Evidence-Based Birth® with Dr. Rebecca Dekker

An interview with Dr. Rebecca Dekker of Evidence-Based Birth® on the research behind labor and delivery

Dr. Rebecca Dekker is a nurse with a PhD who founded Evidence-Based Birth®. Evidence-Based Birth® is an organization that publishes accurate, accessible, inclusive research for birthing families. On their website, you can find many free resources including articles and podcasts on nearly every hot topic related to birth. In this newsletter, Dr. Dekker shares her vast knowledge on the research behind birth to help us all become more knowledgeable and empowered about the birth process.

Source: Jonathan Borba/Pexels

You can read the full transcript below or listen to the interview here:

Dr. Cara Goodwin: Hi, everyone. Welcome to the Parenting Translator newsletter and podcast. I’m Dr. Cara Goodwin. I’m so excited today because I’m here today with one of my personal heroes, Dr. Rebecca Dekker. Dr. Dekker, could you please introduce yourself and tell us what it is you do?

Dr. Rebecca Dekker: This is Rebecca. Pronouns she, her. You can just call me Rebecca. That’s what I always have my students do as well. I live in Lexington, Kentucky. I’m a mom of three kids. I started Evidence-Based Birth® in 2012 after the birth of my second child. At the time I was a Nursing professor, so I had both my PhD and Master’s degree in Nursing, and I focused on research. My work included clinical trials, randomized controlled trials, large data sets, publishing, and enrolling patients in studies. That’s what I was doing before I got involved in the birth world.

Dr. Cara Goodwin: Amazing. I’m personally such a huge fan of yours. I have been following along with Evidence-Based Birth® since pretty near the beginning. All my listeners and readers know I’m absolutely obsessed with the research. When I was creating a birth plan for my first child, I knew I had to do extensive research. I was looking all over the Internet, in books, and online trying to gather research, but it was really hard to find. Then I found evidencebasedbirth.com. It was exactly what I had been looking for. All the research I needed compiled in one place. I just found it so useful. It really inspired me to start Parenting Translator, which is aiming to do the same thing with translating the research for parents. I just think the story of Evidence-Based Birth® is so amazing, which if anybody hasn’t read your book yet, Babies Aren’t Pizzas, goes into the story. Could you just tell us a brief synopsis of your story and why you started Evidence-Based Birth®? I think it’s just so inspiring. Please tell us a little bit about what it provides for any individuals involved in the birthing process.

Dr. Rebecca Dekker: Like you and many of your listeners, I experienced a traumatic birth the first time I had a baby. I didn’t realize it was traumatic until about a year later. When I started thinking about what happened to me, I decided to make a bullet point list of all the things that were done to me that I felt pressured to do. I started looking up the research and I was really surprised to find that most of what had happened to me has been shown by research either to be neutral or not beneficial. There was no point in making me do these things, some could even be harmful for me or my baby. I started thinking, what am I going to do different the next time? I made a list of everything I wanted with the next birth. I had some time to do that because I had several miscarriages right in a row when I was trying to get pregnant with my second. There was a bit of a gap between the first and second babies.

I realized that I was going to have a really hard time getting that care my academic medical center where I was teaching. I decided to talk my husband into having a home birth. We hired a midwife who was practicing without a license because at the time midwives in Kentucky could only practice if they were a nurse midwife. The direct-entry midwives were practicing sort of underground. We did a lot of interviews, I checked references, and I hired somebody that we felt really comfortable with. I ended up having a completely opposite experience with a midwife and it left me feeling so empowered and really altered me and my entire focus as a human shifted.

I used to really be interested in cardiovascular research. But I knew I just had to be part of bringing change to maternity care because I felt like even though I was able to have this amazing home birth, I felt like people giving birth in hospitals should also get this care. Even though I was healthy and low-risk, I believe that if you’re high-risk or even if you’re planning a caesarean, you should get this kind of care. The kind of care I was looking for is family-centered, evidence-based, but really centered around empowering you and lifting you up in your pregnancy, so that no matter what happens, what complications you have, you feel cared for, you feel listened to, and that you don’t leave the process traumatized.

Because I had these two such contrasting experiences, it really made me passionate about making this my new life’s work and switching to childbirth research. As a result, I started reading everything I could get my hands on. I started the blog, Evidence-Based Birth (EBB)®. I did all of this on the side. On the weekends when my kids were napping, on the weeknights after they went to bed, I was reading research, I was writing, I was putting it on the blog and it felt like I had this fire lit underneath me. I just could not stop. That went on for quite some years. I think it was like four or five years of burning the candle at both ends when I finally realized one day that I had to make a decision. I had to choose one or the other, either I was going to be in the university, doing research and teaching, or I was going to do Evidence-Based Birth®. I chose Evidence-Based Birth® and have been doing it full-time ever since. We have a team of about ten people who are working tirelessly behind the scenes to make everything run on the website because you might go to read an article or you Google us and you find an article, but there’s just so much that’s going on behind the scenes to keep that ecosystem moving and I’m really honored to have amazing coworkers where we all keep each other employed and we’re all working to fulfill our mission of making this research evidence publicly available.

