Tearing at birth

Worried about tearing at birth? If so, you are not alone. Although no guarantees (for example baby can come out with their hand by their head - compound presentation, that can result in lacerations), there are things you can do to help prevent tearing during pregnancy and at birth, even if you tore or had episiotomy previous birth. I have helped many mamas not tear or not tear enough to need stitching repair, despite the most serious of tears last time.

First off, say NO to routine episiotomy, in which the provider cuts your perineum and vagina at birth. It is is not only one of the most harmful, painful and unnecessary routine obstetric procedures, but also can lead to more serious tearing extending to the anus (third degree) and even the rectum (fourth degree). Make sure you maintain excellent nutrition, take in low glycemic foods and drink (especially if previous tear was related to baby’s large size - white four, fruit juices and sugar foods tend to grow bigger babies), avoid toxins like smoking, encourage baby anterior as you get close to term to prevent posterior positioning - I go into all this in more depth in my Natural Birth Secrets book 2nd edition. Research is conflicting about benefit of simple perineal massage to prevent tearing. What is more clear according to the research are devices specifically made to stretch vaginal and perinal muscles. In the last three to four weeks of pregnancy, you can prepare the muscles of your birth canal with one of the researched effective, pelvic floor medical training devices like Epi-no, or Aniball (easier to get in the US) as athletes and dancers stretch before working out or performing to prevent injury. They are like a balloon of sorts, that you insert into your vagina and gradually inflate 15-20 minutes daily, over a period of time to the size of baby’s head. They not only significantly reduce the risk of tearing or episiotomy, they also help you feel more prepared physically and mentally (and get a sense of what it feels like to have your birth canal stretch to the size of baby’s head so you relax into it), they ease childbirth, prevent stress urinary incontinence and been demonstrated to have other important benefits from reduced length of second stage of labor to improved Apgar scores - less fetal distress during the pushing phase. Incorporate the practice into your love making and have fun with it. Many mamas in my practice and midwives around the world swear by them, and urge first timers as well as mamas who have had more severe tearing or episiotomy previously to use them because of their successful results.

At the time of birth, to try to prevent tearing, you can honor the resting phase of labor, between end of transition and before feeling the urge to push. Wait for that powerful instinctual urge to bear down, when the baby descends low enough in your birth canal to elicit your natural fetal ejection reflex, and then use soft blowing breaths, to gently allow the emergence of your baby without forced coached pushing or pushing before you feel the urge, especially just because you are told your’e fully dilated. Gentle grunts to work with your body’s natural urges are not the problem. Avoid birthing positions like lithotomy (lying on your back with legs in stirrups, a flat surface or held wide open) or deep squatting. Use more upward, forward leaning, hand and knees or side lying, standing or dangling high squat positions, and if you are concerned, ask for perineal support by your attendants or have a water birth. I discuss this more comprehensively in my Online Guide to Childbirth.

You make plans for the best outcome, then surrender to the journey. Lean into the wondrous intensity of it all.

Routine Labor Interventions Needing to be Abolished

Routine interventions in healthy labor and birth that need to be abolished when all is well include not allowing food and drink, IV, laboring and pushing in bed on back, artificially breaking your bag of water, continuous electronic fetal monitoring - including the admission and periodic strip, using the outdated Friedman curve to asses progress, forced coached pushing during the resting phase before the fetal ejection reflex - during the resting phase once diagnosed as fully dilated, episiotomy, immediate and premature cord clamping.

Many labor in hospitals that don’t allow food and drink, and need IV to prevent dehydration which can cause complications needing more interventions….unless you are sneaking food and drinking plenty orally. If you’re pregnancy and labor are healthy and proceeding naturally, IV fluids aren’t at all necessary and may cause harm. Even the American College of Obstetricians & Gynecologists (ACOG), the American Society of Anesthesiologists (ASA) & of course the World Health Organization (WHO) all recommend encouraging oral fluids instead of IV fluids.

Why is this not happening? Routine intravenous fluids can over hydrate and decrease newborn weight & blood sugar & cause maternal swelling - even in the breasts which impairs breastfeeding, can be uncomfortable, get inflamed, infiltrated or cause infection; IV restricts needed movement in labor, undermines mama’s confidence and sense of feeling empowered and healthy. It’s harmful practice to restrict needed nourishment and hydration during labor and birth. As long as you are keeping well hydrated by drinking, you can absolutely feel no qualms about declining that routine IV. There is also no evidence to support the IV access called saline lock for low risk laboring mamas because in case of postpartum hemorrhage. The risk of that in this population is low, and needing treatment beyond natural remedies and medications without IV even lower. An excellent practitioner can start an IV in that rare emergency.

Artificially breaking your water is another routine intervention that has no place in normal birth. The bag of amniotic fluid is intact for a reason. Let it break on its own. Most often that is late labor or during pushing. Occasionally it breaks before labor or rarely doesn't break at all, leading to an en caul birth with baby born in the amniotic sac.

