Birth Wisdom from an OB-GYN

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What does childbirth look like from the doctor’s perspective? And how can women better work with their doctors – and the medical system as a whole – to improve the labor and delivery experience? This week Dr. Suzanne Gilberg-Lenz shares insights, stories, and hospital hacks with Schuyler Grant, host of Commune's 21-day program Empowered Birth.

If you are pregnant (or thinking about it), head on over to onecommune.com/birth to take the program completely free from August 12-September 1.

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Schuyler Grant: I'm Schuyler Grant, and welcome to Commune, where each week we explore the ideas and practices that bring us together and help us live healthy, purpose-filled lives.

You may have already heard that I've curated a new course that launches this month called Empowered Birth. And to that end, we've been digging into the culture of birth in the US on the podcast, and it's inspired all kinds of questions, some of which I hope I can answer on the podcast today. Yesterday actually, a student came up to me after class and she said, "I've been listening to your podcast about birth and I have a really basic question, what's wrong with just scheduling a C-section? Seems like in some ways that would just be a whole lot easier, right?" And it made me realize that I've been making a really broad assumption about the general understanding of the benefits of a low intervention birth and a vaginal delivery, so I want to dig into that a little bit before we get started with my interview.

First of all, I just need to say that of course we all need to count ourselves incredibly lucky that we live in a time when interventions and surgery are available when we need them, but why should we opt for the most uncomplicated natural birth possible? What's so great about all the huffing and the puffing and the pain and the pushing anyway? Following are a number of benefits of a vaginal birth for both you and your baby.

First of all, beneficial bacteria. We live in a time when gut health is a super hot topic. Your baby's microbiome begins to form in the womb, but it is super charged as it passes through your birth canal where it ingests bacteria that contributes to its lifelong gut health. Some studies have found that babies that are born by C-section are more susceptible to health problems such as food allergies, asthma, hay fever, and obesity later in life. Vaginal delivery is an essential part of your baby's developing immune system.

Your baby's lungs. While your baby's in the womb, its lungs are filled with fluid. Hormonal changes that occur during labor and the squeezing of your baby as it passes through your birth canal expel much of that fluid, and the rest of it is coughed out after birth or it's absorbed by your baby's body. Babies that are born by a C-section are at a higher risk for breathing problems associated with fluid remaining in the lungs for too long.

Your recovery postpartum. If you have your baby at a hospital, you should expect to stay there for a day or two after an uncomplicated vaginal delivery, and two to four days after a Caesarian. After any birth, you're going to want to take it slow before you return to any kind of rigorous activity, but after a vaginal birth, you should be able to reform regular daily tasks within a couple of days. But C-sections are major abdominal surgery, and recovery is longer and more difficult. Add caring for your newborn into the mix, and it is a lot to ask of any woman. Most C-sections will not lead to further complications, but all major surgeries carry risks. These include anything from a bad reaction to the anesthesia, to an infection, even hemorrhaging and blood clots. C-Sections also present some additional risks like inflammation to the uterus, injury to the bowel and the bladder, and then you have to consider effects on your future health. Women who've had C-sections have an increased risk of complications in subsequent pregnancies, including miscarriage, even stillbirth, problems with the placenta and the uterus, fertility issues.

Finally, breastfeeding. Current research indicates that ease of breastfeeding, as well as the overall duration of breastfeeding, is increased with vaginal deliveries. So there you have it. Those are significant benefits for both you and your baby.

Now, regarding interventions, some interventions can be just what a laboring woman needs to help labor to progress. For example, during a protracted labor, a well-timed epidural, which is the most common pain blocker, can give a woman a well-needed chance to rest. And Pitocin, which is a synthetic version of oxytocin, which speeds up labor, might be just what you need to help a stalled labor progress. But one intervention often leads to a cascade of further interventions, which is more likely to lead to an unnecessary C-section. And remember, there are myriad ways to help labor progress without medical intervention, which is a big focus of the empowered birth course.

So I hope I've made the benefits of a low intervention vaginal delivery abundantly clear. I do want to reiterate that a medically necessary C-section outweighs all of these benefits. What we're talking about here is preventing unnecessary surgeries. Nearly one third of babies in the US are now being born via C-section, more than twice the rate recommended by the World Health Organization. And despite the fact that we have a healthcare system that far outspends the rest of the world, American mothers and babies fare worse than many other industrialized nations. Why? Well, there are no doubt many causes, but one likely contributor may well be that medical expediency often takes priority over the best outcomes in evidence-based treatments.