Dr. Cara Goodwin: I can say, personally as a mother—I’m pregnant with my fourth child right now— that it has been so incredibly valuable to me. I know a lot of my friends and other parents I’ve talked to agree. We cannot thank you enough for providing this resource and so much of it is completely free. You have blogs, you have podcasts, there’s just so much there to really help us feel empowered in birth. I’ve written a lot about birth trauma and something that really contributes to trauma is feeling out of control. When you feel empowered and confident with knowing the research, having the knowledge, I think it helps all of us to be able to stand up for what we want for our own births. It’s just so incredibly powerful.

I would love to just jump into some of the research and ask you some questions that I have and I’d like to start with induction. I’m pregnant with my fourth child right now. I had my first in 2015, so eight years ago, and it feels like the attitude towards elective inductions has changed a lot and this is an example of evolving research. With my first two children, my doctors told me they wouldn’t even consider inductions until 41 weeks and now with this baby, I’m being told that a 39-week induction is a great choice.  I would love to hear about the research on induction. I know there’s some recent research that’s changing the thinking on this. Could you give us a brief summary of what we know about inductions?

Dr. Rebecca Dekker: It’s been interesting because now that I’ve been involved in the “birth world,” as we call it, for 11 years now, I’ve seen things change over the years. 2016 is when there started to be a big push for inductions at 39 weeks. Where this came from is, I don’t know if you remember this, but people used to get induced before 39 weeks, as soon as they hit 37 or 38 weeks. Then a big study came out showing that if you induce electively that early, the chances of your baby being admitted to the NICU are high. They set rules in hospitals all over the United States and in other countries that you cannot be induced until 39 weeks and zero days. A lot of doctors started saying, well, if we can’t do elective inductions before 39 weeks, why don’t we induce everyone at 39 weeks because that’s what they believed was the optimal, ideal time for a baby to be born.

In 2016 at the American Congress of Obstetricians and Gynecologists Conference, they held a debate. The debate was supposed to be two OBs debating— one was going to say we should induce everyone at 39 weeks, everyone. Nobody should be allowed to go past that. The other doctor was supposed to give the opposing viewpoint and say, no, we should not be inducing everyone at 39 weeks. Something interesting happened in that debate. One was Dr. Errol Norwitz from Tufts Medical Center, and the other was Dr. Charles Lockwood from the University of South Florida. They both concluded that we should induce everyone at 39 weeks. They used phrases like “rescue by birth”, like we need to rescue the babies by delivering them now. Another one said nothing good happens after 39 weeks. This is what Dr. Norwitz said--think like a fetus. If a fetus knew that there is no evidence of benefit for staying in after 39 weeks and potential risk of harm after 39 weeks, wouldn’t the fetus want to be delivered at 39 weeks? And Dr. Lockwood was arguing that if you induce at 39 weeks, it’s going to lower the number of caesareans and other complications. There were some really icky things in that debate. I watched the debate. It was publicly available at the time. I don’t think it is anymore, but they were both arrogant. You had one doctor saying--we don’t get any respect as OBGYNs. We only have two decisions to make, now or later, from above or from below. We need to inject some respect back into our profession and make these patients listen to us. It was very interesting to see these two old white men basically saying what they’re going to do. Then they surveyed the audience before and after and the debate did change people’s minds in the audience afterwards. They were like maybe we should do that.

On the other hand, you have the whole midwifery model and midwives in the United States were arguing for restraint. There was a Washington Post news story about this debate and they interviewed Esther Hausman, a certified nurse midwife, and she said, we don’t know exactly what triggers labor, so why mess with it? What we were really seeing at the time was this culture clash between the medical model and the midwifery model, between people with values of naturalism versus technology-driven, between people who are minimalists (you do the minimal amount of medical intervention) versus maximalists (you do the maximum amount of intervention). It was this epic culture clash.

At the time, 39-week inductions were happening, but then something else happened, and that was the ARRIVE study. The ARRIVE study was published in 2018 by Grobman et al. Their goal was to see if inductions lowered the rates of death and serious complications for babies and also what it did to the caesarean rate. This was a really large study that took place at 41 hospitals in the United States. They found about 6,000 people who agreed to participate out of 22,000 people who were eligible, the rest of them refused. They randomly assigned them to either be induced at 39 weeks or to have something called expectant management where you wait for up to 41 weeks before you’d be induced, unless you change your mind or a complication happened. They found that inducing labor at 39 weeks did not improve the primary outcome of lowering death or serious complications for babies, even though you might hear doctors say that it does, they did not find that. They did see a slightly lower rate of caesarean in the 39-week induction group. It was 19% in the induction group versus 22% in the expectant management group. There was a lower chance of developing pregnancy-induced high blood pressure in the induction group. It was 9% versus 14%. Although this study did show that you can safely have a 39-week induction without increasing your risk of caesarean, it does not mean that everyone should be induced.