If you’re told there is little to no risk - it's just nothing - you are not getting informed consent or evidence based care. Breaking it artificially without medical reason has drawbacks like causing more intense painful contractions and use of pain medication to cope, increased risk of infection and fetal distress from cord compression without the protective barrier around baby. It can also lead to malposition of baby which can lengthen labor. All this leads to a cascade of other interventions from IV Pitocon, continuous external or internal fetal monitoring using an electrode screwed into baby’s scalp, and c - section. If your cervix is not soft, thinned out or dilated much, the risks of all the above significantly increase. If baby is presenting other than head first, or not yet engaged in your pelvis, breaking the water can cause the cord to prolapse needing emergency cesarean to save your baby’s life. It's proposed benefit of speeding up labor is possible, but no guarantee. Is that worth the risks? Sometimes a provider tells you they want to do it to check for meconium - not uncommon, which baby at some time of stress in pregnancy or labor had its first bowel movement that mixes with amniotic fluid. If there are no signs of fetal distress and heart rate is reassuring, why create more stress? Knowing there is meconium stresses the team, then you, as they now treat you as having a complication that requires more intensive surveillance. There is no need for this when all is well. When there’s a problem, such as prolonged or stuck labor and you’re exhausted or not coping well, after trying all other more natural remedies, breaking the bag can help. But make sure you are well informed by preparing in advance with my Guide to Pregnancy Birth & Postpartum.

Continuous electronic fetal monitoring (EFM) is still routine despite the overwhelming amount of evidence against its use. Non reassuring fetal heart tones is the second most common reason for first time cesarean in the States, after “Failure to progress”’, many unnecessary as babies are born vigorous without any signs of it. Per the research there is no benefit for the admission and periodic 20 min continuous electronic fetal monitoring strip either, in healthy low risk pregnancies. It isn’t just ineffective, it’s uncomfortable, harmful, leads to increased continuous fetal monitoring, other risky interventions and cesarean without making any difference in baby outcomes. There is no evidence to show that this kind of fetal monitoring is safe or effective, and has contributed to huge increase in cesarean rate without improving Apgar scores, cord blood gases, admission to neonatal intensive care unit, low oxygen brain damage and cerebral palsy, stillbirth and newborn death. Even Obstetric professional organizations like ACOG acknowledges this and endorses intermittent fetal heart rate monitoring with a hand held doppler in low risk pregnancies and those laboring without complications. Furthermore, they encourage training of staff to its use to facilitate freedom of movement and increased comfort. NICE in the UK as well as SOGC in Canada agree there is no evidence to justify routine use of continuous EFM & that intermittent hands on listening to fetal heart rate is the preferred method of monitoring. NICE goes as far as opining that providers NOT even offer continuous EFM to laboring women low risk for complications. The ACNM says intermittent listening of baby’s heart rate with a hand held device should be the preferred method of fetal monitoring in those low risk for complications. Research is not clear & guidelines differ even regarding who does benefit from continuous fetal monitoring, when it comes to certain higher risk complications. This is not what is happening in reality of US hospitals due to a variety of factors from big business of EFM, understaffing, lack of training and equipment to outdated policies, providers not keeping current or practicing evidence based care.

I don’t like to disturb a laboring mama when all is well, just periodically need to check on baby. Some mamas prefer the fetoscope but it can best be assessed with mama on her back, & most in labor don’t want to get out of tub and be on their back. I love using it in pregnancy, but in labor, find most prefer the doppler so mamas can stay in the tub, shower or any position they want to, & everyone can hear that most often reassuring heartbeat. Distressed babies usually tell us whether we use hands on doppler or intermittent monitoring - which also allows for freedom of movement and the enormous benefits of upward mobile positioning plus more contact with and support from your provider. Research also documents the benefits of continuous labor support (which can involve plenty of privacy if that’s what you need!). Being a midwife fly on the wall is often the best intervention in normal labor, who can be there if needed, otherwise keep the fly on the wall role- with a huge heart.

Assessing progress by outdated rigid parameters needs to go. According to evidence based birth, the definition of a “normal” length of labor that has been used since the 1950s based on the biased, flawed Friedman curve is obsolete. The new, evidence-based definitions of normal labor should be used, and the vague term “Failure to Progress” should be abandoned. Yet still used in many hospitals.
If the laboring mama and baby are both healthy, and as long as the length of labor does not qualify as an arrested labor, laboring mamas should be treated as if they are progressing normally, even if what seems to be slow and prolonged for the mama. Pregnant mamas - especially first time vaginal birthers should be given more time in the early phase of labor, making sure they keep well nourished and hydrated, mobile and active but also rested, and also well supported with a doula or doula like care. I have many more suggestions in my online course Guide to Pregnancy, Childbirth & Postpartum, as this can be a challenge to mamas and their partners.

If you are wanting or needing an internal exam, six centimeters—not four centimeters—should be considered the start of the active phase for most people and caregivers should keep in mind that normal early labor (before six cm) sometimes includes a period in which there may be no change in dilation for hours. People may decide, together with their caregivers, to delay birth center/hospital admission until active labor. Similar with homebirth, but there is a more intimate relationship there between midwife and mama, with periodic contact in early labor being the norm.

