When I hear about a natural birth from a friend or birth professional at one of our local hospitals where natural births feel more like blue moons... there are two questions I always ask: How long was she there? (the answer is usually less than 8 hours) And what position did she birth in? (most women are made to birth on their back there). I plan to keep asking because I TRULY HOPE that one day the answers will change! But for now, when I ask the latter, it's not uncommon to hear "She was pushing upright, or in a squat, and the nurse asked her to get in a lying squat... it all went great!"

The first time I heard this... I needed the doula to clarify... you might need that too...

Are we all familiar with a birth squat? See the picture. This position is one that many women will get into to birth their babies if they have not been conditioned by their culture to lie on their backs. In other cultures it's a position that people use often... you'll see men squatting during their smoking breaks, people waiting at the bus stop in a squat, and they go to the bathroom in a squat. This is a very healthy exercise to incorporate into your day... I pick up toys, change diapers, sometimes watch tv in a squat and I encourage my students to practice often as well. You can read more about the benefits of squatting here, back to the birth squat...

I also share the many benefits of birthing in an upright position. This can be a squat, which opens the pelvis by 30%, or with one knee down for support, on all fours... lots of options. Here is a list of advantages compiled by Giving Birth Naturally, you can see the whole post here:

"Advantages:

• Squatting opens the pelvis by up to 30% compared to lying down (1). (Just that one on its own is good enough reason for me!)
• Squatting is reportedly less painful than lying down. (2)
• Squatting ‘straightens' the birth canal as it helps the pelvic bones to line up, rather than emphasizing the u-turn caused by the lithotomy position or the semi-sitting position.
• Squatting to give birth makes use of gravity. If you think the effect of gravity is negligible, it isn't. Ever had that experience where you're lying down and the moment you stand up you desperately need to pee? That's gravity!
• All of the above help to shorten the pushing phase of labour. (3, 4, 5,6)
• Which means that less oxytocin is required to speed things up. (2)
• Squatting also decreases the need for the use of forceps when compared to the semi-sitting position. (5
• The dangling squat also helps to lengthen the body which can give the baby space to get into a better position.
• Some studies mention that squatting prevents tearing (3, 6), although some mention that tearing rates are the same (2) or higher (4, 7). As mentioned before I think that increased tearing is due to lack of support, as mentioned by the researchers themselves (4), as well as, in my hopefully well researched opinion, incorrect squatting technique (See above).
• Squatting can decrease episiotomy rates. (2, 3, 6)"
  
  

Squatting sounds like a good deal to me! So what is a lying squat and does is carry the same advantages?

When studies have been done on upright vs non-upright birth positions, the non-upright positions included are usually lying flat on the back (lithotomy), semi-sitting, like leaning back in the bed, and side lying. To imagine what a lying squat is if you haven't heard a nurse tell you to get in the position, or heard your client be told to get in the position... take a woman in a birth squat and put her on her back. Or lean her back into the bed.

Imagining it? Oh geeze... what does that look an awful lot like? A woman birthing on her back or in a semi-sitting position...

Friends... the lying squat is just nurses and doctors using our language against us. They are making women feel like they are getting what they want when in reality they are being manipulated into rejecting what their body is telling them to do and doing what is convenient or comfortable for the provider. The benefits that a woman enjoys in an upright birth position are lost in a lying squat! Who cares what the staff calls it! Lets call a spade a spade here ok?

Why aren't an upright and lying squat the same?

A squat is not all about the position of the legs. Even though in these two positions the mom's legs may be positioned similarly... the lying squat (whether with mom fully on her back, or lying back into a raised bed) compresses the pelvis, changing the size and shape of the pelvic outlet. Gravity is no longer on mom and baby's side. Mom will still experience all of the discomforts of lying on her back.

Most importantly... to me at least... the woman is no longer listening to her body. Also, many women who know enough to get into a squat during a hospital birth has most likely done her research and has decided that she does not want to birth on her back... women are vulnerable and highly susceptible to suggestions in labor, shame on every nurse and provider who uses this kind of language to talk a woman out of the birth she desires.

