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​Ending the Birth Battles

Tales of Natural Birth and Good Medicine

What's Growing in your Garden?

2/10/2022

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Dr. Aristizabal's recent carrot harvest. Some of them look a little funny...

Did you know that February and March are the perfect time to plant in Arizona? Many people are often surprised to learn of the many, many fruits, vegetables, and flowers that grow nearly year round in our desert soil. 

What, may you ask, does gardening have to do with having babies? Gardening has so many benefits to offer pregnant women, women trying to become pregnant, and growing families.

The first benefit is the simple gift of drawing us outdoors, to place our hands in the earth, feel the sun on our skin, and be aware of the sounds of birds and bees. In our highly urbanized, technical world, we need to carve out opportunities to quiet our mind and the pace of our lives. A garden demands you come outside and tend it, lest all your past efforts wilt in the dry earth. Exposure to green space has been correlated with lower levels of stress, anxiety, and depression and higher levels of emotional well-being in multiple studies, all things which are associated with higher fertility rates, better pregnancy outcomes, and happier young children.

Growing fruit and vegetables also encourages us to eat more fruit and vegetables. While we should all be working to incorporate more produce into our diets, this is especially true for women who are trying to become pregnant or who are pregnant. Vegetables should make up about half of the food on our plate. Fruits and vegetables are an essential source of the many vitamins and micronutrients you need to build a healthy baby and they are much more easily absorbed from food sources than supplements. Vegetables are high in fiber, which makes you feel full without the negative effects of foods that are high in sugar and fats. When vegetables are eaten with other carbohydrates, they slow down the body’s digestion of those other carbohydrates, keeping your blood sugar more even or regulated, which not only makes you feel better, it reduces the risk of gestational diabetes and excess weight gain and decreases inflammation. Vegetables also feed healthy gut bacteria and reduce constipation. 

Mothers who eat diets that are low in sugar and high in produce have been shown to be less likely to deliver preterm, have children with allergies or asthma, or experience infertility. 

So, whether you have an acre of land or a little patio, get outside and get your hands in the dirt. It is good for you and your baby.

A great resource about diet for pregnant mothers is: Real Food for Pregnancy: The science and wisdom of optimal prenatal nutrition, by Lily Nichols. 

If you would like to learn to garden in the desert,  How to Grow your own Food, by Angela Judd, is a great resource, as is her website: https://growinginthegarden.com

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So, you want to have a natural birth...

6/26/2019

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Well then, don’t try to have a natural birth, prepare for and do a natural birth!

When I talk with my patients about their labor and delivery plans, many mothers tell me they are going to try to have their baby without any pain medication. Unlike a lot of obstetricians, I am always really positive about this. After delivering close to 3,000 babies, I definitely feel like the less we mess with labor, the better it tends to go. While studies are not conclusive about whether an epidural really increases a woman’s risk of a cesarean, we know epidurals cause blood pressure changes in labor that may lead to fetal distress. Epidurals make a woman more likely to experience a fever or intense itching in labor and often slow labor to the point that a mother requires medications to increase her contraction strength or frequency. Pushing may be difficult and she is more likely to tear or need a vacuum or forceps to deliver her baby. While a natural labor might not be right for every woman or every labor, there are certainly enough reasons to consider not using one if you are able to.

However, a natural birth is hard work! You wouldn’t wake up tomorrow and decide to run a marathon without preparing for it. You need training. A natural birth requires the same sort of mental fortitude and physical conditioning as a full length marathon and even burns around the same amount of calories.

To prepare your body for a natural birth, you need to provide yourself with good fuel throughout your pregnancy and build up your physical strength and endurance. This is easier if you have already been in a good routine of regular exercise and a healthy well-balanced diet prior to pregnancy, but in our fast-paced, work-focused culture, many women do not enter pregnancy in optimal condition. The good news is that the old fashioned advice of “don’t start exercising in pregnancy if you weren’t doing so before pregnancy” has been disproved time and time again.
We now know that exercise is nothing but good in pregnancy and significantly reduces your risk of gestational diabetes, a large baby, hypertension, or a cesarean. By reducing the risk of these complications, it also reduces your risk of being induced, which makes it a lot easier to avoid pain medications and epidurals. Your goal should be to eat a diet high in protein, with lots of fresh produce, that is low in carbohydrates, especially avoiding heavily processed foods or foods high in sugar. This can be hard to do in the first trimester, when most women crave bread and bread alone, but as long as you get your diet on track by 16 weeks, you should do just fine.
As far as exercise goes, you should be striving for a least three exercise sessions per week, of at least thirty minutes, where you get your heart rate up and work up a sweat. It is best if you mix it up a bit and do a combination of cardio, strength training, and stretching/toning exercises such as yoga or Pilates. Unfortunately, just being generally active throughout your day does not achieve the same results as true, dedicated exercise. There is nothing your doctor or midwife can do during your labor that will reduce your risk of cesarean and increase your likelihood of a natural delivery more than if you keep to a regular exercise schedule and a good diet during pregnancy.