Still, people are still being told to labor in bed, and give birth on their back. I can’t believe this is still happening despite not just common sense but loads of research about the harmfulness and risks to this practice.

Laboring and pushing your baby out on your back goes against gravity and trying to do so is more work and stress on your body and baby. Laboring and pushing with the force of gravity is less painful and all the more easier. Lying on your back also causes your heavy uterus to exert some compression on major blood vessels that go to the baby which can cause fetal distress, let alone to your upper body and head - why people don’t feel well on their back late pregnancy. It’s a position that was created by doctors not birthing mamas, who would be more comfortable in any other position when given the choice. As it’s a position best for the provider not the mama and baby. And that’s the best birthing positions - what feels best at the time to work your baby down and out. I go over these best positions to labor and help your baby come through your birth canal and into the world with demos in my Online Guide to Pregnancy, Birth and Postpartum - sold separately or bundled.

Mamas need to be moving asymmetrically as they need to move working with their body and baby as well as using the force of gravity to help them guide baby down and out. The pelvis is three bones connected by ligaments and it can stretch to accommodate baby. It’s at is smallest capacity on your back. Pushing on your back is much harder as you have to work against gravity. Occasionally some mamas need to rest and can lay on their side, and some do want to birth on their back and it works for them. But the routine practice of insisting all mamas labor and birth on their back is harmful.

Good bye to forced coached pushing when fully dilated. If and when you are told you are fully dilated, rest, eat and drink if you need, get up and dance…but wait for the fetal ejection reflex (FER). When you wait for the FER, and naturally feel the urge to push, instinctively push, working with your body. It is a bit similar to pooping - think of what it feels like and what happens when you try to push it out for a prolonged period of time when you don’t feel the urge. Then think of how easy it is when you just go after feeling the urge. Some may need or want a little gentle guidance to get started but avoid forced coached pushing. It’s not evidence based because it’s harmful, associated with such problems as more swelling, tearing, fatigue, fetal distress etc. Honor the FER!

It happens. The sensations of pushing and FER, fetal ejection reflex can be so intense that mamas initially may want to fight it, which makes it all the more harder. What we resist persists. When we dive in and lean into the sensations we birth.
Being in the water helps. Movement in asymmetrical positions & roaring like a lion helps, as does channeling your inner monkey, letting your primal take over. Relaxation & coping techniques to practice in pregnancy so you can just tap right in to them in labor are a huge help, as is bringing fun, joy, the primal & sensual, & enhancing pleasure using all your senses into the birth experience . But a complete change in mindset and perspective is key, as is my preparation. You can learn to use different language for the sensations of labor, instead of pain which implies illness and something that needs to be remedied, and to see them for what they are. You can learn to use other words for contractions, which imply tension and negativity, and the word contraction is not empowering, and does not fully explain what is happening. Yes, the top of the uterus contracts so the birth canal can open and expand, as well as push out your baby. So expansions are also happening in labor – that is really the goal of what you are doing – expanding so your baby can emerge from your womb to the outside world, and you can both be birthed as a new mother and baby.

Suffering is a choice. And you can chose to embrace your intense sensations for what they are, as healthy signs, what is needed to birth, what your baby needs to transition earth side - not that anything is wrong. I go cover this in much greater depth in my online Guide to Pregnancy, Labor & Childbirth.

Routine episiotomy in a normal birth is of the most harmful unnecessary procedures. It’s so not evidenced based care. And if you do tear despite prevention efforts (it can still happen), little tears heal fine on their own; if we have to do a repair we do try to put everything exactly or almost exactly how we found it. The perineal and vaginal area of a mom who has given birth vaginally before never looks exactly like it did prebirth. But we do our best! Sometimes there is some scar tissue that forms and definite changes from muscle stretching. These are our beauty marks and badges of honor.

Immediate and premature cord clamping is another harmful routine intervention that needs to be stopped. Just think about it. We did not cut cords right away for most of history. No mammal cuts the cord after birth. They just allow the normal natural physiological process to proceed instinctively…or they would have not survived as species.

The number one best recipient for cord blood is baby. 1/3 of baby’s own blood backs up into the placenta during birth. Baby needs to get it back - it is loaded with blood volume oxygen, nutrients, stem cells, antibodies and ingredients essential for transitioning from womb to world and long term health. If you want to donate or bank the cord blood, if baby is doing well at least wait 10 - 15 minutes so your baby gets most of it and there is still enough to bank.

Don’t let them convince you to have it cut ever after a minute because they are in a rush or tell you some misinformation that it’s not good. Clamping right away was probably invented for the doctor but now we know it’s harmful. Delayed optimal clamping can even be done after cesarean until placenta is birthed if there is no other problem.

