What's Up With Modern Care?

Something has been very much on my mind lately, and I didn't know how exactly to word it, but I'm going to try now: people don't care about pregnancy and birth nearly as much as they should.

There, I said it.

Why is it that a woman's rights in childbirth are so overlooked? Why can't a mom refuse continuous fetal monitoring? Why can't a mom have more than one person present at her cesarean, planned or unplanned? Why can't a mom make all the calls in a hospital birth? Why must women be subject to hospital/insurance company's/care provider's policy? Why is home birth so frowned on? Why is she not holding the power in regards to her care, as a rule, across the board? Why is this not a bigger issue in the mainstream media?

Why is it that if a woman is told by her doctor that she needs, say, gallbladder surgery, she asks for time to think it over, or gets a second opinion or something like that, but if her OB says her baby might be "too big," etc., she doesn't even question it and goes along with the scheduled induction or cesarean? Why is it that prenatal testing isn't questioned? Why aren't things like dopplar heartbeat scans, or ultrasounds, or Gestational Diabetes testing, or anything pregnancy-related, questioned by moms? Why is it okay (and even encouraged) to do whatever your doctor suggests, even if you don't understand it, and the best explanation they can offer you is, "It's just how things are done?" What is it about pregnancy that turns otherwise independent women into mindless drones who think, "Well, they're the OB, so they must know best," even if they aren't comfortable or don't agree with their OB's advice?

Here are my biggest pet peeves:

1. The Due Date. Why do people put so much focus on due dates? Not every woman's cycles are the same length, and not every child develops at the same pace, so why do people still hold to the belief that every pregnancy should  last the same amount of time? Why is it okay for some women to go into spontaneous labor early, but going past the EDD is such a crime? Babies develop at different rates in the womb, just as the do after they're born. They're not all ready at the same time, and not all moms will gestate for the same amount of time. Some moms and babies are ready later. Some are ready sooner. It. Is. Just. An. Estimate. Don't rely on it solely. 40 weeks is merely the average time women give birth. only a small percentage (about 5%, I believe) of babies are born on their due date, and just as many give birth before then as after. If you induce or have a cesarean before at least 40 weeks, or at any time, really, you run the risk of baby not being ready (due to an incorrectly calculated due date, or our body or baby simply needing more time), and is that really worth it? Is your personal comfort (not being pregnant anymore) really worth risking your baby? ACOG states that postdates is not until after 42 weeks, not 40, and no interventions should happen until then without warning signs. Here's a good reference about this: http://www.theunnecesarean.com/blog/2009/10/3/postdates-separating-fact-from-fiction.html#sthash.ozx9GHMc.dpbs
2. Ultrasound Weight Estimates/Your Baby is Too Big. Not only can ultrasounds be off by as much as 3lbs as far as weight, but the margin of error is at least 50% or so. Also, even if your baby is big, that doesn't have nearly as much influence on whether they can be birthed vaginally as their position, the shape of mom's pelvis, and her active movement in labor and pushing do. I've heard of truly tiny women birthing 11+ pound babies, so size really isn't a big deal on its own. Ignore the weight estimates. Seriously. It is exceedingly rare for a woman's body to make a baby she can't birth.
3. Repeat Cesarean vs. VBAC Safety. In the majority of cases, VBAC is the safer option. Major abdominal surgery is almost never going to carry fewer risks. If you look at the list of possible complications for a repeat cesarean sections, compared to the list of possible VBAC complications, it's astounding. RCS is held up by most care providers as the "safer" option, when really, it carries far more risks, which are far more likely to happen, than VBAC. Don't believe me? Check this out (and this is only one small example of what I'm talking about):
   
4. Inducing Carries Little to No Risk: No. Just no. Have you checked out the facts on pitocin? What about cytotec, or cervadil, or AROM (artificial rupture of membranes)? Do you really think that a medically induced labor, that the body is obviously not ready for since it hasn't triggered labor on its own, is going to behave the same way as a spontaneous labor? Medications carry risks and have side effects, and since the drugs most commonly used to induce labor are either not indicated for use in inducing labor, or are contraindicated by the manufacturer for use in non-medically necessitated induction, should that not give women pause? Why do doctors not disclose these risks? Medically necessitated inductions are not something a mother should feel ashamed of, but if it's not necessary, there's a lot to consider before putting your body and your baby through that.
5. Cesarean Sections, Whether Primary or Repeat, Carry Little To No Risk: Again, NO. Cesarean birth, while a blessing we should be grateful for as a lifesaving measure for mothers and babies who are truly at risk, is far too common these days (more than double what the WHO recommends as the maximum safe percentage of cesarean births). It is major abdominal surgery. It is not the way our bodies were designed to give birth, and therefore is not "the same" as vaginal birth. It should be maternal choice whether to have a cesarean or not, and all the real facts should be given to mothers so they can make their choice based on the best modern evidence. Look up the risks of abdominal surgery sometime, and see how risky is really is. After the second cesarean a woman has, her risk of hysterectomy rises to nearly 1%, whereas if a woman has a VBAC or two under her belt, that risk is only about 0.17%. You do the math.
6. The Birth Experience Isn't Important (as Long as You Have a Healthy Baby): This makes me so angry. The ultimate goal in childbirth is of course to have a healthy baby and mom, but why is mom's experience viewed as unimportant? This is the birth of her child, after all, something that alters not only her state of being (she's a mom now), but her body as well! Should she not have the right to have it happen in the way she wants, and feel respected and in control during the process? Things don't always go according to plan, but mom should be the one calling the shots, and she should feel content at the end, knowing that nothing was done against her will and that she had the power in her hands the entire time.
7. Medication in Pregnancy is BAD, but Medication in (or to Start) Labor is Okay: Just think about that for a second. Really think about it. Why should you avoid anything other than tylenol and antacids while pregnant, but pitocin/morphine/stadol/etc. are fine while you're in labor? Does labor magically stop medications from crossing the placenta and getting to baby? No, it doesn't. The hypocrisy drives me insane.
8. High/Low Amniotic Fluid: This is one of the latest scare tactics used to get moms to schedule an induction or cesarean. "Oh, it looks like you might have too much/too little amniotic fluid. We'd better induce/perform a cesarean immediately." Yeah, right. Do you know how rare it is for low fluid to actually be present? Do you know how rare it is for high fluid levels to actually be caused by a true problem with baby? Do you know what measures can be taken to check on baby's wellbeing before inducing? Yeah, it's really not (usually) as big a deal as it's made out to be, and often the measures doctors take to "save the baby" are counter-intuitive. Like, breaking mom's water to induce labor due to high levels of fluid, when breaking the water with baby high and not engaged in the birth canal can cause the umbilical cord to become trapped and compress oxygen supply to baby, necessitating a cesarean delivery. This is definitely one of those situations where mom should insist on a second opinion or more testing before jumping to delivering baby.
9. Multiples Can't Be Delivered Vaginally: Oh lord. Why not? Even if they're breech, why not allow a TOL (trial of labor)? WHY NOT? Twins, triplets, and even more multiples can be conceived naturally, and have been delivered naturally, since the dawn of time. Yes, cesareans are sometimes necessary, but why assume they will be and refuse to allow mom a TOL? Why jump to the worst possible conclusion? This makes absolutely no sense to me.
10. The Cord Was Around Baby's Neck/Baby Was Breech, it's a Good Thing We Did a Cesarean: Wow. Because no babies are ever born with the cord wrapped around them. It happens in about 1/3 or births, and is not an immediate complication. Breech babies are the same way. Babies are born, vaginally, with the cord around their neck or in a breech presentation, every day, and are perfectly fine. This is one of those "lack of training" issues, where care providers aren't taught how to deliver a baby with a nuchal cord/hand/breech presentation/etc., so they immediately jump to a cesarean delivery. Why is mom's choice not the first priority? This is a serious issue when it comes to lack of training or our care providers. There's no reason to assume these babies can't be born vaginally.
11. You Can Trust Everything Your Care Provider Says: Nope. Don't take anything at face value. If this statement were true, doulas wouldn't exist. If the people delivering babies were infallible, and never made a mistake or did anything against mom's wishes, people like me wouldn't exist. There wouldn't be sites like improvingbirth.org, or evidencebasedbirth.com, or any site like that. There wouldn't be rallies focused on bringing birthing womens' rights to the eyes of the public. There wouldn't be women seeking new care in subsequent pregnancies due to unhappiness with their first birth experience. I am not kidding when I say that you should never settle on a care provider if there's anything they say or do that makes you uncomfortable for any reason.
12. Our Modern Obstetrical Care is the Best in the World, and Has Women's Best Interests at Heart: Wrong. The USA ranks LAST as far as maternal and fetal outcomes/mortality of all developed nations in the world, yet we spend the most on obstetrical care. Why? Because medicated births and cesareans make a lot of money for hospitals and doctors, but they are not in the best interests (healthwise) of moms and babies. We are still employing practices from over 50 years ago, and obstetrics is just about the only field of healthcare to do so. You wouldn't want your general practitioner to practice outdated care from the early 1900's, so why would you want your OB to do so? That's exactly what's happening. So much of the care the modern OB's base their practices on is from around the 1950's. It is not modern, it is not evidence based, and it is not beneficial to moms or babies in any way. Every other medical field has advanced with the times, but obstetrics has not, and yet that is the one field people blindly trust.  We deserve better

These are the main reasons I get so angry and hurt for the sake of other moms out there. These are the reasons I'm wary of another hospital birth. These are the reasons I'm a doula. The lies that pervade the birth world, that come from your OB, your midwife, your mom, your aunt, your friend, etc. need to stop. The modern, evidence-based truth needs to get out there, because all moms deserve it.

Communication

There is something I have learned recently that has made a big change in me. It's all about communication. I was reading my course materials, and one of the three "sections" of the course focuses entirely on communication. I was particularly interested in their definition of "empathy" versus "sympathy." They define the two thus:

"Sympathy: sharing of another’s feelings
Empathy: ability to identify with person

Sympathy is where you feel something of what someone else is feeling, whereas empathy is where you can relate to, or identify with, someone’s feelings. Why is important to distinguish between the two?

When we use sympathy we are focusing on how we would feel in the same situation. When we use empathy we are focusing on how the other person feels."

