The Birth Plan from a Coaching Perspective

Is birth plan the goal or the strategy? 

When birth workers, such as doulas and childbirth educators, first envisioned the birth plan in the eighties, the main idea was to help expectant parents prepare for the physical and emotional aspects of the birth process, explore how they want various situations handled during their actual birth, and provide a tool for parents to communicate with each other, their care provider, and the hospital staff prior to the birth (Simkin, 2007; Simkin & Reinke, 1980). As sometimes happens, the mean comes to be associated with the goal, and as such, expectant couples and some birth workers, associate writing the birth plan with achieving it. This association may evoke some unexpected outcomes: 

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Coaching towards a Successful VBAC

What are the additional challenges of a birth giver who wishes for a VBAC?

While the coaching strategies are valuable in supporting and leading every expectant woman who would like to give birth healthily and experience high levels of satisfaction, they are even more crucial when supporting and leading a birth giver who wishes for a VBAC because of the additional elements or challenges she faces.

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The Trauma of a Doula who Witnesses Abuse in L&D

I wish I would never have to write this blog post, but I am afraid it is the only way for me to heal my own trauma. I witnessed abuse in the L&D room. I felt helpless. I felt I had to remain silent in order to stay in the room. This experience made me think of all my doula sisters who are witnessing abusive experiences all over the world.  They must remain silent in order to stay in the room. I want to be the gatekeeper in L&D. I am like the news reporters who report crimes against humanity and wake the world up to take action.

Can birth support become a traumatic experience for doulas?

Verbal abuse in L&D: threatening, scolding, ridiculing, shaming, coercing, manipulating, mocking, dismissing…

The terms Vicarious traumatization (VT), Secondary Traumatic Stress (STS) and Compassion Fatigue, are professional terms describing the trauma of caregivers. The trauma results from empathetic engagement with traumatized clients and their reports of traumatic experiences. Even this term cannot describe the trauma of the doula who witnessed her birth client being abused. I did not hear the traumatic birth story, I was present when it happened.

I want to stress the fact that this childbirth could have been considered a beautiful, healthy and positive birth process if it weren’t for the abusive behavior of the doctor. In order to convince you of that, I ask that you read the birth story below twice- on the first reading, read only the black text; on the second, read the parts that are in green italic letters as well. The birth story is at the bottom of this post.

I am not the first one to report abusive behavior in L&D. As part of my healing process, I searched for articles about abusive expressions in L&D and found them in the two languages that I speak and read: English and Hebrew. A few months ago, an article came out in one of the most prestigious Israeli newspapers describing the horror and abuse of Israeli birth givers experience in L&D.

We (doulas, patients, L&D nurses) tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them.

The topic has been researched and studied

I discovered this article: Abuse in Hospital-Based Birth Settings, by Susan Hodges, MS, to be very helpful in achieving my goal – defining the trauma of the doula who witnesses abuse.  Hodges describes the expressions of labor and delivery abuse as well as the dilemma of the abused patient: Verbal abuse includes behaviors such as threatening, scolding, ridiculing, shaming, coercing, yelling, belittling, lying, manipulating, mocking, dismissing, and refusing to acknowledge—behaviors that undermine the recipient’s self-esteem while enhancing the abuser’s sense of power, typical of bullying. Most of us would recognize these as abusive behaviors in just about any other setting. However, because we are socialized to both expect trustworthy and professional behavior in the hospital setting and to be “compliant” with medical directives, these behaviors are seldom recognized and interpreted as abuse. Furthermore, staff and doctors are the authorities in the hospital, while the pregnant and laboring woman is merely a “patient.” Such a huge power imbalance allows, even encourages, bullying and abuse. We tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them.

By using the word ‘we’ in the last sentence Hodges implies that patients and doulas, or other witnesses, are in the same position – feeling helpless and rationalizing this behavior as ‘poor bedside manners’ – which we tend to be more forgiving towards, as a society. How many times did you hear the sentence, “He has poor bedside manners, but he is a great doctor”.

