Transcript

Anne Nicholson Weber: 00:00 This is episode 18. I’m so glad you’re here. Today we’re talking about self-advocacy in pregnancy and childbirth. My guests are the two doulas behind Intentional Birth, which offers training for doulas and childbirth education for expectant parents. I hope you’ll join us to learn about advocacy tools that support an empowered and empowering childbirth experience. 

Welcome to the BirthGuide Chicago podcast, conversations about building your circle of support in the childbearing year. We connect you with experts in our community who can help you conceive, stay healthy during pregnancy, have a safe and satisfying birth, and embrace the joys and challenges of becoming a new family. I’m your host Anne Nicholson Weber, and the founder of BirthGuideChicago.com, where every month, thousands of Chicago area families find relationshi- centered care, from conception through the postpartum period. 

My guests today are Alicia Fishbein and Meredith Nelson, the two doulas behind Intentional Birth. Their work prioritizes physiology, client education, and birth room advocacy. And we’ll be talking about all of those, but with a focus on how you can advocate for yourself in pregnancy and childbirth. Intentional Birth is not based in Chicago, but I’ve been so impressed by Alicia and Meredith’s systematic and wise approach to this topic that I wanted to share it with you. So welcome. Thank you,

Meredith Nelson: 01:37 Anne. Thank you. It’s such a pleasure.

Anne Nicholson Weber: 01:39 Maybe we could begin, uh, if one of you could explain what you mean by the term birth room advocacy, and maybe give a few examples of how this comes up.

Meredith Nelson: 01:50 Advocacy can look a lot of different ways. We, as doulas, certainly advocate for our clients, and the first way we do that is by helping them really understand what their options are. So this could look like helping them understand what their medical and alternative options are. It could mean helping them get connected to a practitioner who’s aligned with their needs and values. Um, it can mean helping them navigate insurance or get referrals to other professionals, but it can also mean standing up for their autonomy and for their choices and helping to facilitate smooth conversation with practitioners. So where this plays out for us a lot is inside the birth room. Once a client has made their plan and chosen their birthplace and their birth provider, now they’re there and they’re giving birth, and there are going to be choices to be made at, at some point during that birth.

Meredith Nelson: 02:44 99% of the time someone’s going to have to make a decision. So advocating for your partner or for yourself might mean just asking good questions, right? That’s advocacy. It can also mean standing up for what you’ve decided to do in the face of pressure. And this is something that does come up a lot in the birth room, and it’s not malicious. And I think a lot of people who are very supportive and experienced in natural birth sometimes get the idea that there’s kind of an us versus them thing going on in the birth room. Really what it is, is there’s a difference in values sometimes between the team members and the patient. There’s a difference in training. Maybe they don’t actually have background in the physiologic birth that you are trying to accomplish. Or it could be in another setting too, in the home birth.

Meredith Nelson: 03:35 Maybe your midwife doesn’t have the training in the medical intervention that you’re desiring at this time. And it can also be a matter of hospital policy, which is meant to be a guide for staff, for hospital staff, in what kind of options they offer and in how they do certain treatments or interventions. But sometimes  it’s conveyed as though it’s policy that the patient must follow. Um, so an advocate can also stand up for the patient’s rights and remind the patient — or a partner can remind their partner who’s giving birth —  that they have the right to say yes, they have the right to say no. And just help facilitate and build a bridge between that patient and the provider in sometimes really tense circumstances. So advocacy can also be about deescalation and about helping people hear each other. In the end, we kind of define advocacy as anything that makes a path for the patient toward the birth that they want, right? And that really in the end for everybody is a birth that aligns with their values and in which they receive respectful care. Alicia, what do you have to add?

Alicia Fishbein: 04:50 I wanted to add why we need advocacy. I think that’s so important to make mention of, and part of the reason we need advocacy is because when we’re giving birth within a hospital system, which most American women are and many women across the world are,  it’s like being flung into a foreign country where the language does not resemble your language. You can’t read the road signs. The people dress differently, they eat different food. It’s all new and strange to you. And to them it’s perfectly normal and they’re perfectly comfortable within that world. But it’s important to have an advocate with you or to know the advocacy skills because you’re navigating this foreign land. You — in some respects, you have to learn to speak the native tongue. You’ve got to understand the culture that you’re operating within. And not only that, but we know today that some 25 to 40% of women — depends which research you’re looking at — are coming out with birth trauma.