You also need to prepare your mind for natural birth. Start by reducing the effects of stress in your day to day life by practicing meditation and deep breathing. This is easy to start as early as your first trimester. If there are issues in your relationship, seek out a good counselor to help you both begin to work through these challenges, because the addition of a child into your life is only going to amplify those issues and you will need the support of a loving a caring partner as you journey through pregnancy and labor. Think about labor and your changing body in a positive way, repeatedly telling yourself that this is something you CAN DO!

Avoid negative birth stories, as these only serve to build up anxiety and make you apprehensive about the birth process. When women enter labor fearful of delivery, their bodies tense up in response to the sensations of labor and that tension makes those sensations feel worse! A big part of labor preparation is training your body to soften and work with the forces of labor, rather than clamp down and resist them. 


A thorough labor course, that provides an arsenal of tools to cope with labor discomfort, is an essential part of that preparation. Your childbirth educator is your labor trainer. It is not enough to simply know what will happen on the day of labor and practice breathing through a few contractions while bouncing on a birth ball on one Saturday afternoon. You need to spend several weeks learning and practicing the methods you will use on the day of labor. Hypnobirthing, the Bradley Method and Lamaze International all offer more extensive labor preparation, each with their own philosophy and strategies. You should research several methods and choose the one which aligns best with your own philosophy, however, studies have shown that meditative methods of childbirth education, such as Hypnobirthing and Hypnobabies, tend to have the best results.

Finally, choose a supportive team of labor coaches and health care providers. You will need others to provide hands-on support during your labor process. Your partner is an important part of that support, however a third person in the room, who has experience with labor, is immensely helpful, especially if that person is a professional doula. Having a doula support you during your labor significantly reduces the chance that you will require either an epidural or a cesarean. Equally important is choosing a doctor or midwife for your delivery who is open to and encourages natural birth plans and delivers at a hospital where a significant number of patients labor without pain medications, so you can be assured that the nurses and staff are comfortable with patients walking, eating, using hydrotherapy, and delivering in the positions most comfortable for them. If over 90% of the patients at your chosen hospital receive an epidural or your doctor or midwife tells you “well, you can try to do it without an epidural,” then you should consider changing your team to one that will actively work to help you achieve your labor goals. Because in natural birth, you cannot simply try, you must do.

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Sex, Pineapples, Evening Primrose Oil, Oh My!.....

3/11/2019

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It sounds like a recipe for a wild night on the beach, but no, it is just the beginning of a list of all the things people try to get labor going.

Pregnant women spend the first 36 weeks of their pregnancy worrying about whether labor might come too early and spend the last four weeks (or six weeks for the unlucky) worrying that it will never come. However, it is not so easy to understand what might actually bring about labor too soon or help it along when a pregnancy extends past its expiration date or a mother’s (or her doctor’s) tolerance.


There is a nice little analogy I came up with a few years ago to help my patients understand this complicated process. It starts with a horse in a barn, because, well, I am from the southwest and we talk about things like horses and barns.

The baby is the horse:
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The horse lives in a barn:
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Around that barn, is a fence:
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And all the other little horses, or babies, are out in the pasture:
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The horse lives happily inside your uterus until, eventually, usually between 37 and 41 weeks after conception, it decides it wants to get out, but it doesn’t just want out of the barn, it wants past the fence and out to pasture with all the other baby horses. 

The horse, your baby, is the one that decides to get out of the barn, and sends that signal for labor to start.

So why do people even bother with things like sex, pineapple, acupuncture, evening primrose and all the other things people try to get into labor, or why do they tell women to avoid sex if there is a concern about premature labor? If the horse is the one that decides to get out of the barn, how do any of these things work?