I realized that in my responses to so many pregnant women's questions and concerns (whether I knew them personally or not), I used the word "I" far too much. Yes, it's good that I have my own experiences to draw from, but their situation is not about me. Unless they directly ask what I went through, or if I have any experience with it, or what I did, there is no need for me to bring up my personal experience. "I" am not a factor. "I" have no place in their situation. And "I" need to take "me" out of the equation if I ever want to be a good doula. The last thing my clients need is for the focus to be taken off of them and their pregnancy/birth, and unless my experiences can be of help to them, there is no need for me to bring "me" up.

Because of this revelation, I have found my approach to these situations changing. "I" come up much less in my replies, and that's forcing me to instead do research and find statistics and other answers than just what I went through. And you know what? I'm getting much better, warmer responses, and I think I'm doing more good. I'm getting through. I come across more as an educated woman who knows what she's talking about, rather than someone who expects what worked for her to work for everyone, and for everyone to choose as she did because she said so.People are more likely to take you seriously when you take an academic, professional approach, as opposed to gushing about your own experiences and nothing else.

Sometimes it's good to back yourself up with personal experience. I'm sure personal birth experience makes a difference to moms when choosing a doula, especially if they're a fledgeling like me (who hasn't much to go on other than my own births), but the client will ask for that information if she wants it; there's no need to throw it in her face.

Scientific facts and solid, unbiased information are always going to be better received, especially in my profession. It was a tough lesson to learn, but I had to do it. I am in a position where my opinion is the last thing that matters: I am there to serve, to support, and to cheer on my clients, even if they choose something I would not choose or do not understand. My job is to ensure that their birth experience goes the way they want, not the way I want. Yes, I am there to educate, but not to push my unsolicited advice.

So when a situation comes up with a client where she asks me what she should do, my first response will be to ask her which way she is leaning (and why), offer her the pros and cons of her choice, then those of whatever other choices there are. If, and only if, she asks what I would choose, I will give my opinion. But no matter what, I will always start by asking her what her thoughts and feelings are. To do otherwise would be insensitive and unprofessional, and I know that now.

I will use empathy, not sympathy, unless my client dictates otherwise. I know that the dynamic will change with each client, and I have no problem being flexible. It's about mom, not me. It's about her choices and her birth, not my opinions. Empathy is something I can and will do.

I love Childbirth International. I'm learning so much, and it's applicable in more than just my profession; it's making me a better person.

Pitocin Facts: What Every Mom Needs to Know About the Risks

Doctors these days would have their patients (who either must, or elect to be, induced) view pitocin as a magical drug that induces and/or augments labor with no adverse side effects. This could not be further from the truth. Not only is pitocin not approved by its manufacturer for elective inductions, but even in medically-indicated inductions, it carries a wide range of side effects (both minor and severe)!

There are very valid reasons to be induced. Any condition that threatens the life of mother and/or baby, such as pre-eclampsia, intrauterine growth restriction, etc., is more than enough reason, and issues such as placenta previa (where the placenta covers the cervix and baby cannot be born vaginally) call for an immediate cesarean. The benefits of pitocin and/or major surgery vastly outweigh the risks in these situations.

But what about post-dates pregnancies?  Possible big babies? Mom being tired of pregnancy? Convenience? These may seem like valid reasons, but when you weigh them against the risks to both mother and baby, it might make you re-think the situation. Pitocin is far from risk-free, and the adverse effects on both mom and baby are enough to give anyone pause. Induction of labor can raise the chances of a cesarean delivery by as much as 50% (as I have previously cited), so if you wish to avoid a surgical or interventionist/medical delivery, and your situation is not urgent, induction is likely not the best choice for you. If the benefits, such as saving the life of mother and baby, outweigh the considerable risks, then it may be the right choice. But there is a lot to consider when you might need or want to be induced, for whatever reason.

If you want to be induced because of social reasons, a feeling of being "done" with pregnancy, or simply being past your EDD (estimated date of delivery), you might want to take a look at these side effects (which are more likely than most OB's would have you believe) of pitocin, the most common labor inducing drug, before you make any decisions.

The following list of adverse effects to mother and baby is from the FDA:

"Adverse Reactions

The following adverse reactions have been reported in the mother:

Anaphylactic reaction	Premature ventricular contractions
Postpartum hemorrhage	Pelvic hematoma
Cardiac arrhythmia	Subarachnoid hemorrhage
Fatal afibrinogenemia	Hypertensive episodes
Nausea	Rupture of the uterus
Vomiting

Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.
The possibility of increased blood loss and afibrinogenemia should be kept in mind when administering the drug.
Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.
The following adverse reactions have been reported in the fetus or neonate:

Due to induced uterine motility:	Due to use of oxytocin in the mother:
Bradycardia	Low Apgar scores at five minutes
Premature ventricular contractions and other arrhythmias	Neonatal jaundice
Permanent CNS or brain damage	Neonatal retinal hemorrhage
Fetal death
Neonatal seizures have been reported with the use of Pitocin."

There are further warnings (http://evidencebasedbirth.com/crank-up-the-pit-2/):

• Oxytocin (Pitocin) is a high-alert medication, meaning that this drug has a high risk of causing significant harm if a drug error is made. It also has a black box warning, which is the FDA’s strongest warning for drugs. In this black box warning, the FDA says that Pitocin should only be used when induction of labor is medically indicated (never for “elective” induction), or in “select cases” of stalled labor. Medical indications of induction (according to the FDA) include blood Rh problems, maternal diabetes, pre-eclampsia at or near term (when delivery is in the best interest of the mother or fetus), or premature rupture of membranes (when delivery is in the best interest of mom or baby). (UpToDate, 2012).
•  Pitocin has many potential adverse reactions. For the mom, Pitocin can cause heart rhythm problems, high blood pressure, nausea and vomiting, post-partum hemorrhage, too frequent contractions of the uterus (called uterine tachysystole), constant contraction of the uterus (called uterine tetany), uterine rupture (more common in second-time or more moms), and severe water intoxication.
•  For the baby, oxytocin can cause heart rhythm problems, slow heart rate, permanent brain damage, seizures, jaundice, retinal hemorraghe, fetal death, and low Apgar scores. Contractions of the uterus temporarily interrupt blood flow to the baby. The stronger, longer, and more frequent contractions caused by Pitocin can lower oxygen levels in baby. This leads to bad changes in the baby’s heart rate patterns on the monitor, and could possibly result in mom being rushed to an “emergency” C-section—an emergency that was caused by the induction drug itself.
•  In a recent Cochrane review, researchers found that augmentation of a “slow” labor with Pitocin shortened labor by two hours. However, it did not increase or decrease the C-section rate. The early use of Pitocin increased uterine hyperactivity, which means that moms had stronger, more frequent, longer contractions. The sample sizes are not big enough to look at infant or maternal deaths. The authors of the Cochrane review conclude that although Pitocin has been used for 40 years to reduce the need for C-section, it is not at all effective in doing so. Healthcare providers may feel the need to speed up labor, but doing so exposes a woman and baby to a drug that—in this case—has no benefits and may have dangerous adverse effects (Bugg et al., 2011). My personal advice to moms out there– before agreeing to Pitocin augmentation, ask your provider, “Am I okay? Is baby okay? Then give us more time, please.”

And (http://motherwiselife.org/2013/03/20/i-did-not-consent-my-terrifying-experience-with-pitocin/):

•   Using pitocin reduces the body’s production of Oxytocin. This can create difficulties with the bonding and breastfeeding process after birth. 
• Pitocin, on the other hand is a super scary thing. The insert in the Pitocin package is very clear about the risks of using this drug during labor and delivery. 
• Risks include (per Pitocin package insert):
• -fetal heart abnormalities (slow hear beat, PVSs and arrhythmias)
• -low APGAR score
• -neonatal jaundice
• -neonatal retinal hemorrhage
• -permanent central nervous system or brain damage
• -fetal death
• -fetal asphyxia and neonatal hypoxia
• -blood supply to uterus is greatly reduced
• -contractions are closer together and stronger-reducing the rate at which baby receives oxygen (which can have life long effects on baby’s brain)
• Risks for birthing women:
• Postpartum hemorrhage (due to prolonged exposure to non-pulsed Oxytocin)
• -reduce natural hormones that assist in lactation and bonding with baby
• -hormonal disruption can lead to reduced rates of breastfeeding
• -increased risk of epidura
• -higher intensity contractions
• -higher rate of complications in labor and delivery
• -higher rate of placental rupture and separation

AROM (Artificial Rupture of Membranes): Why is it Done, and What Does it Really Do?

An OB or midwife may recommend to their patient that they should perform an amniotomy (break the bag of waters) for any these reasons:

• in a stalled or prolonged (spontaneous) labor to "speed things up"

• to induce labor (either alone, or in conjunction with labor-inducing drugs) 

• to place an internal fetal monitor

• to check for meconium in the amniotic fluid in the case of fetal distress

Are these reasons evidence-based? Some are, yes. Others are not.

• As far as breaking the water to speed up labor goes, this is not based in any scientific fact. The evidence is actually against it. AROM has been debunked as a method of speeding up labor, with most studies saying that it does not significantly speed up labor, and if it does, it only shortens labor by maybe an hour, at most. The Cochrane Review on this subject states that "Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labor or where labors have become prolonged."

• When it comes to breaking the water as the sole means to induce labor, ACOG states that "Used alone for inducing labor, amniotomy can be associated with unpredictable and sometimes long intervals before the onset of contractions. There is insufficient evidence on the efficacy and safety of amniotomy alone for labor induction." Essentially, it's not reliable, may not be safe, and doesn't do what we've been told it's supposed to do (which is jump-start contractions and get labor going).

• If there is legitimate concern about fetal well-being, such as irregular heartbeat and signs of distress, it may become necessary to break the waters (if they have not broken already) in order to place an internal fetal monitor. In this case, the benefits (keeping a closer eye on baby and maybe saving baby's life) may outweigh the risks.

• This is the same as above. If there are real signs of distress, breaking the water to check for meconium can help you and your doctor to make the best decision, with all the facts in hand, about how to continue in your labor. If baby is truly distressed, has passed meconium, and there are other problems as well, you might need to have an emergency cesarean. This is not to say that it is impossible to vaginally have a healthy baby who has passed meconium in the womb (because it absolutely is, and about 20% of babies after 40 weeks gestation will pass meconium as their bowels reach maturity and begin to work), but it can be a red flag for complications. 