Over the past few decades, the US healthcare system has largely become a labor and delivery machine, often operating according to its own timetable rather than the unpredictable schedule of a laboring mother.

Over the last few decades, the US healthcare system has largely become a labor and delivery machine, often operating according to its own timetable rather than the unpredictable schedule of a laboring mother. Technological interventions are a way of attempting to keep things running smoothly. And as I've said, these can be lifesaving in some situations, but they can also interfere with the natural physiological processes of labor and delivery, and increased risk when used inappropriately. Our C-section rate is a great example of this. As the incidences of Caesarians in this country has increased over the past several decades, we have not seen fewer deaths among newborns, and studies indicate that there's been an increase in maternal mortality.

The student who asked me about scheduling a C-section is an educated, mindful woman. She just doesn't happen to know much about the current state of our birth culture. That's why I've developed the Empowered Birth course for Commune. Not because I believe in birthing in any particular way, but because I want women to have the tools to navigate their pregnancy, their childbirth, and early parenthood from the basis of information and from security in their ability to be an active participant throughout the entire process.

We're offering this course completely free from August 12th to September 1st. Just head on over to onecommune.com/birth to sign up.

Now with no further ado, I'm going to sit down with Dr. Suzanne Gilberg-Lenz. Dr. Suzanne is an OB/GYN who's board-certified in integrated medicine in Ayurveda. She's assisted thousands of women in giving birth, and she feels super passionate about sexual health, pregnancy delivery, and postpartum. You can find more about her at thedrsuzanne.com or on social @AskDrSuzanne. And once again, if you want to hear more from Dr. Suzanne and many other amazing experts in our new Commune course, Empowered Birth, go do onecommune.com/birth to sign up. That's one, O-N-E, commune.com/birth. Hopefully she's going to give us the insider view of hospital births and maybe some good tips on how to hack your hospital delivery. Here's Suzanne.

MUSIC

Schuyler: Suzanne, it's so great to have you across the table from me, and my legs are not up in the air in stirrups.

Dr. Suzanne: After sweating together.

Schuyler Grant: Yeah. We just did yoga together.

Dr. Suzanne: That is so this podcast.

Schuyler Grant: It is, really. I know, it's kind of gross. [crosstalk 00:08:46] yoga.

Dr. Suzanne: But it's awesome.

Schuyler Grant: It's very apropos.

So full disclosure, Dr. Suzanne is my OB, but you were not my midwife because I was in New York then, and I had home births and you're not a home birth midwife, you're an OB. But I have so much respect for you and I know so many women in LA who sing your praises high and low. And it is such a huge honor to have you a part of our panel of experts for this course, because you lend such a depth of wisdom and compassion and balance to all the other people we have on the platform. So thank you.

Schuyler Grant: So last week on the podcast, I was talking to Elizabeth, a home birth and birthing center midwife. And one of the things that is interesting to me about a lot of what she talks about, which I hadn't even framed in my mind going into this course, which was the very basic distinction of a low-risk versus a high-risk pregnancy and just starting from that place, yourself and your support team. So I'd love to get your thoughts on that from the obstetric viewpoint.

Dr. Suzanne: Well, there are sort of criteria, and then, I probably shouldn't say this as an MD, but there's probably a little bit of wiggle room. Generally, a low-risk pregnancy would be a person who's not having any medical issues coming into the pregnancy. And I mean any chronic medical conditions, autoimmune problems, certainly high blood pressure, cardiac problems, diabetes. This might seem obvious, but maybe it's not obvious to everybody. Because I think if that's your normal, you might not realize that once you get pregnant, you're going to be at risk. That's not a home birth candidate.

Age probably is considered a criteria in some communities. So advanced maternal age, shockingly for a lot of us, is considered under 35 years old. I'm not saying that people over 35 can't home birth, but I'm just saying that there is some additional risk there. And certainly as you approach 40, there definitely is additional risk we see even in spontaneous conception, so people who are not doing assisted reproduction, IVF, that kind of thing. And there are plenty of them out there who get pregnant after 40.

