Written by Shay Gabriel // Photography by Annica Quakenbush

Packing a bag to transfer from home to hospital. Once I made the decision to transfer, contractions stopped & I was completely out of labor land. One midwife called the hospital ahead of time to make for a smooth transfer, while the others cleaned up the birth pool and other homebirth supplies.

Today I feel compelled to share a personal story from my daughter Evelyn’s birth, which shifted from a long homebirth to a hospital transfer - to denying a cesarean 3 times.

I share the following with sensitivity in mind, as it might bring up memories for those who have had unplanned cesarean births or who have similarly faced the difficult decision to keep laboring or consent to cesarean. Please know that if you have grief or trauma around your birth experience, you are not alone, and support is out there. Feel free to contact us if you'd like, and we can help connect you.

This aspect of my birth story often comes to mind when I think of the "BRAIN" tool/acronym. So first, I’d like to introduce you to the BRAIN acronym, if you aren’t yet familiar!

using your “brain”

Below is an outline of the BRAIN decision-making tool, which is meant to help us make informed decisions and works beautifully in the labor setting.

THE BRAIN ACRONYM

What are the BENEFITS?
What are the RISKS?
Are there any ALTERNATIVES?
What does my INTUITION say?
What happens if we wait/do NOTHING?

Though "wait" (“do NOTHING”) is the last item on the list, I encourage others to think of it first. Asking "What happens if we wait?" often gets down to business quickly and encompasses other items on the list.

informed choice in labor

Before I dive into my personal account of using the BRAIN tool in labor, I’d like to give some background into the concept of informed choice — which is your right in labor, whether or not that’s made clear by your care providers.

Imagine, for example, that you’re laboring at the hospital and a nurse says, “We’re going to start you on Pitocin.”

First of all, be mindful of language like this — language that makes it sound like there isn’t actually a choice. It’s easy for hospital teams to fall into patterns and protocol and treat birthing persons like medical patients. This can be the case whether the birthing person wishes to labor physiologically, chooses to induce, desired pain medication — or any circumstance. Birth need not be handled as a medical event until/unless it becomes a medical event (or until/unless a birthing person wants medical intervention). But in reality, a hospital team might operate as if your labor is a medical event, whether that’s your wish or not. This is one of many reasons why we believe it’s important for birthing persons to feel empowered and involved in decision making processes, and to know their right to informed choice.

Laboring on my own terms as my homebirth team held space to support me however I needed

The fact is, it’s not your job to appease the hospital — it’s your right to make informed decisions that feel best for you and your baby, and it’s the job of your care providers to support you. You can think of this as a hierarchy; while many hospital care providers operate as if the birthing person is at the bottom of the hierarchy and must adhere to the standards of individuals and institutions higher up, we instead encourage you to see yourself at the top of the hierarchy, with those around you serving you not only physically, but also mentally and emotionally.

Great care providers are more than happy to inform and support birthing persons through any questions and concerns. If ever there is push-back or a power struggle as you embrace your right to informed choice, consider that a red flag (and seek a replacement anytime you need!) Unfortunately, some care providers really do prefer to serve patients who simply comply. But as we see time and time again in the birth world, positive birth experiences regularly go hand in hand with feeling empowered, rather than feeling as if things “happened to you.”

Which brings us full circle to the BRAIN tool!

Imagine, again, that a nurse tells you, “We’re going to start you on Pitocin.” You have the right to ask questions and to consent or refuse the Pitocin. Perhaps you’ll find that when you work through the BRAIN tool, you’re fully on board with starting Pitocin anyway. Even so, the BRAIN tool is worthwhile, because it invites you to become an active participant in your birth experience. (You’re a lot less likely to look back on your labor experience with regret when you are confident you made the best informed decisions you could have made at the time.)

Or, perhaps upon using the BRAIN tool, you discover an alternative to administering Pitocin that is more aligned with your birth values and preferences, and you ask to go with that alternative instead. That’s also wonderful!

Either way, yay! You’ve just advocated for yourself!

And with that, my story…

cesarean, thrice denied

I have been talked through transferring to the OR for cesarean. I have uttered those familiar words, "Whatever it takes to get my baby here safely" and meant them with every fiber of my being.

I had a very long labor at home during what was a planned homebirth. After a few days of laboring with a stuck baby (her chin wouldn't tuck, and I was lingering at about 8/9cm dilated), I opted for an epidural at the hospital in order to get some rest. I knew that an epidural would likely mean Pitocin, and that I was risking a cascade of interventions. But I felt confident in my decision to transfer to the hospital and medically intervene.

Little did I know, I would be talked through cesarean 3 times in the next 9 hours.

Finally able to comfortably get some rest after days of back labor and actively moving around

the first time: failure to progress, essentially

The first time I was talked through a transfer to cesarean, I had still been lingering at 9cm dilated, despite rest and Pitocin.