So what are the risks of amniotomy/AROM/breaking the water? Why would you not want it performed?

• It may increase the strength and intensity (and pain level) of contractions, because it essentially removes the cushion of fluid from around the baby, and causes baby's head to come into more direct contact with mom's cervix (ouch!). This can lead to mom asking for pain medications, such as an epidural, which leads to less physiological labor and pushing positions, which leads to other interventions...well, you see where this is going. The old "cascade/slippery slope."
• The baby may go into distress due to compression of the cord, the placenta, or the baby him/her self.
• Studies have found that amniotomy can alter fetal vascular blood flow, which suggests that there may be a fetal distress response to AROM.
• AROM may cause what is called "cord prolapse," which happens when baby's head is not engaged when the waters are broken, and the cord is swept out of the cervix by the fluid and baby's head then comes down, compressing the cord and cutting off baby's blood/oxygen supply. This is a severe emergency situation, and the baby must immediately be born by cesarean. This is a life-or-death complication that can be directly caused by medical intervention (AROM).
• There may be a blood vessel running through the membranes, and if that vessel is is ruptured by the amni-hook during AROM, the baby could lose a lot of blood, fast. This is another emergency situation that requires a cesarean, caused directly by an intervention.
• There is a (very slight) increase in the risk of infection after AROM, but this is more of a risk to mom than baby, and the risk is greatly reduced if nothing is introduced into the vagina during labor (as with cervical checks, etc.).
• Early amniotomy, on its own, increases your risk of having a cesarean delivery.

To sum up, AROM increases your risk of fetal distress, infection, cord prolapse, cesarean section, maternal and fetal blood loss, and opens the door for further interventions, which themselves carry risks. AROM does not, as some will tell you, significantly speed up a stalled labor, and it is not effective/reliable as a method of labor induction, either. So unless there is a life-threatening or possible emergent situation, it is best to leave the waters intact and not artificially break them. There are too many risks, and not enough evidence of any benefits, to justify AROM without a medical necessity.

1. Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged. - See more at: http://summaries.cochrane.org/CD006167/amniotomy-for-shortening-spontaneous-labour#sthash.tyjUw2Pr.dpuf
   Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged. - See more at: http://summaries.cochrane.org/CD006167/amniotomy-for-shortening-spontaneous-labour#sthash.tyjUw2Pr.dpuf
   Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged. - See more at: http://summaries.cochrane.org/CD006167/amniotomy-for-shortening-spontaneous-labour#sthash.tyjUw2Pr.dpuf
   Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged. - See more at: http://summaries.cochrane.org/CD006167/amniotomy-for-shortening-spontaneous-labour#sthash.tyjUw2Pr.dpuf
   Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged. - See more at: http://summaries.cochrane.org/CD006167/amniotomy-for-shortening-spontaneous-labour#sthash.tyjUw2Pr.dpu

It's Official!

As of October 5th, 2013, I am signed up for my birth doula training through Childbirth International! It feels surreal to have finally taken that first, big step. I'm ready to get this thing going! As soon as I hear from my trainer, I'll be getting started on the coursework. I've already done some reading on the student website, and I'm loving everything I've seen so far. This organization has such an unbiased, realistic philosophy and approach to pregnancy, childbirth, and the postpartum period, and I've already learned so much just from reading the section on the importance of communication. I'm going to grow so much as a person through the course of this.

I also have more news! I have a client! She is due Nov. 2nd of this year, and we have already had our preliminary meeting to discuss her wishes and form a birth plan! We seem to be very much on the same page philosophy-wise, and I cannot wait to support her in her labor and birth.

So many exciting things are happening in my life right now, and I could not be happier! Now, on to the next blog post! :-)

Why You Should Wait Until At Least 39 Weeks Before a Planned Induction or Cesarean

***I'm going to post a little disclaimer here and now before continuing: This post does not include medically indicated/necessary early inductions or cesareans. I am only covering elective inductions and cesareans (and RCS) in this post. Please keep that in mind as you read. Thank you.***

The end of pregnancy is a trial. You're exhausted, you feel horrible (no matter how easy a pregnancy you've had), and you want nothing more than to meet your baby and get it over with. That's normal, understandable, and totally okay. But if you're considering inducing or having a c-section (repeat or primary), there are a lot of good reasons to wait until you are at least 39 weeks.

Did you know that some experts estimate that at least 50% of deliveries between 36-39 weeks are scheduled? Is this evidence based? Does this include medically necessary inductions and c-sections? No, not really.

Did you know that at least 1 in 3 first-time moms is induced? Did you know that inducing increases your chances of having a cesarean birth? Do you know by how much? Do you know what crucial developments happen for your baby in the last few weeks of pregnancy? Here are some statistics:

• At least one-third of these inductions have no medical indication. First-time mothers who are induced at term for no medical reason have a C-section rate of approximately 24%, with the largest percentage of these Cesareans being performed in early labor—before the woman reaches 6 cm. 
• The average gestation of a first-time pregnancy worldwide is 41 weeks, 1 day.
• First-time mothers who undergo elective induction of labor are twice as likely to have a C-section as those who go into labor on their own.
• A significant percentage increase in both C-section deliveries (67% increased risk—that’s big), and NICU care (64% increased risk), for women and their babies who undergo non-medically necessitated inductions.

So, if induction itself, even at term, presents such risks, why are women so quick to request an early induction? And what are the risks associated with inducing prior to 39-40 weeks' gestation, and why is this happening?

• Your baby’s brain grows 35 percent between 34-41 weeks.
• A full-term pregnancy lasts 40 weeks, but elective deliveries are often planned for two or three weeks earlier. And even though 37 weeks is also still considered full term, studies show that babies born even a few weeks too early are at greater risk for health problems than those who are born later. That has some doctors campaigning to curb the trend of scheduled labor and delivery.
• More than 25 percent of infants born electively between 37 and 39 weeks required admission to the neonatal intensive care unit (NICU) for an average of 4.5 days, compared with fewer than 5 percent of infants who were delivered at 39 weeks or later, according to a recent study published in the American Journal of Obstetrics & Gynecology.
•  Labor inductions can set in motion a chain of events that ultimately make a C-section more likely. First-time mothers who have had their labor induced double their risk of requiring an emergency C-section, which typically results in a longer recovery period for mom, according to a recent study in Obstetrics & Gynecology.
•  A recent study by the March of Dimes, National Institutes of Health and the Food and Drug Administration found the risk of death -- however small -- more than doubles for infants born at 37 weeks compared to those carried to a full 40-week term.
•  Most women give birth between 38 and 42 weeks of pregnancy. But very few babies are born on their due dates. It is normal to give birth as much as 3 weeks before or 2 weeks after your due date 
• 10 to 15 percent of all births in the U.S. are "early elective" deliveries (meaning prior to 39 weeks' gestation, via cesarean section or induction, without a clear medical reason), two new studies find -- and some hospitals report that number is as high as 44 percent. But, the American College of Obstetricians and Gynecologists (ACOG) staunchly advises against elective deliveries before 39 weeks.
•  Most recently, a study published in the journal Pediatrics in early July, involving more than 100,000 New York schoolchildren, found that children born at 37 or 38 weeks did worse on third grade math and reading tests than kids born just a week or so later. The study showed that 2.3 percent of the children born at 37 weeks had severely poor reading skills, compared with just 1.8 percent of children born at 41 weeks; that's a 33 percent increased chance of severe reading difficulty. They also had a 19 percent greater chance of having moderate problems in math.
•  The last few weeks of pregnancy are critical to both lung and brain development. Complications of elective deliveries between 37 and 39 weeks include:
  
• Increased NICU admissions
• Increased respiratory distress and TTN
• Increased need for ventilator support
• Increased rate of sepsis
• Increased feeding problems 

• Babies born too early may have more health problems at birth and later in life than babies born later. Being pregnant 39 weeks gives your baby's body all the time it needs to grow.
  Here's why your baby needs 39 weeks:
• Important organs, like his brain, lungs and liver, get the time they need to develop.
• He is less likely to have vision and hearing problems after birth.
• He has time to gain more weight in the womb. Babies born at a healthy weight have an easier time staying warm than babies born too small.
• He can suck and swallow and stay awake long enough to eat after he's born. Babies born early sometimes can't do these things.

Those are some pretty good, science-based, reasons to wait (at the very least) 39 weeks before scheduling your child's birth. If you're considering inducing or scheduling a cesarean, these are definitely some points to consider when it comes to timing.

Other Myths Surrounding Pregnancy, Labor, and Birth:Fact or Fiction?

Time for miscellaneous myths surrounding pregnancy and birth!

• Your pregnancies and births will be just like your mom's: FALSE? TRUE? PLAUSIBLE.
• There is no way to know. If you are built exactly like your mom, your pregnancies take the same course as your mom's did, and you choose to labor the same way and your babies are in the same position as your mom's were, then yes, you have a good chance of your pregnancies and births being just (or at least a lot) like your mom's. But like everything concerning birth, there is no guarantee. I've known some moms who had all (necessary) cesareans, but their daughter(s) went on to have all-natural, uncomplicated vaginal births, and vice versa. Genetics may play a part, but they don't ensure that anything will go the way you "expect," just because it happened that way with your mom.

• Pregnancy and birth are inherently dangerous: FALSE, but also kind of TRUE
• This is difficult. I like to answer this with the phrase I heard somewhere once that says, "Birth is as safe as anything gets in life." There are always risks with anything, and birth is no different. Yes, birth is a natural, biological process that all mammals are made to go through, but that's not to say that nothing can or will go wrong. What you have to look at are the things that can go wrong, how likely they are to happen, and how they apply to you and your situation. If you are of average weight, normal blood sugar, blood pressure, active and somewhat fit, no previous abdominal surgeries or medical conditions, you have an extremely low chance of dangerous complications in pregnancy and birth. If you have maybe one or two things wrong (like gestational diabetes, or high blood pressure, or a scar from a surgery, etc), you still aren't very likely to experience serious complications. 
• Think of it this way: just because there is a risk, however slight, involved, that does not make the thing itself (birth) dangerous, and there are things that can be done (good prenatal care, taking good care of yourself during pregnancy and before conceiving, etc.) to improve your chances.
• Viewing birth as inherently dangerous and a thing to be to be feared does nothing but perpetuate myths and, well, fear. Fear doesn't help. If you view birth as normal, and only to be seen as dangerous if legitimate warning signs show up, you increase your chances of nothing going wrong. It's surprising what fear can do to sabotage your efforts and create problems where there aren't any. Our induction, c-section, and maternal/fetal morbidity rates can vouch for that.