There is an additional risk of high blood pressure and complications at the end of the pregnancy. The problem is you could be a super healthy 42-year-old who does yoga and no issues, and at 37 weeks your blood pressure goes up. Or at 39 weeks your placenta is pooping out and the fluid's low. So there's this coming into the pregnancy low-risk, and then there's as the pregnancy proceeds. And there are a number of tests that we do throughout the pregnancy that you would do with a home birth midwife or a doctor in a facility where you're going to have a hospital birth that would route you. There's an algorithm.

There are a lot of other things that people might take into consideration, but those are sort of the basics.

Schuyler Grant: So I'm a good example. I was pregnant first when I was 34 and last when I was 40, but I had elevated blood pressure in all three of them consistently and it just seemed to be what my body did. Now if I was-

Dr. Suzanne: In the medical model, we wouldn't consider that to be something that we would sit on. Doesn't necessarily mean that ... and not ... intervention-

Schuyler Grant: By "sit on," you mean it's not something that you would take lightly?

Dr. Suzanne: No, not at all. And it might be only observation, by the way. It may be that we're having you do blood pressures when you're at home relaxed a little more frequently and reporting on them, or you're coming in a little more frequently so we can check on the fetal wellbeing. Because people who've got high blood pressure, and I don't know how high your blood pressure was, definitely have risk for stillbirth and things like placental abruption.

These are not super common, but they're catastrophic. And the problem is they're not real predictable. That's the problem. And this is where the conundrum of the "medical hospital model" versus outside of the hospital birth model. I think this is where the greatest conflict comes in is the attitudes about that and the fear around that. Both from the clinicians, from the doctors, there are lots of midwives that only practice in hospitals, from patients, from the community, from family members. There's fear of intervention and fear of "I'm going to have my empowerment-"

Schuyler Grant: Taken away.

Dr. Suzanne: Yeah, breached, and that things will start to happen because of the interventions, which is not an unfounded fear. And there's fear on the side of the "system," which, by the way, is not really a system, that something bad is going to happen and we could've done something. It's rough because it's two different paradigms of thought.

Schuyler Grant: I would say from my own experience, and every midwife is going to be different, every pregnant mother's going to be different, and every doctor. So my midwives, and I had three different ones, they all approached it with concern as something like, "Oh, we need to watch this. And you should be doing this and that." And we did take my blood pressure much more regularly, I was taking it myself exactly like you said. So it was a very similar approach, it just happened to be at-home visits as opposed to a hospital visit. And I think that if it-

Dr. Suzanne: Well, my guess is that it didn't progress to a point where you needed blood work to make sure you didn't have preeclampsia.

Schuyler Grant: Exactly. And that was the concern.

Dr. Suzanne: Because had it ... I think any responsible home birth midwife isn't going to be like, "Yeah, let me just do this at home-"

Schuyler Grant: Yeah, "We're going to wing it."

Dr. Suzanne: ... we'll just see what happens." I mean, that's crazy and dangerous. There are people that are crazy and dangerous out there. There are people crazy and dangerous in the hospital, too.

Schuyler Grant: 100%, yeah. There are-

Dr. Suzanne: There's people that are crazy.

Schuyler Grant: ... radical people on all sides of this [crosstalk 00:14:46].

Dr. Suzanne: Totally, totally.

Schuyler Grant: Yeah. And I think for me, what my hope is that every woman who is on the journey of empowering themself now, whether it's through this course or through their own autodidactic reading, through the process, that they are able to get a sense of what the smart and middle path is. And whether you're instinct-

Dr. Suzanne: And what works for them, too.

Schuyler Grant: Exactly, and where your instinct is fulfilled but also elaborated upon by your care team. And, to a certain extent, where. The where is so much less important than the how. And everybody in this conversation is interested in good outcomes. Even the doctor who wants to schedule C-sections because it fits into their ideas.

Dr. Suzanne: Oh yeah. I'm not going to get into what other people's motivations are. I can really only speak for myself. I will tell you that the other thing that I think is an important difference, an important point to make is that in allopathic medicine, in conventional Western-based medicine, we are data-driven. Data-driven. So we have guidelines that are based on published studies, large, large studies. Not 150 people did this and we watched. Uh-uh (negative). Science proceeds in a very specific way. So we make our decisions and we get our recommendations from our governing bodies based on these longterm ...

