Navigating Cesarean and VBAC Advice

by Laura Shive


Photo used with permission from Michelle Sokolich at 

Have you ever had a conversation about birth with someone who doesn’t have an opinion? We’re not surprised when discussions of politics or religion elicit passionate responses, but expecting parents are often caught off guard by how readily friends, family, coworkers, and even strangers are willing to pass judgement about their birth plans.

Whether you are preparing for your first baby, adding to your family, or think your family is complete, as your bump expands you can probably expect at least a few unsolicited comments about your baby’s impending arrival.

If you’ve had a cesarean for a prior birth, or if you’re concerned about a surgical birth for this pregnancy, these comments and suggestions can take an especially heavy emotional toll and make you doubt yourself.

Take heart – we have several simple steps to help you handle the birth advice foisted upon you.

When our clients are feeling frustrated or hurt by criticism about their hopes for birth, we suggest they try to imagine that the opinion is offered by a stranger in a grocery check out lane instead of a loved one or coworker. It’s easier to give an internal eye roll and brush off suggestions from the nosy grandma you’ve never met than someone you care about. And the intent is often as benign – they think they have information that‘s going to be so helpful to you (even when it’s anything but welcome)!

Once you’ve escaped being “enlightened” about your choices, consider the source:

  • Has the person given birth in the past couple of years?

    It is amazing how quickly evidence about best practices in birth is emerging. What was considered optimal care five or more years ago may be completely outdated now. And if the birth was more than a decade ago… iPhones didn’t even have Siri and Alexa was just another girl’s name. So your loved one may truly believe they’re sharing facts, when it’s really more of a history lesson.

  • Has the person given birth where you plan to?

    Working as a birth doulas in eight area hospitals, I see a great deal of variation in approaches to even routine interventions. For example, some hospitals readily provide clear fluids in the form of ice pops and juices. Other facilities will halt a lengthy induction to allow the mother to eat a meal. Still other hospitals restrict intake to just ice chips from the time a mother is admitted until the baby is born. So unless you are speaking with someone who birthed recently at the same location you have chosen, their advice may be more about their own experience with their hospital’s rules than anything you are likely to encounter.

  • Do you have the same provider?

    Just as “routine care” varies considerably from one hospital to another, different providers subscribe to different practice guidelines. Some providers tell clients that they will be induced at 40 weeks if their baby has not arrived yet. Other providers don’t routinely induce until closer to 42 weeks. Your neighbor may have given birth a few months ago at the hospital you are planning to use, but your provider may have a completely different approach to managing pregnancy and labor.

This is especially true for TOLAC (Trial Of Labor After Cesarean, or the labor portion of a VBAC). Providers differ significantly in their comfort with TOLAC. Some providers encourage most of their clients to schedule repeat cesareans while others are supportive of TOLAC for a majority of their clients. You’ll find many providers who will offer labor induction to mothers with a prior cesarean, and other providers who refuse to entertain induction for TOLAC clients. So if your friend “had” to schedule a repeat cesarean because she didn’t go into labor before 40 weeks, it is more likely that her provider is one with a restrictive TOLAC/VBAC policy.

  • Do you have the same health history and risk factors?

Pregnancy and birth is not one-size-fits-all. It’s difficult to find one mother with multiple identical labors and births, let alone expect that your labor and birth will be just like someone else’s. Before placing too much value on someone else’s experience, consider how closely their health history and risk factors match yours.

What if the advice you are receiving is from your provider?

If your midwife or obstetrician is giving you advice that mirrors your hopes and goals for your birth, then congratulations! If you are given recommendations that are contrary to your wishes for your birth, you still have options.

We suggest our clients try to consider their pregnancy care provider as they would their auto mechanic. Both are skilled and knowledgeable service providers participating in running businesses. And in both of these situations, you are the client with the purchasing power. If your mechanic gives you a listing of several recommended repairs and a couple of upgrades to consider, there’s a good chance you’ll pick and choose what to do now, what to wait on, and what you have no interest in. And if you start to suspect that your mechanic is recommending services that you really don’t need, likely you’ll find a different mechanic.