Alicia Fishbein: 05:59 And there are a lot of ways to define birth trauma, but I’ll keep it simple. If the woman felt that her life was in danger, her baby’s life was in danger, if she felt that she was coerced or manipulated into making certain decisions, those are examples of birth trauma. Women can also come out of birth with physical trauma as well. And so if we have that many women, let’s call it a quarter to a third of American women, who are coming away from their birth with trauma. We must find ways to address that. That’s, those numbers are way too high. We, when what we want for women is we want for them and for their partner to have a mountaintop experience. We want this to be a pivotal moment in their lives as they step into parenthood, have a powerful birth so that they can enter into parenthood feeling powerful and ready for the beauty and the challenges that lie ahead.

Anne Nicholson Weber: 06:56 So one of the complexities of this particular topic of advocating in birth is that as a laboring woman, having to fight is absolutely contrary to what you need for an effective labor and for a happy birth experience. So I’m interested in what — and, and maybe I’ve overstated it, but clearly having to move into that different part of your brain where you’re being kind of analytical and perhaps as I said, adversarial, um, is not an ideal situation for laboring. So how do you teach the skills that can help make that Okay, <laugh> Meredith,

Meredith Nelson: 07:44 Great question. So we actually love it when our clients can just release into their labor and not ever have to advocate for themselves or think about a thing. That’s not always the reality. But here’s how we set it up so that that’s more likely to be true, because we absolutely want her to be able to stay in her flow and have her nervous system at ease so that she can do the hard work that she’s doing and release into her birth. So the first thing that we’re going to do is actually all happening prenatally. And you can do this, whether or not you have a doula, you can really assess what your values are and what you need from your birth, and then try to find a care provider who shares your values, who isn’t just like, okay, we can try that.

Meredith Nelson: 08:35 Or, oh, I’ve done that before. It’ll probably be fine. But a provider who loves your birth plan and is excited to be with you in it, because that is going to make it a lot more likely that you are going to be able to let your guard down and have a more pleasant birth. The second thing is that we actually train partners as advocates. Um, because we, ideally, we, we say advocacy is a team sport. Ideally the partner is the lead advocate on the team. And then we are there to help support that partner and advocacy and sometimes, sometimes step in.

Alicia Fishbein: 09:11 We don’t want moms to be in the fight, so to speak. And that’s why it’s so important to front load the preparation. So it’s so important to get the birth education early and go deep and really understand — for a woman and her partner to understand what her options are and how she can decline anything she would like in the hospital, um, outside of the hospital as well. She’ll never be forced to do anything. That’s because legally and in terms of human rights, she has the right to respectful care and to refuse any intervention that is offered to her. And so understanding that and letting that really sink in, I think is so important for women. And the education has to come early. It’s too late when we’re talking about these things in the birth room. You can’t be doing game time education or making game time decisions. You’ll make some game time decisions, but the big one should be taken care of ahead of time. And a birth plan needs to be thoughtfully crafted and shared with your provider on multiple occasions so that you make sure that everyone who is on the team shares the same vision for the birth.

Meredith Nelson: 10:30 Can I piggyback off with that, Alicia? When you craft that birth plan, you take it to every prenatal visit. And this accomplishes two purposes. One is it allows you to have informed consent discussions with your provider about the items on your birth plan, and assess whether they’re really right for you and assess whether this provider will support you in them. And two, it’s where you get to practice advocating for yourself so that you have that muscle developing prenatally and your partner has that muscle developing prenatally, so that it’s easier come the birthday. So, you know, let’s say on your birth plan, you’ve decided that you want, um, let’s just say you want to decline postpartum pitocin unless you’re hemorrhaging, right? So you’re asking for expectant management in the third stage, and you’ve put that in your birth plan and your doctor at your appointment when you show them your birth plan says, ‘oh, we, we absolutely need to do Pitocin.’