• Home birth is inherently dangerous, and hospitals are the safest place to give birth, with no downsides or risks: BOTH TRUE AND FALSE ON ALL COUNTS


• "Home birth compared to hospital birth.
  One systematic review from the Cochrane Collaboration (Olsen and Jewell 2004) found just one randomized controlled trial comparing home to hospital birth. That study showed that women could be randomized to home birth, but included too few women to interpret the results.
  
  Another review pools the experiences of over 24,000 women from six controlled observational studies comparing planned home birth with modern hospital back-up to planned hospital birth (Olsen 1997). Observational study designs are less definitive than controlled trials. Two of the six included studies were done in the U.S. The pooled home and hospital groups had a similar rate of death for babies after 20 weeks of pregnancy or in the first four weeks after birth. No maternal deaths occurred in either group. The following outcomes favored the home birth group:
  • fewer low Apgar scores (rating newborn well-being)
  • fewer severe tears in the mother's perineum (tissue around the opening of the vagina).
  
  Because of important differences in conditions of the studies, the reviewer did not pool data on rates of interventions. Individual included studies found that women in the hospital groups had higher rates of artificially induced labor, artificially stimulated labor, episiotomy, cesarean section, use of forceps or vacuum extractor, and other interventions.
  
  The author concludes that (1) no good evidence exists to support the view that planned home birth with an experienced caregiver and hospital back-up is less safe than planned hospital birth, and (2) planned home birth may have advantages." 
• Source for the above quote:  http://www.childbirthconnection.org/article.asp?ck=10142
•  That pretty much sums things up. For healthy, low-risk moms, a home birth is no more or less safe than a hospital birth according to the available statistics, and includes a far, far lower risk of interventions (which often lead to complications created by said unnecessary interventions). It is very, very difficult to conduct studies that definitively determine the safety of home birth vs. hospital birth, seeing as only 1% of births occur at home. 
• But if you think about it, 99% (approximately) of births occur in hospitals, and we have a 1 in 3 (and climbing) cesarean rate, 1 in 3 (and climbing) induction rate, at least 60% of women will have an epidural, upwards of 80-90% receive continuous monitoring, over 90% labor and push on their backs, are refused food and water during labor, have routine iv fluids, and so on and so forth. None of this is evidence-based practice, yet it happens every day, and no one thinks to question whether hospital births might carry risks, as well? 
• Another thing to think about is that hospitals are not the sterile, sanitary environments they are made out to be." About 1 of every 20 patients gets an infection while hospitalized and up to 98,000 Americans die from these each year." Is that really what we consider to be "the safest" environment in which to give birth? 
• The benefits of hospital birth absolutely outweigh the risks in moms with health concerns or red flags for potential issues in birth, and it's always a good idea to be in close proximity to a hospital if you are planning a home birth in the event a complication should arise and a transfer become necessary, but to say that there are no risks whatsoever to hospital birth is absurd. All you have to do is look at the most common maternity care practices (and statistics), the fact that they are overly practiced, non-evidence based, and don't improve outcomes, and how high the risk of you or baby being exposed to infection that has nothing to do with childbirth, and you'll see that neither choice (home or hospital) is without risks. What you have to do is assess your situation with your care provider, and make the best choice for you.
• Sources:  http://summaries.cochrane.org/CD000352/benefits-and-harms-of-planned-hospital-birth-compared-with-planned-home-birth-for-low-risk-pregnant-women , http://www.naturalnews.com/036279_hospital_births_risk_injury.html , http://articles.mercola.com/sites/articles/archive/2012/07/26/hospital-birth-vs-home-birth.aspx , http://www.ncbi.nlm.nih.gov/pubmed/20572620 , http://www.nbcnews.com/health/home-births-rise-pediatricians-group-sets-new-guidelines-6C9652075 , http://chriskresser.com/natural-childbirth-i-is-home-birth-more-dangerous-than-hospital-birth , http://mamabirth.blogspot.com/2011/10/obstetric-lie-87-home-birth-is.html , http://birthwithoutfearblog.com/2011/10/26/home-birth-is-3-times-more-dangerous-than-hospital-birth-or-is-it/ , http://vbacfacts.com/hbac/ , http://www.bmj.com/content/330/7505/1416.long

• "Don't VBAC, your uterus will explode!" "Once a cesarean, always a cesarean." "Multiple c-sections are 'the safer option'": FALSE, FALSE, and FALSE (in most cases)
• We'll start with VBACs. This is one of the most talked about myths that is really, truly false. There is less than a 1% chance of uterine rupture associated with a TOL (trial of labor) after one or two (low transverse incision) cesareans. And that less than 1% includes the "window ruptures" (uterine dehiscence), which are not complete ruptures, but rather small openings that do not go all the way through the uterus, and are not associated with any real complications and do not require repair. "According to the National Institutes of Health, 992-993 women out of 1,000 give birth without the complication of a uterine rupture. In comparison, more women without a prior cesarean are at risk for unpredictable complications including placental abruption, umbilical cord prolapse, and shoulder dystocia."  You are more likely, in a first, vaginal birth, to have complications like placental abruption, cord prolapse, and shoulder dystocia, than you are to have your uterus rupture in a VBAC. 
• And as I stated before, within that approximately 1% of VBAC mothers who experience a rupture, only a very small percentage of those are complete ruptures with severe complications. "Limited evidence suggests that there is a 2.8 – 6.2% risk of infant mortality after a uterine rupture."  So in the event that you fall into that 1% (or less) of those who experience a rupture, there is still only a 2.8-6.2% risk of death to the baby. Do you realize how small that risk really is, especially when compared to the risks to both mother and baby that are associated with a repeat cesarean? When you compare the "risks" of a typical VBAC with the risks of a completely normal pregnancy and birth, or a scheduled cesarean (repeat or primary) it really puts things into perspective. 
• There aren't many studies done on VBACs after more than 2 or 3 previous cesareans, or VBACs with a vertical (classic) incision, but there are success stories out there. If you fall into that category, you should find a VBAC supportive care provider and discuss your case with them, because it's hard to make any judgement calls on the safety of attempting a VBAC when there is so little real research out there (due to how uncommon it is for a mom to attempt a VBAC under those circumstances these days). Basically, a VBAC is no higher risk than any other pregnancy preparing for a vaginal birth.
• Some sources: http://www.guideline.gov/syntheses/synthesis.aspx?id=25231 , http://health.usnews.com/health-news/family-health/sexual-and-reproductive-health/articles/2010/07/22/vaginal-birth-after-c-section-4-factors-to-consider , http://www.childbirthconnection.org/article.asp?ck=10210 , http://vbacfacts.com/2012/04/03/confusing-fact-only-6-of-uterine-ruptures-are-catastrophic/
• Now we get to the old adage, "once a cesarean, always a cesarean." It's simply not true in the majority of cases. A minimum of 60-80% of women will be successful if they attempt a VBAC, and at least 90% of women with one or two previous cesareans are good candidates for VBAC. If the old saying (that so many doctors cling to) were true, that would not be possible. Also, ACOG has come out recommending VBACs as the safer option for moms who are good candidates, and that it should be offered as a viable option.
• Source:  http://www.acog.org/About%20ACOG/News%20Room/News%20Releases/2010/Ob%20Gyns%20Issue%20Less%20Restrictive%20VBAC%20Guidelines.aspx
• And our last point, the myth that "multiple cesareans are safer than attempting VBACs." I've already discussed the risks associated with VBAC, and how small they really are, especially when you compare them to the risk of any complications in a normal pregnancy and birth (with no prior cesareans). Here's a little comparison from http://vbacfacts.com/2012/04/11/best-compilation-of-vbac-research-to-date/ :
  "While rare for both TOL [trial of labor after cesarean] and ERCD [elective repeat cesarean delivery], maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7 1,000 versus 0.3 1,000 ERCD). Six percent of uterine ruptures were associated with perinatal death. Perinatal mortality was significantly increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD… VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans… The occurrence of maternal and infant mortality for women with prior cesarean is not significantly elevated when compared with national rates overall of mortality in childbirth. The majority of women who have TOL will have a VBAC, and they and their infants will be healthy. However, there is a minority of women who will suffer serious adverse consequences of both TOL and ERCD. While TOL rates have decreased over the last decade, VBAC rates and adverse outcomes have not changed suggesting that the reduction is not reflecting improved patient selection." And to back that up, here's an infographic illustrating the different risks associated with multiple RCS and VBAC: 

 

• Think about it this way: a cesarean section is major surgery, with all the risks and potential complications that entails. The more c-sections you have, the higher your risks are going to become. But with each successful VBAC, those risks go down. So in general, a VBAC is the safer choice than a repeat cesarean, especially if you want a large family. There are exceptions, of course, where a cesarean really is the safer option and the benefits outweigh the risks, but that is not the norm.
•  Sources: http://www.webmd.com/baby/news/20060607/more-c-sections-more-complications , http://blog.ican-online.org/2010/06/01/peril-of-multiple-c-sections/ , http://vbacfacts.com/2009/08/03/risk-of-serious-complications-increase-with-each-cesarean-surgery/ , http://givingbirthwithconfidence.org/2-2/a-womans-guide-to-vbac/weighing-the-pros-and-cons/ , http://www.childbirthconnection.org/article.asp?ck=10166

• Your body will bounce right back after giving birth: FALSE
• Come on. It took you nine (approximately) months to grow this child and for your body to change this month. Do you really think it's going to immediately go back to the way it was before? If it does, you are one of a very tiny (no pun intended) minority. Most women should expect to take at least as long as their pregnancy lasted (usually closer to a year after birth) for their bodies to truly recover. It also depends on what your fitness level was pre-pregnancy, as well as your weight gain while pregnant, what kind of birth you had, your recovery, your postpartum activity level, and the like. There are too many factors involved for there to be any definitive "rules" regarding the length of time it will take a woman to "bounce back." And that's normal, and okay.

