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Having A Baby In The Hospital? This is How You Want To Be Treated.

23 Sep

Mothers are often disappointed when they give birth in a hospital that offers none of the options they may have read about on the internet or learned in their childbirth classes. Some are literally traumatized by the care they received. At Cedars-Sinai Medical Center in Los Angeles, a teaching hospital where nearly 7,000 women give birth a month, the maternity care is collaborative and the staff believes in offering women evidence-based care and respecting their needs and preferences. Physicians, midwives, nurses, doulas and childbirth educators work together to provide safe, woman-centered care.

A maternity care committee recently put together a brochure titled Choices in Childbirth. Here is an excerpt:

Thank you for choosing Cedars-Sinai! We look forward to birthing with you. We believe that pregnancy and birth are natural experiences that are different for each woman and her family. We honor all families and respect your birth choices. We will share information with you, answer your questions and then make decisions together. When making decisions, it is important to know what “evidence shows.” Evidence is the most up-to-date support from research that helps parents and caregivers make informed choices.

Here are things you should know:


When there are no problems in pregnancy or during labor, a vaginal birth is the safest way to have a baby.

Mothers with a good support team and different comfort options can cope better with labor. We welcome your support team (partner, doula, friends and family), and look forward to working together.

When mothers move and change positions, their labor tends to progress better.

We can check your baby’s wellbeing with a hand-heald tool as needed, or with a fetal monitor that stays on your belly during labor.

Labor progresses better when you drink enough fluids and are well-nourished. We will offer you clear liquids to help you keep your energy up.

Babies have better blood counts and more iron if we wait to clamp the (umbilical) cord.

Babies do better when placed skin-to-skin for one hour after birth.

In labor and birth, not everything goes according to plan; some things cannot be predicted. We will make sure that you and your support team agree with any changes that may need to be made to your care plan. Our goal is a health mom and baby, and a positive birth memory.

The brochure includes a tear-out sheet, MY BIRTH PREFERENCES. Mothers can check off a list of options for labor, birth and newborn care and bring it with them when they arrive at the hospital.


Choices in Childbirth shows that when caregivers work together for the health benefits and wellbeing of mothers and babies much can be accomplished.

Ultimately, it is the mother herself who has the right to make her own decisions about how she wants to give birth.


You can find other excellent examples of birth preferences forms for vaginal and cesarean birth in Deciding if a VBAC is Right for You: Hospital Policies that support VBAC and Physiologic Birth. The forms are free to download and use.

What Are People Saying About the VBAC Education Project?

13 Aug

The VBAC Education Project (VEP)endorsed by the International Childbirth Education Association and the International Cesarean Awareness Network, was developed to empower women to make their own decisions about how they want to give birth after a cesarean and to provide VBAC-friendly birth professionals and caregivers with the tools and resources to support them. Since it’s launch on-line on August 10, this free, evidence-based teaching tool has received many positive reviews from birth professionals. The VEP is accessed by over 150 countries and is downloaded, on average,  500 times a month from   The VBAC Education Project

Here is what maternity care professionals are saying about the VEP:



  • Very well done. Patients across the nation and around the world will benefit from the work you have done.
    Tami Michele, D.O., FACOG, Spectrum Health Gerber Memorial Family Birth Center
  • Thanks for these fabulous guidelines and handouts. You have been providing me with materials to share the evidence with parents making difficult choices for years and you’ve never disappointed me. These materials will shape how we present VBAC information to more parents than you or I can count. For all the families you help, thank you.
    Barbara Anthony Hotelling, Clinical Nurse Educator, Duke University School of Nursing
  • I’ve gone through your wonderful resource. You’ve put so much attention and detail into this project and it’s presented so beautifully. You must feel incredibly proud and satisfied with your life’s work. It’s a massive achievement.
    Wintergreen, Director, Common Knowledge Trust,
  • Thank you for sharing the VBAC Education Project. It is very well done!
    Kate Bauer, Executive Director, American Association of Birth Centers
  • I actually used it as a reference when developing our VBAC101 class. SO helpful. Thank you so much for all the time, heart, and investment you put in. It is clearly evident. I would like to look into integrating it in our training for nurses – That will be the next step .
    Mykel LeCheminant, RNC, BS, Assistant Nurse Manager, Childbirth Education, Cedars-Sinai Medical Center
  • We are thinking of sending this around to many MA hospitals to see if they would be willing to adopt this approach (kind of a “preventive” measure…even though many DON’T ban VBACs, I am worried that they might in the future.        
    Judy Norsigian, Our Bodies Our Selves, Co-Founder
  • Hi Nicette! My name is Amber Magee and I am a childbirth educator and Birth Doula. I just wanted to personally thank you (as personal as you can get on Facebook) for all you do for VBAC Moms and for your VBAC teaching guide! I recently had a successful VBA2C in May and have since been writing a class to teach here in Omaha, NE. I just came across the Teaching Guide this evening and am so thankful I did!! What an amazing evidence-based VBAC bible you have compiled!! I am so excited to share this with VBAC Mommas here.
    Amber Magee,
  • From first glance, I am very impressed and it makes me want to read (and learn from) the entire project.
    Christine Morton, Ph.D., Research Sociologist/Program Manager, CMQCC, Stanford U. Medical School
  •  I first want to say that your VBAC resources for parents and educators are amazing.  They are so thorough and it’s amazing that you are offering them so widely.  Thank you for the work you do. I am a doula, childbirth educator, and ICAN leader and have been teaching a short 3-hour “birth after cesarean” workshop for parents for a while now.  I’ve also been talking with my doula organization about offering an extra course through them to help doulas better support families pursuing VBAC. Thank you again for all you do to support mothers, babies, and families!

    Taylor Davis Doula Services



    Share your thoughts and experiences on our VEP Facebook page.


How To Avoid The Avoidable Cesarean

16 Jul

If you are expecting and planning to labor and give birth in a hospital, you may want to find out about outdated care practices that are likely to increase your odds for a cesarean. Knowing about them and discussing them with your caregiver during your pregnancy will help you to avoid unnecessary complications that can lead to the need for a cesarean that could have been avoided.

Maternity care experts found that, “ Current obstetric care in the United States remains distinctly different from the rest of the world, applying a high-risk model to all women and overusing costly procedures that increase risk.” That includes the overuse of cesareans for low-risk mothers-mothers that should have had a normal birth.

In addition to looking for a hospital with low-cesarean rates with midwives as well as physicians on staff,  knowing about these evidence-based practices will give you the best chance of having a vaginal birth.

Portrait of stressed young woman in bathtub

Your labor is more likely to progress normally if you are admitted to the hospital with regular painful contractions. When your cervix is effaced 80% or more and dilated 4 to 5 centimeters. If you are admitted to the labor and delivery unit too early (at 3 to 4 centimeters dilation) you are likely to have more interventions, twice as likely to be given oxytocin to speed up your labor, and more likely to have a cesarean. Find out more from Lamaze International about what to expect in early labor and how to make yourself comfortable until it’s time to head to the hospital.

Intermittent auscultation, checking your baby’s heartbeat at certain times during labor and birth, is the preferred method of monitoring labor for low-risk women. If you have had a healthy pregnancy and go into labor at term, continuous electronic fetal monitoring (EFM) can increase your risk for a cesarean. Although many hospitals routinely use continuous EFM, this intervention offers no benefit to your unborn baby nor does it improve your health. In addition, EFM restricts your movements. It denies you the ability to walk, change positions, take a shower, or use a tub for pain relief. Women who have freedom of movement during labor, are upright and walk during labor have fewer cesareans. Labor can be monitored intermittently with a hand-held device such as a fetal Doppler. Intermittent monitoring is usually a better choice.

Avoid a routine early amniotomy (breaking the bag of waters) before 5 cm. Many caregivers break the bag of waters during labor. Doing so removes the cushion of the forewaters that can help the baby rotate during labor to a favorable position for birth. Breaking the bag of waters may result in non-reassuring FHR patterns (fetal distress) that can lead to a cesarean.

New guidelines now consider that women are in active labor at 6cm dilation, not 4 cm as previously thought. That is the phase of labor when the fastest rate of dilation begins. Evidence shows that to progress from 4cm to 6cm takes longer than we previously assumed. It may take more than 6 hours to progress from 4 to 5cm, and more than 3 hours to progress from 5 to 6cm. If you are laboring for the first time it may take up to 20 hours to reach 6cm dilation and up to 14 hours if you have labored before. That means that your caregiver should not recommend a cesarean for “failure to progress” before 6cm.

