#129 | Provider Red Flags in Your Third Trimester

October 13, 2021

The third in our series of provider red flags episodes is here. Today,  Cynthia and Trisha talk about the words, behaviors, and "recommendations" that concern us most around third trimester pregnancy topics such as: elective inductions, big babies, due dates, failure to progress, and vaginal exams.  How your provider thinks about, discusses and manages these topics tells you a lot about whether or not your birth goals will be supported.  We are here to give you our best knowledge and advice on when and how to know if your provider is right for you! Don't miss our other two episodes in this series:

#124 | Provider Red Flags: Your Second Trimester

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Please remember we don’t provide medical advice, and to speak with your licensed medical provider related to all your healthcare matters. Thanks so much for joining in the conversation, and see you next week!

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View Episode Transcript

If you're just casually getting ultrasounds week by week in late pregnancy, you are very likely to be told at one of those ultrasounds that you need to be induced for one of these reasons. And they're, they're not linked to safer outcomes, they are doing an intervention that has no benefit. And they're saying it's necessary and has potential downside. I mean, anything that they say you have to do, and there's no clear benefit is concerning. They're doing it just to put a number in the chart. It's just data for them. doesn't mean much. Usually, it's much earlier than a first time mom will even go into labor. So most of us have that anxiety that we see that due date come and go, we start to worry, and we're more susceptible to unnecessary intervention because of that concern.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Trisha, remember when we started this, we started this list. We're like they're all falling into the third trimester. That's right, that we're finally here with the big. The big topics of the third trimester, it felt like the juiciest things are in the third trimester. So we have a lot to say today. Yeah, but like lo and behold, we did have a lot come up in the first and second after all, I mean, they are red flags are always the good thing about red flags is they're always showing up. They don't have to show up just when you walk through the doors of the hospital. They can kind of be there for the taking. Really? Yes, that's good, too. And that, as we said in the earlier episodes, the sooner you see them and start becoming aware of them, the better off you're going to be because you'll have more time to make changes. That is for sure. So let's start off with the first one red flag if your provider wants to give you routine vaginal exams in late pregnancy, but Trisha, why don't we start off? Why don't you tell us why a provider would ever want to do a vaginal exam in late pregnancy? What are good reasons for it? I don't know. You really don't have? I mean, I think that makes sense. Yeah, they're, you know, okay, around 37 weeks, it used to be that when you would get the GBS test at 37 weeks that your provider would do a vaginal exam and do the GPS test for you. And that 37 weeks, they might give you information about your cervix, oh, it's soft. Oh, it's a little bit open. Oh, I feel your baby's head, it means nothing. Now, I think that many people are doing their own GPS tests when they go to the bathroom. Or maybe your providers are still doing them in some cases, but you don't need them. They definitely are. Okay. So it depends on where you practice in homebirth practice, it's not usually that case, the case will usually tell the woman to take the swab into the bathroom and do her own exam. So there's no reason to put your hands in her vagina. But if you're doing the GPS test yourself, you might as well just get in there and have a look at the cervix and see what's happening. But I think GBS tests aside, there are still some practitioners who want to put their hands inside of a woman. And I mean, they'll say like, Oh, do you want us to just check and see what we find out. And it's not uncommon for a woman in late pregnancy to leave her prenatal and say, Oh, I'm 90% effaced, and I'm one centimeter dilated? Well, so someone was in there to get that information. Right. So I guess what I'm saying is without your 38 or 39 week appointment without having that already having your bottoms off for the GBS test, then it's a little bit more effort to get the vaginal exam. It's like, Oh, do you want to have your cervix checked? You actually have to ask the question, as opposed to at 37 weeks, you're already on the table undressed, because you're having this exam, you're having the swab done. So it's a lot easier to just check your cervix at that point. But at 38 or 39 weeks, if they say do you want me to check your cervix? The answer should probably be No. Because it doesn't tell you anything useful. And if they say we need if, when you go into the room, they say take your bottoms off so you can have your vaginal exam because this is just what we do at 38 or 39 weeks that should make you question things and say well for what for what purpose? What is that going to tell you? Even if you're three centimeters dilated doesn't mean much. You could be three centimeters dilated for weeks.