Unfortunately, what you often see is research will sometimes be used to confirm your own biases. A lot of obstetricians start saying, look, this is safer. Even though it really didn’t show that it was necessarily safer for babies, they did show that it may help lower the caesarean rate if the care providers follow the same induction practices that they did in the study. In this study, there was not a specific protocol for induction, but they were highly motivated because they wanted to find inductions worked better. Sometimes when you’re doing research, there’s a type of bias that’s the bias that people are watching you, so you change your behaviors. I’m sure there’s probably some of your listeners who have been like, oh yeah, I had an induction and they told me within 12 hours it wasn’t working and I had to have a caesarean. In this study, they sometimes waited up to three days and three nights before they labeled an induction as failed. They were very patient because they wanted to have a low cesarean rate in the induction group. The pros are there in that if you want to be done being pregnant and have your baby at 39 weeks, it is possible to do it safely.  I think that’s one of the benefits of the ARRIVE study is it showed that if you choose to have an elective induction at 39 weeks, it can be a fine choice. But the problem is of course, because of this belief system and the medical model of intervening before something goes wrong, you have a lot more pressure being placed on parents.

We have a childbirth class here at EBB® that is taught by instructors all over the world. You can see geographic variations. In some places, it’s not a big deal. People are not being pressured. And other places, for example, Chicago, where a lot of the ARRIVE patients were enrolled in the study and the doctors there really believe in 39 week inductions, you are getting outright fear tactics being used, a lot of heavy pressure. You’re told your baby will die if you don’t have a 39 week induction. They’re making these grand claims that aren’t necessarily backed up by the research. Really both options are fine— being electively induced or not. But the pressure from the medical community is to be induced. That’s why you’re probably seeing that. It’s a result of this kind of culture war, culture strategy shift, and then the ARRIVE trial that kind of confirmed what they hoped it would. They hoped it would show a benefit. It did show slightly lower caesarean rates, so they used that as the justification.

Dr. Cara Goodwin: That is so interesting. I love how the research is putting the power back in the hands of the birthing person. I love how you review the research. It’s like, here’s the research and a lot of times, the research isn’t telling you, you must make one choice or the other. It’s like, here’s what we know— now make an informed decision based on what we know. Let’s talk about another hot topic. What about epidurals and pain relief? I’ve had births with both with and without epidurals. I can understand either choice. But for those who need help with the choice, can you talk a little bit about the research on epidurals, on other forms of what I’ll call medical pain relief, like nitrous oxide? And then also, I’m sure you probably have a better term, but non-medical pain relief like being in a warm tub, music, etc? What evidence do we have for pain relief during labor?

Dr. Rebecca Dekker: I have experienced both methods, epidural and birthing without one. I think that there is a myth that we have to debunk and that is that some people think it’s an epidural or nothing and that’s not the case. For people who prepare to birth without an epidural, they’re going to be looking at all of the different comfort measures that they can use ranging from like meditation or self-hypnosis to getting in a warm tub or a shower, using massage, a birth ball, a doula. There’s a whole range of comfort measures you can use to stay comfortable. And those actually have been shown to have a lot of benefits whether you have an epidural or not in the end. I often encourage people, even if you know you want an epidural, to go ahead and learn the comfort techniques that appeal to you because there may be time where you might have to wait for the epidural or maybe it won’t work. We do know that there’s a one in ten chance, sometimes one in eight, that the epidural will not work sufficiently. 

We have a pocket guide to interventions here at EBB® and one for comfort measures. I’m just going to share the research that we compiled on what we call regional analgesia, which is either a spinal block or combined spinal epidural and they’re called regional analgesia because they provide pain relief to a region of your body typically from the abdomen down. Analgesia means pain relief and with the epidural the needle is used to guide the catheter which is a tiny tube into your back and it’s placed right underneath the spinal cord. It takes about 10 to 15 minutes to start working whereas a spinal block is an injection, like a one-time injection of medicine into a sack of your spinal fluid, that you get immediate relief. It only lasts one to two hours whereas with the epidural you can have it continuously and the combined spinal epidural you get the best of both worlds. You get the immediate relief but then you also get the continuous relief of the epidural.

We do have a lot of research on regional analgesia. Usually the epidurals and spinals and combined spinal epidurals are all lumped together in the research. There’s a Cochrane review with more than 40 randomized trials and they found the epidurals lower pain levels by about two to three points on a zero to ten scale compared to having an injectable opioid. They usually don’t put anybody in these studies where they have nothing for pain. They’ll give opioids or you get the epidural. They found that compared to the opioid injections, epidurals lower your pain by about two to three points on that zero to ten scale, and it does not affect the overall caesarean rate. Other research has found that epidurals are highly effective.

Anecdotally, a lot of people say that they’re able to sleep and rest if they get an epidural. They can be given as soon as you want. There’s no research showing that it’s harmful to wait or to do it too early, and you can keep having it throughout labor. You can be given stronger doses if you need a caesarean or a forceps or vacuum delivery. It’s less risky than having injections of opioids. Serious complications are very rare. Anesthesia has evolved as a field so much so that the epidurals and spinals are considered to be very safe now.

