06 Nov Balancing your Birth Wish List with Hospital Practice

By Anchen Verster – SA certified perinatal educator, registered nurse and midwife, mother of 4 including twins

I was scheduled to give birth in a private hospital close to where I lived – my medical aid limited services to this particular hospital but when I went on the labour ward tour I was discouraged to find that they didn’t allow birthing or labouring in the bath (in fact there were no baths); skin-to-skin wasn’t mentioned and no rooming-in was allowed on the first night after a caesarean. And so began my journey to have the birth I desired despite the restrictions (from hospital and medical aid) that I had no control over. Little did I know that added to the above, on night 3 after the birth of my twins I would be strongly encouraged to give my twins a formula top-up despite being a second-time breastfeeding mom.

The problem is that when we signed up to a medical aid and got the option of a lower premium provided we accessed services at one or two specific hospitals we had no idea what our medical needs would be in the future. It is impossible to “check-out” all the options before you make such a decision and a lower premium is usually the incentive that wins out especially when you have a larger family or young children.

This article aims to explore what you can do to have a birth that more closely resembles your wish list despite hospital policy and practices that may be outdated. Hospital policy is often driven by litigation protection and keeping steady flow of clients through the labour ward because it is after all a business. I have also found that policy may be driven by fear of change. Each of us has different aspirations for our births so this article will be most applicable to you if you are planning a normal un-medicated birth.

When to go to hospital:

International guidelines recommend going to hospital when your contractions are 5 minutes apart, lasting for 1 minute, for a period of an hour – the “511 rule”. This is recommended if you have no other risk factors, your waters have not broken and your doctor or midwife is happy with this. When mothers get to this point in their labour they have usually gone through quite a few hours of latent phase of labour (perhaps even a day) which means they are more likely to be close to active labour. If you get to hospital when you are in active labour research tells us that you are less likely to be diagnosed with a poorly progressing labour. If your labour is progressing well at this point you are also more likely to continue without intervention. The opposite is also true. If you go to hospital in very early labour you may not be allowed to go home but you are more likely to have interventions or even end up with a caesarean that you may not have wanted. So, the first key to getting the birth you want is staying at home during early labour provided your caregiver is happy with this. Of course, if you’re planning a caesarean and you go into labour you need to go into hospital sooner.

Alternative pain management:

Most hospitals provide medicated pain management, epidural, possibly a birthing ball and gas & air. Some hospitals have more alternative options, but these are what is usually available in the more traditional labour wards. You need to take along your own repertoire of pain management tools. For this it is imperative to attend a good Childbirth Education Course where you and your partner can build this repertoire. There usually aren’t rules (policy) against music, massage, breathing and movement so you need to be well prepared with these tools. Again, the research shows us that if couples have their own coping tools they have much greater satisfaction with their birth and are more likely to progress well. Many moms think that there is a midwife with you all the time while you are labouring and in general this isn’t the case unless you have booked the services of a private midwife. A midwife may be assigned to more than one labouring mother and her role is to do regular observations and recording and make sure you and your baby remain safe but she won’t be around to provide massage. You are also more likely to cope with the pain better if you use your own “toolbox”.

Move around:

Mothers who move around and stay upright as long as possible birth usually better and faster. When you are required to be on the bed for monitoring, movement will be restricted but usually it is not more than 30 minutes at a time so as soon as you can be up and about again tell the staff you are going for a walk. Most labour wards are happy for you to go for walks but stay on the property. Go and explore the car park and every floor of the hospital. You can stop and breathe for contractions and then move again once you have a break in-between. At some point you will no longer feel like being away from your room but while you are happy to be out and about make the most of it. This will also contribute to your birth satisfaction and mean you won’t get “cabin fever” so quickly.

Water emersion

My experience of water emersion during labour is that it makes the pain feel distant… which of course is flipping fantastic. The problem is that many hospitals prohibit water immersion due to the fear of risk of infection. Some will allow you to use the bath until your waters have broken (membranes have ruptured) and then you may no longer use the bath. If you may use the bath prior to waters breaking then use it as part of your pain management repertoire. The water temperature shouldn’t be hotter than 37°C. If your membranes have already ruptured, then usually they don’t mind you squatting in an empty bath and using the spray down your back or pelvis. This way you can still get some of the benefit of the warm water. If however there is no bath then use the shower intermittently through the labour. There might be a plastic chair that you can put in the shower. Sit facing the backrest with legs straddled round each side and allow the warm water to flow down your back. It will probably be more comfortable placing a towel on the chair to sit on. If a plastic chair is not available you could use a gym ball but this might be less stable depending on the space in the shower so be careful of slipping.

Food & Drink

Eating and drinking while you are in labour keeps you hydrated and stabilizes blood sugar. It also stimulates the release of Oxytocin, which is the hormone that makes your uterus contract… which is what we want. Again, international guidelines encourage eating and drinking during labour if the mother wishes to do so (closer to the birth you may no longer feel like eating or drinking). Partners have an important job here to regularly offer a sip or snack. Both should be limited to low Glycaemic Index (GI) food and drink so that you don’t have spikes and drops in blood sugar. It is very unusual to find a hospital that restricts food and drink during labour and this you can argue with plenty of research if it is the case.