I have way more info on this in my Natural Birth Secrets book 2nd edition but make sure this is clearly communicated to your providers and written in your birth plan. Ideal is to wait until it stops pulsing completely, flat and white, and you can even feel and see that yourself. When all is well I don’t cut it until after the placenta unless they want a lotus birth.

The best intervention in normal labor and birth is no intervention. Beloved obstetrician Dr. Michel Odent goes further and says best intervention in healthy childbirth is to knit. Knitting keeps our hands occupied instead of trying to meddle and fix something that isn’t broken. Part of Hippocrates oath doctors have to take after training is “First Do No Harm.”

But knitting goes deeper. It is the calm presence of an experienced attendant who has seen it all, communicating to you with their body language to relax, all is well. Their calm is contagious and will make you feel more calm. Their heart, ears, eyes and mouth are open to listen, watch, support, encourage and help you as needed; and of course they can put the knitting down as appropriate, but the point is brilliant.

The ideal is birth attendants are there, so there with the laboring mama, especially towards later labor when sensations can get intense, but know that mama needs to feel private, safe and undisturbed to labor best, to not feel watched; so we try to leave her alone, on her own, until she needs us. Even then, we try to be in background so mama doesn’t feel watched, after doing needed assessments without causing much disruption, as a lifeguard just in case and there of course if more support is needed.

Prepare yourself to be empowered, have an advocate and birth YOUR way!

Routine Newborn Procedures

Many mamas who want a natural birth may not be as familiar with the the number of choices they need to make regarding interventions to baby postpartum. These are routine in many hospitals, with more freedom of decision making out of hospital at a freestanding birthing center or home with a midwife. Healthy babies are suctioned, all exams and procedures are done in the nursery, not by bedside, they are bathed, given Vitamin K injection and antibiotics in their eyes, and Hepatitis vaccine, and babies with a penis are told they need medical circumcision. Other procedures are pulse oximetry to screen for critical congenital heart disease not picked up on the mid pregnancy anatomy scan if baby had one, audiology screening, and the newborn screening blood test.

Healthy vigorous babies born vaginally can clear their own lungs and don't need suctioning - even with bulb syringe. That's not a gentle welcoming for them, but invasive and traumatic. Suctioning can be harmful to baby’s transition from womb to world, and isn't evidence based care. It's more effective and less harmful to do percussion and postural drainage or use ambu bag if needed. Most of the lung filled fluid is cleared with the big squeeze through the birth canal. The rest is absorbed into the body, and for ~ first 24 hours, baby spits it up, coughs or sneezes it out.

All routine baby exams and decided upon procedures can be done in room with parents. It’s an important part of bonding, nursing and sensitivity to baby’s nervous system. Baby needs to be skin to skin for warmth and comfort after birth, close to mama for nursing. There’s no medical reason for healthy newborn nurseries, with babies separated from parents in bright rooms in isolettes filled with strangers. Nurseries serve hospitals, not babies. If mama needs a rest, it can be done with baby in room cared for by another support person.

Babies born in hospitals are still be given unnecessary baths with chemically laden soaps and kept dry with toxic talc and artificially fragranced baby powder. The birth juice and meconium can be wiped with your own natural products by you or your partner, but there is no rush to wash off the skin disrupting the flora of good bacteria that protects baby’s health, and remove the vernix (the white waxy, cheesy protective material that covers baby’s skin) so most of it can absorb into baby’s skin and allow baby to receive its protective benefits. It is not only a skin moisturizer and softener, it’s also an antioxidant and skin cleanser with anti-infective properties. It regulates baby’s skin pH needed for health, helps control baby’s temperature and insulate the baby, so crucial after birth from womb to world. It might help babies latch, as the scent of vernix may trigger neural connections in babies’ brains needed for breastfeeding, and bonding with that delicious new baby smell. It also smells of mama, which can provide comfort to baby and enhance bonding after birth. The The World Health Organization (WHO) recommends waiting at least six hours — and if you can go a full 24 hours, even better to give the first bath. Since it doesn’t fully absorb until day 5-6, I’m not sure why the first bath can’t wait until then. Leave it on and even rub it in like body butter. Don’t let anyone wash it off.

Hepatitis B vaccine is given to prevent baby from blood born infection spread by contact with blood and body fluids like unsafe sex, IV drug use, accidental professional needle stick, and high risk communal settings. If baby has not had these sources of exposure, it can be delayed until prior to entering school, if you choose infant and childhood vaccinations. Refer to my blog on immunization for more info.

Vitamin K injection and Antibiotic eye ointment are given routinely to all babies born in US hospitals without considering individual situations. In some states you can refuse, in others it’s the law and they can report you to Child Protective Services - but these organizations have bigger problems to deal with and often the case is dropped after some unnecessary stress and aggravation. We don’t have these laws in most homebirth settings.