Your pregnancy care provider, like the mechanic, has a wide range of options and also opinions on the best course of action (do they trust pregnant bodies, and only intervene when something is concerning, or do they believe they can eliminate some risks by actively controlling labor and birth). As the consumer, you get to decide if their approach is a good fit for you. Several area providers will accept transfer clients well into their third trimester.

When you see signs that a provider may not be a good fit:

  • First, try to have a discussion with your provider about why the recommendation is being made. Open-ended questions give you the best chance of deciphering what is driving the recommendation.

    Examples of open ended questions could include:
    How do you decide if I am a candidate for TOLAC?
    Can you explain why you want to schedule a cesarean now?

  • Don’t be afraid to ask your provider to back up their opinion with current research or practice bulletins. The conversation doesn’t have to be hostile – simply saying “I hadn’t considered that. Where can I read the study to educate myself more?” implies that you are open-minded, but also want to be an informed consumer when making your decisions. It may turn out that your provider is trying to practice evidence-based medicine, but isn’t quite up on the latest quality research.
  • Consider whether you have been given both risks and benefits for scheduling a cesarean and for a trial of labor. If you’ve been given reasons why one option is good and the other is poor, then you have not received the information you need for informed consent. Both cesareans and trials of labor have potential benefits and risks, and often there isn’t an accurate way to predict who will experience specific outcomes. It is important that you have all of the facts to make an informed decision you are comfortable with.
  • If you are considering a cesarean birth, has your provider discussed your thoughts about future birth control and family size, and counseled you about placenta acreta? If not, your provider may not be fully informed about the most recent research. Unfortunately, cesareans increase the chance of dangerous implantation of the placenta in future pregnancies. This should be a part of every conversation about cesarean delivery.

Local resources for exploring cesarean and VBAC/TOLAC options include the Cesarean and VBAC Support of Harrisburg (find it on Facebook or attend its monthly meetings on the third Tuesday at 6:30pm at Om Baby) and area VBAC classes.

National and online resources devoted to quality information about cesarean and VBAC/TOLAC include, International Cesarean Awareness Network, and Childbirth Connection

April is National Cesarean Awareness month. Look for articles, podcasts, and blog posts about cesarean births, VBAC, and TOLAC next month!


The Power of Sound in Labor

holly's birth 155 optimized

Photo:  Lexi Abeln

by Holly Keich

Our voice is one of the most powerful ways that we express ourselves. Whether it be joy, pain, sorrow, fear or one of our many other emotions, sound is integral to letting others know our inner experience of the world. This is still true in labor. Women commonly express themselves through a variety of ways in labor. Let’s take a look at why and how sound can be used to your advantage in labor.

What is Toning?
Sounds may come naturally to you in labor, anything from moaning to singing. When you expel your breath freely in labor while making a low, vibratory sound, you are toning. The sound that is made can be anything from an Oh, Ha, Ow, Om, Roaring, Howling, Swearing, or whatever comes naturally to you. These lower tones help to resonate the lower half of the body as labor progresses.

When the intensity of labor increases a low, deep moaning sound can turn into a guttural growling as your primal self takes over. These changes in sounds can be a cue to your partner not only about what stage of labor you are in, but also provides information about your experience of labor, if you are relaxed or if you are holding tension somewhere in the body. If sounds move to a higher pitch, your support team may know it’s time to provide additional coping, comfort measures or position changes to provide relief and redirect the sounds to a lower tone, if possible.

Vocal toning can also be used during a cesarean birth. It will help to keep you calm and focused, reassure your baby and increase your intake of oxygen and the output of carbon dioxide ensuring a safe and easy journey for your baby into this world.

What are the Benefits of Toning in Labor?
Decrease Sensation of Pain. Toning can help to decrease the sensation of pain in labor. By allowing a free expression of sound you are more able to release and let go of pain. It allows you to find your voice, sing your song.

Mind/Body Connection. Creating sound while expelling the breath allows your mind to connect with your body and stay on top of the contractions, riding them like a surfer on the waves.

Mindful Breathing. Toning is a powerful breathing exercise that helps to increase the length and depth of exhalations. This pattern of breathing releases anxiety and creates a familiar and reassuring continuity for you and baby. Fully expelling the breath also leaves a vacuum that is filled with a fresh breath bringing oxygen to you and baby. While there is no right or wrong way to breathe during labor, it is important not to hold the breath as this creates more tension in the body and increases the sensation of pain.