Meredith Nelson: 11:32 ‘We do this for every, um, laboring woman, the World Health Organization recommends it, and it’s our hospital policy.’ So now you get to practice your advocacy. And that might mean that you ask some questions. ‘How often do you see this happen that a woman hemorrhages? How effective is Pitocin in reducing that risk of hemorrhage? If I haven’t had any risk factors for hemorrhage up to that point, is it reasonable for me to, to use expectant management,” you know, and ask those questions? And then, or maybe you’ve already made your decision, you’ve done your research, you know that you want to decline this unless your health circumstances declare otherwise. And so then you get a practice saying — you could use one of our tools. One of our tools we call “own it.” And the tool is,’ I understand what you’re recommending. I understand why you’re recommending it, and I am making this decision and taking responsibility for it.’

Meredith Nelson: 12:26 Right? So, so in this case, you’d say, ‘I understand you’re recommending Pitocin to prevent hemorrhage. I understand why you’re recommending that it’s standard of practice and you’ve seen it be beneficial. Um, I am going to decline and choose expectant management. I take responsibility for that decision, and I thank you for continuing to inform me about my options,’ right? So there’s an advocacy conversation and you’ve got, you’ve practiced it now. And so then if it comes up in your birth or something comes up, you can use it again. And I’m going to make one more suggestion here, which is, now that you’ve had that conversation with Dr. Jones about your birth plan, and you’ve had this informed consent discussion, you’ve really gathered the information and you feel confident in your decision, have Dr. Jones sign your birth plan. He’s not saying that he agrees with your decision, because he clearly doesn’t. What he’s saying is,’ I’ve had an informed consent discussion with Alicia.

Meredith Nelson: 13:20 She understands the risks.’  signed to Dr. Jones. What this means is that when — and then that goes in your chart, and now when you show up at the hospital and someone else is on call there that day, and they want to go through the whole thing with you again, you can say, I already discussed this with Dr. Jones, you can refer to my chart and not have to go through that whole conversation. Now what? Now that you’re in labor, you don’t want to have that conversation, right? So, um, so it can be a nice way to kind of take the monkey off the back of the provider who’s in the room with you.

Alicia Fishbein: 13:51 I wonder if it would be helpful, Anne, to model two things. One would be a typical conversation with a hospital provider, which is lacking informed consent, and then a true informed consent conversation, just so that your listeners understand what it usually looks like and what it can look like.  Okay. <laugh> Meredith and I do lots of role plays together. <laugh>. All right. Meredith, do you want to be the doctor or the woman?

Meredith Nelson: 14:22 I’ll be the doctor.

Alicia Fishbein: 14:24 Okay. Sounds

Meredith Nelson: 14:24 Good. What’s our scenario, Alicia, should we do breaking the water?

Alicia Fishbein: 14:29 Sure. Yeah, let’s do it. Okay.

Meredith Nelson: 14:31 So first, let’s do it the wrong way, and then we’ll do it the right way. Okay, Alicia? Um, you’ve been at this quite a while. It’s time for us to break your water so we can get things moving forward in this induction.

Alicia Fishbein: 14:44 Oh, but I, I really don’t want to break my water. I said that in my birth plan.

Meredith Nelson: 14:50 I understand. You know, your birth plan is the things that you want to happen and that you really hope for, but we’re at a place now where we need to move this labor forward and meet your baby. So breaking the water is the best option

Alicia Fishbein: 15:04 Really, but I’m, I’m just worried about infection and also being on the clock once you break my water,

Meredith Nelson: 15:11 It, you know, it is our policy that we need to move this, this labor onto the next step. Um, breaking the water is how we do that. Um, we’ll be monitoring for you, you for infection and, um, you know, we can treat you if that does come up.

Alicia Fishbein: 15:25 Could I just wait, because I really don’t want to do this,

Meredith Nelson: 15:29 This, I really don’t think so. We need to do, we need to do this in the next 30 minutes, I think.

Alicia Fishbein: 15:33 Is there anything else I can do instead?

Meredith Nelson: 15:37 Um, not really. You know, we need, we need to move on to the next step.

Alicia Fishbein: 15:43 Okay. I guess so.

Meredith Nelson: 15:45 Great. Okay. Well, um, you guys get situated. I’m going to be back in about 10 minutes and then we’ll do that.

Alicia Fishbein: 15:51 Okay?

Anne Nicholson Weber: 15:53 Okay. <laugh>,

Meredith Nelson: 15:54 How’d that feel, Anne?

Anne Nicholson Weber: 15:57 It’s, I’m sweating.