I was heartbroken when I reflected on all my baby and I had been through in labor; it felt as if our hard work was about to be undone. I had labored, unmedicated, for 53 hours at home and had envisioned a smooth, gentle birth in my living room, surrounded only by people I knew and loved, as well as my trusty pup. It was perfectly normal to grieve. But I was also desperate to birth my baby, by belly or otherwise. As I came to accept the change of plans, I realized I felt pressure in my pelvis, so I asked to be checked. I had progressed from a 9 to fully dilated!

BRAIN: "What happens if we wait?" My intuition says to wait.

I decided to continue laboring.

The second time: Epidural leads to fever.

I hadn't pressed the epidural drip a single time in 8 hours. Eventually, an OB put her hands inside me in attempt to help my baby tuck so she could pass through the birth canal. I was shocked and felt intense pain and scrambled to give myself more epidural. Without thinking, I pressed the button several times.

I was angry. The OB should have asked for my consent, but didn't, and the fear-tension-pain cycle had set in. In other words, the shock of unexpectedly feeling internal pain and pressure that was not initiated by my body sent me into a completely different head space, and rather than mindfully work through the pain, I panicked.

Here’s a different picture, for contrast: Earlier at home, our homebirth midwives (there were 3 midwives plus a student with us by that time!) had talked us through some additional options for trying to reposition my baby. We decided to have one of the midwives attempt to reposition baby internally, by placing her hand inside me and gently nudging baby upward. Remember, I was at home, unmedicated. And you know what? I didn’t feel any pain. In fact, I was surprised that the midwife’s hand was already inside me as I was breathing through it all. There are even images of me laughing and smiling!

Yes, asking for consent makes a difference! And when the OB in hospital placed her hands inside of me, it caught me off guard and felt just plain wrong. Epidural or not.

Back to the hospital: The increased epidural caused a fever. I was told that if my temperature went up one more degree, I was headed to the OR.

BRAIN: "What are the risks associated with fever?" My intuition says to wait, and to reconsider transferring to the OR if my temperature goes up.

I chose to wait. My temperature came down.

The third time: Meconium leak and heart decels after hours of active pushing

I hadn't anticipated active pushing as I trusted in the fetal ejection reflex, but laboring with a "stuck" baby in the hospital changed the way I thought about everything.

My baby had released meconium, which was evident in the leaks from my body. The team was preparing to transfer me to the OR, and they told me to stop pushing. That's when I realized I didn't even need to be pushing; my body was pushing whether I actively participated or not. The fetal ejection reflex!

I told the team that my body was pushing, as they continued talking me through the transfer to cesarean.

BRAIN: "Are there any alternatives?" My intuition says vacuum.

I began talking over the OB as my body continued to push my baby. "Vacuum! Vacuum!" I repeated. The OB said she doesn't do vacuum extraction. I felt like my baby was so close to coming out, and I couldn't fathom working against that - the way you can't really stop yourself from releasing a poo when you're already mid-poo. I continued to talk over her. "Vacuum! Get someone who will."

A resident applied the vacuum, tucked my baby's chin, and in two FER pushes, Evelyn was born!

reflections, takeaways

Would it have been okay if I'd consented to a cesarean sooner? Yes! Was it okay that I didn't? Yes! Birth can be wildly unpredictable, and sometimes strange circumstances occur. Making important decisions can be difficult, but there are some things you can do to help set yourself up to feel empowered, however things unfold:

Understand your rights in birth, including the right to informed choice
Understand the risks of cesarean & what might impact cesarean rates (search “cesarean” at the blog for related posts)
Build a birth team who empowers you, advocates for your birth wishes, and embraces evidence-based practices
Understand the medical model of care and the concept of the "cascade of interventions"
Understand & use the BRAIN tool! Practice throughout pregnancy
Seek support any time you're in need; you are not alone

One final note this blog post wouldn’t feel complete without: throughout my labor with Evelyn, I had my chosen midwife and doula by my side. Even in the transfer to hospital, which I am indescribably thankful for. The presence of personal birth support makes a difference. And, when things start to move quickly or you’re unable to advocate for yourself, it makes an incredible impact to have someone there who knows just how to advocate for your specific wishes.

If you’re interested in doula support here in West Michigan, look no further! Sprout and Blossom’s very own Annica Quakenbush and Brianna Trammell are absolute gems. Have a chat with them, and see if they’re the right fit for your team!

All the best as you prepare for any birth adventures that await you!

xo, Shay

Shay Gabriel is the Content Director for Sprout and Blossom whose love of parenthood and psychology has merged into a super-obsession of all things birthy and baby. She believes an informed experience lends to an empowered experience, no matter where you are along the journey.