The antibiotic eye ointment is to prevent sexually transmitted infections gonorrhea and chlamydia that could cause blindness in newborns after exposure in birth. It is given within the first hour of life during the most alert time of baby after birth, interfering with vision at such a sacred crucial time when initial bonding and breastfeeding take place. It is irritating to baby and disrupts the delicate balance of flora in their eyes which can lead to other infections. Needing to give antibiotics is not relevant to babies born to mutually monogamous parents who do not have these infections. Taking into consideration that one may not know for sure there is another secret partner, these infections can be tested for in a pregnant mama at term, and if negative, the antibiotics can be refused in good faith. If you do test positive for one of these sexually transmitted infections, you and partner can be treated and retested to see if cured, but it may be wise to consider the antibiotics for baby’s eyes, since exposure can happen again. Then you can delay the medication until after you and baby look into each other’s eyes, have some time for bonding and breastfeeding.

To give vitamin K to the newborn within the first hour of birth is to prevent a rare but serious blood clotting disorder called vitamin K deficiency bleeding (VKDB). There is an early onset VKDB that happens within the first 24 hours, classical expression in 2-7 days, and late onset that usually occurs in 3-8 weeks of life. Our bodies need vitamin K to help the blood to clot when needed. Giving it to babies at the recommended dose via injection is currently evidenced based care, but still not a simple matter.

The American Academy of Pediatrics opines strongly in favor of it. The current evidence does support the injection, saying there is little risk other than rare potential allergic reaction, and that the benefits far outweigh the potential risks. The injection is mega dosed, with 20,000 times the amount new baby has at birth, 5000 times the recommended daily allowance. It is injected into the muscle, which is a more rapid route than oral. In its synthetic form, it is considered a class C drug which means its safety is unknown in pregnancy, risk cannot be ruled out, there are no satisfactory studies in pregnant women, but animal studies demonstrated a risk to the fetus or potential benefits of the drug may outweigh the risks. The package insert itself warns that it can cause sometimes fatal allergic reactions when injected into a muscle or vein, and is ideally take by mouth or injected under the skin. The synthetic medication contains concerning chemical preservatives. It is available, but not accessible in most hospitals without the preservatives, but the preservative free vitamin K still does have some chemicals to increase absorption. It is also concerning to ponder the impact of overdosing on a fat soluble vitamin that stays in the system, as opposed to water soluble vitamins in which excess is excreted out in the urine.

In formula fed babies, the risk of VKDB is negligible as the formula contains synthetic vitamin K. For babies who breastfeed, an alternative is the oral form of vitamin K, in which some protocols have not been as effective as the injection in preventing VKDB - although some of the increased risk was related to parents not administrating of all the doses. Vitamin K using the Danish protocol is just as effective at preventing VKDB, though not accepted by modern medicine and hospital practice in the USA. Several European countries have a licensed oral vitamin K available with varied protocols, for those who wish to decline the injection, which is most effective according to the research to prevent vitamin K deficiency bleeding in babies. Except the Danish protocol. The Danish protocol is preferred as it seems to be just as effective as the injection according to the studies. It is vitamin K1 - phytonadione: 2 mg orally at birth, the 1 mg once weekly for 6 months as long as breastfeeding is greater than 50% of the baby’s diet. As it is a supplement in the USA, it is not regulated, FDA approved or certified like the injection made from pharmaceutical companies, for preventing VKDB in new babies. That does not mean it is not effective or unsafe. Still many who decline the injection prefer it as a viable alternative. Finding it in the states can be a challenge, but some homebirth supply companies and midwives carry it. If doing this protocol, best to do with a feeding as vitamin K is fat soluble, to increase absorption.

Little research is available on the alternatives, such as breastfeeding mamas eating more vitamin K or supplementing (like with 5 mg daily) to boost levels in breastmilk and prevent the rare vitamin K deficiency in newborns.

But as with all other routine interventions in the entire healthy normal physiological process of having a baby, the more we study, the more we find their lack of benefit and increased risk, and that mother nature or the Divine intelligence that created it all did not get it wrong. Maybe there is a reason we do not know yet why newborns are born with low vitamin K that does not reach optimal levels until the eighth day of life, from the gut flora. Is it a deficiency if they are all born that way? I defer to Dr. Sara Wickham who has analyzed the research for over 20 years and even wrote a book on this subject alone. “Several thousand babies need to be given vitamin K in order to prevent each case of vitamin K deficiency bleeding (VKDB), a disorder formally known as hemorrhagic disease of the newborn. Unfortunately there is little research interest (as is so often the case) in questions such as 1- how we might be able to pick out the babies who are truly at risk rather than giving the universal prophylaxis and 2- whether and why it might benefit babies to have a relatively low level of vitamin K compared to adults.”

Newborn screening checks a baby for serious but rare and mostly treatable health conditions at birth. It includes blood, hearing and heart screening. The newborn screening blood test may screen for up to 50 diseases, including phenylketonuria (PKU), sickle cell disease, and hypothyroidism but know it is only a screen that leads to more testing to confirm or more likely rule out the rare diagnosis. It has a high false positive rate, as there are more than 50 false-positive results for every true-positive result identified through newborn screening in the United States. This means baby tests positive on the screen but do not actually have the disease. Screening is mandatory in and funded by nearly all states - despite the varied diseases for which each state screens; although most will reluctantly allow parental refusals on religious and other grounds, and such refusal does not usually engender civil or criminal penalty. The American Academy of Pediatrics opines strongly about the importance of the screening, but it does not control the different conditions screened for by each state. You or your partner can certainly hold and comfort baby during the blood test which hurts for a few moments.