And most often the best kind of data you can get is something that's a placebo-controlled, prospective, double-blind study. So what that is, is we're taking two groups of women, in this case, pregnant women. It's harder to do this in pregnancy, but I'll bring up a really interesting controversial study that was published last year. You probably know what I'm talking about. But anyways, so we take two groups of women who are pregnant, let's say, and we randomly assign them to different groups, make sure that these groups are relatively similar so that there is a comparison. And then going forward, watch and see what happens when we do X, Y, Z. What is the outcome? Okay, so that is the gold standard. You can't blind it when you're pregnant, because you know that you're getting induced or not, let's say. Okay, but the gold standard is double-blind, meaning that the scientist or the doctor and the participant have no idea what arm of the study they're in. That's not ever going to happen.

So let me give you an example. And this was real interesting. So very large study, multicenter, all over the United States, a very diverse population, fairly reflective of the US population, demographics, racially, age, blah, blah, blah. They looked at women who had never had a baby before and they randomly assigned them, obviously with their consent, to be induced at 39 weeks, a week before due date, or not. And what did they find? Because a lot of the fear around induction of labor is higher C-section rates. Guess what? In this study, and it was like almost 10,000 women, it was a big study, their C-section rates were lower. They were in the hospital longer, because if you come in at 39 weeks and your cervix is long and closed, and you're not ready to ... you're going to be there for three days. So they were in the hospital longer, but they had lower rates of C-section. Oh my god.

So now, does that mean everybody at 39 weeks should be induced? No. And that was not what the study authors or what the community said, but it was like, "Hm, interesting." So we have to check some of our biases out there. And this is a very important piece of information, this rocked my world. Because I grew up in the era of sort of the cascade of intervention. Is this going to apply to everybody? Of course not. Of course not. But-

Schuyler Grant: And do you think that was because-

Dr. Suzanne: And this is data.

Schuyler Grant: So not necessarily your, but what is the expert reading of that data? Is it because babies were smaller?

Dr. Suzanne: Well, okay. So then the C-section thing is also really interesting. And I think it really depends on, again, what the pregnant person is bringing to the table. I think a lot of it is about ... not a lot of it, all of it is about having as much information as possible, both sides, me and them, and coming to the table with trust and love and compassion. Trust is the single most important thing. It's the only thing. If you do not trust yourself and your team and you do not trust your doctor, that's the root of the problem. Those things. So you come to the table and you work it out. You talk about what's going to be best. I have patients that are traumatized, that have had sexual trauma, 

Dr. Suzanne: That I've had sexual pain for years, that they finally got through. They do not want to use, they don't want to have vaginal birth, and you know what? I get it.

Schuyler Grant: Fine. 

Dr. Suzanne: I get it. 

Dr. Suzanne: And that's so funny because for the longest time that was really my focus. Like let me create a space that is safe, trusting and consent based. I'm super serious about making sure they understand the options, they understand the potential consequences of the actions and the decisions that they're making, that I'm making, that some of them can't be predicted. But I, for most of my career, was really, that was what I was thinking about. This person wants this and I don't know if that's gonna happen. I'm going to do what I can. They understand that I'm going to do what I can and that whatever happens, happens. 

It's been a real challenge to me, because I have, look, I just did yoga with you. Okay. And I'm not saying everybody who does yoga feels this way, but I'm gonna, I have Ayurvedic background. I make herbs in my house. I look a certain way, but I kind of, I flow and I'm, my bent is definitely more on the holistic or integrative tip. So it's been really interesting to me, and a challenge to me and my ego, and getting out of my own way when I have people coming in saying, "Look, I'm 42. I never thought I'd have a baby. I'm doing it and this is how I want to do it." And okay, so here are the issues for you potentially, and let's make a decision. 

Schuyler Grant: Right, and you have to be their support team for that. 

Dr. Suzanne: For sure. Do I agree or not agree? It's not about that. I mean, this is off topic, but really I want you to understand, want the listeners to understand, like how intense this is for us too. I'm not trying to make your birth about me, but understand this is what we do. We hold space, we take responsibility and accountability for people's body, and their health. I'm in a private group on a social media platform with other female OBGYNs, and there is a thread that I was glued to this morning about, "Hey, have you guys had an experience where you've informed the patient there's a major emergency going on and they deny consent for an emergency c-section, and they understand that the baby or them may die and they, that's what they want?" 

