​The discussion about Pitocin use after the birth of your baby is based around Expectant vs Active Management.

Active management means actively participating in the process of birthing your placenta. Many providers routinely administer Pitocin immediately after birth via IV drip or an intramuscular shot.

After the birth of your baby, your uterus will take a brief rest and then continue to contract to help deliver your placenta. On average, this process can take up to an hour after birth. I have found some providers will not, or perhaps do not have the time to patiently wait for a woman’s body to naturally release and deliver the placenta. They will use Pitocin and sometimes additionally use cord traction (light tugging on umbilical cord) to facilitate the birth of the placenta.

Active management means actively participating in the process of birthing your placenta. Many providers routinely administer Pitocin immediately after birth via IV drip or an intramuscular shot.

After the birth of your baby, your uterus will take a brief rest and then continue to contract to help deliver your placenta. On average, this process can take up to an hour after birth. I have found some providers will not, or perhaps do not have the time to patiently wait for a woman’s body to naturally release and deliver the placenta. They will use Pitocin and sometimes additionally use cord traction (light tugging on umbilical cord) to facilitate the birth of the placenta.

However, there are times the placenta will indeed need assistance to be birthed and Pitocin is medically necessary including when bleeding is excessive or when the placenta is being retained by the uterus.

Expectant management would mean belief in your body’s ability to expel your placenta, and so, the provider anticipates you to feel cramping contractions which will release the placenta. Your provider would look for signs such as the umbilical cord becoming limp or a small amount of separation blood and would then instruct you to attempt to push your placenta out of the birth canal.

After the placenta is birthed, it is your uterus’ job to contract and involute – retracting itself to a more pre-baby size. After long labors, it is possible for the uterus to become tired and go on strike! A shot of Pitocin would help your placenta find the motivation to contract, slowing bleeding more quickly.
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Pitocin for labor isn’t always great, but Pitocin after isn’t quite the same. Not every woman will need Pitocin after birth and even if it is the policy of a hospital or provider, it is your right to choose to decline now and still accept at delivery if medically necessary.

In childbirth today, women have more choices than ever in history. There are high tech options, surgical interventions, low tech management options, pharmacological interventions, pain medications, augmentation capabilities, natural remedies, and other paths that can be used to help manage complexities of labor.

With all the options, good childbirth education is key to understanding the options available to you. Still, even with a solid foundation of knowledge, every family is going to have their own path to walk as they bring their baby into the world. How a family prioritizes their options are going to be unique to them.

When navigating labor, a mother will make many choices. Having a simple but efficient way to weigh risks and benefits as you navigate labor is of tremendous benefit. So, just remember, when you are faced with a decision in labor, use your B.R.A.I.N.(E.D.)
How does this look in the application? Say you are in labor and your provider suggests augmentation with Pitocin. Go through this list so you can be fully educated and comfortable with your decision.

Benefits – What are the benefits of this particular intervention at this time? How will it change my provider’s approach to my care? What outcome are we hoping to achieve with beginning Pitocin? What will we have as a result of this intervention that we currently are not experiencing?

Risks – What are the risks associated with this option? Explain the risks that Pitocin carries and their effects on both mom and baby.

Alternatives – What can we do instead of Pitocin? Are there natural remedies we can try? What about nipple stimulation? Can mom walk around on the labor and delivery floor a while?

Intuition & Indication – Mom, what does your intuition tell you about this course of action? Never ever underestimate your gut feeling. Your intuition is strong and wise and it’s prudent to heed its warnings and follow its peace, especially in labor. Also ask and consider, what is the indication motivating the provider's recommendation? 

Nothing – What happens if we do nothing? If I choose not to go forward with augmentation with Pitocin, what is going to happen? As long as mom and baby are doing fine, sometimes doing nothing is the safest option. This requires patience, but it’s many times worth it.

Evidence – What does the evidence say about this option? For instance, pharmacological augmentation with Pitocin is supported by evidence after a woman’s water has been broken for 18 hours. It is not supported for a woman who is not progressing at the same rate as the Friedman’s curve. What reason is your provider giving for wanting to go down this particular path?