The American Academy of Audiology supports early identification, assessment, and intervention for all types of hearing loss in infants and young children to minimize deleterious effects on speech, language, education, and social/psychological development. The screening should take place by an audiologist at 1 month of age and does not need to be done after birth. It is not an invasive screening and can be done in your room by your side, so if you gave birth at the hospital it can be more convenient doing it there. Or you can take baby to an audiologist by one months of age if you choose the hearing screen.

Pulse oximetry screening is a simple and non-invasive procedure used to measure how much oxygen is in the blood and has been found effective in screening for critical congenital heart disease (CCHD) in newborns, if done within 24 hours after birth. Current evidence supports consistent accuracy for detection of CCHDs in newborns by pulse oximetry screening in addition to prenatal ultrasound and clinical examination. Overall, early diagnosis of CCHD with pulse oximetry is judged to be beneficial, identifying disease that may be treated and lifesaving, and potential harms associated with false-positive tests are not serious, but stressful, while missing CCHDs and other serious diseases detected by hypoxemia without pulse oximetry screening can lead to serious consequences. It is interesting that this is not the position of other institutions such as the United Kingdom National Screening Committee and the Royal College of Pediatrics and Child Health. Further research is required to understand and improve the effectiveness and efficiency of the screening and its algorithm. Some mamas do not want this philosophical standard medical approach of looking for diseases, prefer to address the issue if baby shows signs, and have Divine faith that whatever happens is meant to be.

Medical (non-religious) circumcision is the most controversial routine surgical procedure done mostly in the US on babies with a penis, prior to discharge. The vast majority of boys in world aren't circumcised. There's no evidence to justify this routine procedure on medical grounds & its risks are downplayed. The American Medical Association classifies it as a non-therapeutic procedure, as it has no proven benefits and risks outweigh them. The American Academy of Pediatrics has never, in its over 75 years of operation, recommended routine newborn circumcision. The foreskin is a normal, sensitive, functional part of the body, protecting the head of the penis from urine, feces, and irritation; it also has an important role in sexual pleasure, as it has specialized, erogenous nerve endings, gliding and lubricating functions. For a thorough analysis of the literature, science & research, potential risks & alleged benefits, cultural/religious roots & human rights bioethical issues see here.
THIS ISN’T ABOUT PAST, HOW WE WERE ADVISED MEDICALLY OR CULTURED TO DO. IT’S ABOUT DECISIONS MOVING FORWARD.

I like to promote informed choice, question routine status quo, and help those interested in studying the data and what factors create opinion and dogmatic policies, as well as encourage those who wish to ponder this topic with a more critical eye and make their own decisions about their baby’s health care.

Educate yourself & make an informed decision about what you want or don't want for YOUR baby, with my online Guide to Pregnancy, Birth and Postpartum. And in adjunct, my Natural Birth Secrets book 2nd edition, as in many cases, it is totally safe and appropriate to investigate natural alternatives.

Premature Rupture of Membranes at Term

How do you know your main bag of water breaks? You feel a pop & fluid bursts out of your vagina like a river, making a large ~ 2 1/2 - 3 cup puddle on the floor, or it totally saturates your clothes or where you were sitting/lying. You keep leaking fluid throughout the day that’s not pee, saturating your maxi pad like the first morning baby diaper, or your poured at least a few cups in it. It looks clear, blood tinged with white specs of vernix, or it’s brown/green color of baby’s first poop meconium (let your provider know). It does not look or smell like pee or semen (no history of recent sex). Your provider sees it flowing out of your vagina, pooling in your vagina on sterile speculum exam or on microscope, or simply + Amnisure test.

And it’s not the few tablespoons of fluid between the two membranes that can release before labor making ~ pancake size stain on your underwear, seat, sheets. It is important to know that as main membranous bag is intact. When in doubt discuss with your provider. They can confirm or rule it out. The test strip that turns blue with amniotic fluid is not diagnostic by itself as it can also turn blue with other things, like blood and even the fluid in between the membranes. It is important to be certain of the diagnosis of PROM. You do not want to be falsely diagnosed as “ruptured membranes” with all the possible unnecessary potentially treatment that entails.

PROM - premature rupture of membranes means when the main amnion bag of amniotic fluid breaks at term, before labor. It happens 8-10% of the time. It’s important to know for sure it’s not just a crack in the inner chorion membranous bag, leaving the main bag intact, so you’re not on the “clock” unnecessarily. Babies are double wrapped with a few tablespoons of fluid in between the two membranes - enough to make a pancake sized stain on your underwear or whatever you’re sitting on if outer bag tears, but then no further leakage. If in doubt, I advise wearing a maxi pad & walking around a few hrs. If it becomes saturated like an overnight diaper that’s the main inner bag with lots more fluid just > 1/2 liter; if it remains dry PROM is unlikely.
But is this “clock” evidence based? No. Recommending to induce to avoid risk of infection & stillbirth is based on outdated low quality studies from 1959s-1960s. According to newer quality research, as long as mom & baby are doing well & meet certain criteria, induction is just as much an evidenced based option as waiting for mama to go into labor on her own up to 48-72 hours later, without increased risk newborn health problems or death. 77-95% will go into labor anyway by 24 hours.