And I was floored at how many of us have been in that position and held space for a family that decided, it's mostly cultural, that a cesarean was an absolute impossibility, and the fetal death, this baby's death was preferred. And they did that and they watched and waited. I'm getting the chills. And I was like, "Whoa, these women really are my sisters." You know, these women were like the, these doctors were saying this killed me to do it. They understood, understood, understood, understood, understood. It is documented, because we're all about documentation, and I don't want to get too detailed because it's going to be super triggering for people. I couldn't believe it, because I haven't encountered that. 

Schuyler Grant: Have you been in that?

Dr. Suzanne: Never. I've never encountered that. I have had people give me a hard time, but I'm in Beverly Hills. People were like, no, actually in the end, save me. 

Schuyler Grant: Right, right, and don't you feel like because of all the conversations that happened before, there's an established basis of trust where you have an understanding-

Dr. Suzanne: Yeah, you know each other. 

Schuyler Grant: You know each other and you know that if you say, "Sister, we're going into get a quick operation right now, and that they'll be like, "Yeah, okay. Yes please." 

Dr. Suzanne: Yeah. Well I'm very fortunate in that regard because I do have a long history in the community, a lot of my patients are not new to me, they've been with me for a long time, they know each other. But I've had situations where I'm stepping in for a partner on call and I don't have a relationship with the person and I've had to make difficult decisions with that family. And generally it goes well. Sometimes it's rough and it's because of the lack of trust, and I get it.

Schuyler Grant: What I would love to know is your thoughts on, say we do move towards something more like a universal healthcare option or whatever that might look like, does that then also open up the playing field for funding for more freestanding birth centers, coverage of low risk home birth? 

Dr. Suzanne: I hope so, but I don't know. 

Schuyler Grant: Because it's cheaper. 

Dr. Suzanne: Yeah, and in other countries they do that very effectively. I think one of the problems that we have here is that we have such a mess with maternal mortality, and if you look at especially in communities of color. We have a lot of other issues that, Sweden it's not 100% white, but it's a lot more homogenous of a population. So Sweden, we get a lot of obstetric data from them because they're just like so organized and they have nationalized healthcare and they've always done it that way. They collect everything and they publish a lot. But you know, this country is super heterogeneous in terms of, excuse me, so many characteristics. And we know that we have baked in, racial bias, racist, this country is built on racism. Sorry. 

Schuyler Grant: Right and it's certainly reflected in our healthcare system.

Dr. Suzanne: And it's literally built by slaves. Okay, and even those of us who feel like we, "I don't do that," there's bias that's internalized that we're not super aware of. I think the fact that we're having a conversation, and we really are having a conversation about this in medicine, people need to know that is happening. We're looking at how we treat each other, how we treat our patients, and why is that affecting our outcomes? Well, that's funny to me too, because from my more holistic perspective, of course the energy that we're directing at ourselves is going to be projected in how we deal with people, but whatever. 

Fine. We're figuring this out. So that's going to make things a little more complicated. 

Schuyler Grant: So how do we take our sense of the wider range of options and then apply that to the model of hospital care? And so how do you, even if you are going into a rotation of five doctors, you don't know who you're gonna get, what I'd like is from your perspective as a doctor who's in a hospital and sees a variety of different hospitals, how do you basically, how do you hack your hospital birth? 

Dr. Suzanne: Yeah. So this is really important. I mean part of it is doing your homework well and in advance. Okay? Really investigating your community, like what are the options for you to birth, really preferably before you're pregnant. Like get the lay of the land down so that you know, because there might be options that you didn't know about. Maybe there's a hospital in the next town over that has a much friendlier labor and delivery. I don't know. There are a lot of places in this country where you can't, it's a small community hospital, there's not enough coverage, and so you can't do a high risk birth there or you can't have a vaginal birth after cesarean. So just sort of know your community. That would be sort of the baseline stuff. 

Dr. Suzanne: So if you're going to meet a doctor that you've never seen before and that's going to be the person delivering your baby, having someone that you have trust and respect for, that you know has your back, is going to be very helpful. Very, very, very helpful. I think that's probably the single most helpful thing. 

Schuyler Grant: And somebody who's not your primary partner. 

Dr. Suzanne: Yeah, I think that's too much pressure. They're going through their own experience. It's very stressful for them often.