Labor Progression. While there are no studies that say toning enhances labor by making contractions more efficient, it is the relaxation that sound brings which allows the body to open and the baby to descend. Relaxation is a key component in the progression of labor, so why not relax through sound?

Relaxation. Vocal toning releases sound vibrations throughout the body. Sound Therapy is commonly used as an alternative healing process which effects the body on a cellular level. It is touted to relax the muscles by carrying tension from the body, improving circulation and maximizing energy flow within the body.

What is the Science Behind Sound in Labor?
To better understand the benefits, we must understand that there is a nuero-muscular connection between the throat and pelvis. When our throat is choked from fear, pain or unexpressed emotion, it effects our pelvic region and in the example of birth, the dilation of the cervix, potentially slowing labor. We can use toning to tap into and enhance this connection allowing us to achieve focus and relaxation during labor.

When we have a voice in our labor process, we are empowered. Toning in labor leaves no room for doubt, fear or self-pity as we focus on the sounds and move more deeply within ourselves. Physiologically, we are opening that link between the throat and pelvis, the connection between the vocal cords, diaphragm and perineum when we tone. Giving sound to our feelings, we open not only our mouths, but also our bodies as the cervix is able to relax and open as well.

While vocalizations are common during childbirth, only one study on sounds in labor was found by Pierce in 1998. Of participants who were taught toning in pregnancy, 86% used it in labor. 61% found it helpful in dealing with pain, 42% indicated it promoted relaxation, and 50% said it helped them stay focused.

Moving Beyond Inhibitions
It is important not to try to contain your feelings of pain, but to be fully uninhibited about letting them out. It is a time to let go to your instincts, to let your body take over and to be completely free. If you feel inhibited, your throat will close up and labor could be slowed. It may be that you are feeling more conscious of your surroundings in a hospital setting. But know that you aren’t the first person they’ve heard roar in labor and likely won’t be the last.

When a mother wants to keep the pain to a level she can manage without making noise, the mind sends the body an urgent message, “Wait, Slow Down!” Fear of pain, of loosing control, or being unladylike will stimulate the release of adrenalin, which slows down labor. Labor pain may remain “manageable”, but the labor process will take longer.

In yogic tradition, the chakras, the seven energy centers that are arranged vertically up the spine, can help you to shed inhibitions and release tension during pregnancy. Toning relates to the to Vishuddhi chakra at the throat center. This is the center of creativity and communication. There is a strong link, as demonstrated in science as well, between the throat chakra and the root chakra (at the base of the body and includes the cervix). Making sound in pregnancy and labor helps to stimulate this chakra and one’s sense of survival. Neck looseners, Lion pose, Ujjayi breathing and Om all activate this chakra, as well as the practices described below.

Our typical reaction to intense feelings is often to tense up and to express our discomfort. These are habitual reactions to painful or fearful situations. What our mind believes our body follows. These negative thoughts and expressions can be counter-intuitive to the progress of labor. Let’s learn to use our voice in a way that doesn’t trigger the fight or flight response.

When we change the habit through toning, we are actually triggering our brain’s relaxation response. In turn, we are telling our body to release more oxytocin (the love hormone that stimulates and advances labor). This hormone when created by you and not in it’s synthetic form, helps labor seem less painful and can aid in mother/infant bonding.

Many women feel inhibited making the low earthy sounds of toning in front of others. Overcome these inhibition by practicing at home during your pregnancy.

Start experimenting with different sounds. Humming or “Ah” are easy ones to start with. Practice with all the vowel sounds and notice how they feel in your body, especially your throat. You can even bring two fingers to the notch at the bottom of your throat, right above the breastbone, and feel the quality of vibrations and how it changes with each sound. Note the change in the opening of the lower part of the throat. Remember to practice with a loose and relaxed jaw which correlates to a loose and relaxed perineum.

Feel free to practice by combining sounds or even using a word.

Practice with your birth partner so that they know what to expect during labor. Have them join in. Their voice can add powerful support for your momentum during labor. Don’t have a birth partner, practice with music as your backdrop. Practice with your dog, they just might love to howl along with you.