• Doctors know exactly what it is that triggers natural, spontaneous labor, and can replicate it exactly when inducing: FALSE
• Well, kind of false. There are some pretty good theories and studies, but they don't all agree. Some say that it has to do with fetal adrenal glands, others sat that it is a protein secreted by the lungs once they're mature (and lungs are the last things to mature in a growing fetus, so that makes sense, right?), some say that the key is that tiny micro-fragments of RNA (DNA’s single-stranded cousin) in the uterus become extra active at the end of pregnancy. As circulating progesterone levels fall, these miRNA pieces are expressed strongly. The miRNA affect two important genes (ZEB1 and ZEB2). These two genes keep labor at bay, because they keep levels of contraction-inducing hormones, like oxytocin, down. Rising miRNA block the two genes, letting oxytocin loose, and labor beings.  There are still other studies that say it is a combination of some or all of the above. So yes, doctors have some very, very good ideas about what triggers the onset of spontaneous labor, but none have pinned it down completely definitively, and they are all difficult to predict. So even if they know what will cause it, that doesn't necessarily mean that they can predict when it will start, and they can not replicate it exactly while inducing. 
• Sources:  http://www.news-medical.net/news/2009/04/01/47759.aspx , http://www.drmomma.org/2008/01/fetal-lungs-protein-release-triggers.html , http://mamasandbabies.blogspot.com/2010/07/what-triggers-spontaneous-labor.html

• Breastfeeding is easy: FALSE
• I can vouch for this. I have one inverted nipple and one flat nipple, and my firstborn had nothing to latch onto. I had to pump to even give her anything to latch onto, and since my body apparently doesn't "let down" for pumps, my supply was greatly compromised and I had to supplement her with formula, even after we achieved a good nursing relationship (when she was 13 weeks old). My supply never recovered. With my second, she has an undiagnosed upper lip tie that caused her to have what seemed (on the outside) to be a good latch, but inside she was compressing my nipple, and I ended up with severely cracked nipples and real injuries (she took a chunk out of one, essentially, and I now have a scar). So I started pumping, and again, my supply disappeared. I tried nursing her again once I had healed, but she refused to latch on. 
• You would think breastfeeding would be the easiest and most natural thing in the world, but just as some women require help to give birth (either induction, vacuum, forceps, or cesarean) because their bodies have trouble, so some women have problems breastfeeding. And even if it does come naturally for you, that does not make it "easy." You are the only one who can feed your baby, it is physically exhausting, and for the first few weeks (sometimes months), you feel like baby is nursing around the clock, because their stomachs are so small that they need regular nourishment, and this "cluster feeding" helps to build your supply and help your milk come in fully. Even in the best of breastfeeding situations, there is difficulty. 

• Everything in your pregnancy and birth will go according to plan: FALSE
• Birth is unpredictable. There is just no way to know what will happen. It is not a controllable situation. There are things you can do to ensure things go as close to your plan as possible (supportive care provider, setting you feel comfortable in, a solid plan, lots of education, a doula, etc.), but there are no guarantees. So be prepared and armed with information about your preferences should you have to diverge from your ideal plan, and it can still be a positive experience. Don't let anyone dissuade you from forming a plan, though; just include your wishes should things go off-track within your plan.

• Vaginal exams pose no risks: FALSE
• I addressed this in a previous post about dilation before labor starts. Vaginal exams increase the risk of infection (before or after your water breaks), accidentally breaking your water, and starting labor (which can be a bad thing if you're only 36 weeks, which is when most care providers offer/perform routine vaginal exams). There is no information to be obtained about your body's ability to give birth, or when labor will start, from a vaginal exam. Even vaginal exams in labor may be unnecessary, as there are other, less invasive methods of assessing dilation. Also, vaginal exams are only about 48-56% accurate, so why rely solely on them, anyway?
•  Some more sources: http://birthwithoutfearblog.com/2013/06/06/alternative-methods-of-checking-dilation-the-purple-line-and-more/ , http://www.scienceandsensibility.org/?p=5547 , http://pregnancy.about.com/cs/interventions/a/vaginalexam.htm , http://www.scienceandsensibility.org/?p=5673 , http://midwiferyramblings.blogspot.com/2011/01/vaginal-exams-why-they-are-unnecessary.html , http://www.pregnancy.org/article/are-vaginal-exams-pregnancy-necessary 

• Midwives are not as competent as OB, and an OB is the best choice for your care provider. OR: all doctors are evil, and all doctors and midwives have the same birth philosophy: FALSE, and FALSE
• Let's just specify this here and get it out of the way: OB's are surgeons. Their training is to see, prevent, and (failing at prevention) deal with problems medically. Midwives don't do c-sections, but they can usually do most everything else. They are specifically trained in birth itself as a natural process, not a medical condition. They are just as competent as an OB; their training is simply different. And if you are being cared for by a midwife (whether at home or in a hospital or birth center), she will know when things have moved out of her abilities and will get an OB (or transfer you). So OB = surgeon and sees birth medically, and midwife = birth professional who sees birth as normal and cannot perform surgery.
•  As to whether an OB or a midwife is the best choice for you, that's your choice. Not all midwives are created equal, and neither are all OB's. What you have to do is decide what your ideal birth would be, what options and providers are available to you, and which of those fit into your insurance/preferences, and find the one whose philosophy best blends with yours. Your medical condition can sometimes make that decision for you. A lot of midwives do not take high-risk mothers due to the likelihood of medical interventions becoming necessary, and in that case it's best for you to be in the hands an OB.
• No, not all doctors are evil. And some midwives certainly are. As I said above, none are created equal. There are some OB's who are more naturally-minded than some midwives out there. You can go to a practice with multiple OB's or midwives, and no two of them will have the exact same philosophy, even though they all practice together. You have to give yourself the time to interview care providers and find the one that fits best for you. 

• Pitocin is risk-free: FALSE
• This could not be more false. Doctors would have you believe that pitocin is this miracle drug that starts your labor just like if it were spontaneous labor, and has zero negative side effects and won't have any effect whatsoever on your baby. In fact, it makes for longer, stronger, harder contractions, which put a lot of stress on baby (and can cause fetal distress and oxygen problems), and make the contractions more painful and harder to bear than natural contractions. That's the short list of side effects. It also isn't approved by the manufacturer or the FDA for use in elective inductions. What does that tell you? I'll leave the rest to my sources. Suffice it to say that it is not a miracle drug, there are risks, and if your doctor says otherwise, you need a new doctor. 
•  Some serious sources: http://www.jhppharma.com/products/brands/pitocin.php , http://www.acog.org/About%20ACOG/News%20Room/News%20Releases/2013/Study%20Finds%20Adverse%20Effects%20of%20Pitocin%20in%20Newborns.aspx , http://www.rxlist.com/pitocin-side-effects-drug-center.htm , http://www.naturalnews.com/033259_pitocin_ADHD.html , http://evidencebasedbirth.com/crank-up-the-pit-2/ , http://www.autismspeaks.org/blog/2012/06/01/autism-pitocin-connection , http://abcnews.go.com/Health/study-pitocin-harm-babies/story?id=19148043 , http://www.huffingtonpost.com/2013/05/07/pitocin-risks_n_3224811.html , http://www.sicklycat.com/2012/05/24/21-reasons-to-say-no-to-pitocin-according-to-manufacturer/

• All of your pregnancies and labors will be the same (if you tore/had a c-section/had any complications/etc. once, it will definitely happen the next time): FALSE
• Again, I know from experience that this is not always true. My two pregnancies were very different (though they did have some similarities). I went into labor very clearly/obviously with my first and labored for 11 hours, and with my second I had prodromal labor for 3 weeks and a false labor scare, and my active labor was only 4 hours long. They differences were like night and day. Just from my own experience, I can tell you that no two pregnancies are guaranteed to be the same. 
• You may have had a completely natural, unmedicated labor and birth for your first, but you might develop pre-eclampsia with your next and have to be induced or have an emergency c-section. Or, you could have a c-section for "failure to progress" with your first, and go on to have a successful VBAC with your second. Anything can happen, and to expect all of your pregnancies and births to be exactly alike is absurd. That's not to say that they definitely won't be similar, though. Some moms do experience that. It's just not a guarantee. Sure, if you're healthy and take care of yourself, and your body "takes to" pregnancy and birth well, you're more likely to have all uncomplicated deliveries, but again, nothing is for sure.  

• Multiples pregnancy = automatic c-section: FALSE
• Many, many studies are coming out now that show that planned cesareans do not improve outcomes for twins, and vaginal births do not pose any more risks than a cesarean. If twin A is in a good position for delivery, even if twin B isn't, there is no reason not to attempt a vaginal delivery of twins.
• Sources needed to back this up:  http://www.ncbi.nlm.nih.gov/pubmed/7234227 , http://www.webmd.com/baby/cesarean-section-in-multiple-pregnancy , http://www.fitpregnancy.com/pregnancy/labor-delivery/ask-labor-nurse/how-safe-vaginal-birth-twins , http://www.futurity.org/c-sections-no-safer-for-twin-births/ , http://www.sciencedaily.com/releases/2013/02/130211102207.htm , http://www.ctvnews.ca/health/health-headlines/c-sections-not-better-for-twin-births-canadian-study-says-1.1160754
•  There isn't a whole lot of information out there about birthing more than 2 babies vaginally, but I did find a fun success story of a mom who delivered triplet girls vaginally in the hospital! It seems that the same rule applies here: If baby A is head down, and everything else looks good (no emergencies), why not give a vaginal birth a try?

