Artificial rupture of membranes (Amniotomy)

The rupture of membranes is what we commonly call “water breaking.” Despite how its portrayed in the movies, spontaneous rupture only occurs in 8-10% of births. It can look like a rush of fluid or a slow trickle, depending where the bag breaks.

Amniotomy is one form of augmentation of labor (see below). It is thought to encourage labor hormones and get labor moving, however there is not strong evidence that this is effective. ACOG recommends delaying this as long as possible in low risk births. In rare instances without any intervention, babies may be born with the bag fully in tact or what we call “en caul.”

Augmentation of labor

Refers to any intervention with the purpose of progressing a labor that has slowed down or stopped once it has already begun.

Some instances that may call for this are if epidural slows labor down, contractions lessen and become irregular, cervix stops dilating, or pushing is not moving baby.

Natural forms of augmentation include walking or bouncing on birth ball, stimulating nipples (produces oxytocin), relaxation techniques, or resting. Other options are to rupture the membranes (“break your water”) or administer Pitocin (synthetic oxytocin that encourages contractions).

With the exception of breech babies and those who’ve had prior cesarean births, ACOG guidelines recommend doing few augmentations or natural ones, if you must. Often times a slowing of labor simply means baby is not ready yet, but they will be eventually!

Cesarean section

Refers to the surgical procedure by which baby is born through an incision on the birther’s abdomen. It is usually performed, either planned or after attempted vaginal delivery, when the baby or birther are considered at risk from vaginal birth.

Because it is a major surgery, delivery via cesarean usually requires parent and baby to recover 3-4 days in the hospital and takes about 6 weeks to heal. It is within your rights to request a “c-section” without a medical reason.

While not all hospitals may offer it outright, it is within your rights to request skin to skin after a cesarean birth and there is evidence supporting that this is both safe and beneficial.

Cord clamping

There is clear evidence that delaying the umbilical cord clamping is beneficial for infants. Specifically, it increases hemoglobin levels and improves iron stores the few months of life. There is evidence that delayed clamping slightly increases chances of jaundice.

While it may not be automatic policy, you can request a delayed cord clamping. For births under the midwifery model of care, cord may be cut after a few hours as placenta sits in a bowl connected to baby. Some cultural traditions leave the placenta and baby joined until the cord releases itself from baby’s belly button.

Eating and drinking during labor

Many hospitals will tell patients not to eat or drink during labor. Many will allow drinking of clear fluids such as water, tea, or broth.

There is no major harm or benefit of eating during labor. Many prefer to eat or drink for the caloric energy since labor is so physically demanding. In fact, the UK started recommending light eating and drinking during labor in 2007.

These “Nothing by Mouth” policies were created in the mid 1900s when anesthesia methods were much less safe and a danger was posed if food or drink resurfaced. Another reason hospitals have said its preferred to have an empty stomach is in case of emergency surgery, but there is no guarantee that a stomach is empty from fasting during the labor only.

Low risk and people with epidurals have the right to choose if you want to eat or drink regardless of hospital policies.

Epidural anesthesia

Refers to the regional anesthesia that blocks pain in the lower spinal segments, which greatly reduces (or for many eliminates) the pain of labor contractions. It is administered by an anesthesiologist through a needle into the lower back that allows a catheter to pass through and administer the pain medication (click here for video). It is considered the most effective form of pain relief, but is not an option for homebirths.

Due to the nature of being connected to a catheter through the back and numbing that limits lower body motor function, birthers who get an epidural are not able to walk around and will have a urinary catheter inserted to empty the bladder. There are many reasons people may choose an epidural, so here is an in-depth video (with transcript) addressing the pros and cons of this intervention

Episiotomy

Refers to the practice of cutting the perineum to widen the vaginal opening. This practice began in the 1920’s and was commonplace for many years.

Today, many doctors agree that this practice can do more harm than good due to the increased chance of tearing all the way to the anus. Ask your provider about their policy as not all hospitals have ceased making this incision automatically. You have the right to decline regardless of their policy.

You do have a chance of tearing on your own which is repairable with stiches. There is evidence that perineal massage, water birth, and birther-led pushing decrease the chances of tearing.

If you're concerned about tearing, watch a video on how to do a perineal massage Warning: don’t be fooled by the name “massage” as it is very uncomfortable and can feel like a burning sensation. It should not be painful or cause bleeding. Ask your doctor if you’re unsure and always be sure to use clean hands

There is some evidence suggesting the benefits of Evening Primrose Oil (capsules ingested starting 35 weeks, 1 inserted vaginally starting 37 weeks) and Vitamin E oil for perineal elasticity.