Many leading professional organizations like ACNM, RCOG, NICE, AOM, & RANZCOG recommend offering both options as acceptable as long as certain criteria are met - like single term uncomplicated pregnancy, clear fluid, no fever, no GBS, & normal fetal heart rate. ACOG says induce immediately but that if mom declines, waiting for labor to start on its own (expectant management) is acceptable. Waiting for labor to start on its own has very good outcomes for moms & babies. Induction of labor has strong consequences like the cascade of interventions, cesarean & birth trauma, & many opine it can not be justified as standard of care for a normal physiological occurrence in healthy term pregnancy.
It’s important to know your rights to autonomy, & be educated to make an informed decision if this happens. Do avoid or minimize internal exams or anything internal as it increases risk of infection.

If you are interested in more gentle ways of bringing on labor naturally refer to my Natural Birth Secrets book second edition.
Be informed, empowered & educated with my online course Guide to Pregnancy, Birth & Postpartum - sold separately or in a bundle.

Induction of Labor: Invalid Reasons

According to the research, not many of the common reasons for induction are evidence based. People are feared into induction too often unnecessarily. For a surprising number of conditions, there has been no proof of the benefit or effectiveness of labor induction but actually have been shown to cause more harm - like suspected big baby, being labeled as high risk by your age alone, isolated ow amniotic fluid, and intrauterine growth restriction before term.

The benefits of imminent birth must outweigh risks of induction of labor and all that entails. That is when mama’s or baby’s life is in jeopardy and imminent birth is life saving as compared to possible dangers of continued pregnancy.

Thanksgiving, Christmas or any holiday are certainly not complications of pregnancy. Rates of induction continues to skyrocket, remarkably so in the days leading up to the holidays, with US rates in general, way above the rates from even 20 - 30 years ago, but our outcomes are continuing to get worse! A large amount of research demonstrates the risks far outweigh the benefits of induction especially when mom and baby are healthy. Elective induction without a well-supported medical reason clearly increases risks - for babies especially before 39 weeks. Induction before 41 weeks significantly increases chance of having a cesarean birth, major abdominal surgery with all its associated risks - especially for first time vaginal birthers and having a cervix that is unripe - not ready. Induction also greatly increases the chance of needing pain relief like epidurals which have their own risks for both mom and baby.

For example, induction of labor is absolutely appropriate in worsening gestational hypertension or preeclampsia, if mama or baby has a serious illness in which prompt treatment is needed after birth. But even in pregnancies that go beyond 41-42 weeks, there are pros and cons, potential risks and benefits to watchful waiting versus labor induction, which must take into account mama’s preferences, knowing that she has medical legal right to autonomy and declining induction of labor.

IUGR is not an evidenced based reason to induce labor. There are a variety of known causes of true IUGR (intrauterine growth restriction), like high blood pressure, heart/lung/kidney disease, diabetes, malnutrition, serious anemia, cigarette smoking, drug and alcohol abuse, certain infections, and fetal abnormalities. But do know that in well dated pregnancies, the majority (80-85%!) of babies identified as having IUGR are simply constitutionally small but healthy. They are just weighing below the tenth percentile. All of my four babies were off the growth charts diagnosed small for gestational age (SGA) but I and my husband are not tall and I simply make six pounders who consistently grew but stayed way below average in growth by height and weight even as kids.

Oligohydramnios - low amniotic fluid, by itself (not associated with other problems such as preeclampsia or birth defects) is also not a reason for induction as it is not associated with increased risk of poor outcomes, nor backed by the research. Actually, the main risk of low amniotic fluid at term in a healthy pregnancy is induction and cesarean as a result of the induction, and potentially the risk of lower birth weight of a baby born too early. There is no evidence that inducing labor for isolated oligohydramnios has any beneficial impact on mother or infant outcomes, but rather the risks of induction far outweigh the alleged benefits. A large body of research indicates that ultrasound measurement of low amniotic fluid is a poor predictor of actual amniotic fluid volume, so potentially inaccurate assessments dictate risky recommendations. Amniotic fluid in an otherwise healthy pregnancy lessens in the few weeks before birth, and post term related to decreased swallowing and urine output by baby. But it is often related to dehydration, seen more in summer months. If a mama drinks 2 - 2.5 liters of water daily she is likely to increase the amount of amniotic fluid volume, and she can up her amount if a low amount was detected on ultrasound.

