatal Services of BC, induction rates vary widely across the province and have been risen substantially since the early 90’s. . In 1991, 12.9% of births were induced, and by 2000 the rates were up to 27.2%. Current estimates continue to sit at around 25%.
This is a very high percentage! Induction of childbirth is often part of what childbirth professionals call the “Cascade of Interventions“. According to the Royal College of Midwives in the UK,”The adverse effect of the injudicious use of induction is the possible triggering of the so called “domino” or “snowballing” phenomenon of increased intervention, which could end in emergency caesarean section if induction fails.”
Optimal Birth BC states that the most common reasons for induction are “pregnancy extending beyond 40 weeks and prolonged prelabour rupture of membranes. Induction of labour is associated with increased cesarean section rates among first time mothers.”
The reason given for inducing childbirth for being post-dates is the hope of minimizing risk of still-birth. However, induction is a very serious procedure that comes with many risks, and there is controversy about whether or not any of its potential benefits outweigh those risks.
Resources for understanding why women are starting to decline routine induction based on being postdates (“overdue”):
Reducing Inductions: Lack of Justification to Induce for Post-Dates: an excellent paper by Judy Slome Cohain on why induction for being post-dates, or “overdue” may not be the best practice:
Excerpt 1: Drawbacks of routine induction include: a 13% increase in premature births between 34–36 weeks, no improvement in perinatal mortality, no documented decrease in stillbirths (except in low-level studies), no research showing safety as regards immediate and long term brain function, 5% increase in the elective cesarean rate, a possible increase in brachial palsy, no decrease in meconium aspiration syndrome and two to three times more maternal deaths or near misses from amniotic fluid embolism.
Excerpt 2: Two thousand women would have to be treated to prevent one still-birth at 41 weeks and the treatment would have to be one that does not increase perinatal mortality itself. Would inducing 2000 women at 41 weeks prevent one stillbirth? So far, there is a lack of quality evidence to indicate that this is the case. Two reviews found no significant difference in perinatal mortality including stillbirths between induction and expectant management groups (Sanchez-Ramos 2003; Gülmezoglu and Crowther 2006). Systematic induction before 42 weeks has not been shown to lower the perinatal mortality or stillbirth rates (Zeitlin et al. 2007). There is no high-quality research clearly supporting induction at 41 weeks.
Excerpt 3: Does stillbirth increase significantly after 42 weeks? Yes. However, induction of labor has not been shown to significantly decrease stillbirth or overall perinatal mortality.
Check out the BC Midwifery Guidelines on Management of Uncomplicated Postdates Pregnancy.
The ACOG very recently updated their guidelines, urging OB's to scale back on interventions + New Professional Recommendations to Limit Labor and Birth Interventions: What Pregnant Women Need to Know
Fetal Monitoring (fetal auscultation)
VBAC (Vaginal Birth After Cesarean)
http://vbacfacts.com/Power to Push Campaign BC Women's Hospital
Power to Push Campaign Best Birth Clinic VBAC Booklet
Society of Obstetricians & Gynecologists
Optimal Birth BC VBAC Brochure
Video: An Unnecessary Cut?
Vaginal Exams / Stretch + Sweeps
3rd Stage - Physiological vs Active Management
Cut - www.cutthefilm.com
Why I didn't choose circumcision - www.huffingtonpost.com/brian-leaf/why-i-didnt-choose-circum_b_5318636.html
The Circumcision Decision - thecircumcisiondecision.com
Vitamin K - evidencebasedbirth.com/evidence-for-the-vitamin-k-shot-in-newborns/
Erythromycin Eye Ointment
The Canadian Paediatric Society no longer recommends routine use of Erythromycin Eye Ointment: www.cps.ca/en/documents/position/ophthalmia-neonatorum
Heel Prick Tests