Fetal monitoring

Refers to the practice of monitoring baby’s heart rate and rhythm during labor. This can be done in 2 ways: Electronic Fetal Monitoring (EFM) or Hands-on Listening.

With EFM, baby’s heartrate is monitored with an ultrasound machine and birther’s contractions are monitored with a pressure sensor, both linked to a recording machine. 90% of hospitals use EFM. Hands-on listening is an evidence-based approach that uses a fetal stethoscope or handheld ultrasound (Doppler) to listen to the heartbeat periodically throughout labor. This is also often done at prenatal visits.

Hands-on listening has a lower rate of Cesarean, vacuum, and forceps birth. It also allows birther to move and sit upright and can be used with water therapy, tubs, or showers. It does not automatically record and may not be appropriate for people with complications. Not all hospital staff may be trained to monitor this way.

Many hospitals prefer EFM as they have the recording on hand in the event of a lawsuit.

Forceps delivery

Refers to an assisted delivery that uses forceps to guide baby out of the birth canal. You can watch a video simulation (performed on a dummy) here. This method is used during the pushing phase of labor for reasons including prolonged pushing, fetal distress, baby is stuck in birth canal, and often in an attempt to avoid a Cesarean.

This is a fairly low risk method that may cause some bruising on baby’s scalp, temporary swelling, or in very rare cases nerve loss damage in the facial muscles or head injury. There is no evidence of longterm developmental effects on baby’s delivered with assistance of forceps.

Induction of labor

Refers to assistance methods of starting labor with the goal of stimulating uterine contractions to progress toward vaginal birth. There are several medical reasons to induce and you also have the right to choose an elective induction without medical necessity after 39 weeks gestation.

Some methods include:

• Cervical ripening

• Breaking your waters

• Intravenous medication: you will be admitted to the hospital and connected to Pitocin through an IV which will cause the uterus to contract.

Membrane sweeping/stripping

Drug-free induction method in which your care provider inserts 1-2 gloved fingers into the vagina and using a sweeping motion gently separates the bag of waters from the uterus. If cervix is too closed, provider may massage the cervical opening itself.

This can increase your body’s hormonal release to encourage cervical ripening/softening which could lead to contractions and labor.

Typically it is offered by providers when baby is full term, or around 37 weeks gestation. There is some evidence that membrane sweeping may increase chances of spontaneous labor.

Ultimately, there is no overwhelming evidence that this works and because it is a vaginal exam that majority report feeling pain during, some choose to decline the offer.

Narcotics for pain relief

There are 2 types of pain relief: analgesics (narcotics/opioids) and anesthetics. For anesthetics, see “epidural anesthesia.”

Analgesic pain relievers may be offered intravenously (usually fentanyl) or as nitrous oxide (“laughing gas”) that is inhaled. Side effects of intravenous opioids may include nausea, vomiting, and drowsiness. It may affect baby’s breathing and heart rate temporarily or make them drowsy the first few hours earthside, but this is a generally low risk option intended to “take the edge off” labor pain, but unlike an epidural you will feel the contractions.

NST/AFI: Non stress test/Amniotic fluid index

An NST is a non-invasive test that monitors baby’s heart rate, oxygen supply and movement. “Non stress” refers to the fact it does not put stress on baby to do. It may be done after 26 weeks gestation if your provider has reason to believe baby is in a high risk condition. Depending on you and baby’s health, it could be recommended weekly or even daily. It is performed by placing a monitoring belt around your belly while you recline in a seated position for about 20 minutes. If baby does not move on their own (it’s possible they’re sleeping!), your provider may encourage them to move by touching your belly.

AFI is a method of assessing the quantity of amniotic fluid done in people who are at least 24 weeks pregnant. This is done via ultrasound and while there is no precise way to measure the fluid, it is possible to tell when there is too little (oligohydramnios) or too much (polyhydramnios). While not necessarily an emergency, your doctor will discuss your options in the event this occurs. If either of these is the case, your provider will likely request more frequent visits and NST’s. In some cases, it may be recommended to plan an induction.

Perineal massage/warm compress during pushing

Refers to the practice of manually stretching the perineum during pregnancy, first or second stage labor with the intention of reducing chances of tearing. The evidence supports that this may be helpful for first time vaginal birthers, but it is not overwhelming enough to suggest this as a necessary measure.