Birthing position

This is a tricky one. If mothers are ‘allowed’ to move into the position they choose for pushing, they often go onto ‘all-fours’ or ‘squat’. However, hospital policy or doctors practice will usually require you to lie in semi-sitting position on the bed. I have a friend who asked her caregiver if he would be happy to let her choose her own position for pushing. He said “Listen here dear, if you think I’m going to crawl around after you on the floor you’ve got another thing coming”. Of course, we laughed so much at this response but at least he was honest. If you’re required to be on the bed, plan for your partner to prop you up so that you are more upright. You can also ask to change position while on the bed or get your partner to strap two scarves to the cot sides so that you can pull on them while pushing. Some care-givers are happy for you to change position as long as you stay on the bed.

Skin-to-skin immediately after birth

In some hospitals this is already routine practice, but some are a little behind. If the hospital insists on the Paediatrician check first, then make sure you can do skin-to-skin as soon as possible after that. Before your due date do plenty of reading so that you and your partner know how to practice safe skin-to-skin. Mothers and babies should not be separated after birth unless one or both are in danger and need more medicalized intervention. I still see babies lying in incubators while their mothers are well enough after birth to be able to practice skin-to-skin. If the hospital practices routine separation of mother and baby, then you need to decide on a different strategy. It may be worth booking a meeting with the labour ward sister and taking some research with you and explaining to her why you feel so passionate about practicing skin-to-skin after birth. If she sees that you both have a good understanding of safe skin-to-skin, then she is more likely to try and make it possible for you. You can also ask your Paediatrician to help you with this process.

Rooming in

The International Baby Friendly Hospital Initiative recommends ‘rooming in’ for moms and babies. In other words, they recommend no separation of mothers and babies – 24/7. Some hospitals still separate moms and babies especially in the first 24 hours after birth – particularly after a caesarean. Again, the international guidelines discourage this. Even in hospitals where separation is practiced you can ask to have your baby with you throughout your hospital stay. Rooming-in helps you get off to a good breastfeeding start. Mothers who room-in feed their babies more often and learn their babies cues faster. Rooming in also means your partner can be more involved from the get-go. After a caesarean you may be very drowsy from the pain medication as well as unable to get out of bed. To ensure your and your baby’s safety while practicing rooming-in, it is first prize that your partner has time off from work and remains with you.

Dummy use

It astounds me how many hospitals still actively encourage dummy (pacifier) use. Although we use dummies in prem babies a dummy in a full term baby can have a significant impact on how the baby sucks at the breast and how much milk a mother makes. Feeding and sucking at the breast maximizes oral development and weight gain. The tongue of the newborn moves into a different position with dummy sucking and a dummy also changes the height of the oral arch which can significantly affect breastfeeding and cause other problems with breathing and orthodontics. Dummys’ also lie around and may not be kept as clean as they should increasing the infants risk of bacteria ingestion. If they are cleaned with a sterilizing solution they may increase the risk of oral thrush, which can also be transferred to the mothers nipples. For all these reasons we try and steer clear of dummies. If your hospital requires you to bring a dummy it is usually sufficient to state that you do not want to use a dummy.

Exclusive Breastfeeding

A few days ago a mother messaged me to stay her baby’s blood sugar is a little low and the hospital is insisting on giving formula and she doesn’t want to give formula. They were about to be discharged. The next message she filled with her own solutions. She messaged again to say that the baby was only drinking every four to five hours and she was sure if she increased the frequency then the blood sugar would improve. She was also able to hand-express colostrum to give a little extra via finger or cup feeding. There are occasions when formula may be necessary but again this should not be the first intervention. This mother could express her own colostrum to give baby. Your baby should never be given formula without you signing consent and without other options being tried first (your expressed milk or trying to access pasteurized donor milk as recommended by the World Health Organization). In this example I just shared it makes me sad that moms and dads have to come up with solutions to make sure their baby gets only breast milk. This is a reminder again that you should be well prepared before the birth. Childbirth classes, pre-birth lactation classes or consultations and breastfeeding support groups can all help you glean the right knowledge to help you overcome these possible obstacles.

Arm yourself with research. Make sure you are well informed and don’t assume that a hospital practices the most up-to-date research. Attend a reliable Childbirth Education Class with a Certified Perinatal Educator.

Gain the support of your Paediatrician and Obstetrician. They will usually help you attain your goals but you need to make sure you’re on the same page.

A few months ago a pregnant mother showed me her “birth wish list” and asked what I thought. It was a few days before her due date and she was booked to give birth at a hospital with a very high caesarean rate (usually 85% to 98%). At this point it would have been too late to make big changes and she was convinced she was going to labour at the right place for her choices. I was skeptical because I know of the high caesarean rate. However, this mother had researched her birth wish list and discussed everything with her obstetrician. Much to my surprise she got EVERYTHING she wanted on her list from lifting her baby onto her chest as he was born to delayed cord clamping to immediate skin-to-skin after birth and time for him to follow the 9 Instinctive Stages. I was astounded. It just shows again that if you are armed with knowledge and communicate well with your care-giver you can literally move mountains!