Well, sex, evening primrose, pineapple, spicy foods, and acupuncture are the equivalent of leaving the pasture fence with the gate open. Once your little horse decides to get out of the barn, these things help your body be ready to receive the signal and make it easier for your horse to join the other little horses in the pasture.
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There are also middle of the road tools to aid in the labor process, things that open the fence gate, but also lift the latch on the barn door, things that achieve both cervical ripening and promote uterine contractions, things like membrane sweeps and nipple stimulation or castor oil...they are a little more aggressive, but will often get the job done without a medical induction.
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​A true induction, utilizing medicines like pitocin, cytotec, or cervidil, is different. The medicines in an induction are the equivalent of opening not just the fence gate, but also the barn door. Even if the horse was locked up tight a few hours before, induction will get the labor process started. Even if the horse wasn't quite ready to do so, when the barn door is open, the horse will usually wander out, though it still might take many hours and the horse might get a little stressed out in the process, especially if the fence gate wasn’t open. And sometimes, no matter how long you leave the door open or how hard you pull and tug, that horse will simply stay put in the barn.
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So what about premature labor? What if I don’t want to inadvertently put myself into labor. Will sex or a pineapple smoothie make my baby come too soon? Premature labor is poorly understood, but it seems that it really is an inherent problem with the barn door. The barn door is dysfunctional and broken and it doesn’t matter how we lock it or try to secure it, it won’t stay closed. We can stitch the cervix closed, put a mom on bedrest, or give her medicines to make contractions stop, but if that barn door isn’t working, all we are really doing is slowing down a horse who is already on its way. Eventually, the horse will get out of the barn and even if the fence gate is closed, it will simply jump the fence.
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However, if our barn door is functional and locked up tight, we can leave our fence gate as open as we like, and that little horse is not going anywhere. ​
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It's Not about Gravity...

1/23/2019

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One of the most commonly repeated “alternative facts” in the natural birth community is that women in labor are aided in the process by gravity and, thus, should be encouraged to labor and push in upright positions. Pregnant mothers will come across this in nearly every natural labor text, website, or blog and, on the surface, it seems to make a lot of sense. Why not let the force of gravity work for you? Why work any harder than you have to?

This gravity idea causes a lot of anxiety in pregnant mothers and they often fear that they will be “tied to the bed” or have to deliver “flat on their backs,” working against gravity. I will often be working with an exhausted mother, who is pushing well on her back and has no energy for any other position, that suddenly cries out, “but shouldn’t I try to get up so I can get some gravity?”

But the simple fact is that gravity has nothing to do with getting a baby out. If it did, babies would be falling out of women left and right and there would be little need for advice about birth. No, getting a baby out is about moving a baby past an obstruction: the mother’s cervix, soft tissue, including cartilage and muscle, and the hard bones of the pelvis. In order for this to happen, the mother’s soft tissues need to mold, stretch, and relax and the connections between the bones in the pelvis need to loosen. Adequate force must then consistently work the baby through these structures. The baby has to rotate into different orientations so that it may move more easily through pelvis and the bones in the baby’s skull must shift and mold in order to decrease the diameter of the baby’s head squeezing through this narrow passage. It is an extremely complicated process and given that mothers and babies come in all different shapes and sizes, it is no wonder that it can be a significant challenge to achieve.

This is not to say that freedom of movement, ambulation, and alternative pushing positions do not benefit women in labor. They do. Studies have shown that mothers who are able to move freely throughout their labors report less pain, have shorter labors, and less need for pitocin and epidurals. Alternative pushing positions, such as hands-and-knees, side lying, and squatting, are associated with less perineal tearing, shorter pushing stages, and less observed fetal heart rate changes, however in the studies that have been performed, no one pushing position was so superior as to consider it a preferred position for delivery. Furthermore, none of the studies examining position in labor and specifically pushing positions have demonstrated higher spontaneous vaginal delivery rates in mom’s who spend their labors upright or push in upright positions. In fact, a recent well-done study in the UK which specifically looked at women with epidurals, found that women who pushed on their backs actually had higher vaginal delivery rates than those that sat upright, even though their deliveries where performed by midwives who reported that they believed upright positions were superior.  (Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomised controlled trial. BMJ 2017; 359 :j4471)


The apparent conflict in these observations is because the forces acting on a baby during labor and causing changes in the mother’s body are internal, not external. The observed benefits of alternative positioning are not due to the external force of gravity, but are due to their direct effect on the mother’s musculoskeletal system, which alters the dimensions of the maternal pelvis and the direction in which internal forces are acting on the baby. The combination of these factors aid in rotation and proper alignment of the baby’s head with it’s mother’s pelvis. Anything that enables proper muscle relaxation and alignment of the fetal head in the pelvis can achieve this same effect, including hydrotherapy or even an epidural. Any position that allows the forces of uterine contractions and maternal pushing to effectively move a baby through the pelvis is a good position. For some women that will be upright, for some women that will be a side-lying position, and for others it will be on their back.