Caregivers often call for a cesarean too early in labor. If a cesarean is recommended for labor that is “too slow” or for “ arrested labor,” you should be at 6cm dilation, with a broken bag of waters, and have labored for 4 hours with adequate contractions without any cervical change. All three conditions must be present before a cesarean can be considered for “failure to progress.” If you were given oxytocin, at least 6 hours should have passed without cervical change before a cesarean is recommended. If you have an epidural during labor, change positions every 20 minutes to help the baby rotate to a favorable position for birth.

Allow for passive decent of the baby. Many mothers don’t feel the urge to push at 10cm dilation. The strong urge to push may come as long as two hours after full dilation. Mothers who wait for the urge to push tend to have a shorter pushing time and greater chance of a spontaneous birth.

Caregivers often call for a cesarean too early during the second stage (pushing phase) of labor. Before your caregiver recommends a cesarean for second stage arrest you should have tried to push for at least 3 hours if this is your first labor and for 2 hours if you are a mother who has labored before. If you continue to have an epidural during the pushing stage, you can push for up to 4 hours if this is your first labor and for up to 3 hours if you are an experienced mother as long as vital signs are normal for you and your baby. If you ask for the lowest dose of epidural analgesia, you are less likely to need an assisted birth with a vacuum or forceps and more likely to have a shorter pushing phase.

Although these evidence-based practices will give you the best chance to avoid the avoidable cesarean, many caregivers and hospitals have not yet made these changes in their practice guidelines. Take the time to talk to your care provider about them during your pregnancy and during your labor to help you have a normal birth.


ACOG Reaffirms the Need to Respect Women’s Choices

1 Jun

The American College of Obstetricians and Gynecologist Committee on Ethics just published Refusal of Medically Recommended Treatment During Pregnancy. The update to the 2005 Committee Opinion Number 321 reaffirms in no uncertain terms that a woman has the right to refuse any recommended treatment or intervention despite the fact that it may create an ethical dilemma for her obstetrician–gynecologist.


With regard to pregnancy and childbirth, a physician may feel strongly that not following through with his or her recommendation may put the expectant mother or her baby at risk but, ACOG emphasizes that it is the caregiver’s ethical obligation to “safeguard the pregnant woman’s autonomy.”

A U.S. national survey of healthy, low-risk pregnant women with a prior cesarean reported that almost 9 out of 10 physicians strongly recommended a routine repeat cesarean to their patients rather than laboring for a VBAC.  Many women felt they had no choice but to comply.  Healthy pregnant women’s informed decisions to refuse routine hospital policies such as continuous fetal monitoring  and restricting a woman’s movement to the hospital bed have often been denied.

Evidence in the California Maternal Quality Care Collaborative  Toolkit to Support Vaginal Birth and Reduce Primary Cesareans indicates that when used routinely, without evidence of improved outcomes, both labor and delivery policies can increase the risk of an avoidable cesarean.

The following are highlights of the Committee on Ethics recommendations:

Informed refusal is the corollary of the doctrine of informed consent; it is an ongoing process of mutual communication between the patient and the physician and enables a patient to make an informed and voluntary decision about accepting or declining medical care.

Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.

Obstetrician–gynecologist’s actions should be guided by the ethical principle that adult patients who are capable decision makers have the right to refuse recommended medical treatment.

Forced compliance—the alternative to respecting a patient’s refusal of treatment—raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.

Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.

Intervention on behalf of the fetus must be undertaken through the pregnant woman’s body. Thus, questions of how to care for the fetus cannot be viewed as a simple ratio of maternal and fetal risks but should account for the need to respect fundamental values, such as the pregnant woman’s autonomy and control over her body.

(The) patient should be reassured that her wishes will be respected when treatment recommendations are refused.

ACOG’s document also outlines various recommendations to improve physician/patient relationship, develop patient trust and communicate effectively. Refusal of Medically Recommended Treatment During Pregnancy reinforces existing national and international policies and human rights protections to include all patients in the decision-making process and respect their individual values and cultural beliefs.

The concepts of respectful maternity care, and childbirth rights specifically are two of the most prominent issues that expectant women and birth advocates are currently talking about.



Human Rights in Childbirth

Improving Birth


World Health Organization 

The White Ribbon Alliance