That happened to me do you know that? Um, yeah, maybe. Yeah, I was like two centimeters out my 40 week and then I went to work. No, no, I was to send to me There's my Yeah, it was my it was a week before I was supposed to go home which was at 38. Anyway, they threw an emergency shower because we thought the baby was coming. And a few weeks later like on my 40th week they checked me I was in centimeters emergency shower. Yeah. Well, you know, corporate Americans have the baby about that day like she's leaving earlier than we thought everyone like fail, canceled meetings and surprised me later in the afternoon, and I went home under these urgent conditions, because I was led to believe because someone was up in their checking that the baby might be coming any day, any hour. And then there was three weeks later with people from work texting, like, did you have the baby yet? Or you're just hanging out at this point? Like, I'm still three centimeters. i You do wonder why I had that information. It didn't serve me very well. And it definitely put everyone on alarm. Like I could have the baby any minute. But the point is, the way I like to sum this up is what Nancy Wainer says when she said to me, years ago, I said why should we not do vaginal exams in late pregnancy, but what's the reason you know, I'm looking for like risk of infection or, you know, could rupture the membranes. And she simply said, what I've said already before on this podcast, because in childbirth, everything is meant to go down and out. And nothing is meant to go up in in. And even though that's not the data that we like to find and look for who can dispute that, who could disagree with that. vaginal exams occasionally have their place. But let's talk about that. Let's talk about when they have their place. When do they. So vaginal exams definitely can have their place in labor. But there are very few if any reasons to have a vaginal exam in pregnancy, I do understand why women sometimes want to have them, it feels like some sort of marker, bring the data, bring the data, like, you know, you get excited about all these little bits of information, you get your fundal height, the baby's heart rate as if the baby's heart rate number matters either. It doesn't matter that much. As long as the heart beat is normal. And it's beating, we're good. But you know, we get kind of attached to these little details about the progress of our baby and our body. So I get why women want to know, but you just really have to think about what it's going to do for you. Is it going to serve you? Is it going to make you feel anxious? Or is it going to make you feel nothing different? You have to know yourself, if you're fine with the day if you're fine with whatever it is, and it's not going to change the way you anticipate labor or not been fine. So let me ask you this. Why is it a red flag if they want to do routine vaginal exams and pregnancy, because if they say they need to do routine vaginal exams, they are doing an intervention that has no benefit. And they're saying it's necessary. So that's a red flag, anything that they say that is necessary, but has no beneficial side and has potential downside. I mean, there is a potential downside that they could accidentally break the bag of water. That's a red flag, right? I mean, anything that they say you have to do, and there's no clear benefit is concerning. They're doing it just to put a number in the chart, you know, cervix, zero centimeters, 0% effaced, long, thick and closed. It's just data for them. doesn't mean much. Not to mention they can be uncomfortable, and a lot of women gent really, really don't like to have those exams. So if your might be a choice, if you're planning an induction, that is one reason to have a vaginal exam, because it's important to know where your cervix is to determine the course of induction, the method of induction that you're going to go with. So that's probably why a lot of people have them. Alright, let's go to the next one. Speculations around having a big baby major red flag. The number one reason 40 Laughing we've been talking about big baby so much lately. It just keeps coming up. And it forever will because it's it's a totally pervasive issue. It just it does come up all the time. And there's so much misinformation around it. Alright, so let's start with what is the fear around a big baby? Why is everybody so afraid of a big baby? I can answer that. I'm raising my hand. Good go. Yeah, because women typically start off fearing childbirth to begin with. So the concept of birthing anything is frightening. And the bigger the more frightening. I think it's that simple. Yeah, I mean, they don't understand that it has to do with positioning and that the fatty part of the baby is squishy. No, it's just the notion of something bigger and all the the bad comedian jokes out there about giving birth to like a bowling ball or watermelon. Like no, that would kill someone. No, you're not meant to give birth to anything like that. You're meant to birth ahead that will require effort, very much effort in most cases. Typically birthing the rest of the baby is far easier. So why are providers afraid of big babies? Because when I see fear around big babies, I think much more from the provider perspective than the moms perspective. I don't think they're afraid. I think they love feeding the misinformation and the fear. Well, why like, oh, look, baby's looking big. Alright, cool. Let's book a C-section. That's, that's usually how it looks. I don't know, if they were so concerned, they would do a little education on fetal positioning. Surely they've had that opportunity. I just think it's, I feel like it's their opportunity to induce or to perform a C section. That's if they're so inclined, if they're if they're the kind of provider who is so inclined. That is probably true. I do think that there is definitely provider fear around Shoulder Dystocia. It is one of the biggest concerns. So I would say that providers are in fact afraid somewhat of big babies because of the risk of shoulder dystocia. So this is where, you know, there's a relation between size of baby and Shoulder Dystocia. And we've been talking about this a lot as well. But Shoulder Dystocia is probably the is one of the scariest things as a birth provider to come across in labor. And if a baby is bigger, the chances of shoulder dystocia is in their mind higher. So there is a connection between the two. But the data actually shows that almost half of shoulder dystocia does occur and babies that are not technically big babies. So it's it is misinformation. That's when you think about that about half on each side, right? Wasn't it? 40 to 52% or something like that. So in one study, 48% of babies, less than 44,000 grams still had shoulder dystocia. So it's interesting, because when you look at all the cases of shoulder dystocia, half were big babies and half were not big babies. I mean, so what does that tell you? Very little, that tells where it tells you that it's not correlated very well with size. Now, what is correlated is big babies as a result of gestational or diabetes and pregnancy, that those babies have a fourfold risk of sort of shoulder dystocia. But you can't translate that. So what gets hot, what happens is that gets translated to every woman who has a big baby, that she has a big baby because she has some sort of undiagnosed gestational diabetes, or it just kind of gets all lumped together. Can we just make sense of what you just said? Because I think it's worth explaining that. And I've heard you say this. So if I'm not remembering what you have to correct me here, but didn't you say that the reason that there's a greater link, or correlation with gestational diabetes is that because of whatever glucose issue is going on, those babies will have extra fatty deposits around their shoulders. And that's why it's could potentially be harder for them to be born, or that's why it's more prevalent. So, yes, so what happens is that in a big baby, overall, just a genetically Big Baby, baby over 4000, or 4500 grams, that's the technical definition of a big baby, you have proportional head and shoulder size, and the head paves the way for the shoulders. So if the shoulders are in proportion to that overall size of the body, and the baby in the head is large, that opens that creates the space for the rest of the body to be born. If you have an abnormal proportions, smaller head, larger shoulders, which can happen in babies of diabetic mothers, that's where you can have a little bit more of a problem, because the head isn't creating that space. First, There are so many ironies in all of this. And one irony that I'm picking up from your explanation is, you're kind of want the baby with a bigger head than yes. But that's normally a terrifying concept to women is funny, that is exactly right. That paves the way toward a safer birth exactly right. But then, again, we have the small babies you can have, you can have a six pounder that has Shoulder Dystocia. So that's a more about maternal and fetal positioning, and just the baby not making the correct maneuvers to fit through properly. You know, if you really break it down, it does not so scary.