I've noticed some apathy from some doulas on this subject. I don't know why... because it makes me really mad. We are working SO HARD to inform women, give them options, give them the tools and the vocabulary to communicate openly to their providers what THEY WANT for their birth. This is simply a trick to get women to comply without resistance. It's not fair. We need to warn women just as we warn women about breastfeeding "booby traps" put out by formula companies. Lets remember whose corner we are in.

Moms, doulas, birth educators... it's ok to be mad! Let's not be so quick to give up and get on our backs! Saying "Well I/she pushed upright for some of the time." So? Did you/she want to BIRTH upright? If that's was the desire, and it was not allowed, that is not a victory! That is not progress... because YOU/SHE only births that baby once.

So let's not buy into the "lying squat" ok? Let's not be ok with putting women on their backs when they don't want to be there. Lets choose and praise the birth places who consistently support women in birthing how they desire.

Ok I feel better now... thanks for reading guys!

When preparing for my first birth with a natural childbirth curriculum all I knew about induction was to not do it. Just say no! And no I said… and said and said. But at 41 weeks with poorly controlled, insulin dependent gestational diabetes (because all I learned about that was to eat this and that won’t happen, then it did), I knew it was probably time. We were not happy, we were not prepared, we were determined to still salvage our natural birth but that wasn’t enough. We knew what we wanted, but had no clue how to achieve it. This post is kinda a letter to me, then… and maybe you, today, will find it helpful.

Before we get started, I am completely opposed to inducing labor for non medical reasons due to the risks of induction for mom and baby. Being tired of pregnancy, being over 40 or even 41 weeks, suspecting a big baby or an impending holiday are all reasons that I personally would not consider legitimate enough to justify the very real risks of induction. If you are planning an induction for a non medical reason, please consider letting your baby come when he or she is ready. However, there are times where the risks of continuing the pregnancy outweigh the risks of an induction, and for the health of mom and baby it is necessary. To the mom facing a medically necessary induction, you don’t have to give up your birth! You can still be an active participant and have a positive birth! You are not a failure, you just might need to adjust your game plan.

Medical Induction
There are many different ways in which labor can be induced. In my classes I cover 10 natural induction methods and 6 medical induction methods. Chances are my students will not need the information, but if they do then they can make informed decisions with their provider about what is best for them. I hope you have taken a truly comprehensive class that covers the pros and cons of these options, and you have a knowledgeable doula to help you… or you will have some late night researching to do. Briefly, medical induction usually begins with a cervical softener if your cervix is not already soft and dilating. Though less common in some areas, sometimes a Foley bulb is used to mechanically open the cervix up to 3cm. Some doctors choose to go straight to Pitocin, a synthetic form of oxytocin that creates contractions. These contractions can be longer and harder than natural contractions, and that is one reason inductions are hard on mom and baby. Some doctors begin Pitocin after using a cervical softener or Foley bulb. There is also a pill that can be used called Cytotec, though because of the risk of uterine hyperstimulation and rupture, some doctors and midwives no longer use it. Take some time to research the risks and benefits of these options, one method will not be ideal for everyone. If you have that information, let’s get on to our survival guide!

You need an induction, first take a time out.
You have been preparing for this birth for 9 months, maybe longer. You might have very specific visions for your birth, like laboring at home and arriving at the hospital late in labor… or maybe you were planning a home birth and you are now having to transfer care. It’s ok to take a minute and be mad, or sad, or frustrated. For one of my births I gave myself from the doctor's office to my home to blast my favorite pity party song and cry and be super angry that I wasn’t going to have the birth I had originally planned.  I just happen to do my best crying on the road but you do what you need to do. Get it out, and then collect yourself, because you can do this. You are already an awesome mom. You are making a hard decision for the health of you and your baby. You may have to induce your labor but you still have options and can still have a positive birth.