Alicia Fishbein: 15:58 <laugh> <laugh>.

Meredith Nelson: 16:01 All right. Um, now I have to say that that level of pressure and lack of informed consent …  it does happen and we’ve, we’ve seen it happen, which is why we do this work. That said, this is not the most likely provider you’re going to run into. You know, Alicia was asking and really showing she was uncomfortable. Most people are going to respond to that with more information. But now we’re going to show you the way this should look. Okay. Hey, Alicia, you have been doing an amazing job. Um, I, I have noticed that your labor has kind of plateaued a little bit. We’re not seeing contractions  coming as quickly as we’d like to, you know, be able to meet your baby. So I would like to propose that we break your water at this point because that can help move, uh, you know, — help your labor pick up and we can move forward with it.

Alicia Fishbein: 17:00 Huh? Okay. Well, I would love it if you can talk me through this. So, you’re saying that the benefit of doing this is to help my labor move along. Is there any other benefit?

Meredith Nelson: 17:10 Yeah, I mean, that’s absolutely the benefit that we’re looking for, right? We want to see your, um, you know —  we don’t want to be here so long that you get too tired or that your baby gets too tired to finish your birth vaginally, which I know is really important to you. Um, mm-hmm <affirmative>. And so, yeah, what will happen is, is when we open your water, most of the time, especially with your baby being where they’re in the pelvis, I think we’re going to see your contractions pick up, your labor’s going to get stronger, and we’ll be able to kind of continue with your birth plan. You know, you’ll be able to continue laboring in these varied positions but you will just have the contractions be a little bit more powerful.

Alicia Fishbein: 17:49 Okay. I get that. What are the risks of this procedure?

Meredith Nelson: 17:55 There are some risks associated with breaking the water that I’d love to walk you through. Some of the more serious ones I’m not too concerned about at this point, because your baby is nice and engaged in the pelvis, I don’t think that cord prolapse is going to be an issue. That is one of the rare risks of breaking the water. The main one is that your contractions are likely to get much stronger and more intense very quickly. And so we can, um, you know, we have pain management options for you, if that’s something you wanted to talk about. Uh, you know, we do —  I should inform you that once your waters are open, we would like to see this baby born within 24 hours from that point, because there is a risk of infection that is going to increase the longer your waters have been open. Now I think personally that your baby is low enough and, and you’ve been doing such a great job. I think that we’re not going to run up against that deadline, but it is there.

Alicia Fishbein: 18:51 Okay. So what about the risk of if nothing happens when you break my bag of waters and my contractions aren’t closer together or stronger?

Meredith Nelson: 19:00 Yeah. At that point, we do have other options. We could introduce some Pitocin, um, to, again, support those contractions in being stronger and longer and closer together.

Alicia Fishbein: 19:11 Okay. Well, what if I don’t want to break my bag of waters? Could we go to those other options first?

Meredith Nelson: 19:19 We could, we could, we could talk about Pitocin.  I didn’t bring that up first ’cause I saw that you really valued having a low intervention unmedicated birth. Uh, but we can absolutely talk about introducing some Pitocin at this point. Yeah.

Alicia Fishbein: 19:34 Okay. And what if I don’t want to break my bag of waters ever in the labor, then what? And I don’t, also don’t want any of other suggested alternatives.

Meredith Nelson: 19:43 Yeah, I wouldn’t recommend writng off breaking your water completely. I feel like it’s going to be an effective tool for us. That said, you absolutely have the right to decline and you can keep doing what you’re doing. You know, we can keep monitoring you and your baby to make sure you’re safe. And if you want, we can revisit this conversation in a few hours.

Alicia Fishbein: 20:08 Okay. Well, you’ve given me a lot to think about. Thank you. Um, I think right now we’re just going to put our heads together, chat about it, and if we feel ready to proceed, we’ll let you know.

Meredith Nelson: 20:19 Great. I trust you. I think you’re doing an amazing job.

Alicia Fishbein: 20:22 Thank you.