So, long story short, a laboring mother should be encouraged to try many different positions during labor and delivery, in order to help her relax, labor in the way most comfortable for her, and move her baby through her pelvis effectively. If something doesn’t seem to be working or doesn’t feel right, she should simply try something else. There is no right position for every woman or every baby or even one single labor and there are times that lying down may be just what a woman needs.

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Unicorn Birthers...

1/9/2019

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In the natural labor world, there are tales of a mystical, magical creature: the Unicorn Birther.  The Unicorn Birther is a woman who somehow reaches near complete dilation with little to no discomfort and only mild, infrequent contractions. Many people confuse the Unicorn Birther with women who manage their labors extremely well, utilizing breathing and other techniques. I commonly see patients who have studied Hypnobirthing who resemble Unicorn Birthers in their calm demeanor, but a true Unicorn Birther is something very different. Women who cope well with labor will still communicate discomfort and have contractions in short intervals that build both in intensity and frequency as the labor progresses, while Unicorn Birthers will look at you, smiling and bewildered when asked about discomfort, reporting only a little tightening or pressure. The other type of woman who is often confused with a Unicorn Birther is the woman who has a very fast labor, what is referred to in the medical community as a precipitous birth. However, anyone who has taken care of a woman delivering precipitously or anyone who has had such a labor can tell you that it is far from a serene experience. This labors are usually fast and furious, with strong, frequent, and painful contractions that seemingly come out of nowhere and result in a bright red, mad and screaming infant in under four hours. This is very different than a unicorn labor.

It has been estimated that as many as 1% of women fall into this category, reporting little to no pain in labor, but it is still a fascinating experience to work with the real life, walking and talking version of these tales, even when you have seen it before. Just recently, I helped a Unicorn Birther deliver her baby, staring at her in disbelief, as she bounced around the labor room, contracting only every six or seven minutes, smiling, laughing, with perfect makeup and beautiful eyelashes at a good eight centimeters of cervical dilation. I would watch each contraction peak on the monitor, but her smile was unmoved. Sometimes she would touch her belly, feeling the firmness, and state that she “thought” that one may have been stronger. I found myself surprised and relieved that she was aware enough of her body to come to the hospital rather than having her baby on the kitchen floor.

However, very interestingly, of all the Unicorn Birthers I have delivered, I have never had a single “easy” unicorn delivery. Each one of my unicorns have, in fact, had a malpositioned, usually sunny-side up or OP, baby that did not descend into the pelvis without a whole lot of encouragement. This may be why the sensations of labor are so different for these patients, the lack of decent with a cervix that somehow dilates nicely despite the baby remaining high in the pelvis. In each of my experiences with unicorns, once their babies finally did descend, typical sensations of labor ensued and suddenly they looked like normal laboring women, though they often delivered so quickly that the story remained that the labor was essentially pain free.

So, what can these Unicorn Birthers teach us mere mortals about pain in childbirth? Probably something we already intuitively know: that much of the pain of childbirth comes from the forces of labor moving the baby against resistance: the resistance of the not yet fully dilated cervix, the resistance of the muscles, soft tissue, and bones of the pelvis, and finally the resistance of the vaginal wall. When we lessen the resistance, the pain of labor is reduced. This is why epidurals contain medicine to relax the mother’s muscles, not just numb pain sensations. This is why labor tubs relieve pain, the buoyancy lessens the effective weight of the baby moving through the pelvis, thereby reducing the friction acting against it. This is also why mothers who have labored previously often do not feel painful contractions until much later in labor process, as their tissues and pelvis are already stretched and do not resist the descent of the baby to the same degree. This is why meditative methods of childbirth are the most effective. Women learn to control their responses to discomfort and relax their bodies, allowing their labors to progress in an easier fashion. It is also why alternative positioning that promotes an open and relaxed pelvis is usually more comfortable and effective than more constricted positions.