I mean, I think, I think when we get into that territory of overanalyzing, and for the woman who's pregnant and listening, like but how do I know if I'm having? How do I know my baby's head size? How do I know that proportion? We have to remind ourselves that every mammal is giving birth very easily, in part because they don't know. So there is, you know, there, there does have to be such a degree of trust in your body and in your baby and in your provider. And you have to find your place where you can surrender because we can all get really hooked on trying to get as much data and information as possible. As someone who's inclined toward that information. I know it doesn't serve me and my work has been coming away from it and getting more into my instinct and surrendering and trust. And we have to go back to low risk healthy pregnancy with normal physiologic labor, the chances of these things happening are extremely small, its position and interview, its lack of being able to move your body throughout labor, the interventions of labor that can start to set off this cascade of problems just as we discuss all the time. Alright, let's move on to our next red flag. Non medically indicated scheduled induction. So why do we have non medically indicated scheduled inductions most often? For the doctors can mean a baby. Oh, big, is that right? It's not because of due dates, oh, well, then due dates. You're going past her due date. So we're afraid the baby's gonna be too big exactly, it always comes back to the same thing, your baby's measuring big, we should induce you now. First of all, we know and this kind of links to the second one. The next thing on the list, which is about determining baby's size in late pregnancy. Late trimester ultrasound is very inaccurate for determining baby size. Even ACOG specifically states that the diagnosis of microsomia or big baby is imprecise. It's off significantly. And it's not an even bell curve distribution. So more likely, you'll be told the baby is larger than the baby is. And there have been some really good meta analysis published on this where they have found all these women who are told their babies were too big. And the conclusion of that meta analysis that I share all the details in my class, so I'm really familiar with it is that a care providers perception of a big baby is actually more dangerous than a big baby and results in far higher cesarean sections, and far more inductions, and when all those quote big babies were born in that study that involved 10s of 1000s of women, the average weight of the baby was just under eight pounds, because they just don't know. So you have women like me who walk around, pregnant with really big babies, no one says anything. No one ever mentioned that her babies look big, and then they're born and they're big. But then you have the women where they're crowding around her and saying, the ultrasound says your baby is big, we need to induce your schedule A C section, and it's those decisions that result in more than quadruple the rate of adverse outcomes. And those ultrasounds only have a 60% sensitivity for accurately determining a technically big baby, which is 4000 or 4500 grams 60% 40% of the time, it will be wrong. My babies were quote, macrosomic. They were 814 and nine seven, and I completely reject that term. I think it's an injustice, I don't think it's making birth any safer. I have a real problem with the term macrosomia I never use it. I don't give it I don't give it any validity whatsoever. And I certainly don't apply it to my own children. The misinformation is the problem and that women start off uninformed with fear makes us a vulnerable population. So you add misinformation to that. And there's, it's we're not going to be heading the right direction. So I think the takeaway here and this is what I usually tell my clients in class, is just think twice before you get any late pregnancy ultrasound. It's not to say don't do it, it's just to say think twice, because you're going to really want that ultrasound who isn't going to want to look at their baby and get all excited to see their baby. So you're going to be very willing to say yes, but if you get that late pregnancy ultrasound, you're very likely to be told the baby is too big or your fluid levels are too low. We won't get into that topic here today. But do it when it serves you do it when there's a reason to do it. If you think you have a breech baby and it serves you to find out exactly the position of the placenta and cord in there. If you're just casually getting ultrasounds week by week, in late pregnancy, you are very likely to be told at one of those ultrasounds, that you need to be induced for one of these reasons. And they're not linked to safer outcomes.

