The Birth Scale

In the wee hours on a Saturday morning, I was reading a post on Longreads titled, “A Birth Story” – so you know it piqued my interest.

It’s a long story, and I applaud the publishers for printing it. All too often, we’re only given sound bites, just sexy headlines and maybe a short summary of a story. The reading ticker on the page told me it would take me an estimated 57 minutes to read “A Birth Story” – much too long for me to read at one go before heading into work that morning. But that was okay by me, because about halfway through, I just wanted to stop. The story completely depressed me.

According to the subtitle, the author of this piece “had the perfect pregnancy and the perfect birth plan – and then she went into labor.”

Given my personal belief that birth is too big to plan, and that I rarely meet a person who’s had a birth go according to their birth plan, you might think that I’d be eager to read a story that supports this viewpoint. But nothing could be farther from the truth! I braced myself for what would be yet another person’s sad tale of a birth gone wrong. Another person’s retelling of how they expected this, but in the end, got that.

Our birth system in this country is broken on so many levels, and I was prepared to read this story and how our system had failed yet another person. But as I read on, I realized something else: I’m not sure that we’re adequately equipping today’s expectant folks with enough of the right information to even begin to realize the birth they’re hoping for.

I met with some labor and delivery nurses recently at a training for advanced labor comfort skills and many of them expressed frustration. They’re frustrated that when they first walk into the L&D room to greet their laboring patient.  Many of them feel like they need to be on the defensive, as many families enter the hospital with an attitude of “us against them”.

These nurses expressed how much they really want to be advocates for these families and help them achieve the birth they’re hoping for, but often feel like they’re met with suspicion. They understood why there might be feelings of suspicion and thoughts of having to “fight” for the birth they wanted. But these nurses also sensed that many laboring families were not prepared to fully participate in a birth they wanted to be free of intervention or medication.  

In reading this woman’s story, I felt sad for her, because even though she frequently stated she was fine with whatever happened next, I’m not sure I believe it. It’s possible there could be some unresolved trauma from this birth. On the one hand, I’m happy she wrote about her birth and maybe experienced some catharsis in doing so. On the other hand, I consider my expectant families and feel like this might be just one more “horror story” writ large. Where are the good ones? Where are the positive stories that can lift expectant families up and provide hope for a birth story they’re happy to tell others about?

I’m also left feeling sad for all of us – hospitals, providers, nurses, doulas, natural childbirth advocates, childbirth educators, birthing folks and their partners – because this birth story shows all the cracks, too many places where this birth could have had a very different ending.

Let me be clear. I’m not here to negatively reflect on this woman’s experience or her choices. There’s absolutely no judgement intended. I only wish she had a different story to tell and so I offer these thoughts on how it might have been different.

This is what the author has to say about her relationship with her provider:

“I don’t even particularly like my doctor. I love her as a character. I love her from afar. I admire her. I would never choose to interact with her. She makes me uncomfortable. She is cerebral, nervous, she over-explains and my jokes are off-putting to her, but I think she likes them. Every interaction with her I am left feeling like, What was that?! Why was that so hard? We don’t connect, she and I. Somehow, this helps me trust her better. Our relationship is strictly professional, unmuddied by affection.”

When you’re giving birth to your baby, there must be a level of trust between you and the other members of your birth team. Otherwise, when it’s time to make big (or even little) decisions during birth, you won’t feel like they’re working for you, on your behalf, that they’ve got your back. You’ll second-guess everything they say and wonder if it’s true or medically necessary. With a trusting relationship with her provider, this woman could have had the exact same end result to her birth, yet feel very differently about how things turned out.

Maybe she never received the message that it’s always okay to switch providers.

I’m not saying that it’s easy to switch providers – it’s not. But if you feel at any point during your pregnancy that you have issues of mistrust with your provider, then by all means express those issues! Give your provider the opportunity to win back your trust. But move on if they can’t. Fire them and find a provider that you can have a trusting relationship with. You would never have a guy in a repair shop rebuild the engine of your car if you didn’t trust them – why would you have a provider that you don’t trust be in the room with you during your baby’s birth? You’re not a “difficult patient” for making this hard decision – you’re just an active participant in your healthcare.

The author mentions that she’s gone to “natural childbirth classes” – but did these classes do an adequate job of preparing her for the reality of her birth?

I think it’s okay to say that birth will be painful. I’m happy when I hear a someone say that their birth wasn’t painful. But I’d rather they be pleasantly surprised rather than gobsmacked by the level of intensity they feel with contractions. I don’t think we are doing anyone any favors when we sugar-coat birth. I think we need to be straight up and make sure that birthing folks who want a birth without medications or interventions are fully prepared for the sensations they will feel and the participation that will be required of them to get through it.

I’m concerned that the childbirth classes this woman took didn’t prepare her for that level of participation. And she expresses such a negative relationship with all interventions and medications even before labor has begun that when she makes the decision after she feels like her body “was washed up” and she gets the epidural, she writes, “Bring on the cascading interventions. And they came.” It’s almost as if the outcome had been preordained and there was no other way around it. She even questions at one point “Was I walking the plank?” toward her unplanned Cesarean, and then “(I was always walking the plank.)”

This makes me wonder if her classes had covered interventions and medications at all. Had anyone taught her how to use the B.R.A.I.N. decision-making tool?

This is the acronym that I and many other Childbirth Educators use when discussing interventions and medications in birth.

B = Benefits: what are the advantages in choosing this intervention or using this medication at this time?

R = Risks: what are the potential risks or drawbacks in choosing this intervention or using this medication at this time?

A = Alternatives: are there any alternatives to try avoiding the use of this intervention or medication? Are there any alternatives to try and achieve the same intended result?

I = Intuition: what does your gut have to say about using this intervention or medication at this time?

N = Nothing: what would happen if you did absolutely nothing at this point? If you just took the approach, “watch and wait?”

This part of classroom teaching can be tricky for some educators – they are committed to making sure that their families have a birth that is free of complications. And this is most likely to happen when there are no interventions or medications used during birth. Unless they become medically necessary.

But there are times when using an intervention or medication makes the most sense, no matter what the birth plan says. An educator must make sure that the objective of the B.R.A.I.N. activity is realized. Pregnant people must understand that there’s a scale upon which they will have to weigh every decision of their births in real time. They need to realize that every suggested intervention has a true benefit, a true alternative and a true risk. 

And the scale that they use to weigh decisions in the classroom or at their desk while typing up their birth plan is one thing: in this setting all they are able to see are the disadvantages or risks. But the scale upon which they’ll need to weigh decisions during birth might be something else entirely.

Unless the objective of providing balanced information is achieved in class, a laboring person hasn’t been given the tools necessary to be a participating decision-maker in their own birth.

Click here for Birth Scale Part II where I will compare this experience with a similar birth story from one of the Mommas from my classes, who’s unplanned Cesarean Birth had a very different outcome.

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