There are side effects. I already mentioned that one in eight to one in ten people will not have satisfactory pain relief. It’s going to require additional interventions. Once you have an epidural, there are other interventions needed. They’re going to be giving you IV fluids. You’re going to be on the continuous fetal monitor. You might need your bladder to be catheterized through your urethra. You might need Pitocin. You probably won’t be as mobile as before. You might be restricted to bed and you’ll need to have like a continuous oxygen monitor on your finger and you’ll be having your blood pressure checked all the time. And then there’s other risks as well. Unfortunately, it’s going to increase the chances that you have a longer pushing phase, that you might need forceps or a vacuum, that you might have a fever or low blood pressure, or you need a caesarean for fetal distress. For some people, it can make their skin really itchy. About 1% of people will get what we call a spinal headache, which is a really painful side effect. And for the baby, if your blood pressure drops, the baby’s heart rate could be affected and that’s why it can lead to an emergency cesarean. Babies might have more difficulty with feeding after they’re born for the first couple hours.

These side effects go up the higher the dose you get. It’s not like all epidurals are alike. You can get a low dose epidural and you’re less likely to have these side effects. For me, I ended up having a very high dose epidural that basically made it so I could not move my lower body at all. I felt like I had elephant legs. When I talk with people about getting epidurals, I talk with them about thinking about the dose you want. You can ask for a low dose epidural if you don’t want to have a really heavy one, and also knowing what are the other alternatives that you want to have in place while you’re waiting or if you decide you don’t want one or if it doesn’t work. That includes nitrous oxide, which we just came out with a new podcast episode on the Evidence Based Birth podcast about nitrous oxide.

Dr. Cara Goodwin: Amazing. That is also helpful. This will be my fourth time giving birth, and I’ve never heard that you can ask for different doses of epidurals. There’s so much information out there that I feel like we don’t know as birthing people.

The next thing I want to ask about, you have a resource guide on your website on big babies. I found this really interesting. My babies have gotten bigger every time. I started with a six pound baby and then seven and a half. And then my third was almost nine. Immediately after I had my third, my OB and some of the nurses said to me, if you have another one, you’re probably going to end up with a C-section because your babies are getting bigger. My third experienced shoulder dystocia, which for those who don’t know, is when shoulders get temporarily stuck. I feel like now that I’m pregnant again, people will say you’re going to end up with a C-section because your belly looks big, which is an annoying thing to say for many reasons.

Dr. Rebecca Dekker: I used to get that all the time. You look so big. I think that they’re just trying to be nice. I’m sure there’s no bad intention there. But you’re like, thanks for commenting on my body. I did not need that today.

Dr. Cara Goodwin: It is also putting this fear on me when they have idea what’s going to happen to my birth. So can you tell, there’s a lot of fear about big babies? The fear is added to by the fact that we don’t have a really great way of knowing exactly how big your baby is until you give birth. Can you talk a little bit about the research on big babies and maybe take away some of the fear that a lot of us pregnant people may have about having a big baby?

Dr. Rebecca Dekker: There are a couple of questions in there. I know you talked about how your babies seemed to be getting bigger, but I believe your first was born early. Correct? You can’t really compare if a baby was born early, that’s like comparing apples to oranges. My first was six pounds, eight ounces. She was born at 39 weeks, and then the next two were born around 41, 42 weeks, and they were closer to nine pounds, two ounces. I think if my first baby had stayed in longer, she probably would have also been a nine pound-er.

The medical term for big baby is macrosomia, which literally means big body. There are different cutoffs to what’s considered to be a big baby. Some researchers consider it to be eight pounds, 13 ounces or more, and then other people consider it to be nine pounds, 15 ounces or more. Babies are usually considered extremely large if they’re 11 pounds or greater. Yours would maybe fall into the first category, but not the second. Unfortunately, the only way to diagnose a big baby is to weigh the newborn after birth. It’s very difficult to predict newborn birth weight during pregnancy, both from measuring you or from ultrasounds. Even with the modern ultrasounds, there’s still a pretty wide range of the accuracy, and the ultrasounds can be unreliable. So for every ten babies that the ultrasound predicts will weigh more than 8 pounds, 13 ounces— half of them will weigh less than that and half of them will weigh more than that. Care providers have similar error rates when they’re trying to use their hands to measure the baby. It’s just a very inaccurate thing to do.

The main health concern is what you talked about with potential difficulty with birth of the shoulders called shoulder dystocia. That happens to 7 to 15% of big babies. Most cases are handled successfully by the care provider with no harmful consequences to the baby. The only problem that most providers are worried about typically are permanent nerve injuries due to stuck shoulders. And that happens to one out of 555 babies that were your baby’s size and one out of 175 babies who weigh 9 pounds, 15 ounces or greater. Newborn death is extremely rare, but there have been cases reported.