It's really what are they looking for in late pregnancy, if you know your baby's head down, you don't need an ultrasound to determine that if your provider has any skill with their hands, they can determine that easily through your abdomen. You don't need to know where the court is. Right. So what do we what are we looking for in late pregnancy other than size and fluid levels? Right? What am I missing something? No, those are the two things that result in a lot of scheduled C sections and inductions. And my first pregnancy I didn't have a single ultrasound that one through the whole thing. Wow, that's amazing. You know, a skilled provider can palpate on the belly and even feel fluid levels. But Trisha people didn't they're not so good at this anymore. Most providers can't even tell if a baby's head down anymore. Usually it's the older providers who can but they've lost that skill because we used to touch women and touch is love. I'm not talking vaginal exam touch I'm talking Like, such as some touches too much and inappropriate or unwanted, I'm talking just a touch like research has shown just contact with another human being a handshake, placing changing someone's hand and having physical contact, placing our hands on a woman to feel to palpate. To say all this feels just right, Ellen, there you go your baby's head down. There are benefits to that actually a skilled provider who is good with their hands on the abdomen, or their Leopold maneuvers, and who puts their hands on mom's bellies all the time, their estimate of fetal weight is better than ultrasound. That's unbelievable. That's incredible. A midwife, my midwife mentor used to always tell me in labor, when we would get to a birth, she said, No, put your hands on her belly, do your Leopold maneuvers, get your sense of this baby. Because then we were going to the only way you can actually know the size of the baby. The only way there's only one way. And that is to give birth and weigh the baby, right? And then so that we would do that and compare it to my guestimate through the Leopold maneuvers. And then that's how you get good at it. So it's a dying art. It's a diner. And it can't be it mustn't be and the reason we really don't know a baby's weight in utero is because we're on Earth, and we're not supposed to wait as a function of gravity. And your baby is in water, which messes with gravity's so much common sense, it's almost hard to, it's almost hard to believe it. But they're just these algorithms that they they plug in to guess right, they're measuring the femur or whatever they're entering, right, and then they plug it into an algorithm and it spits out a number. And it looks very legitimate when that number shows up. But they really don't know what the baby weighs at all. Ultrasound is notoriously poor at guessing fetal weight. And we don't need to know anyway, which is the big thing we keep forgetting and in the greater, you know, in the grand scheme, we keep forgetting, it doesn't serve us to know anyway. That is correct. It's not it doesn't matter. All right, the next one actually kind of goes very much along with this non medically indicated scheduled inductions that we talked about earlier. Which is to if your provider treats your due date, like a hard fast deadline run. It's late to run but run. So non medically indicated scheduled inductions happen because of big babies and due dates, right. And the arrive trial, it was a study a very large study that was done to determine if elective induction at 39 weeks improved outcomes for babies. So when we talk about inducing, were really trying to reduce poor outcomes for baby most notably stillbirth. And the arrive trial did not show any improvement in outcome for babies with elective induction at 39 weeks versus expected management or just a woman going into labor on her own. So this was monumental this study. But because it had a very small reduction in cesarean rate for moms who were induced at 39 weeks, a lot of providers are still sort of promoting this idea of being induced at 39 weeks. It's kind of like what doctors to set on our podcast a couple weeks ago about how we can look at numbers in aggregate. And it's very compelling. And it has nothing to do with the individual. So they can look at 10s of 1000s of women and say, well, let's induce because there is this slightly lower chance of a surgical birth, which is shocking to me. I don't understand that. And I really questioned that honestly. And well. So do the so do the data analysts. Because there does there is something it's already in question. It is a real question. I'm happy to hear that because it just that is just not credible to me at all. It doesn't make any sense. of expectant management, we shouldn't have a higher