Decision – What is your decision? Own it. The consequences of this decision lie with you and you alone. If you choose to have Pitocin and it leads down a common path of causing further intervention and complication, ultimately you are the one that is going to be living with that decision. Your provider is not, your doula is not, your partner sometimes is not. Responsibility for the decision you make needs to be yours alone and you can move forward with it confidently after weighing all the factors at hand.

Using this acronym is something your birth doula can help you with at each step of the way as you labor. It can be applied to each decision in your pregnancy, labor, birth and postpartum time. For instance, you can use it to decide if you want to move forward with artificial rupture of the membranes (AROM), induction, cesarean, or even epidural anesthesia.

Labor is never “textbook.” It is a very individual experience for each family. Every situation is different the way labor progresses, the priorities that a family places on certain values and the way those two things come together as a baby is being born. There are no wrong choices in birth – just make sure your choices are fully informed ones.

By now, many people know and understand the way birth doulas support mothers in labor and how this support creates healthier births. While the research backs it up, it’s kind of just plain old common sense. Women need support on the biggest day of their life, performing the greatest physical and emotional feat they will ever accomplish – of course!

But what about doctors and midwives? For their patients that employ the service of birth doulas, what benefit is a doula to the care provider? It’s a sad reality that many people – physicians included – think of doulas and care providers as being opposing forces, always trying to “win” on the side of what they feel is best for the patient/client. A professional birth doula will do no such thing.

In fact, a well trained, professional, career doula will make every effort to be of service and support to the client while being a valuable member of the birth team. Professional doulas recognize and respect that they are working within a limited, yet extremely valuable scope of practice. Fully embracing that role, they can be of benefit to care providers in many ways.

A primary priority for birth doulas is making sure that their clients have all the information to make a fully informed decision. The care provider can rest assured that their patient is discussing at length the risks, benefits, and alternatives to their options. Patients are not alone in their rooms consorting with Google, but with someone who is knowledgeable. Furthermore, the birth doula is not emotionally or financially attached to the birth so the information they give is unbiased toward any particular path. Providers are busy in hospitals caring for several patients at a time and they don’t always have the time to have great, lengthy discussions with their patients. A doula’s job is to stay with the client through the whole birth. She is committed to being there anyway and she can take all the time needed for an informed decision to be made that satisfies the family.

Once a birth doula has spent time discussing options, she can help facilitate open communication between the provider and the laboring mother. Since she has a client relationship with the mother, the doula can make sure that the mother is fully understanding what the doctor is saying. Doulas do not speak on behalf of their clients. Rather, the doula’s priority is to facilitate an open conversation where fully informed consent can be made and this limits a provider’s liability if complications arise.

Research shows that women who hire birth doulas are much more likely to rate their birth with a high level of satisfaction, regardless of how the birth played out (http://evidencebasedbirth.com/the-evidence-for-doulas/). Patients are more satisfied with their natural birth, their induction, and their cesarean. Satisfaction with the overall birth experience naturally translates into higher satisfaction with the provider. This increases the likelihood that this patient will return to this provider and that they will recommend them to others.

Doctors and midwives can also rest assured that the patient is being monitored with trained eyes. For instance, if a woman spontaneously begins pushing, a doula can recognize that and notify the staff. A professional doula knows that her scope of practice does not include any clinical skills, including catching the baby. She can sometimes be the first line of defense in ensuring that everything happens as it should ensure a healthy birth.

Evidence also shows that births with doulas have lower intervention rates. This benefits the physician because it means lower complications associated with interventions. Patient satisfaction further increases and makes the birth with a doula more likely (but of course not guaranteed) to be straightforward and uncomplicated. These tend to be simpler births for physicians.
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Doulas work primarily for women in labor. However, their unique expertise in the labor room is beneficial to all of the birth team, including the primary care provider. A doula is an advocate, a source of information, and a benefit to all involved in the birth.