You can see why there’s a lot of fear related to shoulder dystocia because it seems really unpredictable. It has this potential bad outcome. But I think it’s important to remember that shoulder dystocia by itself is not a bad outcome and it can happen at any birth. It could happen with the birth of a smaller baby as well. It’s just more likely with a bigger baby and there’s this really amazing body of research showing that when healthcare providers do interprofessional drills where they’re practicing managing shoulder dystocia, that they can almost completely reduce and in some hospitals they’ve eliminated the risk of nerve injuries in babies simply by practicing the measures you do to release the shoulder and practicing how you communicate with everyone in the room. How are you communicating, how are the nurses, the doctors, midwives talking to each other? How are you talking with the patient? Because it’s really often important to have the patient engaged and involved in helping with the situation because you’re going to have to be changing your position. I think that’s really empowering to know that not only can shoulder dystocias be handled appropriately but there are things that care providers can do that increase or decrease the risk of shoulder dystocia. One thing that can increase the risk of shoulder dissociation is not having you give birth on your back. Giving birth in upright positions or forward positions such as hands and knees has been shown to lower the risk of shoulder dystocia. You can look at the evidence on birthing positions. We have the evidence on big babies at https://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/. We have the evidence on birthing positions at https://evidencebasedbirth.com/evidence-birthing-positions/.

 Another thing that I have found really interesting is the difference between one-step and two-step delivery. This is something that—most OBs are trained in one-step delivery where the head comes out and then they kind of pull and tug the rest of the baby out. What that does is it does not give time for the baby’s shoulders to get into the optimal position for birth. Most midwives use something called a two-step delivery where they wait, there’s a pause between the birth of the head and then the birth of the shoulders and they’re not tugging gently on the baby’s head during that process. If you want to learn more about that, we talked with an OB about that in Evidence Based Birth Podcast Episode 168. It was an episode with Dr. Amber Warmsley where I shared the research on that.

I think it’s hard because we can also talk about the evidence on induction for big babies that’s listed at the weblink I said earlier. The evidence shows that although induction early, like or 37 to 38 weeks would only lower the risk of shoulder dystocia from 7% down to 4%. And then the risk of nerve injury from 2% to 0.4%, but it doesn’t have any impact on NICU admissions. Most people aren’t going to induce at 37 or 38 weeks anyways. The best timing for birthing a big baby is not clear and we never know if the baby’s going to be big or not. Each baby is unique. So sometimes it comes down to your intuition. Your intuition might be more accurate than what they’re telling you. We get stories from both sides. We get stories from people who say, they induced me at 39 weeks, my baby was huge, it’s such a good thing that I was induced. And then others will say, they told me my baby weighed 11 pounds and it was like 8 pounds. Because of the inaccuracy, you’re going to get some people who it turned out well for and some people who it did not. It’s a tricky situation.

Dr. Cara Goodwin: That’s so interesting. I love how you really get into the nuance here, that it’s not a straightforward answer. It is not, big baby, you’re going to end up with a C-section, or big baby, you must be induced early. It’s actually way more complicated.

Dr. Rebecca Dekker: I think it’s unethical to put those kinds of really dramatic opinions as fact to someone when they’re pregnant or they’ve just had a baby. It messes with your whole mindset. Now you’re thinking, “Oh, my body can’t do that. This is going to be really risky to have another baby,” when everything could be fine. Each person is unique, but I’m a big believer in not using fear strategies or talking down to people about their bodies and just focusing on what you can do.  If you want to induce at 39 weeks, as we talked about it, that is a safe option. But if you want to keep going with the pregnancy, that’s also an option. And then ensuring that you ask your healthcare provider, do you and the nurses drill? Do you practice handling shoulder dystocia? And if not, why not? Because evidence is clear that if they’re doing drills at least once a year, that they’ll be prepared and they’ll know the latest strategies and the evidence.

Dr. Cara Goodwin: My baby’s shoulder dystocia was managed very successfully.

Dr. Rebecca Dekker: But from what I’m hearing from you, the one thing that was not successful is they did not talk you through it.

Dr. Cara Goodwin: They didn’t.

Dr. Rebecca Dekker: They did not reassure you. And to me, that can be just as traumatic as having some kind of injury. I think there’s no reason why nurses and doctors and midwives cannot talk you through what’s happening and explain to you what’s happening. To me, that’s a sign that they probably don’t practice it enough. They don’t have formal evidence-based drills that are out there that they’re using. That would be my concern. Because communication is one of the biggest pieces. And that sounds like it was missing.

Dr. Cara Goodwin: Yes, that was definitely missing.

Can you talk a little bit more about birthing positions? You mentioned that giving birth on your back increases the rate of shoulder dystocia. Are there any other reasons that we should not be giving birth on our back? With my first, I was led to believe that with an epidural, I had to give birth on my back. Is that true? What positions are available to you if you do have an epidural?

Dr. Rebecca Dekker: It is a myth that you have to birth on your back with an epidural. There are plenty of positions you can get into. One of the easiest is side lying, and that is evidence-based whether or not you have an epidural because it makes it a little bit easier for your tailbone to move, so that you can make more room for baby to come out.

Another thing to think about is, are you talking about pushing positions or delivery positions? Because evidence is pretty clear that both are beneficial, like if you’re pushing upright. And delivering, I don’t like the word delivery, but that’s the one that doctors use. I sometimes use that because that’s the moment the baby is emerging. You want to have have an upright position or a position in which you’re not lying on your back or semi sitting on your tailbone. It’s important to have different positions or upright positions for both the pushing and the delivery.