Anne Nicholson Weber: 20:25 I’m not sweating <laugh> <laugh>. That’s, that is a —  it’s great to see these played out, and I think, um, it’s really helpful, particularly for a family that’s going through labor for the first time, to understand how confusing these situations might feel. So one question I have for you out of that is, is in the period when you’re preparing for births, and you’ve talked about the importance of writing your birth plan early and beginning to educate yourself quite early in pregnancy, but how many of . . .  I mean, there’s so many branches to the labor path that could happen. Do you think that it’s helpful to kind of confront most of the things that might go differently than you hope, um, before you’re in labor?

Alicia Fishbein: 21:18 100%. A thousand percent. We think it’s important to, well — Pam England is a wonderful author and creator of a childbirth class called Birthing From Within. And she likes to talk about what are called birth tigers. Those are the things that hold fear for us around birth. And she talks about how it’s important to look at your tiger and face it. And so we’re of the ilk of doula who talk about everything. We’re going to talk about loss, we’re going to talk about cesarean, the things that women don’t want. What happens if things go wrong, and you don’t get the result that you wanted. And it’s so important to look at that because once we’ve spoken our fear, we’re able to release it at least somewhat better than trying to shove it down and hope we never have to meet it. Instead, face your fears head on and talk about them, talk through them, understand what your birth will look like if that fear becomes your reality. And then once you’ve done that, then you’re going to spend 99% of your time focusing on what you do want and preparing for the birth that you desire.

Anne Nicholson Weber: 22:31 Going back to the role play, and you said this, Meredith, you said that the first one was kind of a bit extreme in terms of the . . .  bullying essentially mm-hmm <affirmative> that underlay it. I could imagine that in some ways the hardest scenario is one where you have a provider who’s really nice and really sympathetic and mirrors back all of your concerns, and then says, and we really need to break your waters. And how do you sort out the difference between what you could call bedside manner and empathetic provider from the issue that’s at stake?

Meredith Nelson: 23:14 Great question. <laugh>, we’ve seen this happen so many more times, you catch more flies with honey, as Alicia likes to say. So I think that the biggest tool there is just getting some space, right? Because in that moment, it’s really easy just to go along with whatever you’re being told, especially if you do like and trust the person saying it to you. So just to — with any critical decision to say, I’d like five or 10 minutes to think about this, and ask them to leave the room while you do that. And then you can get alone, you can talk to your partner, you can talk to your doula, and that gives you the opportunity to come back to your values and ask, does what we’re considering doing right now really align with my values? Um, does it align with my birth plan? Um, will it support my values in some way? Will it support my ultimate goal in some way? And really just have time to be still and ask what we call the golden questions. Do you want to teach us the golden questions, Alicia?

Alicia Fishbein: 24:24 Sure. Am I okay? Is my baby okay? And what do I want? I think you get to remember in these critical moments, these decision making moments, that what matters more than anyone else’s expertise is your intuition and your own expertise in yourself. No one knows you the way that you know yourself. So trust yourself more than you trust anyone else. The information that you get from a doctor, a midwife, a nurse, a doula, that’s good information, and you bring it into play with everything else, with your values. But ultimately, you have to sit quietly with yourself and ask, what do I want? And this . . .  what we’ve found is that when women really check in with themselves, their baby, their body, their intuition, and they make a decision, they’re far less likely to regret that decision later down the line because this decision came from them. It didn’t come from anyone else. I think this is also where trauma comes from. When we feel that we were coerced or pushed in a certain direction, then we look back and we say, oh my gosh, I’m not sure I really wanted to do that. And what if I had, what if I had chosen something else? So checking in with yourself helps you avoid a bad case of the woulda coulda shoulda’s.

Anne Nicholson Weber: 25:54 You talked about being in a foreign land, and it’s not just a foreign land, it’s a, um, that, that we have, we have put physicians in particular up on a status pedestal, and there is a kind of authority behind the hospital. And honestly, there’s a lot about hospital culture that’s designed to reinforce that and to kind of make you feel small and powerless and yeah, to lose your voice. And I know doulas who have said, you can’t win that game. Um, who’ve actually kind of, I won’t say given up, that’s way too strong, but who go into it with the sense that their job is to avoid trauma that comes from the overt  adversarial relationship and keep things smooth and keep the temperature in the birth room down, but not necessarily really try to fight the machine <laugh>. Um, and you have clearly made a very different decision about how you’re going to support families and about your own philosophy. Is that something that you wrestled with earlier in your careers?

Meredith Nelson:<