I believe that that the doula position is different in regard to an abusive environment in two aspects:

  1. Doulas know better than their clients on what to expect: While the doula and the expectant couple can both equally recognize rude behaviors such as “ridiculing, shaming, coercing, yelling, belittling, mocking, dismissing…,” the doula is more knowledgeable and experienced in the field of birth support and is far more equipped to recognize threatening, manipulation, and lying.  Identifying these in Labor and Delivery will require basic knowledge of the field terminology, ‘evidence-based care’, and a basic understanding of causality in childbirth. This means that the doula can detect and identify abusive behavior that her clients may perceive as an act of care. Hodges points out the need to educate birth givers in order to reach an informed consent:Women who are well-informed and ready to ask questions about procedures, treatments, and interventions during labor can address some deficiencies of “informed consent” and not be hoodwinked into unnecessary interventions.“ However, this kind of education breaks the rapport and trust between birth givers and representatives of the medical system. This situation is described by Christine Morton as the doulas’ advocacy dilemma in her book ‘Birth Ambassadors’, and there is a general agreement among doula certifying organizations doulas should avoid initiating a tug-of-war in L&D.  Additionally, this type of education seems to work prenatally, but is flying out the window when birthing individuals are overwhelmed with fear.

A doula who speaks-up is taking the risk of becoming an unacceptable or unwelcomed at this facility in the future

  1. Doulas lack the ability to file a complaint or take any affirmative action: Several organizations, such as CIMS, LAMAZE, and Citizens for Midwifery, encourage birth givers, who suffered abuse in L&D, to file a complaint following the birth. According to Hodges, this action is not only with the purpose of reducing the expressions of abuse in L&D, but instead is perceived as an act of empowerment. “Filing complaints alone will not solve the problem. However, women, I’ve spoken with who did so felt empowered, and it helped them acknowledge to themselves that they had been mistreated and were not at fault. Well, here lies a big difference between the patient and the doula. Doulas remain silent.  A doula who shares her negative experience with a caregiver or with hospital staff is taking the risk of becoming an unwelcomed persona in this facility.  We are lucky to have our doula support circles, and we can always cry on our peers’ shoulders and get their support, but this is equivalent to the birth giver sharing her trauma with a friend, and this might not be enough for true healing and empowerment.

Please read the story twice

Now that I’ve shared some general insight about abusive behavior in L&D, here is the birth story that I promised to share with you. For your own benefit, please read twice as previously requested.

