One of the most important skills I have as a midwife is being flexible.  I think this is an important skill for clients too.  

A lot of work and preparation goes into planning and preparing for a home birth.  Shopping for and setting up the nursery are such fun as you anticipate birth.  Lining up pet sitters, or child care for your little ones, getting a car set and stocking up on diapers are all part of being ready for baby's arrival.

Taking a childbirth education class, finding a doula, deciding if you want a birth photographer, deciding if you want to use a birth pool or not, reading books and watching videos about breastfeeding are some of the things I encourage clients to do to be prepared for labor, and the immediate postpartum.

Sometimes though, even though you have gotten all the things, have all the help lined up and have everything ready, plans will change at the very last moment.  I operate from the principle of the Boy Scout Motto: Be Prepared.  Being prepared means having a basic birth plan written out, and having a bag packed and ready to go with the essentials you will need for a birth at the hospital.  Being prepared means having the car seat installed and ready to use, as well as giving the petter sitter and child care providers a heads up that you might be calling on them soon.

There are many reasons plans can change.  Baby's heart rate may tell me that we need more help than we have at home.  Mom may not respond to the tools I have to stop bleeding if it's too much.  Mom may decide she wants pain relief.  Mom may start running a temperature, or her blood pressure may become higher than is safe for a home birth.  These are just some of the reasons plans may need to change.

When plans change from home birth to hospital birth, I like to let the hospital know we are coming and why.  I also like to send them pertinent records, and lab results so they have time to look them over and be familiar with past care before Mom arrives. I will go to the hospital with Mom and Dad if they want.  Because of hospital rules on how many people can be with Mom, sometimes parents want the doula or a family member to go instead.  If that is the case, I will be available by phone. My assistant will stay behind to do a thorough clean up. Once Mom is home from the hospital,  I will do postpartum care if Mom wants me to. 

While it is stressful to change plans, sometimes we need to change them. To lower the stress for everyone,  I try to hold space for my client and family to adjust to the idea that birth will now happen in a hospital, and I work to have a smooth transition to the hospital setting. In the end, I want families to feel heard, respected and cared for regardless of where birth ends up happening.

Eating during labor is something I encourage (or push depending on who you ask) clients to do during labor.  Your body is working hard and needs fuel to keep your energy up through the end of the birth.

I do have a few foods that are my favorites for labor.  

• honey
• chocolate
• berries
• grapes
• cheese
• nuts and nut butters
• jerky
• protein shakes
• eggs
• yogurt

I like clients to eat some protein when they have something sweet to help reduce blood sugar fluctuations.  I have watched clients literally eat peanut butter by the spoonful out of the jar, and other clients have a charcuterie board. I'm not too picky about what clients eat so long as they are eating pretty regularly during labor. That looks like a bite of something between contractions and then another bite 3 or 4 contractions later.  

Eating and staying hydrated will help keep energy levels up to finish labor strong, and will make the midwife happy!
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I had my hospital births a good number of years ago.  Since then I have learned so much as I worked as a doula, and later as I began my midwifery practice.  When my babies were born, doulas and lactation consultants were not a thing, and midwives were rare.  Laboring in a hospital bed on your back while hooked up to an IV was expected for hospital birth.  If I knew then what I know now and what is available today was common then, I'd do things differently.
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• I would have a doula.
• I would  be up and moving instead of laying in bed.
• I would labor using water for comfort, preferably in a tub.
• I would eat more than ice chips.
• I would labor at home, and wait before heading to the hospital.
• I would go to LaLeche League meetings, read books and watch vidoes on breastfeeding to be better prepared to nurse my baby.
• I would be less of a "good" patient and more of an advocate for myself.
• I would ask questions to better understand the risks and benefits of my options during labor.
• I would take a childbirth class such as a Bradley class in addition to the hospital class.
• If was an option back then, I would use a midwife and plan on a home birth.
• I would come home and spend the first 4-5 days snuggling with my baby and not doing anything besides nursing my baby and sleeping.

The changes I would make are changes that empower women in labor, and support them in a way that does not restrict choices.  They are the changes that I incorporate into my midwifery care and that I have many conversations with my clients about.  I want my clients to ask questions, to eat and drink during labor, to move how their body tells them to move, to be prepared for breastfeeding, and to have good labor support.

Labor can take awhile, especially if this is the first birth.  I anticipate 24 hours of labor for a first time birth, and I have served clients whose labors have lasted longer than 48 hours.  Sometimes a Mom who has had previous short labors can be in for a longer labor than she expects.  As a midwife, I want my clients to have the tools they need to handle a labor that goes on for a while, so I encourage all my clients to be prepared for a long labor.

My biggest tip is to ignore labor as long as you can.  The less energy and attention you give it, the more you will have to pull from when you really need it.  I've had clients use many different techniques to ignore labor.  Some go shopping, some cook or bake, I've even served a client who played video games.  