• Bigger hips mean you will have an easy delivery, and narrow hips mean you'll need a c-section: FALSE
• "You can't judge a book by its cover." This applies to women's shape in regards to birth. There really is just no way to know if a baby will "fit" by looking at mom's hips. The female pelvis has a remarkable ability to open up to allow a baby to pass through. It's as simple as that.
• To back that up, some stories, as usual. I have decently proportionate hips (not too big, not too small), but most people would classify them as narrow. I quickly and easily gave birth (vaginally with no complications other than some tearing) to two Occiput Posterior babies, and that positioning is supposed to make for longer, harder births, and some doctors will do a c-section if they know baby's in that position, without even allowing a trial of labor. I'm proof that a labor that would be "difficult" for any woman can be easy, and I had narrow hips. If I had been judged based on that, I would never have been allowed to deliver vaginally. I know some women who are teeny-tiny and have no trouble giving birth, and some who have "birthing hips" and needed assistance (vacuum, forceps, cesarean) to give birth.
• A lot of these "baby won't fit stories" have less to do with the actual shape and size of mom's pelvis, and more to do with her positioning for labor and pushing. I've already talked about how the supine position over 90% of women are forced to labor/push in is counter-productive. It effectively closes the pelvis, or at least prevents it from forming as big an opening as it is capable of, which often leads to a diagnosis of "small pelvic opening" and a cesarean. Also, epidurals can make for less effective pushing (you can't feel what you're doing!), especially in first-time moms, which can also lead to the "inadequate pelvic opening" diagnosis and a cesarean.
• Sources:  http://thebirthteacher.blogspot.com/2008/12/shes-got-good-birthin-hips.html , http://www.bellybelly.com.au/birth/small-pelvis-big-baby-cpd#.UjDhFT_y1pA

• The US has the best maternity care system in the developed world: FALSE
• I'm going back to my favorite infographic for this. It really says it all. 

 

• Also, does that fact that this blog (and sites like improvingbirth.org and evidencebasedbirth.com) exist not say enough about the state of our maternity care system to put that myth to rest?

• Gestational Diabetes and Pre-Eclampsia mean automatic inductions (or c-sections): TRUE (for Pre-Eclampsia), and FALSE (for Gestational Diabetes)
• First, Pre-E. It is a very dangerous condition that included high blood pressure and protein in the urine, which can be deadly to mom, and the only cure is delivery of the baby. If your condition isn't too severe and you're close to your due date, your doctor will probably induce. Yes, induction raises the chance of a c-section, but the benefits to saving mom and getting the baby out safely far outweigh the risks in this circumstance.
• Sources: http://umm.edu/health/medical/pregnancy/specialcare-pregnancies/preeclampsia-2 , http://www.marchofdimes.com/pregnancy/preeclampsia.aspx
•  On to GD.  The theory that induction of labor in moms with well-controlled GD improves outcomes for mother and baby is not supported by evidence. Yes, fetal macrosomia is more likely in women with GD, but a "big baby" alone is not enough of a reason to induce or perform a cesarean, as I have already talked about. There may be other complications, such as Pre-E, high blood pressure, birth defects, low blood sugar and jaundice in the infant, and stillbirth (worst case scenario) if GD is untreated or not controlled, so it is imperative for a mother with GD to receive adequate prenatal care to keep her GD under control and improve her odds of a spontaneous vaginal birth.
• Sources:  http://evidencebasedbirth.com/does-gestational-diabetes-always-mean-a-big-baby-and-induction/ , http://www.marchofdimes.com/pregnancy/gestational-diabetes.aspx

• Recovery from c-sections and vaginal births are "the same": FALSE
• I'm not even going to go into detail on this. There is no need. C-section births are major surgery, and vaginal births are not. Therefore, the recovery processes for each are different. And each mom who has a cesarean will react to and recover from it differently, as will moms who have vaginal births. There are too many factors that can influence recovery to count. But my point is this: cesarean births and vaginal births happen differently, and therefore recover differently.

• Inducing increases your chance of c-section: TRUE
• By 40-50%, to be exact. Here's a table that illustrates the factors that can increase your risks of a c-section, including induction and epidurals (which women are statistically more likely to get in an induction than in spontaneous labor):

• A suspected "big baby" is a legitimate reason for induction or planned c-section: FALSE
• I've already blogged about this one. It drives me crazy when I hear that someone is planning an induction or cesarean for suspected macrosomia (big baby), and no other reason. The evidence is definitively against this practice. Not even going to go into this in further detail, as I have already blogged about it, but I will cite some good sources.
• Sources: http://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/ ,  http://www.childbirthconnection.org/article.asp?ck=10456 , http://www.improvingbirth.org/2013/03/march-20-2013-news-from-acog-re-elective-procedures/ , http://www.peacefulbirthing.org/topics-of-interest/what-is-the-evidence-for-induction-or-c-section-for-a-big-baby-2/ , http://sarahockwell-smith.com/2012/11/04/big-babies-the-curse-of-mis-diagnosing-a-macrosomic-infant-part-1/ , http://summaries.cochrane.org/CD000938/induction-of-labour-for-suspected-fetal-macrosomia

Labor and Birth Myths: Fact or Fiction?

This post will be all about myths surrounding labor and birth! Again, if there's anything that you'd like me to address that isn't covered in this post, let me know and I'll look into it!

• Routinely pushing and/or laboring on your back is the best way to labor and give birth: FALSE
• Oh, oh, oh, this could not be more false. Think about it: you want the baby to descend into the birth canal, put pressure on your cervix so that you will dilate and efface, and for your pelvis to open up and stretch so that baby has room to come out, right? So, how does it make sense to lie back (forcing baby and your body to work without the help of gravity), and have your legs together in bed while laboring (which doesn't exactly open your pelvis), and push while supine (which keeps your pelvis closed and again takes away the benefit of having of gravity working for you). The best, most physiological positions for labor and birth are standing, side-lying (with the legs open, usually with the help of your OB/midwife/nurse/doula/partner), sitting on a birthing ball, squatting, and on hands and knees. The pelvis can open wider this way, which facilitates descent of the baby and mother's dilation/effacement, and reduces the likelihood of things like tearing, poor fetal positioning, back labor, and baby getting "stuck." Movement in labor (such as walking, rocking, crawling, and swaying) are also good pain management techniques.
• Here are some sources on the matter:  http://evidencebasedbirth.com/what-is-the-evidence-for-pushing-positions/ , http://www.birthingnaturally.net/birthplan/options/push.html , http://www.bestchance.gov.bc.ca/birth/preparing-for-labour/comfort-positions-during-labour.html

• You should not have food or drink while in labor: FALSE
• This is an old myth. It comes from the idea that a woman can aspirate (essentially vomit and it goes into her lungs, to put it simply and bluntly) if she has to be put under general anesthesia during labor. Good reason, right? Well, not really, actually. The likelihood of that occurring is less than the likelihood of being struck by lightning. And even if your stomach is empty, that is no guarantee that you will not throw up stomach acid (I certainly did in my first labor), which will get into your lungs and cause the real damage if you aspirate. Also, fasting during labor has been associated with longer and more painful labors, maternal exhaustion and low blood sugar issues, and dehydration. IV fluids can help, but they're not the same, and they carry some risks. And the likelihood of actually needing general anesthesia to perform a cesarean is miniscule, due to our modern advances in regional anesthesia (spinal block, epidural, etc), so this notion is quite outdated. 
• So then, why are we adhering to a practice that has no basis in evidence, and is doing more harm than good? Luckily, policies are starting to change, thanks to recent studies. I personally was allowed to drink as much water as I wanted while in labor with my second (I did not want to eat due to vomiting, and my labor was fast anyway), and it made a world of difference.
• Good articles and sources with recent studies: http://evidencebasedbirth.com/q-a-food-and-drink-during-labor-9/ , http://summaries.cochrane.org/CD003930/eating-and-drinking-in-labour , http://www.ncbi.nlm.nih.gov/pubmed/21073829 , http://www.sciencedaily.com/releases/2010/01/100119213043.htm

• Routine, continuous fetal monitoring is beneficial and improves outcomes for mother and baby: FALSE
• There is no evidence supporting continuous fetal monitoring in healthy, low-risk mothers. In fact, it can increase the risk of instrument-assisted birth (forceps or vacuum) and cesarean section. It limits a mother's ability to move, which increases her likelihood of requesting pain medication due to being immobile and unable to deal with contractions, which in turn can slow labor and increase the risk of interventions. Also, the monitoring is not always accurate and can have "false positives" for fetal distress. There are of course circumstances where continuous monitoring can be beneficial (pre-eclampsia, some VBACs, or any high-risk situation), but it has been proven that it does not improve outcomes when used on low-risk mothers; rather, it increases the likelihood of intervention.
• Sources: http://evidencebasedbirth.com/evidence-based-fetal-monitoring/ , http://www.medpagetoday.com/OBGYN/GeneralOBGYN/14840 , http://www.uspreventiveservicestaskforce.org/uspstf/uspsiefm.htm , http://evidencebasedbirth.com/q-a-continuous-electronic-fetal-monitoring-2/ , http://www.childbirthconnection.org/article.asp?ck=10201 , http://apps.who.int/rhl/pregnancy_childbirth/childbirth/routine_care/cd006066_nardinjm_com/en/ , http://summaries.cochrane.org/CD000116/fetal-electrocardiogram-ecg-for-fetal-monitoring-during-labour

• Modesty will matter to you when you're in labor and giving birth: FALSE
• Don't worry, I was freaked out about this, too. I was worried about having my nether regions on display while being checked, pushing, and everything in between. I didn't want everyone in the room (I think there were four nurses, my husband, and my OB in the room with my first was born) staring at my ... you know. But when the time came, I honestly didn't care. I didn't think twice about having my L&D nurse down there helping to stretch me and using perineal counterpressure as I pushed. I didn't even think about it. Second time around, I cared even less. Once you're there, you really won't be thinking about modesty: you'll be focused on dealing with labor and the excitement of meeting your baby.
• This doesn't need any sources. It's a mom thing :-) 