Dr. Suzanne: People don't know how they're going to feel. You know the other thing that I wanted to bring up, and it is related to all of this, is that we know that when people are anxious and scared, there are changes on your hormonal status and your neurotransmitters and your immune system. So, that really has a big effect on the choices that people will make about their birth. Okay. So people who are like, "Hell no, I don't want anybody touching me. I want to do this in the woods alone." Or "Hell No. Do not put any intervention," like whatever, or "I don't want to have anything coming out of my vagina." You already have anxiety and fear there. So I think if you address those things as early as possible, and sometimes you can't know what's going to happen until someone's in labor, you're gonna have a better, that's also going to create a better outcome. People's pain threshold is completely altered. Their labor is altered. 

Your body, if your body is in fight or flight, the primal brain is like, "Not a time to have a baby. Obviously we're being chased by a saber tooth-"

Schuyler: Running by a mastodon.

Dr. Suzanne: Yeah, exactly. Like, "not going to drop a baby out." It's going to kill your labor. So again, this isn't to like stress people out, like don't get stressed, but the more support you have, again, the more trust, I can't say this enough, the more trust you have in your team or in your support people, just the more you can be the laboring person. I tell my patients exactly kind of what you said. If you care about X, Y, Z, you're probably not in labor. The thing is, you're going to, the gift that you get is you're altered. When you're really in labor, you are so altered. 

Schuyler Grant: Yeah, you're super high. 

Dr. Suzanne: You're totally in a different space, and what is important to you is completely different than what you think it's going to be, which is awesome. 

Schuyler Grant: Well let me, I'd like to back up a little bit too, in the interest of doing your homework. Yes, so ideally even before you got pregnant, you've done a bunch of your prep homework. And then one of the small sections of this course I really love is on day seven, I think, you and and Elizabeth Bochner give your separate big list of questions to ask your potential midwife and your potential OBGYN, and people can watch the course for free and listen. But in case someone doesn't get to that, what comes to mind for you as the really salient questions, say three of them, when you're sitting down with a potential OB, to get a read on whether they're your girl or your guy? 

Dr. Suzanne: Yeah, well I think some of it's going to be, do the little, like you've got to do the gut check. So I don't know. That not a question, but-

Schuyler Grant: It's a vibe thing.

Dr. Suzanne: If you're feeling it with the person-

Schuyler Grant: You need to smell their armpit, you mean? 

Dr. Suzanne: Right. No, and that's really hard to determine, and that may sound really weird, but like you know who you think you can vibe with and who you can trust. So that's not a question, but that's, because I feel I get that with my patients all the time too. I'm like, "How's this going to be?" I'm pretty good at reading what's going to go down with that person. 

Schuyler Grant: Right. It's a relationship. 

Dr. Suzanne: It's a relationship. Oh my God, it's so intimate. 

Schuyler Grant: Yeah, swipe left or swipe right. 

Dr. Suzanne: Totally. Oh my gosh. Totally. So that's number one. Number two I think is understanding, like I said, doing your homework in advance. What is the environment in which this person does their births.? and details about it that, like I don't want you to get too crazy if you're five weeks pregnant, but you do want to know like are they going to be there? Is their partner going to be there? Do they have midwifes? Because there are a lot of practices where there are midwives who do the low risk pregnancies. Is it a teaching hospital? How high is the volume? What's the environment? And then, you're not going to ask them 50,000 questions, but at least find out from them where do they deliver, basically what it's like, and go do your research. Make sure is this, does this place have the things that you think you want or need? You may not think you need a level three NICU, but maybe you do. Maybe that makes you feel more safe. Maybe you want a small cozy labor and deliver that only has five labor and delivery rooms, and basically you're being managed by the nurses. Maybe you want a teaching hospital that has 25 rooms and every single kind of possible academic resource available. So just kinda get that. Where do they birth? 

Schuyler Grant: And does that also mean, I assume but I've never actually toured a hospital delivery-

Dr. Suzanne: I'll take you. You should come with me.

Schuyler Grant: I should come with you.

Dr. Suzanne: Seriously. 

Schuyler Grant: I would love to. 

Dr. Suzanne: Yeah. Yeah. 

Schuyler Grant: So does that also mean just asking the logistical questions of what does my room look like? What can I do to my room? Do I have a private bathroom? I mean it's all of it. Is it just also that-

Dr. Suzanne: It's hard? I'm going to be honest with you, if you ask all of these questions at your first visit, your doctor is going to be really annoyed. Because they have a lot of things that they need to get through with you. That's like about your pregnancy. Not that this isn't important, but this is where a hospital tour could be really important. And some people, I usually tell people wait till later in the pregnancy, because people coming to me it's like a known quantity. They know I'm at Cedars, they know Cedars, but if you're really coming in blind, you might want to go arrange a hospital tour immediately, where you can actually see it. 