Ultimately, birth is something you must flow with, not fight against

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How to know if you really have a VBAC-supportive obstetrician or midwife

10/21/2018

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    Many of my scheduled appointments each week are what we call in our office a “preconception consult.” This is a visit where a patient is planning a pregnancy and wants to get to know our practice, make sure they are healthy before getting pregnant, and receive information or help with conceiving. There are also a certain percentage of these visits that are what I call “the VBAC interview.” These are patients who had a previous cesarean and are trying to find someone who will “let” them have a vaginal delivery in a future pregnancy. They will often dance around the questions they really want to ask, trying to figure me out and whether I am really VBAC (Vaginal Birth After Cesarean) friendly. I try to quickly relieve them of this anxiety and cut to the chase: “I see you had a previous cesarean, where you hoping for a vaginal delivery with this upcoming pregnancy?”
    Unfortunately, more and more women are finding themselves in the position of having to explore their options after a previous cesarean. According to the CDC, 21.8% of women, 1 in 5 women, who have never had a cesarean before, will deliver via cesarean. If these women go on to have another child and desire a vaginal delivery, their chances of actually delivering that way are small. Only 12.4% of women with a previous cesarean will have a VBAC in a future delivery, despite the fact that a VBAC can be successful over 80% of the time it is actually attempted. While there are certainly patients who make an independent decision to have a repeat cesarean, there are many more who want a VBAC who are not being given the chance.
As an obstetrician with a large percentage of patients who choose me specifically for a VBAC, I have an insiders take on what it really means to be a VBAC-supportive provider and how women can identify whether or not they have one. Here are the four most important questions women who desire a VBAC should be asking:
  1. How many VBAC’s do you perform on any given month? If your doctor or midwife is not regularly performing VBAC’s, it is a red flag. It could mean they simply don’t have many VBAC patients or it could mean they are not routinely offering a trial of labor to their patients with a previous cesarean. It could also mean that they are not managing labor in a way that is allowing their VBAC patients to succeed. Even if your provider seems open and supportive of your plan for a VBAC, if they do not regularly perform them, they are not likely to be as comfortable performing one as a provider who commonly cares for VBAC patients. An alternative version of this question gets to the same point is: “What percentage of your patients with a previous cesarean deliver by cesarean the next time around?”
  2. Do you think that I am a good candidate for a VBAC? There are some patients who are not good candidates for a VBAC. Patients with a history of a classical cesarean or a prior uterine rupture, for example, would be much safer having a repeat cesarean and most consider these contraindications to a trial of labor. Other patients who may not be good candidates are those with a significant maternal medical complication or fetal complication, such as growth restriction or low amniotic fluid. However, often women will be told they are not a good candidate on the basis of their previous labor history: such as a history of a big baby or a failure of labor progression or inability to push their baby out. These are often described as “recurrent indications for cesarean” on the basis of presumed pelvic insufficiency, or too big of a baby for too small of a pelvis. In truth, less than 5% of cesareans are performed for true cephalopelvic disproportion...most of the time there is only a relative disproportion...the baby couldn’t fit in the way it entered the pelvis. These stories may also simply be cases of doctor impatience, where aggressive augmentation was initiated or a section was called in a labor that didn’t progress quite quickly enough. Regardless of the reason your doctor or midwife may not think you are a good candidate, if they don’t believe you a great candidate, they are not likely to be very supportive of your VBAC on the day you go into labor. You are better to VBAC with a provider who thinks it will work!
  3. Do you manage labor any differently during a VBAC? The answer to this question actually should be yes. Patients undergoing a trial of labor after a previous cesarean should have continuous fetal monitoring, rather than intermittent, as changes in the fetal heart rate tracing, specifically recurrent variable decelerations, are the most common warning sign of an impending uterine rupture. You want a provider who takes that risk seriously and wants to do everything they can to recognize it and respond to it. Most providers will also recommend at least a hep lock IV, in order to have the ability to perform an emergency cesarean without any time delay, should that worse case scenario occur. Some providers will also insist or strongly recommend an epidural, also with the goal of being able to perform an emergency cesarean without the patient needing general anesthesia. However, this is a shortsighted recommendation and is not indicative of a VBAC supportive philosophy of care. Epidurals are associated with a number of different factors that are associated with higher rates of cesarean and thus VBAC failure, such as maternal fevers, blood pressure changes, and fetal heart rate changes. Epidurals are  also associated with higher rates of pitocin use. Pitocin should be minimized in a VBAC and only used if truly necessary to avoid a cesarean, both because it is associated with a small, yet higher rate of uterine rupture and is also associated with a higher rate of fetal heart rate tracing abnormalities which a provider must take more seriously. However, VBAC patients are not in any more danger from a long labor or malpositioned baby than other patients and strict time limits on VBAC’s are not necessary, though some providers impose them. Meconium, or fetal stained amniotic fluid, is also not any more dangerous in a VBAC than a normal delivery, and, in and of itself, should not be a reason to abandon a VBAC.
  4. Will you schedule me for a repeat cesarean at any particular gestational age? Some providers claim to be VBAC friendly, but schedule all their VBAC patients for a repeat cesarean on their due date or a few days past their due date. A history of a previous cesarean section does not necessitate delivery by any earlier gestational age than any other patient. If there is a medical indication for delivery prior to labor, a truly VBAC-supportive provider should be willing to discuss all options, including induction, and not simply assume a cesarean. Scheduling a cesarean according to some artificial time constraint is also a signal that a provider may be unwilling to discuss options if challenges occurred during  even a spontaneous, timely labor.   

