Q and A with Drs. Mussalli and Worth:


I think I want unmediated birth—am I crazy for wanting this?

Unmedicated birth is an amazing achievement. Ask any mom who has done it. Almost without exception when our patients climb this steep mountain and reach the very pinnacle they tell us they are changed forever and incredibly proud. But remember — it isn’t easy and sometimes not possible on the first try. For example, think about how many Olympic gold medalists failed to medal or even qualify in prior events before winning gold. What helped them be successful was their past experiences, determination, great coaching, and a little luck. So it is with unmedicated birth; very hard accomplishments take practice and patience!

The triple D winning recipe is Determination, Doula, and Doctor. If you want it, we promise you that you can do it if you give yourself time (baring an unexpected complication with the baby or placenta- that’s the luck factor). If you don’t get there for your first delivery then almost certainly you will for your second.

Why do patients want unmedicated birth?

Why would anyone want unmedicated birth when pain-free birth is available. This is a complex question. Probably the answer is very personal and different for every mom but these are some of the answers we have heard: my breastfeeding goes better; I am closer to my baby; I am incredibly proud of myself; I bond better with my baby; I recover faster; my husband or partner is proud of me; I am more present at my child’s birth; It is the moment in my life so far that I am most proud of.

However, there are some labor situations where an epidural is the very thing that is needed to help achieve a vaginal birth. For example, a baby that is occipital posterior (facing the ceiling instead of the floor). An epidural can help us to rotate the baby before it’s too deep in the pelvis. Once it’s deep in the pelvis either the baby delivers in that position (5%) or the baby doesn’t descend more and a c-section is needed (95%). What’s hard is if your plan is for unmediated birth and you get an epidural you didn’t want then don’t have a vaginal delivery. In these situations, we have found some moms who feel they didn’t do birth their way. The alternative may be a c-section but the mom got to call the shots. Think through what would be best for you. Above all we want you to have a birth experience you are proud of.

What if unmedicated birth is not for me? How soon can I get my epidural and is it ever too late to get one?

Epidural anesthesia for labor pain is a magical solution that almost immediately removes virtually all labor pain. We support this for our patients whenever you want it. Just ask for an epidural and shortly the pain will be gone. However, remember that old saying “there’s no such thing as a free lunch.” Epidurals come with a cost, especially for the first vaginal birth. In our experience of delivering over 10,000 babies, we’ve seen epidurals that sometimes have led to a c-section that otherwise would not have been needed. Epidurals do alter the strength and frequency of contractions. Often just as the labor is getting into a good pattern that’s when many ask for an epidural. The natural labor has now been interfered with, the contractions often too weak, too far apart, and not coordinated with the fetal status. The epidural also often interferes with the natural rotation of the baby leaving the head in a transverse or occipital posterior position- a frequent position that prevents the baby from fitting through the birth canal. Once the epidural is in, And with all the pain gone it’s tempting for many to want to go back to the plan of non-interventional natural birth, but often the worst thing to do is break the momentum of labor with an epidural and then not get the labor back on track.

We counsel our patients that the correct timing of epidural anesthesia is very important. Try not to get an epidural too early. Use your doula and other supports to help push yourself just a little further past your “I’m done” point. Then when you get the epidural allow us to help restore the labor you were having before you got the epidural and keep the momentum going. That hard work of early labor is so helpful to your success for a vaginal birth and also satisfying to you knowing what labor feels like and knowing you did all you could to help yourself and your baby. Oh yeah, if the baby’s head is already out it’s too late for an epidural, but almost up to that point it’s never too late for your epidural.

I think I might want a birth center with a midwife. How is VOB different?

“First do no harm” is part of the Hippocratic oath that doctors swear to. Safety, safety, safety. That’s our #1 job as doctors. Safety for mom and baby, in our opinion, is the key difference between hospital birth and birth centers or home birth for that matter. Safety to us means being able to immediately help you, your fetus, or your newborn baby if there is a problem. A timely cesarean section or immediate expert pediatric resuscitation if your baby is in distress is a real challenge if you are not in a hospital. Some of the most traumatic stories we have heard are from couples who have endured the incredibly stressful and chaotic transfer process from home or birth center to hospital when something is wrong.

Birth centers separate patients based on predetermined risk factors. They accept only “low risk” patients. Epidural, C-section, and pediatric staff are not available on-site at birth centers. Birth centers also typically require discharge home 18 hours after birth which might be hard to do if you’ve had an unexpectedly long hard labor. Some people worry that the increased fetal monitoring that happens in a hospital creates unnecessary cesarean sections. We disagree. It’s not the information that is bad, it’s what a doctor does with the information that is the key. VOb enjoys an extremely low rate of cesarean section because the fetal monitoring gives us the information we need in labor to know it’s safe to continue. Our opinion is that when labor is active the baby should be watched as closely as possible. Information is critical to making the best decision. Think about going to buy a new home. Would you not get an appraisal or engineer’s report. We all seek information in everything we do to help us make the very best decisions- and so too in managing pregnancy and birth.

We don’t practice at a birth center because we disagree philosophically with the current birth center approach. To us, information is our friend, the more the better.