• Labor always starts with your water breaking: FALSE
• Just from my personal experience, I can tell you that this is false. My water has never broken on its own. With my first, the OB broke my water (routinely and unnecessarily) at 6cm, and told me that I had very thick membranes. With my second, my midwife broke my water right before I started pushing in earnest, because my bag of waters was bulging into the birth canal (I had excess amniotic fluid) and preventing my daughter's head from fully engaging. She also commented how think my membranes (amniotic sac) were, and said that they probably would not have broken on their own.
• Only about 10% of labors begin with the water breaking. Your labor starting will more than likely not be the embarrassing moment in the grocery store that you see on TV, where a mother's water breaks and she's standing there in a puddle of amniotic fluid and screaming that she has to get to the hospital right now. Not only is SROM (spontaneous rupture of membranes) statistically unlikely to happen without noticeable contractions, but when your water breaks, it is unlikely to be a huge gush like that. If you are standing or sitting and baby's head (or any other body part) is blocking your cervix, the amniotic fluid won't be able to escape as well, and you may only notice slight trickling, and it may not even be a steady flow. It may become more noticeable if you lie down, but it still probably won't be the flood most first-time mothers imagine. 
• Resources on this subject:  http://www.bellybelly.com.au/birth/waters-breaking#.Uh--ej_wa1s , http://www.mayoclinic.com/health/water-breaking/MY01442/NSECTIONGROUP=2 , http://www.parenting.com/article/labor-and-delivery

• You need to go to the hospital the second you start having contractions: FALSE
• "Come to the hospital once your contractions have been 3-5 minutes apart and longer than 30-45 seconds for at least an hour." Ever heard that? I did. And that's what I did. I arrived at the hospital for my first at only 3cm dilated. And I then got stuck in bed, unable to move, vomiting uncontrollably, and ended up with all kinds of interventions that I didn't want (iv fluids, continuous monitoring, blood pressure cuff, stadol in my iv, anti-nausea meds, and an epidural). Evidence suggests that if you want to avoid interventions and you are low-risk, you should stay home as long as possible before heading to the hospital (or birthing center, or before calling your midwife if you're having a home birth). The rule of thumb is that if you are having trouble walking and talking during contractions, or you are starting to sound "grunty" during intense contractions, you should get going. 
• If you live a good distance from the hospital and you're worried about making it there in time, call your doctor/midwife, and they can help you decide if you should go in yet or not. But remember, early labor, especially in first time moms, can last for hours (even days for some), so heading to the hospital too early, just to be told you haven't progressed enough to be admitted (or aren't in active labor at all), can be a big disappointment. It's much more comfortable to labor in your own home, where you can eat, drink, bathe, shower, sleep, and do things your way while in early labor. Going in too early can mean taking the control out of your hands, and putting you on the hospital's timetable (which may not be evidence-based care). 
• Also, if your labor stalls at any point (which is perfectly normal), you may be diagnosed as a "failure to progress," and your labor could be augmented, or you could be sent in for an unplanned cesarean, whereas if you labor where you're more comfortable and off of the "hospital clock," you might be able to wait it out and give your body the time it needs and not fall victim to a doctor's "failure to wait." If such interventions are things you want to avoid, it's best to stay home as long as possible before you head up to the hospital.
• Some sources: http://www.babies.sutterhealth.org/laboranddelivery/labor/ld_when-hosp.html , http://pregnancy.familyeducation.com/labor-and-delivery/signs-and-stages-of-labor/35965.html , http://pregnancy.about.com/od/laborbirth/f/goingtohospital.htm

• You are in active labor at 3-4cm dilation, even without effacement, regular contractions, etc.: FALSE
• I wasn't. I walked around at 4cm dilated and 60-80% effaced, with prodromal labor, for weeks with my second before I went into real, active labor. Some women dilate as much as 6cm before active labor starts. If my midwife had gone simply off of my dilation and had augmented/induced my labor, my daughter would have been born too early. Some women take longer to dilate. Some dilate faster. Some aren't in active labor until more like 6-7cm. The definition of active labor has to be flexible, because no two women are going to dilate at the same rate. Dilation in and of itself isn't the "be all, end all" deciding factor in labor. 
• I blogged about this, and had some good sources in that post, so I'll just link it here as my source: http://mamadoulayourway.blogspot.com/2013/08/cervical-dilation-and-effacement-prior.html

• Induction is "just like spontaneous labor" and "no big deal": FALSE
• This might get me attacked a bit, but induced labor is not the same as spontaneous labor, no matter which way you slice it. That's not to say I'm wholly against inductions, because I believe that there are very legitimate medical reasons for inducing that save the lives of mothers and babies. But spontaneous labor involves a chemical dance between mother and baby that medicine simply can't define or pinpoint, so how can they replicate it? Inducing is, to put it bluntly, forcing the body to do something that it is either not ready to do, or unable to do (for those very rare cases where women's bodies cannot start labor on their own). It is, by definition, not the "same" as spontaneous labor.
• To the point: inducing involves such things as inserting prostaglandins, artificially rupturing the membranes, and iv drugs such as pitocin, that start labor. Pitocin-induced contractions are longer, closer together, stronger, and harder on mom and baby than natural contractions. Pitocin, cervidil, cytotec, and any other medications carry the risk of side effects, and therefore will require more monitoring and intervention (even in a healthy low-risk mom), whereas a spontaneous labor in a healthy, low-risk mom may require little or even no intervention whatsoever. 
• Induction increases the risk of cesarean for first-time mothers by as much as 40-50%, whereas the cesarean rate among first-time mothers with spontaneous labor is closer to 10% (and even less in low-intervention births, some as low as 5%). Induced moms are also more likely to request pain medications such as epidurals, which also increases the likelihood of a cesarean birth. The statistics are quite clear: if you are induced, you are more likely to have an interventionist, medical birth, and about twice as likely to have a cesarean; if you go into labor spontaneously, those risks are cut drastically. Induced labor is simply not "the same" as spontaneous labor.
• I think I need sources, and again, I'll use my previous blog post on (elective) induction, but I will also include more sources, because this is a very big, very common issue: http://mamadoulayourway.blogspot.com/2013/06/to-induce-or-not-to-induce-such.html , https://childbirthconnection.org/printerfriendly.asp?ck=10652 , http://pregnancy.about.com/od/induction/a/risksinduction.htm ,  http://www.sciencedaily.com/releases/2012/03/120306131531.htm , http://www.skepticalob.com/2010/07/inductions-increase-risk-of-c-section.html , http://health.usnews.com/health-news/family-health/womens-health/articles/2010/06/22/labor-induction-boosts-c-section-risk , http://evidencebasedbirth.com/crank-up-the-pit-2/ , http://content.time.com/time/health/article/0,8599,2007754,00.html

• Episiotomies save you from tearing worse and are easier to repair/less painful than a natural tear: FALSE
• Episiotomies can actually increase the likelihood of an even larger tear, and take longer to heal than most natural tears (more than 3 months, as opposed to 6 or so weeks with a natural tear). They are falling "out of fashion" these days, and are no longer routinely performed by the majority of doctors. If a vacuum or forceps assisted birth becomes necessary, then an episiotomy is usually warranted. Most mothers do better recovering from a natural tear.
• Sources:  http://www.medicinenet.com/episiotomy/page2.htm#5whatarte, , http://www.givingbirthnaturally.com/benefits-and-risks-of-episiotomy.html , http://apps.who.int/rhl/pregnancy_childbirth/childbirth/2nd_stage/jlcom/en/

• Medications (epidurals, iv pain meds, pitocin, etc.) in labor don't affect the baby: FALSE
• I have blogged about this one recently. Think about it this way: if you would avoid medications in pregnancy, because they might affect the baby, why are medications in labor any different? Labor meds like pitocin, morphine, stadol, demerol, and epidurals are much stronger than tylenol and the like, and carry more risks. Medications don't stop crossing the placenta and getting to baby just because you're in labor.
• Just going to link my blog post here, because I had good sources cited there:  http://mamadoulayourway.blogspot.com/2013/08/medications-in-pregnancy-vs-medications.html

• The cord around the baby's neck is an immediate cause for concern and is an emergent situation: FALSE
•  "About 25 percent of babies are born with a nuchal cord (the umbilical cord wrapped around the baby's neck) (1). A nuchal cord, also called nuchal loops, rarely causes any problems. Babies with a nuchal cord are generally healthy."
•  Nuchal cords are present in about 1/3 of births. The problem with the argument that a cord around baby's neck is a problem is flawed in that it assumes that the baby is breathing. Babies do not "breathe" or get their oxygen by inhaling air. They get it from the mother, through the placenta and umbilical cord. 
• The only times that the cord presents a true issue in birth is 1. if there is a knot in the cord that is preventing blood flow, and hence oxygen (but true knots in the cord are very rare, and not always fatal or even problematic), or 2. the cord is too short to allow baby to fully descend and come out of the birth canal, and the care provider delivering the baby is unable to maneuver baby out without pulling the cord.
• Sources: http://birthwithoutfearblog.com/2011/10/10/cord-around-the-neck-isnt-an-emergency-birth-pi/ , http://midwifethinking.com/2010/07/29/nuchal-cords/ , http://vbacfacts.com/2009/09/16/umbilical-cord-around-babys-neck-rarely-causes-complications/ , http://cord-clamping.com/2011/11/04/cord-around-the-neck-what-parents-practitioners-should-know/

• The pain of labor serves no purpose: FALSE
• I'm not going to lie: birth hurts. There's no way of getting around that. I know that everyone has different perceptions of pain, and what might be the worst thing in the world for one is a breeze for another, but it is exceedingly rare for a woman to say that her labor didn't hurt, and that she experienced no discomfort or anything at all (and I don't really believe the ones who say it, either, do you?). But the pain really does serve a purpose, even if it just means that you're refusing medications and avoiding those risks.
• Second (after avoiding the risks), natural labors tend to be shorter. Mothers refusing pain medications tend to move around more in labor, which (as discussed above) helps baby to put more pressure on the cervix, which facilitated dilation, and the pelvis has an easier time opening. Without the numbing effects of an epidural, women can push more effectively, which shortens the pushing phase, too.
• Recovery tends to be faster. The endorphin and oxytocin release after a spontaneous, unmedicated labor plays into that, as does the lack of medications coursing through the body. Fewer interventions usually means less to recover from (iv's, effects of medications, episiotomies, etc.)
• There are fewer effects on the baby, and babies born without medications are often more alert, have higher APGAR scores, and breastfeed sooner and more easily.
• Sources:  http://news.bbc.co.uk/2/hi/8147179.stm , http://naturallysavvy.com/Nest/the-benefits-of-natural-childbirth

• Medical interventions (in non-emergent situations) always improve outcomes for mom and baby: FALSE
• Let's just refer back to that table I'm so fond of for this, shall we? 