My client, Beverly, woke up at 4 am in a puddle. Her first labor began with a rupture, and her contractions began shortly after. By 7  am her contractions were around 50 seconds long and about 5 minutes apart. At 10 am, her contractions intensified and occurred every 3 minutes for about 1 minute at a time. At that point, Bev noticed that she was bleeding and decided to meet me at the hospital.  Upon arrival at the hospital, she was vaginally checked and measured to be 4-5 cm dilated and 90% effaced, and after a 30 minute EFM, we went to the shower. Bev was breathing beautifully and handling her birth with grace and confidence. Her OB was out of town, and the on-call OB from his group showed up and went into the shower to listen to her lungs. After the OB visit, Bev’s partner came out of the shower and shared that the doctor was commenting on the couple’s request to delay the cord clamping, by saying that he can wait only 90 seconds, as too long of a wait can lead to disasters. He shared an article he has just read about the baby’s leg amputation due to a cord clamping delay. I went back to support Bev in the shower, and she shared her disappointment that her OB was not the one to see her through her birth. After a long hour in the shower, Bev felt some pressure towards her anus and was asked to come out and be checked. She was 6-7 cm, 100% effaced, baby in a station (-2).  It felt for her like the right time to get the epidural that she has planned on taking. At 4pm, the nurse started the drip of fluids. Coping with the contractions in the room Bev was convinced that taking an epidural is the right thing for her. She asked for a low dose epidural, but the anesthesiologist has said that preference is, to begin with, a good dose and then slowly lower it. Following the administration of epidural, Beverly’s contractions have totally stopped, her blood pressure went deeply low, and the fetal monitor showed a 4-minute deceleration, which was controlled and recovered with a change of position and oxygen. She had no sensation nor the ability to control her legs. While the nurse and the anesthesiologist were mainly occupied with recovering the low blood pressure and the baby’s FHR, I was concerned with the lack of contractions. I thought it will be wise to prepare my clients for the possibility of administrating Pitocin, reminding them that it is one of the possible side effects of epidural. After 3 hours wait, with no sign of contractions, The OB came into the room and began explaining to the couple that as for now, a process of deterioration of the baby’s brain has already begun. The OB further explained that if they do not manage the birth and bring it to an end than this deterioration can become brain damage. (I am sharing the nuggets of it, as he rambled on and on for a good 10 minutes, sharing ‘studies’ and medical schools ‘All in favor of the couple making an informed decision’. ) When the couple asked for a few minutes to think about all that they have heard, the OB looked me in the eyes and said: ”Just for you to know, under the law of California, any medical advice is considered practicing medicine and you will be in big trouble”.  The couple decided to follow the OB’s suggestion, who has inserted the IUPC and began Pitocin. Following the administration of Pitocin. Bev’s contractions have recovered; by 8 pm she was fully dilated, with the baby still in (-2). A dose of antibiotics was given to the birth giver due to maternal fever and the long rapture. By 10 pm, with the baby in (-1), she began to push. When the baby came down to (+1) Bev was able to feel the pressure building, and she pushed strongly, making progress with each contraction. The nurses changed shifts and we had a new, refreshed and very supportive nurse in the room. As the baby descended, there were a few more declarations that recovered after the contractions were over. The nurse kept encouraging and complimenting Bev for her effective pushing, and then the OB came again to the room and began talking to the partner. In his words, he said, “I know you do not like it when I bring things ahead of time, but I think it is important for you to make an informed decision, therefore I want to talk to you about choosing between forceps and vacuum”. Then he stopped because Bev felt the urge being built and we all attended to her as she pushed, the husband is next to her head and counting, the nurse at her perineum and I stood by her side supporting her leg. The contraction is over and the OB continues talking: ” I personally prefer the forceps, but it is a matter of medical schools, as most doctors these days will use the vacuum…..” and he stops again as Bev is asking for our attention and is pushing like a lioness, I swear. As he went out of the room, leaving the partner to make his decision, the partner asked me what was going on. He felt like one of us is lying to him, not telling the truth.  How can it be that the nurse and the doula are being all excited about the progress, and the OB is asking him to choose between the vacuum and the forceps? The nurse and I tried to reassure him that there will be no need for him to choose.  He was so terrorized and said:” I know the vacuum to be safer for the baby, but I’m afraid to choose against his preference, he might get really angry and decide to end it now with a cesarean”. In order to lead him back to his logical thinking, I began asking questions: ”What do you know about vacuum and forceps”? And then asking the nurse: “Percentage-wise, what would you say is used more here in the hospital?” The nurse was reassuring the dad that he needs to choose based on what he feels more comfortable with.  This coaching conversation took place between moms pushes. I went ahead asking the nurse: “Is there a medical reason that you are familiar with to end this birth with a cesarean now?”, and we both reassured the dad again and again, while all along the mother kept pushing, and — here comes the head!  The OB was called to the room and began dressing. While it was clear that in the next contraction the head was going to show up, he said “Well, because you were waiting so long since the water broke, and as I explained the deterioration has begun hours ago, and there is already maternal fever, your baby will go to the NICU and will stay there for two days for special care”. The NICU team arrived and a few minutes later we heard the baby crying his lungs out. The neonate doctor said: ”Why was I called? This baby boy is so strong, here mama” and she puts the baby on the mother’s chestBev’s healthy and strong baby boy was born at 12:30 am, and he nursed right away. The couple had two beautiful hours of bonding with the baby.

Webinar: Breaking through the Fear-Tension-Pain Response and Beating Failure-To-Progress

How do you stop the Fear-Tension-Pain Syndrome from becoming a Failure-To-Progress in childbirth?  