Practice in the shower, in the car, while doing dishes, before falling off to sleep… Wherever you don’t feel concerned about the reactions of others.

Be Empowered by Your Song and know that your voice can be spoken in labor.


Feel free to leave a comment and let us know if you’ve used toning in labor and how it helped you.

Coloring Away Stress

By Holly Keich

Bringing Baby Earthside coloring book by The Art of Birth, illustrated by Trinity Natay, colored by thrivingwives

Bringing Baby Earthside coloring book by The Art of Birth, illustrated by Trinity Natay, colored by thrivingwives

Holding a child in each hand, I entered the book store in the typical rush that has become my life. There to look at the toys, peruse the children’s books and play with the myriad of toys designed to entice you to make a purchase, I spied out of the corner of my eye a wall full of coloring books. But this wasn’t in the children’s section of the store. What could be the interest in adult coloring books, I wondered.

Much to my surprise there is A LOT of interest. So much so that there is such a thing as coloring parties where adults gather to sip wine and socialize. This burgeoning trend can be traced back to 2012 when Art-thérapie: 100 Coloriages anti-stress, by Hachette Pratique, was published in France.1 The craze continued for 3 years and now has begun to spread around the world. The first book to really hit the mainstream, however, was Johanna Basford’s Secret Garden: An Inky Treasure Hunt & Coloring Book, a beautiful treasury of intricate garden themed drawings with hidden items that make it even more interesting to explore and make your own with a bit of color.2  Coloring books are so popular in fact that as of June 2015, five of the top 30 titles on Amazon’s best-seller list were adult coloring books and there are over 2000 titles out there and rising.3

In exploring the phenomenon a little deeper, the touted benefits of coloring range from stress reduction to preventing dementia. Well, we all have stress in our lives. And while some stress is good, in excess it is damaging to our mind and body (and it’s not so good for our relationships either). In our fast-paced society where things seem to be spinning out of control stress seeps in at every angle, school, work, illnesses, politics, world events, wars, hate crimes, deaths,.. We live in a stressful world and even if we don’t keep in touch with the daily news our brain still absorbs the information whenever we hear it or see even small bits and clips of it throughout the day. In the information age, it can seem as though we are bombarded with negativity at every turn. Who wouldn’t want to shut that off?

Which is exactly what coloring is said to do. Coloring allows the fear center of your brain to go offline and get some rest. And over time the amygdala is retrained to respond less harshly to stress. Joel Pearson, senior lecturer at UNSW in the school of psychology suggests that the books “would offer users a source of stress relief, in the same way the patients with anxiety or PTSD (Post-traumatic stress disorder) use “Tetris” to distract the brain, and provide a sense of calm and clarity. He said during studies psychologists have found that when watching a scary or traumatic scene, if a person plays “Tetris” immediately after, the flashbacks of the event are fewer and less dramatic if they were to not do anything at all.

“The idea is that when you watch something traumatic the memory goes through a consolidation period (the process in which it becomes a permanent memory) and because your brain is focusing on the ‘Tetris’ shapes, instead of the event, you stop the consolidation process, and stop bad memories from turning into flashbacks,” he said. “Colouring-in books act in a similar way.””4

While the studies actually proving many of the benefits of coloring alone is nil to none, anecdotal evidence is strong. Pearson also claims that “there seems to be a greater drop in self reported anxiety for colouring-in mandalas and patterns compared to just drawing colour on a blank page.”5 So it sounds like the shapes and patterns in these adult coloring books may also play an important role. While coloring in the pictures you are focusing on the colors and spaces, occupying the part of your brain that would otherwise be engaged in anxiety-provoking thoughts. Therefore, even though there isn’t research that specifically supports coloring as a treatment, it is perceived to be beneficial as part of a larger plan for coping with uncomfortable feelings.

In fact, this has been know since the early 1900’s when Psychiatrist Carl Jung, the founder of analytical psychology, prescribed coloring to his patients, more specifically the coloring of mandalas, to calm and center their minds.