 

•  So basically, very very false. Modern interventions have gotten us a 1 in 3 induction rate (which is not supported by evidence), a 1 in 3 c-section rate (also not supported by evidence), and procedures that are also unsupported by evidence are routinely practiced, and they do more harm than good.

• Routine iv's for fluids are beneficial, risk-free, and evidence-based: FALSE
•  When one reads the list of potential complications associated with too much fluid in labor, it’s a bit baffling that modern obstetrics has not picked up on this risk.  Excessive fluid was associated with longer duration of labor, increased risk of needing forceps or vacuum, and increased incidence of emergency cesarean birth.  The negative association did not stop with effects on the mother, however;  for babies whose mothers received excess amounts of fluid, there was an increased risk of low blood sugar, difficulty establishing breastfeeding, and weight loss in excess of 10% of the birth weight.
• Routine fluids are not needed if the mother is allowed to stay hydrated by drinking throughout her labor. There are cases where iv fluids are beneficial (such as with extensive vomiting), but to assume it will be needed seems to do more harm than good.
• Some sources:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730908/ , http://www.preggiepals.com/three-hospital-routines-to-reconsider/# , http://birthsen.tmdhosting930.com/?p=1014 , http://www.improvingbirth.org/wp-content/uploads/2012/11/Big-Walkin-letter-flyer-wtr-mark.pdf

• If your labor stalls or slows down, that automatically means something's wrong and you need a c-section ("Failure to progress"/The Friedman Curve: FALSE
• Oh my, is this ever false! This goes back to the "one size fits all" box that care providers try to stuff women into regarding birth timelines. No two women will dilate at the same rate, and there are often natural "plateaus" in labor with little to no cervical change, and these women are often mis-diagnosed as a "failure to progress" and sent to the OR for a cesarean (even though mother and baby are still doing fine), when really, all they need is more time. The Friedman's Curve (which is the method most care providers adhere to when it comes to dilation) is over 60 years old, and based on a study that only included 500 women. 500. That is not a very big sample size, especially by today's standards, and the study is very outdated and frankly incomplete.
• Here's my new favorite article on this matter. It contains lots and lots of other sources for good information:  http://evidencebasedbirth.com/friedmans-curve-and-failure-to-progress-a-leading-cause-of-unplanned-c-sections/

• You can't vaginally birth a breech/posterior/nuchal hand baby: FALSE
• Both of my girls were Occiput Posterior (face up) throughout my labors. My first corkscrewed herself around at the last second and came out Occiput Anterior (face down, which is normal), but my second was born face up. It is absolutely possible. 
• Posterior babies often make for a longer labor (not so in my case), intense back labor (definitely true for me), longer pushing stages (not true at all for me), higher likelihood of tearing (kind of true for me), and fetal distress (not true for my girls). There can be slight risks involved, but when 15-30% of babies are posterior before and during labor, and 5% are born face up, it's just a different version of normal.
• Sources:  http://spinningbabies.com/baby-positions/all-positions/myths-about-op , http://www.caroldenny.com/index.php?option=com_content&view=article&id=123:posterior-presentation&catid=65:special-circumstances-and-complications&Itemid=78 , http://wellroundedmama.blogspot.com/2009/05/how-fetal-position-can-affect-labor.html , http://midwifeinfo.com/articles/the-dreaded-persistent-occiput-posterior
• Babies with a nuchal hand (or hand up by the face, essentially) can present more problems, but with proper care and a talented care provider, they too can be birthed vaginally. 
• Fun source:  http://birthwithoutfearblog.com/2011/09/22/grapich-birth-photo-of-baby-born-with-a-nuchal-hand/
• The same goes for breech babies. It is a variation of normal. 3-4% of babies are breech at term/delivery. Fewer and fewer doctors are learning how to deliver a breech baby, however, which is why 90% of breech births are cesareans. That is not to say that all breech births should be surgical; this simply highlights a gaping hole in medical education. Most modern studies agree that attempting a vaginal breech birth does not present any more harm to mother and baby than a scheduled cesarean, and a cesarean does not necessarily improve outcomes. So yes, a breech baby, under the right circumstances, can be birthed vaginally.
• Sources: http://jeremyscorner-grifter.blogspot.com/2009/03/breech-vaginal-birth-is-not-emergency.html , http://americanpregnancy.org/labornbirth/breechpresentation.html , http://www.inamay.com/article/undervalued-art-vaginal-breech-birth-skill-every-birth-attendant-should-learn , http://spinningbabies.com/baby-positions/breech-bottoms-up/339-vaginal-breech-birth , http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/Mode%20of%20Term%20Singleton%20Breech%20Delivery.aspx

• You have to do everything suggested to you, you don't call the shots in your labor and hospital policy trumps maternal autonomy: FALSE (mostly)
• Sadly, this is becoming less and less of a myth. It should fall to the mother to call the shots when it comes to her body and her baby, but more and more moms are falling victim to hospital policies, insurance demands, and doctors who don't practice evidence-based care. Mothers should have autonomy when it comes to birth, but in some places, that is not the case. In an ideal world, this is a truly false myth.

• Breaking your water speeds up labor and has no downsides, and you MUST give birth within (x) hours after your water breaks: FALSE, and FALSE
• AROM (artificial rupture of membranes) has been solidly proven to not speed up labor significantly. What it does do is increase your risk of infection, put you on the hospital's "clock" for time allowed to labor with waters broken, can cause cord prolapse, and increased the intensity of your contractions, because there is no longer a cushion between baby's head and your cervix. 
• Sources:  http://thebirthingsite.com/interventionsacomplications/item/506-the-pros-and-cons-of-the-artificial-rupture-of-the-membranes-procedure.html , http://midwifethinking.com/2010/08/20/in-defence-of-the-amniotic-sac/ , http://www.nytimes.com/2007/10/30/health/research/30chil.html?_r=0 , http://bellybumper.wordpress.com/2011/04/03/rushing-water/ , http://www.bellybelly.com.au/birth/waters-breaking#.UiAloz_wa1s
• Similarly, there is this notion that once your water breaks, you have to deliver within a certain amount of time. Some doctors will say 12 hours, others 18, others 24, and some will say 36. What you should know is that the risk of infection (which is the risk doctors lean on heavily) is significantly decreased if you refuse vaginal exams. Also, it isn't as though you're going to run out of amniotic fluid; it replenishes regularly until after baby is born. So, if you avoid risk factors for infection such as vaginal exams, you can more than likely labor as long as necessary with your waters broken and have no adverse effects.
• Sources:  http://mamabirth.blogspot.com/2010/12/obstetric-lie-99-you-must-deliver.html , http://www.ncbi.nlm.nih.gov/pubmed/8598837?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=5 , http://www.ncbi.nlm.nih.gov/pubmed/6859160?ordinalpos=&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.SmartSearch&linkpos=1&log$=citationsensor , http://www.nbcnews.com/health/when-water-breaks-does-labor-need-be-induced-733244

• Your pushing should be coached by your doctor/midwife/nurse:FALSE
• A mom should follow her instincts when it comes to pushing. This is obviously more difficult if there is an epidural in the equation, but in general, a woman's body will know when and how to push. Directed pushing raises the likelihood of tearing and lack of oxygen to the baby, and if there is no urge to push, it will not be effective, mostly because an absence of that urge indicates that the baby has not descended far enough in the birth canal yet.
• Some sources:  http://birthsen.tmdhosting930.com/?p=386 , http://www.giving-birth-naturally.net/avoid-tearing.html , http://www.rcm.org.uk/midwives/features/second-stage-of-labour-challenging-the-use-of-directed-pushing/

• C-sections are always traumatic, and skin-to-skin is impossible after a c-section: FALSE
• There are very, very few reasons for a c-section to have to be traumatic. Only in a truly emergent situation (life and death) should a mother be put under general anestheisa, and she should always be made to understand what is going on and should be treated with as much care and respect as a mother having a vaginal birth. Unless there is maternal or fetal distress, there is no reason for Family-Centered Cesareans to be anything but the norm, and skin-to-skin should be allowed immediately whenever possible.
• Sources:  http://evidencebasedbirth.com/can-hospitals-keep-moms-and-babies-together-after-a-cesarean/ , http://evidencebasedbirth.com/the-evidence-for-skin-to-skin-care-after-a-cesarean/ , http://www.improvingbirth.org/2013/04/a-family-centered-cesarean-taking-back-control-of-my-sons-birth/ , http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2613254/

• L&D nurses/your midwife or doctor/your partner serve the same purpose as a doula: FALSE
• No. Way. Labor and Delivery nurses, more often than not, will have other patients besides you to care for, and will not be able to stay in the room with you at all times and provide the individualized comfort measures that your doula can, nor will they know or be guaranteed to respect your birth philosophy. Even the very best of nurses may not agree with you, know the techniques you'd like used, or have the time to devote to you.
• Your partner should be a good supporter, but it's a lot of pressure to put on someone who is also as invested in the experience as you are. A doula can be just as helpful to your partner as to you, the laboring mom. Your partner will most likely not have the experience and education that your doula will have, either, and therefore may not be as effective an advocate for your rights should anything go awry.
• Your OB or midwife, like the L&D nurses, likely has other patients to tend to, and will not be able to give you constant support like a doula can.
• The long and short of it is, your doula is there to focus on you and your partner, and do whatever you ask. She only has you to focus on; no other patients, nothing.  

• It's a bad thing when baby gets a "cone head": FALSE
• In a vaginal birth (or even after a c-section, if baby was dropped in mom's pelvis or she labored and pushed at all), baby's head will mold to protect the brain and fit through the birth canal. The bones of the skull are not fully hardened or fixed yet; they are meant to develop that "cone head" so that they can fit through the pelvis. It is not a cause for concern, and will usually round out after a few weeks.
• Sources:  http://www.nlm.nih.gov/medlineplus/ency/article/002270.htm , http://www.aurorahealthcare.org/FYWB_pdfs/x13603.pdf , http://www.cyh.com/healthtopics/healthtopicdetails.aspx?p=114&np=304&id=2328 , http://pregnancy.about.com/od/laborbirth/ss/pictureguidechildbirth_5.htm , http://www.kidsgrowth.com/resources/articledetail.cfm?id=265 , http://www.healthychildren.org/English/ages-stages/baby/pages/Your-Babys-Head.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token