Failure- to- Progress is the downfall towards birth management and the opening of the cascade effect of medical interventions

In this webinar, I share some of the most effective coaching strategies which will allow you to conduct the coaching conversation around labor pain and the fear of it and help your clients adopt a better concept that is serving them better. The Fear-Tension-Pain response (FTP) leads to another FTP- Failure-To-Progress, and that’s why we think you should become an FTP fighter! Failure- to- Progress is the downfall towards birth management and the opening of the cascade effect of medical interventions in childbirth. Coaching your client in order to prevent the first FTP (Fear-Tension-Pain) will prevent the last one, and will keep your client on the safe path to a healthy birth.

 Please visit the store here, and we will email you the password.

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The Misleading Concept of ‘Natural Birth’; Let’s Talk About a Healthy Vaginal Birth

The dichotomy of Natural Birth vs. Medicalized Birth had been established in the discourse about birth for the past 30 years and was accepted by both birth professionals and moms. The most obvious and urging question expectant woman is concerned with is whether or not she will take epidural or will try for a ‘Natural Birth’,  and in accordance with what she feels inclined to, she will then educate herself and prepare for her birth. She will decide on a childbirth education class and make decisions regarding her caregivers and support group for the birth based on her decision for or against taking epidural. A woman who gave birth vaginally will almost always be asked whether or not she took epidural, or in other words “did you have a natural birth’? This situation is reflected also in birth stories we read online; where we can always find statements in this spirit:  “I decided not to take epidural and try for natural birth…and here is what has happened…or “So I decided it was time for my epidural…”. What I find even more concerning, is the shower of praises and cheers that the mother who went ‘naturally’ will perceive, vs. the mother who helped herself cope with an epidural.

I think that that the concept of Natural Birth is so misleading that while preparing for this experience, a woman might find herself giving birth in a way that cannot be farther away than what nature planned for women- a rather medicalized birth. Natural Birth’ is a proposition which describes the conceptual event of some sort of birth that the speaker or listener have in mind. But what type of birth is it?  What’s on our mind when we think ‘Natural Birth’? Which pictures come to mind? Which words are associated with it?  Which scenarios do we envision and are they really ‘Natural’ for the women we know and support?

 I argue that for modern women, there is nothing natural in the process of giving birth and therefore the concept ‘natural birth’ by itself presents women with a dilemma: Giving birth is part of our nature, this is how we procreate, and yet as an occurrence in the life of modern western women, there is nothing ‘natural’ about childbirth. 

To support my argument, I checked the dictionary for the definition of ‘natural’, and found the following definition:

nat·u·ral Natural, adjective 1. Existing in or caused by nature; not made or caused by humankind. 2. Or in agreement with the character or makeup of, or circumstances surrounding, someone or something. So now let’s take the propositions of ‘Natural birth’ and read these two definitions with it: Natural birth is: 1. Natural birth is caused by nature, not made or caused by humankind. 2. Natural birth is in agreement with the character or circumstances surrounding expectant moms.

My understanding is that when we oppose ‘Natural Birth’ to ‘Medicalized Birth’, we probably mean to say or imply that this kind of birth occurs and unfolds with no humankind intervention. Well, firstly we need to recognize that this concept tells us what Natural Birth is not, and not what it is. Secondly, I want to point out the misleading implication of this definition- that when we think about something that happens naturally, with no humankind intervention, the connotations that come to mind is of something ‘simple’ or ‘effortless’, which are not at all true when it comes to giving birth. Let’s take a look at the second definition and see how it resonates with us: “Natural Birth is in agreement with the character or circumstances surrounding expectant moms”. Really? Would you agree that in terms of ‘the character of life circumstances surrounding women’ nowadays, nothing about birth is natural for the modern western woman? Do you feel the tension? There is also a conflict between the two optional meanings of the concept ‘natural ‘. I think that healthy vaginal birth, which we refer to as ‘natural birth’, has become so rare because of the dilemma that the word ‘natural’ presents. Here is the dilemma of the modern in regards to childbirth:

   “It is in my nature to give birth, yet there is nothing about birth that is natural for me”

Here are some of the reasons why childbirth can’t be or feel natural for us:

  1. Birth is unpredictable and impossible to plan for. (How many of you already planned their summer vacation? Christmas vacation?)
  2. Birth requires us to agree to be in pain, and we live in a culture that is obsessed with alleviating pain. We also lost all our coping pain techniques and skills while being born in this culture.
  3. Healthy birth is a process that lasts an average of 18 hours for first-time moms, and we live in a fast pace culture; we use instant coffee and instant pudding and order food in drive through…We like our results fast! In movies and TV sitcoms birth takes five minutes max.
  4. Being a long process, birth demands physical and emotional performance, it demands strength and stamina which the modern woman who drives her car, uses elevators, sits in a perfectly air-conditioned office, uses washing machines and dishwashers, and does not squat down the river every day, absolutely lost.
  5. Our cultural inhibitions, which are the cultural circumstances surrounding expectant moms, are in conflict with our primal and intuitive response to birth.  The progress of labor depends on the release of hormones like Oxytocin and endorphin, that are being released by the part of our brain that is called ‘primitive brain’. The primitive brain activates primitive and uncontrolled reactions and behavior like moaning and groaning,  crying and screaming, throwing up, the spontaneous motion of the body like spiraling, and other types of behavior that are not considered to be attractive or feminine, and therefore are in conflict with our cultural inhibitions.

 To summarize my argument, talking about natural birth is misleading. In a subconscious matter, which women are unaware of, thinking about ‘natural birth’ lead women to either think about something as natural as a sneeze or a yawn, something that happens spontaneously with no investment or effort and therefore needs no preparation or intentional engagement. Ironically, expectant mothers must have a thorough and deep preparation in order to give birth spontaneously, in a healthy vaginal way. For the modern woman, giving birth in the way nature planned for her is quite a performance.  It requires her to perform physically, emotionally and mentally in a way that is much different from her everyday life circumstances. And just like no one says natural marathon or natural success, nor should we talk about natural birth. 

I

Practicing for an Active Birth

   I have been a childbirth educator and a birth doula for the last 14 years. During the first year of my doula practice I realized there is a difference between Knowing about birth and Being in birth. With no exception, all of my birth clients took childbirth education classes and read pregnancy and birth guides. Most of them were also committed to have a natural birth, to avoid medical interventions as much as possible, and to design their birth experience according to their belief system and their emotional and physical needs. While supporting them in birth, their knowledge did not serve them well enough. The mothers whom I have worked with were missing tools for labor.

   So I have decided to begin my support earlier than the birth, and became a childbirth educator. As an instructor I teach the Active Birth philosophy, mostly affiliated with Janet Balaskas.  In my classes I always focus on practicing  labor tools. My perception is ,that in the Google era ,couples are exposed to so much information and knowledge, that my special contribution is in teaching them the hands-on practice of being with the birth.  I have created the Practicing for an Active Birth workshop especially for clients who wanted more hands-on practice. I taught this workshop for ten years in Palo Alto. My students were raving about this class, and the local midwives were continuously recommending it to their birth clients. On November 2012 I launched the DVD “Practicing for an Active Birth; The Most Comprehensive Hands-On Guide for a Healthy and Active Birth”. This DVD presents 2.5 hours of labor support tools and comfort measures for birth, and many coaching tips for both birthing mothers and their partners In accordance with different phases of the birth.

   Labor tools are in support of the progress of your birth as well as your ability to cope with labor pains.  Labor tools are relating to the physiology and anatomy of birth, and when you practice them, you have better chances of having a healthy birth which progresses in a timely manner (Off course it takes some collaboration from your baby too). It is hard for me to accept philosophies of childbirth education which deny the presence of pain in labor. Contractions are strong cramps of our uterus, and when a muscle cramps, pain is present. So how are you being with that pain and what are we doing when you are in pain? 

When we are in pain, our habitual instinct is to react with fear and tension.  We refer to these phenomena as the Fear-Tension-Pain syndrome. This is our survival mechanism.  Pain is a signal our brain translates as:  “Something is wrong; there might be a risk to the organism”. Neglecting the pain might lead to a serious threat on our survival.  Therefore, we emotionally react with fear and alert; we activate our Fight –Or – Flight syndrome, a remaining of early phase in our evolution and the number one cause of tension and stress. The Fight or Flight syndrome is a set of physiological symptoms, designed to enable us to fight a source of danger or flight when fighting is not optional.  Both these reactions will take: lots of adrenalin, shallow breathing, tightening of the muscles, fast heart rate, and an alert somatic system.