Unfortunately, what we still see around the United States and many other countries is that doctors might support you pushing with an epidural in an upright position, but as soon as the baby’s head is about to emerge, they tell you to get on your back. Rates of complications are higher when you’re birthing on your back including rates of shoulder dystocia, rates of tearing, rates of episiotomy (which most people want to avoid being cut with scissors on their vagina). There’s a lot of evidence showing that the birth is smoother, quicker and less painful in an upright position.

Importantly, research has looked at pain as well when you’re birthing in an upright or sidelining position compared to back. When I say back, I mean lying on your back or having your feet up in stirrups or kind of semi-sitting in bed like in a throne position. Those are all technically back lying positions because the tailbone at the bottom is not able to flex. Also, those positions expose you to more interference from doctors or midwives or nurses. Some people call it the dead bug position. One time I was teaching a class in our community. It was at a local brewery. I asked for a male volunteer to come get up on the table and get in the lithotomy position. You can see how disempowering it feels. A lot of us think that’s our only choice because it’s what we see in the movies. It’s what they tell us to get into. Unfortunately, it’s how most doctors are trained. They are afraid that if you have a shoulder dystocia or any other problem and you’re not in that position, lying on your back or sitting back, that they won’t know what to do because they think you’re upside down if you’re any other way.

But if you let somebody birth instinctively, they will very rarely choose to birth on their back. It’s proven by research to be helpful to be upright both during the pushing and delivery. If you have an epidural, the bed does all kinds of things now. As I said earlier, you can ask for a lower dose, you can turn it down as you get closer to the delivery in hopes that you’ll have a little bit more mobility. It does take more people. It might take your partner and a doula or your partner and a nurse to get you into upright positions, but it’s possible because you can kneel on a bed with an epidural, you can squat with an epidural. There are all kinds of things you can do in the bed.

Dr. Cara Goodwin: This just blows my mind that we know from research that giving birth on your back is the worst position, but that is still in 2023 what most women are doing. It’s kind of mind-blowing that we’re going so against the research.

Dr. Rebecca Dekker: I’ve talked with Dr. Nicole Rankins, who hosts the All About Pregnancy & Birth podcast. Your listeners might want to check it out. There was an episode I did where we just talked all about this issue. If you want to learn more about the barriers to upright positions and why so few doctors feel comfortable with it, you can go listen to that episode where we dive into how we can get more people and more doctors to support upright birthing and delivery positions.

Dr. Cara Goodwin: Very interesting.

When most women come to the hospital to give birth, the first thing that happens is they are hooked up to an IV and to continuous fetal monitoring. Are these measures really necessary? Can you refuse these measures? What does the research tell us?

Dr. Rebecca Dekker: So are they necessary and can you refuse them are two interesting but related questions. Electronic fetal monitoring was introduced in the 1970s before there was research supporting its use. It was marketed as a cure to prevent all cases of cerebral palsy for babies. When they finally started doing research on it, they found that it actually did not seem to have any health benefits for babies. The main thing that they found is that it increased the caesarean rate. They were not sure, but they think there’s a connection between the introduction of this in a widespread manner and the huge increase in caesarean rates in the 1970s and 80s. There is some evidence that it might lower the risk of very rare newborn seizures by a little bit, but that seems to be the only benefit they found.

Some people say, it definitely should be used in high-risk situations, but we don’t really have much research on that either showing that there’s any benefits. But if you’re going to be doing high-risk interventions like Pitocin and an epidural, it is possible that the continuous monitor might pick something up that the baby’s not tolerating these interventions. But in terms of a healthy low-risk labor where you’re not having Pitocin or an epidural, there’s really no reason to do continuous monitoring. It only increases your risks.

The problem is it becomes what we call standard of care, which is kind of a legal term where doctors are worried in hospitals that if they don’t do it, they’ll be sued if something goes wrong. It can be difficult to decline continuous fetal monitoring. It is possible. It depends on where you’re giving birth. There are a few hospitals in the United States that support what we call intermittent auscultation, where they just check on your baby with a Doppler on a schedule. That’s really nice and that’s really the best alternative because then you’re not strapped down, you’re not hooked up to the continuous monitors, you have a much lower chance of having an unnecessary caesarean with that kind of handheld monitoring, but there’s very few hospitals that I know that will welcome that. Even the ones that do often require you to be on the monitor for a few minutes to get a strip is what they call it. The research shows that even being on the monitor for minutes when you get there increases your risk of caesarean by quite a lot. It’s because of all the false positives. It’s not an accurate way to assess baby. There’s a lot of subjectivity involved. Doctors and nurses can interpret strips different ways. If they’re not following the current guidelines, they could move really quickly to an emergency caesarean when maybe you just needed some fluids or you need to be turned on your side. Laying on your back makes the monitoring results worse because you’re putting pressure on the aorta that’s delivering blood to your fetus.

At EBB®, we have an Evidence-Based Birth® childbirth class, and we talk about for people who don’t want the continuous monitor, you can refuse it. I mean, they can’t force you to do things. They could, but it would be then an assault, right? So, there is such a thing as obstetric violence, things being forced on people, but technically you have the right to decline anything. The problem is if you decline something that the hospital sees as a must, even though you’re not required to follow their rules. You could, but that’s where we get into making decisions. If I say no to this, how are they going to react? You don’t want them to get irritated with you. So that’s where if you feel really strongly about not having the continuous monitor, I usually encourage people to either find a hospital that supports intermittent auscultation instead and that you know that they are trained and that they offer that. Or find a birth center if you’re not high risk or if home birth is an option for you because it’s really, really difficult to get into a situation where they are upset with you for not getting on the monitor.