scissoring. Well, yeah, it has to do with the fact that the longer you are pregnant, the higher your rate of cesarean section because the longer you're pregnant, the greater chance of developing hypertension, that word of prior C section or preeclampsia that require a C section or too big a baby where your provider gets uncomfortable. But the other thing is that okay, the difference in cesarean rate was only it was the difference was 19% versus 22%. Now, that's a statistically significant difference. But if you look at low risk, birth, physiologic birth with midwifery led care, you have a cesarean rate on the high end of 15% and on the low end of 5%. So we're talking about inducing women at 39 weeks to lower the C section rate from by 3% to 19%. When you could go and have a midwifery led birth and reduce that number by twice as much For more, yeah, if they were serious about maternal outcomes here, that would be the conclusion of the whole study Exactly. By default plan to birth with a midwife and, or unless you can't. So we're going to put women at risk of all the risks that come with induction, just to potentially decrease the C section rate by a small amount and ignore the fact that we can have a rate half that by giving birth of midwives. What also bothers me about these studies, though, is that they do feel inherently biased sometimes because it doesn't ever seem to include what happens with all those women with any of the side effects of Pitocin. That won't be included there. No, nobody's nobody's talking about the follow up data on that. You know, how they ended up with a hysterectomy. If anyone that ended up with some kind of postpartum hemorrhage delay breastfeeding, it's not in there. I can't tell you how many studies I've read, where I jumped to the conclusion first, and then I have questions. And I scroll up and I, I and then I go up to the beginning and read the whole long study. And I'm like, Oh, my gosh, this is completely not in alignment with that conclusion. They left this out. This is an important part. But it's almost like they know what conclusion they want. And they get just enough cursory data to be able to get away with it. But they're leaving out really key information. Well, here's the thing they example of it, the outcome they expected with this study was that they were going to see a reduction in stillbirth that was the main objective, and they did not find that. So that's enough. That's enough for me. Right? That could be the conclusion right there. So your if your provider treats your due date as a hard and fast deadline and starts saying, you know, at 38 weeks, let's schedule your induction for 39 weeks, or by the time you hit your due date, you know, you get one one more day. And that's it. For us. That's a red flag, red flag. How many babies come on their due date? 4%? How many come after, a lot. I always play around with my clients. Because I save every class. Usually the first day, I'll say, Alright, I want you to think about your due date. And just tell yourself this fact. That's the day where there's a 96% chance, my baby is definitely not coming because they're so confident the baby will come then. But it's laughable from the baby's perspective. A human baby is on time and in about a five week window and we pick this one date. Usually it's much earlier than a first time mom will even go into labor. So most of us have that anxiety that we see that due date come and go we start to worry. And we're more susceptible to unnecessary intervention because of that concern. I have always told my clients when you get your due date, add a week. And that is the day you tell people your due dates October 1. No, no, no. You tell your mother and your friends. And everybody you know that your due date is October 8, especially your mother. In HypnoBirthing, we say tell people your due month. Yeah, we say sometime in October or if your due date is October 1 Sometime between September and October. You know people are gonna press and I come home what's the no I got away with it. You know, and I you know, my second pregnancy because it messed with me so much. My first when everyone was asking it really was a lot of stress for me. So the second time I took my own advice as a HypnoBirthing. Instructor and where I never even uttered Vanessa's due date with my husband. I didn't even want it in my brain. I only focused on weeks pregnant. So I looked at my 37 to 42 week mark. And my mother in late pregnancy said but just just tell me like what When is the baby supposed to come? And I said Mom, I don't know what to tell you other than sometime between Memorial Day and the end of June. No one knows. So it's it was empowering was fun. And it was empowering. Yeah, I just went by weeks.