There are certainly many other questions that can signal incomplete VBAC support, but these questions get to the heart of VBAC support and can quickly help a woman decide if her current care provider will really help her reach her goal of a vaginal delivery. For help in finding a VBAC-friendly practice, reach out to your local ICAN chapter

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The Last Word...

10/5/2018

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I was recently giving a presentation regarding natural birth and low intervention models of care to a group of physicians at one of my local hospitals, which coincidentally has one of the highest cesarean rates in the country. I am accustomed to receiving push-back regarding my support of natural birth from members of the medical community, just as many women seeking a natural birth receive push- back from their providers. However, one of the comments at the end of my presentation struck me, particularly because I did not have the chance to respond, as his comment dragged past our time limit and he claimed the last word. The commentator was obviously very disturbed by my argument that women should have autonomy over their birth process and a right to share in the decision making with their care provider. He insisted that obstetricians were like pilots on a plane. No one questions the pilot’s decisions regarding how to safely get a plane from point A to point B and, likewise, patients should not be questioning their doctor’s judgement, given their years of training and expertise, to safely care for them during labor and delivery.

Many in the room agreed with him and at first blush, it is a convincing argument. Of course, any surgeon provides care that is comparable in the skill level to that of other highly specialized professions, such as pilots. Certainly, when the time comes to actually perform the procedures needed by their patients, such as a cesarean or vaginal delivery, women must trust that the training and credentialing of their physician is sufficient to enable them to safely perform that procedure, as we trust when we sit down in our plane seat that the pilot on board has the proper training, credentials, and oversight to carry us to our destination in one piece. 
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Women are not asking to fly the plane.

They simply want to be able get up and move around during the flight, except during the higher risk times of takeoff, landing, or turbulence. But, if that fasten seat-belt sign is left on too long or activated too often, the passengers may begin to question whether it is truly necessary and a brave few might even begin to roam the isles.

They want to be seated with their travel companions and have enough space to relax. They want to be able to turn off their passenger light and have a quiet environment to travel in. They want comfort and care from their flight attendant. They want to eat and drink, even if there is a chance they might get a little nauseous while on board.

They want to be able to pick their flight and they don’t want to be forced to take a sedative before getting on board.

They also want guidelines and check-off's in place to promote safe, uneventful flights with very little use of the pilot’s many highly specialized skills. The pilot shouldn't fly the plane too fast just because they believe it is more efficient or they want to go home. The vast majority of the time, the flight should be on autopilot. While a pilot may be skilled enough to perform a crash landing, if he or she was doing that on any regular basis, it would not be considered a good thing.

It is okay to question the judgement of a system that is landing at the wrong airport 32% of the time, which is the national rate of cesarean, and crash landing far too often, with frequent near misses in maternity care. It is okay to say that level of restriction on ambulation, diet, time in labor, and access to alternative comfort strategies is not necessary for patient safety. It is okay for women to have a say about their flight experience.

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Why yet another natural birth book?...