If you have time, revise your birth plan.
I was given less than 24 hours notice for my induction, though I managed to negotiate 2 more days so I could try to induce labor at home, and pull myself together. Chances are if your induction is medically necessary you will not have weeks to prepare, you may only have a couple days. If you have a birth plan, look it over. If you can do this with your provider, please do. You may have “no IV,” “intermittent monitoring,” or “use tub and shower,” and depending on your hospital's policies and the type of induction, these may no longer be negotiable. Pitocin is administered by IV, because of the risks associated with Pitocin, it’s very important that baby is being monitored continuously, and most hospitals do not have wireless, waterproof monitors so water may not be a tool available to you. It’s better to know this now, and make a new plan, than to be disappointed when you arrive. You may still be able to use other tools like movement, massage, counter pressure… and if your doula is skilled with a rebozo, peanut ball,
essential oils… yeah… you still have lots of options even if they were not a part of
your original birth plan.

Prepare for a long stay.
Inductions are usually a long process. Shame on the doctors who love to say, “We’ll have this baby by dinner time!” when a mom is checking in for a 7am induction. Sometimes this is the case, but not usually with first time moms and it does no one any good to be unrealistic. Inductions usually take a couple days. This is ok, you probably won’t be in active labor that long. The first day, or night, depending on when you begin your induction, will likely be spent with a cervical softener like Cervidil, or on a low dose of Pitocin. Even on maxed Pitocin sometimes contractions just don’t begin for a long time, 6, maybe 12 hours. So prepare for a lot of waiting. In the evening, have an eye mask and ear plugs so you can sleep. Bring your own pillows and blanket if you like, and it’s ok to ask the nurse for a medication to help you sleep. In the day, bring a book, magazines, cards if you like to play card games (I do!) and your laptop or tablet with some favorite shows and movies. Maybe arrange for a friend or family member who is supportive of your birth plan to come give you a pedicure if not much is happening. Maybe you WILL have a baby by dinnertime, but you might not so come prepared.

Induction Day: Celebrate!
Celebrate? What? Your whole birth just came crashing down around you! Well… no… it didn’t, you have looked over your options, you are prepared, and guess what… you are having your baby! This does call for a celebration. Inductions are best started in the evening, so request an evening appointment and make dinner reservations at your favorite restaurant. Relax at home before, take a long shower or bath and a nap if you can, maybe you and your partner can get a massage. Massage stimulates oxytocin! Go out to dinner and be sure to order something with plenty of carbs and protein. If you are an athlete you know how important carbs are for an endurance sport! If you aren’t… trust me… you will be burning lots of calories in labor and some doctors will not let you eat during your entire induction (though more on that later). This meal is important, but also enjoy it. You might not be eating out in a nice restaurant for a while.  Toast (maybe with a little wine) the baby you will soon have in your arms!

Check in and pass out.
I mentioned sleep above, but I want to stress how important it is that you sleep as much as you can in the hospital before labor is established. This isn’t easy… nurses are in and out, it might feel like there is a cord attached to every limb, machines are beeping… but please try. If you are inducing in the morning (and you can request inducing in the evening) but had a restless night, nap once the nurse has you set up in your room and started your cervical softener or Pitocin. If you are over tired and anxious, this may make your labor more difficult and painful. Put in some ear buds with some relaxing music and zone out. If you have had a full night of sleep and feel energized, then choose a relaxing activity. This is not the time to be walking halls, save up your energy for once labor begins.

Now what might happen next?

Scenario 1: Labor begins!
Whoo hoo! You are having strong contractions with a great pattern! Your body was ready to have this baby and all it needed was a nudge in the right direction! Be in contact with your doula and decide together when she should arrive. If you can smile and talk through contractions, continue with the relaxing activity you have chosen, though try to remain upright and use movement occasionally.  If your contractions require you to stop everything and focus, use movement, upright positions, and establish your rhythm. Tap into those tools you learned in birth class, but don’t exhaust yourself if you don’t truly need them yet. These contractions may be harder than you expected or saw in birth videos, there might not be breaks like you prepared for.  Some women will need pain medications, but some women will still be able to have a natural birth. Both scenarios are ok, don’t be hard on yourself. If labor is well established, you can always ask for the Pitocin to be turned down, or turned off and be unhooked from the IV, to see if your contractions continue naturally. You can labor the way you planned to originally, work with your doula and partner to stay on track for a vaginal birth!