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Alright. Okay, next on the list we have provider red flag, duration of labor comments, failure to progress, the number one reason for cesarean section in this country? Yes. So if your provider says anything about how long your labor should take, or how has an expectation around, you know, the length of first stage second stage progression, how fast they want you to dilate, that is concerning. Yep. Remember what my doctor said to me? We want to see dilated at least at least a centimeter an hour? Yes, as if it's linear. Where does that come from? Well, that is what obstetricians are trained to believe, based on the data that was done in the 50s. By, you know, the Friedman, the Friedman curve, you know about that. That, you know, there is a set parameter and an actual curve develops that this is how labor is meant to progress. And I was even taught this in midwifery school in the 2000s. That if a woman does not achieve these benchmarks, then this is slow stalled labor and eventually failure to progress. And this is when you need to augment with Pitocin. And this is when you need to go to C section. Fortunately, there was a huge study done in 2010. And these guidelines have finally been eliminated. And I think I read somewhere that Dr. Friedman is like in his 90s. And he's still furious about it that they have eliminated right before he died. If I go down a legend, exactly. He says this has been used for 60 years, too, and has heard the term and healthy normal waveform to all societies globally. Yeah, well, he's gonna keep rolling over in his grave after he's gone, because nobody's paying attention to those parameters anymore. And of course, what the new information showed us is that labor takes longer than the Freedman curve. And that active labor used to be, it used to be that you were considered to be in active labor at the three to four centimeter mark. Now, it's all the way to six centimeters. So it doesn't matter how long it takes you to get to six centimeters, you cannot be diagnosed with failure to progress if you have not been in labor. If your if your cervix has not reached at least six centimeters dilated, then you're considered to be an active labor. And then there's some parameters around, you know, progress there, but still, are there? Well, yes, I can read you specifically what the new guidelines say? Should we read them just so people know? And then we can there's evidence based guidelines, they're still trying to turn this into a science as to how quickly a woman should dilate. Are you surprised? I mean, I'm disappointed. We're talking about hospital birth here. No, but I'm surprised and evidence based provider like you would give merit to it. So are you saying it's evidence based, I'm saying this is what women will face it. These are the guidelines that they're going to face in the hospital that I'm wondering what they are, this is what I'll read them. It says first stage labor rest can only be diagnosed if a woman has reached six centimeters and her water has broken plus she has one of the following one, there has to have been no cervical change for four hours or more with adequate contractions or to no cervical change with at least six or more hours of inadequate contractions with oxytocin augmentation. Notice they said oxytocin that Pitocin I know the nerve. But you know what I don't like I don't like the word inadequate because who's to judge that? That's not something that a couple can measure. So if the doctor says that's inadequate, well, look, this is the language that has always for me. This is a kg This is a kg, they should still know better if the mother if the mother is less than six centimeters dilated and she needs additional time and or interventions before a rest of labor can be diagnosed. Because she is still in early labor. What a term What a thing to say a rest of labor. What a thing to say. They still want this to function like a science and not like an art. Well, this is why a woman shouldn't get vaginal exams and labor then because this whole thing about no cervical change. Well, you know what, get your hands out of there and no one's gonna really know how much I've changed. The whole approach to just be make her comfortable. make her comfortable. The baby's on its way out. If there's no medical indication, heart rate is fine. Leave her alone. That's not how it works in hospital birth and well then check out and go home. I had a client once who checked into the hospital on a Friday night. Nothing was going on. She went home the provider supported that went back Saturday and labor not much was going on. After a few hours. She went home. She ended up coming back on Sunday and having the baby Sunday. I love that story. I wish much, far more people would do that. Me too. I mean, fortunately we have expanded they have now expanded this definition of active labor to six centimeters, it used to be three or four centimeters. And that's why so many women were getting diagnosed with failure to progress because it three or four or five centimeters you're not in active labor your body is it could take a very, very long time to have any cervical change. So hopefully, these new guidelines are going to reduce the number of diagnoses of failure to progress, which actually isn't even a term anymore. It's a rest of labor. Oh, that's even worse than failure to progress. I think that's even more alarming. Yeah. I don't like the word of rest. A rest is I don't like the word failure, failure is horrible. I it's worse. I think a rest sounds. They're both bad. I think it sounds intimidating and scary. I think it's just a threatening term. Yeah, because it makes it but language affects all of us differently. It just, I don't even know if I'm thinking of it like that arrest to me feels like the word. What it what it what's what it's supposed to mean. It feels like stopping and to me it to me, it almost sounds like well, what's stopping is the baby, okay, is the arrest of labor makes it sound like the baby is at risk. And that's very frightening to me. You're right language matters. So this is a good reason to decline vaginal exams in labor. We welcome these situations, sometimes we raise our hands and say, Sure, go ahead and do that. And then we get a problem on our hands, we open up a can of worms that are, it's hard to, it's hard to close back up. So it's often easier to say, No, there's no reason to do a vaginal exam. I'm good. As for privacy, get everyone to leave the room. If labor stalls and HypnoBirthing we say we just focus on in most evidence based childbirth classes, it's going to be well, let's make the mom more comfortable. Let's keep her relaxed, happy. Anyway, yeah, I think the challenge sometimes