Most people these days tend to find a middle ground, which is the wireless monitor. You can have the wireless monitor, which is more like stickers that go on your abdomen, and then you’re not hooked up, but there’s no research showing that that’s any better than the continuous one. A lot of people end up staying in bed anyways because the nurses say that every time you move around, it messes with the monitor. We go into a lot of detail on this subject at an article on our website. So just go to https://evidencebasedbirth.com/fetal-monitoring/ and you’ll see all the research on that subject.

IVs are also a whole other subject that I could go into, but I’ve already covered that at www.ebbirth.com/ivfluids . So if you want to learn more about that, I recommend that article as well. They’ve both been updated with research evidence. The IV fluids are another thing where it’s not required, but it might be presented to you as if it’s required. I love talking about with people about their rights and just knowing that you do have the right to say yes or no can be really empowering. That’s the right to informed consent. You have the right to information that’s accurate and complete and you have the right to say yes or no without pressure. Because if you are allowed to say yes, but you’re not allowed to say no, that’s not really consent. As my friend Cristen Pascucci of Birth Monopoly says, the right to say no is what gives the teeth to the right to say yes. So you have to have both rights.

Dr. Cara Goodwin: Yes, I think that’s such important information going into birth, that this is your birth. You have the right to say yes and no. It’s amazing how many people don’t have that very basic information, that you’re allowed to say no. You’re allowed to make decisions about your own medical care.

Dr. Rebecca Dekker:  You don’t have to explain your choice, you know, to say no or no thank you. But it can get tricky and that’s why we go into a lot of details on self-advocacy in our childbirth class, in our pocket guides, and our other materials. Because, I hate to say it, but it’s almost like if you had a narcissistic partner where you’re like always tiptoeing around managing their feelings. Sometimes you feel like that if you don’t want the normal care that is typically delivered in hospitals, you have to be prepared to stay firm in what you want, but also to manage the situation because you don’t want to create enemies. We do a lot of discussion about how do you you keep things friendly. How do you keep things light so that you have a warm supportive atmosphere in the room. You don’t want it to be adversarial. There’s a lot of coaching we do with partners specifically. I don’t necessarily think that it is the laboring person’s role to make friends, but I really see that as part of the family’s or the partner’s role is to help create that environment where everybody is friendly and focused on what we have in common, which is helping you get through this labor and have a good outcome.

Dr. Cara Goodwin: Could that also be the role of a doula?

Dr. Rebecca Dekker: It depends on the doula. Advocacy is a controversial subject in the doula world. Unfortunately, for many years, doulas were taught that they should not speak up ever to doctors. In some hospitals, especially in the deep south, you can still get kicked out of a hospital for speaking your mind, which is just outrageous because anybody should be able to speak up if they see someone’s rights being violated or if they see something that’s not safe, right? If you have a doula and you hope that they’re going to help advocate for you, that is an important question to ask them— what are your thoughts on advocacy? How will you work with my partner or my family to make sure that someone’s speaking up for me if I can’t speak up for myself? Find out what their philosophy is on advocacy.

Dr. Cara Goodwin: We don’t have time to get into it, but there’s a lot of research evidence on the benefits of doulas too. I know you have that on your website as well, so if you want to read that, make sure you check out the EBB® website! [https://evidencebasedbirth.com/the-evidence-for-doulas/]

I have just a million questions for you. I could literally talk to you for hours, but I know we’re running out of time, so I’d love to just touch quickly on what you should think about, your decisions for after the baby is born? A lot of us mothers, as we’re planning for labor and delivery, think about the birth plan, but we don’t always think about what’s going to happen right after the baby’s born. What does research tell us about newborn care after the baby is born? Delayed cord clamping, skin-to-skin care, potentially delaying the newborn bath — what are some of the choices you should think about?

Dr. Rebecca Dekker:  I love this subject. I could write a whole pocket guide on newborn care, which I have not yet. I think one of the most important things is keeping the pair together, so not being separated if at all possible. There are obviously situations where maybe you’re under general anesthesia and you have to recover from that or your baby has to go to the NICU immediately. But as much as possible, keeping that pair together is really important. Then doing skin-to-skin as much as possible and as quickly as possible. A lot of parents might not realize that skin-to-skin is encouraged and we talk about the golden hour, that a lot of nurses will still lay a towel on your chest and then put the baby on top of the towel. We know it’s going to be direct to my chest, naked baby to my chest, is really important for that first hour, if not two hours.