Scenario 2: Contractions begin, but you can’t feel them!
Sometimes during an induction contractions begin to show up on the monitor but mom doesn’t feel them. This happened for a full day for me on the maximum dose of Pitocin. Had I known this was possible I may have not had an embarrassing meltdown after 12 hours of not understanding what my body was doing. So, this can happen, it’s ok. Rest or do a relaxing activity. You might not begin to feel contractions for a while. Choose an upright position, hang out on your birth ball, use your doula’s peanut ball, this is all still normal!

Scenario 3: Approaching day 2 and still pregnant!
This is also ok! Hopefully you have been resting and passing the time with enjoyable activities and you are not exhausted (like I was). If labor has not begun, you can ask to be unhooked from Pitocin so you can walk around, have a hearty meal (send dad to get it, they probably won’t feed you in the hospital), and take a shower. If mom and baby are doing well and your water has not broken, ask if you can go home to recharge for a bit and return in the evening. The uterus is most receptive to oxytocin in the evening, so this is a great plan. THIS is when choosing a supportive provider will really pay off! It may feel like this will just delay meeting your baby, and while it might add a few hours to the whole process, it’s better to go into labor relaxed and energized than discouraged and exhausted. No one has ever been pregnant forever and you will not be the first.

Tips for a positive induction!

Keep your waters intact as long as possible.
Once the doctor breaks your water, you may be on the clock for a cesarean. It’s true that this can really kick up labor, but it can also cause baby to distress, a cord prolapse, maternal infection, or more painful contractions. There is a time and a place for it. I chose to induce my third child at 42 weeks and 2 days by just having my water broken with no medications. I was already 5cm and I weighed the risks and benefits. For me, it was right. For most moms, saying no to having their bag of waters ruptured will help them have a more positive induction experience, for some it will be the right decision. Weigh the evidence you have gathered prior to your induction and consult your doula during your induction.

Stay nourished and hydrated.
Many doctors will not allow a mom to eat or drink during an induction. This is a recommendation, no one can tell you that you cannot eat. Even though you are in the hospital, you are an adult with a right to fulfill your basic needs. I have heard nurses say “the doctor says you can’t eat, but there is a lot of time that I’m not in this room and what I don’t know won’t hurt me.” The fear is that should you need a cesarean under general anesthesia, which is very rare, you could possibly aspirate. This fear is not supported by evidence. Bring snacks, send your partner or doula out for light, easy to digest foods that will give you the energy you need to birth your baby. I personally have not asked permission to eat or drink since my first birth. I just do it, and I have not had a nurse say anything, even during an induction.

Move!
Use movement and position changes during your induction! Most of us have an image of a woman in a gown laboring in bed. Staying in one position in bed may prevent your baby from getting in an ideal position for birth. Some positions like squatting open your pelvis by up to 30%! Rock, sway, slow dance with your partner… even hooked up to an IV and monitors. Once those contractions begin you don’t want to exhaust yourself, but you also don’t want to be completely sedentary.

Never give up your birth.
This is my biggest regret in my first induction, and something I refused to do again. Often times when enough of a mom’s birth plan has been compromised she gives up on everything else. To every mom who desires a natural birth, I believe you can do it and I hope you do! However, even if you have an epidural, your whole birth is not lost! Once you have rested, or if you are fully dilated, ask them to turn it off. Get up in a squat using the squat bar and support from your partner and doula and bring this baby into the world on your own power! If baby is poorly positioned and needs to be turned with forceps or a vacuum, once baby is on your abdomen bring him or her up to your chest for skin to skin yourself! Even if your induction ends in cesarean, ask that the curtain be lowered and baby be brought straight to you. No matter what happens, this is still your birth and a day that you will cherish.

I hope this post helps to make what might be a scary experience a more positive one. I would love to hear what has helped other mothers through their inductions or what doulas have found helped their clients!