comes in when a mom is trying to decide if she should have an intervention like Pitocin. And so then they want to do a vaginal exam. And as a provider, I can see the scenario I've been there. It's, it's well, do you want to try Pitocin? Well, I'm not sure what we can check your cervix and see where you are. And if you haven't, if it hasn't changed at all in an hour or two, then maybe we decide to start the Pitocin. And that's how you get into doing vaginal exams. But you could also alternatively, say, let's give it an hour or two. And if I don't feel different, and I don't feel my contractions have changed, and I don't, you know, not feeling the pressure of the baby and my bottom, then I'm just going to start the Pitocin. You don't have to have a vaginal exam. And all you have to do is say to yourself and your provider, what happens if I do nothing? That's the question you can own and be aware of the rhetoric that follows. Right? And choose the right question like, is there any medical indication? At the moment? How's the heart rate? How's my blood pressure? I don't have a fever. Right? Right. No presence of meconium that we can see. I think we're good. I mean, you have to navigate it yourself. But that's the kind of conversation you could potentially have. All right. That's a tough one. Last one, for third trimester. What I feel like we're doing to women is like you're halfway through labor. They're like mid vaginal exam, and they're giving her voices like that's a red flag. Run. Oh, my gosh, wait a second. I'm pretty sure this was a red flag. I hope we're not doing that. Well, hopefully, we're giving people questions to think about for their prenatal visits, like if couples are listening to this, but also, you know, we're giving them the scenarios that this is why in hospital birth, 30 of women feel traumatized by their birth experience, maybe the scenarios and what we're discussing is going to help you choose an out of hospital birth or birth center birth or a midwife led birth, even though this can happen in a midwife led birth in a hospital too. I mean, there is in a hospital birth, there are going to be you're going to run into the red flags more. There's just no way around it. Yeah. It's not to say every obstetrician will be that way. It's just your work to find out if you're with one of them. There are great obstetricians that wouldn't do any of this. And there are many midwives who would not do this. And there are midwives who would? Absolutely not. So you know, it's just not that black and white. That's, that's not the problem. I tell my clients, if you're throwing darts, and you want a low or no intervention, birth, and you want a natural birth, and you're throwing darts, then sure, like, go for a midwife. But your work is nowhere near done. You really have to get to know every provider to know if you're aligned. And it's not to say that some obstetricians out there aren't going to be more hands off than certain midwives. Yeah, that's definitely true. Yes, totally. But first, you have to know your own birth preferences. Right, right. Yeah. So what do we have left? Okay. The last one we have for third trimester red flags is a provider who expects you to birth on your back tells you that that is the only position they can deliver your baby in So even the ACOG no longer says that, fortunately, since 2017, even the ACOG, the American College of Obstetricians and Gynecologists, I always say, but because you know, if it's their first time listen to the episode, the ACOG, the even ACOG I know the Aika I have this I have this funny way of saying things sometimes donate just getting like just a little bit off. I remember the time I said like an obstetric school instead of medical school. Yeah, everyone thought it was funny. Even if well, it is be American. Yes. That's why you said that. Right? Right. Right, right, right. But even they say no one position should be prescribed. So they're using their soft language so as not to be too hard on all their doctors. But they're saying, there are, there are good outcomes when women choose their own positions. But the truth is, being on your back is a fast path to fetal distress. And it prevents the pelvis from opening up about 30%. So you want to get off of your sacrum. And mainly, you want to be comfortable and choose your own position. It's not a big deal, you don't have to get permission to do this. You can flip over on your hands and knees on the bed, you can stand with your feet on the floor and lean with your palms on the mattress and lean against the bed. You have no liability, you can't get in trouble. There's nothing you can do wrong in that space. No, no, you're in it is their job to support you. And your provider needs to get your baby, wherever you're birthing it from whether that's on the toilet, whether that's standing in the bed, whether that's squatting on the floor, whether that's hands and knees wherever, meaning doesn't matter. I mean, you do not have to birth in the position that is convenient for them, you being on your back is convenient for them. That's the only benefit. Yeah, and if you are having a natural birth, one of the advantages of feeling everything and experiencing everything is your body, and your baby will guide you into the optimal position. So you just have to listen to your body and then go into that position to listen to any prescribed position would be to deny yourself one of the benefits of a natural birth and a safer birth outcome. Now I will say there are women who choose to be on their back for birth, because they're tired, that maybe are on their side, then they roll on to their back. I mean, sometimes it is the position that just feels best to the mom. So there's, it's it's not like it's a forbidden position. It's just that this is the position on your back legs up is the position that has been classically portrayed in hospital birth. And it is not to be forced into that position is not good for you or your baby. But if you find yourself naturally in that position, then it's working for you. That's true. That's a good point. So Trisha, you know what's going to happen? As soon as we're done recording today, right? We're gonna think of another red flag. Yes, I'm sure that will happen. Of course, it will. If not several, you know, that makes me think of it makes me think of the one of the best selling books in the world, The Seven Habits of Highly Effective People. And that book sold like, millions and millions of copies. And then he came up with another book, The eighth habit, I'm like, oh, no, you don't know. There are seven habits. You don't get to do that. What was the missing as a habit? I don't know. I refused on principle was like, Nope, you had your chance. I read your book. Nope.