Induction at 39 weeks of pregnancy is based on the Arrive study, which has flaws and goes against common sense as well as all the science & research up until now. The American College of Nurse Midwives does not support it and continues to advocate for spontaneous labor & healthy normal physiologic birth as well as a women’s right to self determination. For a thorough analysis of the the Arrive study on which these recommendations are based here are a few resources:

- evidencebasedbirth.com/arrive
- midwife.org/ACNM-responds-to-release-of-arrive-trial-study-results

- sarahbuckley.com/should-every-mother-be-induced-the-arrive-trial

- Lamaze.org/connecting-the-dots/parsing-the-arrive-trial-should-first-time-parents-be-routinely-induced-at-39-weeks.

Inducing labor or cesarean for suspected big baby in pregnancy isn't evidence based care and is potentially harmful. Estimated fetal weights based on ultrasound or abdominal assessment are notoriously inaccurate. They do not account for the ability of the pelvis to stretch, the power of mobility and gravity, baby's head’s ability to mould to navigate through the birth canal.

Especially because of the inaccuracy of estimated fetal weights, it is not evidence based care to induce labor or send you to the operating room for this alone. It is a fear based practice and has way more risks than benefits and again, not backed by the research. Time to stand firm. Don’t let them scare you. Fear increases your stress and negatively impacts your labor. You have the right to decline and even switch providers to those more calm, supportive of your choices and who practice evidence based care.

Even if baby is a good size, baby’s not yet fused skull bones can mould to fit through the pelvis which can stretch and increase capacity in asymmetrical upright and mobile positions, which also work with gravity. Plenty of mamas birth ‘big’ babies when given the opportunity and support. You have your provider there also as a lifeguard in case of need, like to relieve the uncommon but potentially serious complication of stuck shoulders called shoulder dystocia which can also happen in smaller babies. It’s certainly easier to push out smaller babies, and you can do your part by staying off sugar foods, refined carbohydrates, and juice. But no, don’t succumb to this routine practice of induction or scheduled cesarean for suspected big baby (macrosomia).

TRIGGER WARNING: With permission I share a tragic story of someone I knew who was having her first baby. She was told she needed to be induced before due date because they said baby’s weight was almost 10 pounds and she had a small frame. It was a top notch, highly esteemed medical center and hospital. Induction at 39 weeks no surprise didn't work, so birth was by cesarean. Baby weighed 7 1/2 pounds. Mom bled profusely during surgery. That is a risk of cesarean especially followed by medications for induction. She bled so much they removed her uterus. She ended up in a coma in the ICU and despite blood transfusions and intensive care she died. There is a patch for her in Ina May’s large Safe Motherhood patchwork quilt project, one patch devoted for every maternal death in the US.

For a more inspiring birth story of redemption, on a happier note, another mama came to my practice wanting a VBAC. Her first cesarean was done for suspected big baby over 9 pounds, but baby weighed only 7 pounds. She said her doctor told her no trial of labor as her pelvis was too small for her big baby and it would be too dangerous. She had a lot of trauma from her birth experience which propelled her to educate herself, prepare big time do things in a whole different way next baby. She took my online signature course Guide to Pregnancy, Birth & Postpartum & used my Natural Birth Secrets book 2nd edition as her “bible” she called it. She read lots of other books, took my prenatal yoga classes….and switched to midwifery care with me against her obstetrician’s warnings she and her baby might die. We worked closely together. She was so proud of her ability to have a beautiful VBAC at home (HBAC), and that a 9 pound baby slipped right through her birth canal without a tear. She actually wrote her obstetrician telling him that her pelvis grew.

Sometimes I have to get real with you to drive a point. Despite all the money and technology of modern US medical and hospital care, the United States ranks the worse among developed countries in terms of birth outcome statistics - our maternal mortality and morbidity rates are on the rise like no other country, and rates of neonatal morbidity and mortality and birth trauma are also horrendous. The countries who have best outcome stats are countries that have more midwifery care that services the low risk healthy population who benefits most by not disturbing physiologic birth when all is well, leaving the obstetricians to provide care to those who have higher risk conditions, complications and need lifesaving medical and surgical care. When high risk care is applied to healthy low risk people, we see more problems, we contribute to the horrid outcome stats of our country.

So let baby come when they are supposed to come and don't let anyone pressure you into an unnecessary induction. Even back in 2013, a listening to mothers survey showed that 4 out of 10 mothers (41%) said their care provider tried to induce their labor. You have the right to say no and switch providers to those who support the natural process of letting labor start on its own when all is well. Rates of routine unnecessary inductions are on the rise - from 9% of births in 1989 to 31.37% of births in 2020, which increases risks - including failed induction as the body is not ready, & unnecessary cesarean with all that entails.

Remember we are not in control or as wise as the greater intelligence that designed the process. Giving birth is such a lesson in surrendering to that greater power that transcends us all.

What can you do? Empower yourself with resources like my book & online course Guide to Pregnancy, Birth and Postpartum - bundled together or sold separately! Say No!! Prepare like a boss. Go to supportive providers. They are out there. We must be the change we want to see.