Keep your routine normal.  If you are in labor and it is your normal time to go for a walk, then go for a walk (you might want to go for a shorter walk, or have a pace that is slower than your usual pace).  If it is time to go to sleep than get in bed and try to get some sleep.  Even if you aren't able to sleep but you can rest and relax, that will be beneficial and let you have energy for the long haul. 

Keep your activity levels low key.  Labor is not the time to head to the gym to try a new HIIT workout or go outside and thatch your 1/4 acre lawn.  By being mindful of your activity levels, you will be in a better place to have the energy to finish labor strong.  When you are worn out at the end of labor, it can create challenges in the immediate postpartum such as increased risk of hemorrhage, difficulty getting up safely to use the bathroom, and you may not have the energy to truly soak in that you have a brand new baby in your arms.

Eat and drink.  Long labors require lots of calories to keep going.  I don't expect clients to eat full meals, but I do want clients to eat. Small, frequent snacks are what most clients do so have some easy snacks and light food on hand.  Some ideas are fruit, yogurt, cheese, jerky, crackers and nut butters, nuts etc.  Drink plenty of liquids to stay well hydrated.  Have a grazing mindset, and eat something every half hour when you are awake.  I also like it when whatever you are drinking has some calories.  Watered down electrolyte drinks, coconut water or homemade laboraide are fine ideas.  If you want to drink juice or soda, I'm fine with that too.

Sleep.  I know it sounds hard, but you can sleep during labor.  I've been at many births where the client is able to doze off between contractions.  I always find it interesting that if Mom is really tired and lays down, labor slows down.  The body recognizes the need for sleep and accommodates it.  If you can't sleep, but you can rest and relax between contractions, that is so very beneficial to replenish energy and get through to the end with some reserves.

Pace yourself.  To make it through a 24 hour or longer labor with some reserves to finish strong, you need to pace yourself.  By that I mean being active and working with your labor for an hour or two and then laying down to rest or sleep for 30 minutes to an hour.

Change the energy.  Long labors require stamina, endurance and sometimes a breath of fresh air.  You can go for a walk, talk to someone on the phone, take a bath or shower, write a letter to your baby, anything that builds you up, nurtures your soul and gives you a change of pace.

Long labors are not unusual, and do not mean something is wrong.  Unmedicated labor has its own pacing and for the vast majority of births, it's not a lickety-split pace.  Being prepared for a long labor will pay off  for you if your labor is like the majority of labors, and if it is fast you can still pull from the preparations you have made to get you through with plenty in the tank at the end.
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Cervical checks are one of the mainstays of obstetric care.  It is not unusual to get checked around 38 weeks even though labor has not begun.  Then you get checked at the hospital while they are admitting you when you are in labor.  You might get checked more than a few times during labor.  Why all these checks? Do they tell how much longer you will be in labor? Are they risk free? Do you do cervical checks in your midwifery practice?

Let's start with the last question first.  I do not do cervical checks as part of routine care in my midwifery practice.  If a client asks me to do a check, we will discuss the risks and benefits of checking before I actually do a cervical check.  In all honesty, I prefer not to check.  I use external cues to assess how well labor is progressing, and those cues have served me well during my midwifery career.

What are the reasons for cervical checks anyway? Before labor begins, a provider may use a cervical check to assess how likely it is a pitocin induction will work.  Sometimes providers want to know if dilation has started before labor has begun.  A check when you are admitted to the hospital is done to confirm dilation is happening during labor and can also be to show insurance enough progress has occured to justify admitting you.  During labor, many providers have an assumption of how quickly you should be dilating, so they check to see if your body is conforming to their assumption.

Cervical checks do not tell you how much longer until your baby is born.  They tell the provider how dilated your cervix is in the moment, and potentially how your baby's head is positioned in your pelvis.  A cervix can be at 4 cm dilation, and baby could be born in the next 30 minutes or less, or a cervix can be dilated to 9 cm and labor may last another 6 or more hours.  Honestly, I think medical providers feel the need to check dilation because they are not staying with you in the hospital as labor progresses, so they don't have the opportunity for assessing progress by external cues.

Cervical checks do have risks.  Cervical exams increase bacterial levels in the vaginal canal which might lead  infection, especially after the membranes have ruptured.  Even with the most scrupulous hygiene, and wearing sterile gloves for each check, that risk does not go away.  There is a risk they may unintentionally rupture the amniotic sac.  Cervical checks are uncomfortable and may cause stress or anxiety, which can slow your labor.  Cervical checks are subjective, dilation is estimated because we can't use a measuring tape to get a precise number, and the estimation may vary between providers.  I have seen this personally when the nurse estimates dilation at 7 cm, and the doctor checks within 10 minutes and estimates dilation at 5 cm.  Hearing that you have gone backward after hours of labor can be disheartening to put it mildly, and can cause unneeded stress.

I like to watch and wait for the body to let my clients know when dilation is complete.  Because cervical checks are uncomfortable, intrusive, have risks and don't give me big picture info, I rarely use them.  As a midwife, I understand each birth has its own unique pace and rhythm and my job is to support and nurture that, not try to manage it.
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