9/14/2018

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There is no shortage of natural birth books. I should know. My bookshelves are full of them and, as an obstetrician who cares for a large number of women wanting natural births, is my business to know what is in them. I definitely have my favorites and regularly refer my patients to one book or another, depending on their needs. However, as I worked to build support for naturally laboring moms within my delivering hospitals and tried to offer my patients better options and techniques for working through their unmedicated births, I found the supply of books and information about natural birth lacking. Here are some of the main challenges I discovered:
  1. Religious-Type Devotion to Natural Birth: Many of the natural birth books available to women offer incredibly inspiring natural birth stories and useful tools and strategies for working through an unmedicated birth. Unfortunately, this is often presented in an overzealous fashion, that exaggerates the benefits of natural birth and describes birth and the woman's body with terminology usually reserved for the divine. Birth is presented as something to be "believed in" or "trusted." Naturally laboring women are referred to as goddesses. While I fully support efforts to normalize a physiologic birth process and give women confidence that it is something they can achieve, such biased views of natural birth create unrealistic expectations for women and their partners as they embark on their birthing journey and set women up for disappointment, guilt, and even depression if their own birth does not happen in such a heavenly fashion. This bias also rings very untrue for those who work within the medical community, who each day have experiences with birth that make it extremely difficult to trust. When natural birth is presented with such fervor, doctors, nurses, and even some midwives are less inclined to hear the valuable information contained within natural birth texts or take the women desiring a natural birth seriously.
  2. Fear-Mongering: While the medical community is frequently accused by natural birth proponents of fear-mongering or "playing the dead baby card" in order to get women to consent to medical interventions, there is quite a bit of fear-mongering on the other side as well. In most natural birth texts, articles, and blogs, medical intervention is painted with a broad stroke of negativity. For example, women are often told that epidurals definitively increase their chances of a cesarean, drug their babies, and lead to more difficulty breastfeeding, when there is surprisingly little evidence for these supposed facts. Doctors are described as scalpel-wielding villains, without the philosophy or even knowledge to care for women laboring in a natural fashion. Women are told to avoid the hospital for as long as possible in order to help reduce their chance of unnecessary intervention.  It is no wonder that women planning a natural birth feel frightened of their care providers and write multi-page birth plans.
  3. Lack of in-depth information about common natural birth requests and strategies: Many natural birth books present overly simplistic explanations of common natural birth techniques. For example, women are encouraged to walk or ambulate, because it "promotes gravity" or is what our hunter-gathering ancestors did and any efforts to restrict movement in labor are reduced to paternalistic holdovers of old-fashioned delivery techniques that kept the physician in control of the process. While these explanations may be partially true, they do not go nearly far enough in helping women and their care providers understand why ambulation is important and the barriers that are currently in place in many maternity units that prevent women from moving as freely as they would wish. This understanding is necessary in order for women and their care providers to work together to achieve this portion of a woman's labor plan. Another thing that is necessary is broader knowledge of the science that actually exists regarding natural birth requests and strategies. For example, most nurses and doctors are unaware of the studies suggesting that a labor tub may speed up labor and aid in correcting a malpositioned baby or the studies showing the impact of a doula or the hospital environment on the labor process. Due to the abundance of misinformation readily provided everywhere from the internet to the supermarket checkout line, pregnant woman may also be more concerned about the impact of certain medical interventions on their birth process than is warranted by the actual science. Women and healthcare providers alike need better information about natural birth in order to make informed choices.
So, I spent two years reading hundreds of studies about natural birth and writing the book I wish I had, both when I was pregnant with my second child and when I was a young attending working with naturally laboring mothers. It is a natural birth book that is not trying to convince anyone to have a natural birth or pick any one magical method of preparing for a natural birth. The only case this book tries to make is that natural birth plan requests are reasonable and can be met without abandoning good and safe care and women have the right to make those requests and the medical community has the obligation to respect them. By adding a little science to natural labor, women and their providers can embrace what has been shown to work, let go of the fear and distrust that too often taints provider-patient relationships, and find that elusive middle ground where women can be both safe and heard.
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    Author

    Dr. Michelle Aristizabal is a board-certified General Obstetrician and Gynecologist in Montclair, NJ. She is the author of Natural Labor and Birth: An evidenced-based review of the natural birth plan ​and runs a busy, private practice, with a special focus on supporting women who desire low-intervention, un-medicated births. 

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