Then, delayed cord clamping. There’s a ton of evidence supporting that and a lot of parents don’t realize that delayed cord clamping does not mean like 30 to 60 seconds. We’re talking at least three to five minutes. Hopefully the cord goes limp and turns white and that’s the best way to ensure that your baby gets all of their blood and their stem cells and their iron that they need for those first few months of development, especially brain development. So those are the two probably most important things to advocate for and in the immediate aftermath of birthing a baby, when this baby is on your chest, hopefully, it is very distracting and you might have no clue or care what’s going on with the cord. That’s where it’s helpful to have the doula or another person who’s not your partner assigned to keep an eye on that cord, especially if it’s a hospital where they typically clamp the cord in the first minute. There’s a difference between clamping and cutting. So clamping is clamping off the blood flow. And the cutting happens later with scissors, like in that ceremonial cutting of the cord. You want to be watching out for clamps. I did that at one of my sister’s births. She and her husband were just gooing, oooing and awwing over the baby. Then all of a sudden I see the medical team go to clamp the cord and I’m the aunt and said, “Stop”. You have to keep an eye, especially if you’re in a facility where it’s almost like muscle memory. That’s not going to happen at a freestanding birth center or at a home birth, but in some hospitals, you do have to assign someone to keep an eye on that.

Delaying the newborn bath. Research shows that that also is an important thing to do and it’s gotten easier now. I think hospitals are not whisking the baby away to bathe it as often. Because there’s a lot of research showing that the baby has an easier transition. Their temperature stays stable, they feed better, they have better blood sugars if they are kept with their parents and if they’re not bathed. The first bath is a little stressful. It affects their temperature, it wears them out, they can’t feed as well afterwards. So delaying that until at least 24 hours is supported by the research.

Dr. Cara Goodwin: I think the big point you make in your book, which I think is so important is that nobody can separate you from your baby without your consent. This has happened to me a lot in the hospital after birth— they will say we need to take the newborn for tests. I usually say, you can test him right here. It is important to know you can say that. When I was having my third during COVID, the hospital I was going to give birth in told me if I tested positive for COVID, it would be mandatory separation for my baby until we were discharged.  I said, that is not acceptable to me. If I test positive for COVID, I want to be able to breastfeed. The OB told me, well, there are people dying alone right now, so you shouldn’t be worried about this. I was just flabbergasted. Yes, I understand there are people dying alone. That’s very sad, but this is still violating my rights to be separated from my baby. I ended up switching hospitals and then contacting the head of OB at the original hospital to get the policy changed because you cannot call yourself a baby-friendly hospital and have policies where mothers and infants are being mandatorily separated.

Dr. Rebecca Dekker: We don’t even do that to kittens and puppies. I’ll tell you something funny. We have a skunk who has built a den in our yard under the sidewalk. We tried to flush it out and then close off. Then I was like, I wonder if she or he has babies in there because the reason we knew it was there is because it was coming out during the day to search for grubs. I read sometimes they do that if they’re nursing and they need more calories, they’ll come out in the daytime as well. And so, last night, we were able to use a hose to fill up the hole with water so that the skunk ran out and then we plugged up the hole with cement bricks and stuff in front of it. Then I was like, if there’s babies in there, we’ll we need to check in the morning to see if there’s babies. Even though it’s a skunk, I don’t feel okay separating a mama skunk from its babies. I read that they have very strong maternal instincts. We go out this morning, and guess what? She had already dug a new tunnel to get to that den. I was like, there must be babies in there and we’ll leave them alone till they’re grown up and then we’ll plug up the hole. But if I wouldn’t even do that to the skunk who lives in my front yard, like how dare people do that to humans and their babies? It does not make any sense.

Dr. Cara Goodwin: Yes, I was reading recently that it’s illegal in most states to separate a mother dog and her puppy until eight weeks.

Dr. Rebecca Dekker: And we send people back to work at three or four weeks. I know.

Dr. Cara Goodwin: That’s a whole different discussion on maternity leave. But just knowing that this is your baby after the baby’s born and you have the right to decide what happens with that baby. I think that’s just such an empowering point for birthing people to remember.

Dr. Rebecca Dekker: I agree.

Dr. Cara Goodwin: Thank you so much. You are just an incredible wealth of information. I could ask you questions forever. But you do have so many free resources available on your website. Can you remind everybody where to find more if they want to know more about birth?

Dr. Rebecca Dekker: Just go to evidencebasedbirth.com or Google it. I forgot to mention earlier, when we talked about the ARRIVE trial and 39 week induction, we do have an article all about that. That’s at ebbirth.com/arrive. You can check out our podcast or follow us @ebbirth on Instagram.

Dr. Cara Goodwin: Amazing. Thank you so much, Rebecca. This has been incredible. I cannot thank you enough. I know that my readers and listeners will find it so useful too. Thank you.

Dr. Rebecca Dekker: Thanks, Cara.

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Welcome to the Parenting Translator newsletter! I am Dr. Cara Goodwin, a licensed psychologist with a PhD in child psychology and mother to three children (currently a 3-year-old, 5-year-old, and 7-year-old). I specialize in taking all of the research that is out there related to parenting and child development and turning it into information that is accurate, relevant, and useful for parents! I recently turned these efforts into a non-profit organization since I believe that all parents deserve access to unbiased and free information. This means that I am only here to help YOU as a parent so please send along any feedback, topic suggestions, or questions that you have! You can also find me on Instagram @parentingtranslator, on TikTok @parentingtranslator, and my website (www.parentingtranslator.com).

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