And therapists continue to use coloring as a method of calming anxiety in their clients to this day. Art therapists may use coloring as a beginning technique with their clients, but want to be clear that art therapy it is not. Art therapy, which involves the creative process, is more than just coloring in the lines. But other therapists have found coloring can be beneficial on a variety of levels, especially when working with children. New York-based clinical psychologist Dr. Ben Michaelis uses coloring with his own family. “We do it on Fridays as a way to kind of take the steam out of the week,” he said, “and also when my kids are kind of fighting or the temperature is starting to rise a bit in the house.”7

Coloring can be beneficial for women as they approach their birth. Not only can it reduce stress and promote calm thoughts towards labor and parenting, birth coloring books like “Bringing Baby Earthside” released locally by The Art of Birth and illustrated by Trinity Natay (pictured above) can help mamas-to-be focus on positive affirmations for birth. Who wouldn’t want to guide their focus with these inspirational and beautifully penned drawings of women in all their divine glory?

If you are ready to give it a try, you’ll want to head out and get some supplies. Of the 2,000 available books, I’m sure you’ll find one that you fancy, one that brings you peace just paging through the pictures. Some adult coloring books have fine detail (yet another benefit as it helps to preserve fine motor skills as you age), but this may make it a bit more tedious to color, so you may want to drop the kids crayons and buy your own coloring supplies. Get a nice sharp set of colored pencils or quality markers and you’re all set to go. Now, if I could only find the time…







Surgical Birth and Motherhood

by Meredith Sullivan

Photo Credit:  Michelle Sokolich at

Photo Credit: Michelle Sokolich at

Many parents have a vision of how their baby (or babies!) will come into this world. For some, this means a hospital setting, while others chose to deliver in their own home. Whatever the case, there are times when this vision does not play out for a variety of reasons. One such outcome, that continues to be a very concerning, increasing method, is surgical birth, also known as, Cesarean section.
Although there are sometimes clear clinical indications for a Cesarean delivery, the short- and long-term benefits and risks for both mother and infant have been the subject of intense debate for over 25 years. In 2007, nearly one-third (32%) of all births were Cesarean deliveries. In central Pennsylvania, there are 3 major hospitals with Labor and Delivery  units, each with surgical birth rates ranging from 23%-37%, according to the Pennsylvania Department of Health’s 2008 statistics.
Experiencing a surgical birth can be a completely healthy, happy experience for many mothers, yet others have feelings sadness, anger, fear, and loss of power. With one in five women experiencing Postpartum Depression, we must factor in what role their  childbirth experience factors into this concern as well as how these feelings impact a mother’s ability to take care of her baby and herself in the postpartum months and beyond.
Some issues relating to birth in the United States are virtually taboo and a common notion put upon a new mother who may have had a birth experience that was not what she had hoped is that of “but the bottom line is that the baby is healthy”. To have one’s emotions dismissed is insulting and frustrating, but that is exactly what happens over and over to all too many women.
While most childbirth classes and numerous books include a discussion of Cesarean Section, this segment is often skipped over in hopes that it will not pertain to mother. Surely scenarios play out where either mother or baby are better suited with a surgical birth, where the pros outweigh the cons, such as with severe pre-eclampsia, Intrauterine Growth Retardation, cord prolapse, placenta previa, etc. However, with the Caesarean rate continuing to climb to 1 out of 3 births for the last 13 consecutive years in the United States, one of the most “developed” countries in the world, there are no doubt situations where surgical birth was the riskier method of delivery, for both mother and baby. Additionally, informed consent is rarely given in a thorough manner from many practitioners.
A resource for families that have experienced or are facing a surgical birth is the International Caesarean Awareness Network (ICAN). ICAN’s mission is to promote awareness, prevention, advocacy, and support for mothers who have experienced or may be concerned about facing a Cesarean section. In dialogues with mothers, doulas, nurses and other community members, it was most recently realized that central Pennsylvania would greatly benefit from a local chapter of ICAN. That being said, the  International Cesarean Awareness Network now meets on the third Tuesday of every month at 6:30pm at Om Baby Pregnancy & Parenting Center.  We encourage you to join us in this forum regardless of when or why you experienced a surgical birth, if you have concerns that you may be faced with a necessary or unnecessary surgical birth or if you simply would like to educate yourself about the topic for you or a loved one.