If you choose to do this, start around 34 weeks gestation for 10 minutes a day.

There is evidence suggesting that placing a warm compress (ie washcloth in warm water) against the perineum during the pushing phase may reduce tearing. If you are concerned about tearing, let’s include this in your birth preferences. It will not be offered.

Positions for pushing

Most hospitals will have you lie on your back once you are 10cm dilated and tell you its time to begin pushing. Under the midwifery model of care (and your rights!), there is no “time to push” other than when the birther’s instincts lead them to get into position themselves.

There is evidence that positions that get weight off the tailbone increase likelihood of spontaneous (unassisted) birth. Examples of these positions are kneeling, standing, hands-and-knees, side-lying, squatting, and using a U-shaped birth seat.

We will practice birthing positions together in person, usually during our 2nd prenatal visit.

Routine IV/Heparin lock

Also called a saline lock, this is an IV catheter that is often inserted once roomed in the hospital and capped off in the event that you need something injected at a later time. This is done as a “just in case” measure as an IV is needed for Pitocin, Fentanyl, antibiotics, or if you get an epidural in case there is an emergency.

There is not much evidence on how often this is needed unexpectedly, but anecdotal evidence from nurses claims that adding an IV during an emergency is more difficult.

Ultimately it is your right to accept or decline, but unless you are very committed to an unmedicated birth, it will be offered at the start of your visit.

Routine newborn interventions

APGAR Testing

This stands for Activity, Pulse, Grimace, Appearance, and Respiration and is more of an observation than a test. It is done 1 minute and 5 minutes after birth and assesses a score of 0-10, with 7+ being normal, 4-7 possibly requiring resuscitation, and 3 or below requiring immediate resuscitation.

Eye Drops/Ointment

This is sometimes done to prevent pinkeye in newborns in the event that the birther has a Group B Strep bacteria. Your provider will likely ask you to test for this around your 37th week. If negative, ointment isn’t needed. If you test positive, you still have the right to decline the ointment.

There are other methods of preventing pink eye such as breastmilk or waiting to see if treatment is necessary. This ointment is 80% effective and there is a low risk of eye irritation or blurred vision impairing immediate bonding. It is your right to accept or decline.

Read more evidence on eye ointment

Vitamin K

This is offered to prevent the rare but potentially deadly occurrence of brain bleed during the first 6 months of life. Vitamin K is a vitamin needed to clot blood and there is a lower amount in breastmilk. It is administered as a shot. There is no evidence that this has any harmful effects on baby aside from discomfort or pain at the injection site. Read the evidence for Vitamin K

Measuring Weight & Length

Some parents choose to delay this measurement until after the first hour of life in order to have optimal bonding/skin-to-skin. There is no urgency to this measurement and under the midwifery model of care it won’t be done immediately.

*not routine but a choice to be made: Circumcision

If you plan to circumcise your baby, decide if you want to do it before being discharged from the hospital or if you’ll come back at a later time. Here is the evidence for the necessity of circumcision.

Third stage/birthing the placenta

Its easy to forget once baby is born that there is still a placenta to be birthed as well! About 5-25 minutes after baby’s exit, you may feel contractions again and that is the moment to push out the placenta. Provider may massage the belly to encourage this. In some cases, Pitocin may be used to boost contractions. Some midwives at out of hospital births carry injectable Pitocin for this purpose.

Depending on your cultural tradition, you may choose to keep the placenta. Some use a third party service to encapsulate it, some cook it and eat it, and others will slice and freeze it to blend in smoothies. There is no clear evidence on the positive effects, but given the fact this organ grew your baby, many believe in its nutritional benefits!

Urinary catheter

Like the name suggests, this is a catheter placed in your urethra to empty the bladder involuntarily. If you have an epidural or Cesarean, it will be placed as you will not be able to get up and go to the bathroom on your own. You do not feel the urge/awareness to pee with this catheter in. Urination is very important during labor as to not damage the bladder, so this is a medical necessity if you receive anesthesia.

Vacuum extraction

Refers to a method of assisted birth that assists baby through the birth canal through a suction cup attached to baby’s head. Similar to the forceps method, this is employed if pushing period is prolonged, birther is too exhausted to push, or if fetal distress requires getting baby out immediately.

This is generally low risk, though there is a rare chance of scalp swelling (goes away within a few days), skull fracture (extremely rare), or should dystocia (when shoulder gets stuck after head is delivered. Risks for birther include increased chance of tearing. This method is used in about 2.5% of births in the US.