What if it was the best one of all? I can't do it. Yeah. Imagine if it's like the secret of the mall. And I'm missing out. Well, we might just come back in next week's episode or next q&a with another red flag because we can't stop talking about them. Well, we'll see. Yeah, they're infinite, really. So we I just want to remind everyone, we had a wonderful episode with Barbara Harper of waterbirth. International, I believe was that episode 122? Do I have this gift? Or I can just is it really I believe it is. Wow, isn't that it's not great? She's I imagine he should because well, before I start bragging about how well I remember episode numbers are gonna say she was wrong. Anyway, Barbara Harper, did a great episode with us. So if you want the positive spin on this, and what you are looking for, please listen to that wonderful episode. It will inspire you, it'll probably bring tears to your eyes. And, and you'll just get so much out of it from a more positive perspective. But this is valuable to me No, because it gives you specific things to be alert to, and we know your intuition is going to do its job at, you know, guiding you to the right provider. So with that, so a couple of people have reached out and said that they've experienced some of these red flags and have asked the question, so do I now leave my provider? How do we answer that? I think there are some of these red flags that are grounds for leaving your provider. But you don't have to leave your provider if they're late. to one or two appointments? Yeah, this is what I tell people when they asked me that. This is what I say it's kind of like if you have a close friend, or Oh, certainly over the years of having friendships, you've seen friends go through boyfriends or relationships where they get to a point where they're not sure if they should stay, it's not any different from what I would tell that friend. If you're not ready to take action yet, just keep observing. Just keep observing. Get Yourself Into observation mode. So if you say, oh, there's a little red flag, you don't have to take we're not here to say that means what to do. If we do say that we're, we're kind of kidding sometimes about it, because it's really your decision. And we don't know what options you have. But do be aware. That's what mindfulness is, you might soon enough observe that your intuition is starting to say, I'm not comfortable with this person anymore. I've observed too much now. So you don't have to make a decision or put any kind of pressure on yourself. I mean, if for me personally, if a provider said you can only give birth on your back, and I'm going to mandate an induction, or require you to be induced at 39 weeks. I don't need any more red flags than that. Right? Right. Right. But if they say we let's do a vaginal exam for good measure at your 39 or 38 week appointment, and you say, No, I'll pass, you don't have to leave them because they suggested it. That's right. If they say you don't have a choice, then that is a very strong red flag. I'm not gonna be shy about saying it because you always have a choice. Like that's a really hard one. If they ever say you don't have a choice, I personally would say, and I have had clients who've had to change after 40 weeks, I would say let's do whatever we can to scramble to get to someone who is going to treat you with more respect than that, because that's just false. It's very intimidating situation as well, but it's very unethical. So yeah, they're not every flag is an equal shade of red. Yeah. So having these conversations along the way, this is why developing your birth plan early on and developing it with your provider is really important. Because the sooner you're having these discussions in pregnancy, the sooner you're going to know. Yeah, we can just come back to one of our favorite ones, which is just see how you feel when you're showing up to the appointment and then compare that to how you feel when you leave and see if you felt better after having engaged with that provider or not. So thank you for participating by listening to these red flag episodes. This is the third in our three part series. The first one came out in August with our first trimester red flag. What number was, what number was it? What number what? Oh, I don't know. I'm not that good.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.

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About Cynthia Overgard

Cynthia is a published writer, advocate, childbirth educator and postpartum support specialist in prenatal/postpartum healthcare and has served thousands of clients since 2007. 

About Trisha Ludwig

Trisha is a Yale-educated Certified Nurse Midwife and International Board Certified Lactation Counselor. She has worked in women's health for more than 15 years.

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