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​The “birth community” has a rather unfortunate reputation that precedes us. Some tend to come across as harsh and judgmental toward western medication, not unlike this childbirth educator in the 2008 comedy, Baby Mama.

We rather giggle about this interaction as Amy Poehler’s character makes it very clear where her decision lies. And yet, we all know that, especially when it comes to all aspects of childbirth, the media has a reputation for being woefully inaccurate. This includes the education and support personnel in the field of childbirth, namely birth doulas and childbirth educators.

As a doula who has attended all kinds of births, let’s clear the air about medical birth a bit.

When it comes to birth, women have many medical options. Some of these options are what we call “interventions” because they intervene in the normal birthing process. These can be natural interventions (such as natural induction) or pharmaceutical interventions (such as epidural anesthesia for labor and birth).

There is, fortunately, a lot of readily available information about the risks and benefits of interventions. Women have more knowledge available at their fingertips than ever before in history. It’s true that evidence shows that most of the time, interventions do carry more risks than they do benefits.

That does not make them bad. Or evil. Or unnecessary.

And it doesn’t invalidate the women who choose to have them for their birth. It simply says that there are risks associated with them.

But, there are also benefits.

So let’s talk about some benefits to interventions. The most obvious benefit is that some interventions can be life-saving. Birth is rarely complicated, but when it becomes so, western medicine is very good at handling acute care situations for both mothers and babies.

There are many interventions used in modern obstetric units, but for the sake of simplicity, we’ll stick to 3 of the most well known: Induction, Epidurals and Cesarean section.

Induction is a great benefit for when it’s really necessary. Evidence supports induction in 3 cases. 1: Preeclampsia. 2: When the waters have been broken for 18 hours and labor hasn’t started yet. 3. Being induced past 41 weeks is supported by evidence – not because going past 41 weeks is dangerous, but because induction is likely to be successful at this time.

When induction is successful (meaning that it leads to a vaginal birth), it keeps a mother from having to go through a cesarean. It can save a mother and baby who are headed toward toxemia which can be very dangerous. Waters being broken for extended periods without labor starting can cause infection. The benefits of induction are obvious in these cases.

Epidurals (pain relief that is injected into the dura part of the spine) are being hailed as either Heaven’s gift to women or the devil’s invention itself. Emotions and opinions aside, when is it useful? One of the side effects of an epidural is that it causes a drop in blood pressure. It’s so predictable for this, actually, that nurses are required to give women a bolus of fluid to prevent that drop. However, for a woman with out of control high blood pressure in labor, an epidural’s blood pressure lowering effect may be of tremendous benefit.

What about sexual abuse survivors? Sometimes their bodies can respond in a similar fashion to labor and birth that they did to their abuse: by closing up and pulling away from the situation. This is not helpful in childbirth since a baby needs to come down and out. This reaction can be subconscious and out of an abuse survivor’s control. An epidural’s numbing effect on that region can allow a woman to open her body for birth.

Epidurals are also popular because they are generally a very effective form of pain relief. This can be important to many women for many reasons that go beyond just not wanting to experience pain. The way that epidurals are given today, most women are numbed enough that they feel pain relief, but they are also left with enough sensation to push. Birth doulas as very helpful to mothers that have epidurals as well since they can help explain what is happening, keep the mom comfortable, and help aid in the laboring process to keep the baby moving down.

What about the exhausted mother who has a baby that is perhaps malpositioned and causing labor to go longer than the range of normal? Or the baby that simply caught the birthing mother in a completely exhausted state? An epidural can allow for some much-needed rest from what is surely the biggest physical job a woman will ever have.
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It’s true that cesarean section is nothing to shake a stick at. It is major surgery and a mother should only go into a cesarean if the situation truly warrants it. But it does save lives. And the ones that have been saved by surgical birth are grateful for it.
Interventions are tools and nothing more. They are neither good nor bad. They simply carry risks and benefits. Which risks and benefits are important to a birthing mother are solely up to her. Sometimes the benefits outweigh the risks. In those situations, mothers, doulas, and providers are grateful to have them.

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