   Now going back to the birth experience, when we react to the pain of contraction with our habitual instincts described above, we are in the way of a good healthy birth.  The uterus works on two kinds of “fuels” –oxytocin and oxygen, both are in charge of effective contractions. In the presence of high levels of adrenalin, the release of oxytocin is inhibited, and our contractions are not becoming stronger and closer together, meaning- Failure to Progress.

We can summarize it this way:  FTP leads to FTP.  Meaning- The Fear –Tension- Pain reaction in birth leads to Failure To Progress.  Labor tools are related to the physiology and anatomy of birth since they allow the mother to de-activate the fight-or-flight syndrome, and by practicing them the mother is suppressing the release of adrenalin, increases the release of oxytocin and the flow of oxygen to her uterus, and reacting to her contractions with acceptance.  Here are some of the labor tools we practice: breathing techniques, massaging, positioning, several visualization techniques, positive affirmations, relaxation, and hydrotherapy.

About four years ago I studied to become a life coach. The coaching practice brought up a new understanding in the way I think about labor tools these days, and led to the development of the Labor Practice.  In coaching we are supporting potent clients in making a change in their lives.  The change can be in the way they act or in the way they are being with something.  A very central term in coaching is the change of the habit. As a life coach I encourage my clients to explore and distinguish habitual ways of doing and being, which do not serve them any more.  These old habits are in the way of getting what we say we want and doing what we say we are committed to.

With this understanding, I was able to see that acquiring the labor tools as part of the childbirth education class is not enough. That if our reaction to pain is indeed a habitual instinct, then it takes a lot more practice for the mother in order to break the habit and rely on a different set of tools. With that thought in mind I developed the Practicing for an Active birth  DVD. This is the most comprehensive Hands-On Visual Guide you can find !  Now couples can watch this DVD at the comfort of their home,  and practice labor tools as many times as they want, until the mother really fells she owns this set of tools.

   The DVD presents a wealth of labor tools – Positions for birth, Breathing techniques, different techniques of visualization – like spiraling of the body and expansion of the belly, Massaging techniques, hydrotherapy and more.  You will learn these tools in accordance with the different phases of the birth. In each phase of the birth, a different progress needs to take place, and I introduce the right tools to invite this progress. Whether it is a release of oxytocin in Early Phase or the engagement of the baby in Active Phase, you will understand the logic behind the tools and how they can best support you in achieving a healthy and empoweirng birth.

Here is a clip you can watch

Practicing for an Active Birth; Learn a New Set of Responses to Labor and birth.

I have been teaching a childbirth education workshop called “Practicing for an Active Birth ” for ten years in Palo Alto. My students were raving about this class, and the local midwives were continuously recommending it to their birth clients. On November 2012 I launched the DVD “Practicing for an Active Birth; The Most Comprehensive Hands-On Guide for a Healthy and Active Birth”. This DVD presents 2.5 hours of labor support tools and comfort measures for birth, and many coaching tips for both birthing mothers and their partners In accordance with different phases of birth.

After becoming a Life Coach I could reflect on my work in the field of birth from the coaching perspective, and  I realized I want to find a way to encourage my birth clients to practice their labor support tools more than just a couple of times in childbirth education class. I wanted clients to understand that their habitual reaction to pain is in their way to a good healthy birth. Our habit is to respond to pain with rejection and contraction, tightening the muscles. Labor support tools were designed to help birthing moms cope with labor sensations and pain and to invite progress at their birth. But they need to own them, to make a new habit out of them so that in labor they will respond with them to labor contractions and strains. This apparent need for changing the habitual response to pain motivated me to publish this DVD  which allows couples to practice labor support tools at the comfort of their home until they own them. Since its launch, the DVD has been sold on Amazon and getting great reviews.

As a student of the  Birth Coach Training program, you will watch clips from this DVD in accordance with the phases of the birth. This will enable you to practice all the breathing techniques, positions, massage techniques, visualizations and other coaching tools that you want to implement when your client goes through this phase.  The same is true if you are registered to the “Hands-On Series” membership level.

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