Schuyler Grant: First, right? 

Dr. Suzanne: Yeah, exactly. Because a lot of stuff, in a smaller community hospital, it could be super chill, 

Dr. Suzanne: It could be like old school nurses that are still living in 1970, and they are in charge, and they are the boss. That may make you feel super safe. It also may really not be your cup of tea.

Schuyler Grant: Right. So maybe it's better to go look at the hospitals first and then from there find the doctor ... then go interview the doctors at those hospitals to see-

Dr. Suzanne: I think if you do not have a really established, wonderful relationship with your OB-GYN, yeah I would look at where the options are for you to birth. That's a great idea. And then find out who-

Schuyler Grant: Births where.

Dr. Suzanne: Has privileges there. So I think that would be probably the most important thing. I know that the question to ask for a really long time was what's your C-section rate? Which is also going to annoy your doctor. Because if you don't know that much ... you don't know their practice. You don't know how many high risk patients they have. Twins, 55 year olds with donor egg IVF, I mean that's going to change your C-section rate.

So I usually, and before that study, but I still like it. I usually think people should ask like how often you do induce patients? Here's the thing. I think that that tells you a lot about that doctor. I don't know what my induction rate is, I couldn't quote it, but it'll stimulate a conversation like, "Oh, interesting, these are the reasons why I do it. I kind of tend to not do it for this reason. I do it for that reason." I think you're going to learn a lot about their practice patterns. I think when you come in with C-section rate, we all know what that means. Whether or not you mean it this way, it's going to feel-

Schuyler Grant: It's a trigger for the doctor.

Dr. Suzanne: Yeah.

Schuyler Grant: Interesting.

Dr. Suzanne: Yeah. Because we're under the gun, by the way, by our institutions and by our hospitals. Our C-section rates at Cedars are published and sent out every couple months and you can see everybody's C-section rate.

Schuyler Grant: Great.

Dr. Suzanne: Yeah.

Dr. Suzanne: Okay, so you know, part of the problem with the C-section rate is understanding the culture that ... not just the culture of medicine, which unfortunately frequently, yes, it's data driven, but it's also fear-based. So it's like not getting in trouble, not doing the wrong thing. This is a saying, this is a saying. Nobody ever gets sued for doing a C-section too early, but you will get sued for a bad strip, a bad fetal heart rate monitoring strip.

Schuyler Grant: Okay.

Dr. Suzanne: So if you guys want to understand why the C-section rate is high, I mean that's a lot of it. It's driven by fear. It's driven by the fact that we want the best outcomes. And so do you. But then it's a very litigious society that we live in. I pay the second highest rates of malpractice insurance of any of the specialties. Neurosurgeons have the highest, obstetricians have the next. So not trying to make you feel bad, just understand.

So the fact that we're only at 30% is pretty good. In other cultures, there's a lot of body fear. Brazil has like a 85% or 90% rate of C-section. It's nuts. So it's other things too, but that's a big driver. 

Dr. Suzanne: The other driver is, and I mentioned it when I made reference to that kind of little homily that we have, I don't know what the word is, the little saying that we have in medicine, fetal heart rate monitoring is kind of a mess. It's actually questionable whether or not it is helpful. And it definitely drives sc-section rates, because now we have to be responding to what looks quote bad. When how many times have we all delivered a baby anyway with a strip that looked a certain way and the baby comes out and it's fine, or the strip looks great and the baby comes out and it's not fine.

Schuyler Grant: Yeah. My baby, my first daughter, was under a tremendous amount of stress and we are monitoring it. it was a untethered one. But she was under tremendous stress and she did have complications. But she was fine. It was definitely a situation where under different circumstances, with a different mother, and a different caregiver, I may well have ended up in a C-section, but everything, everybody say calm. It was like calm under ...

Dr. Suzanne: Yeah. It's just kind of like the whole fear of the cord around the neck thing. Somebody was telling me ... I mean it's really interesting, when people come to me who I haven't delivered and they're giving me their birth history, it's just so interesting to hear the story that they heard-

Schuyler Grant: Or have been telling themselves.

Dr. Suzanne: Yeah, and I'm like that's not even a thing. I don't say it. I'm like, "Okay," because she was traumatized by that.

Schuyler Grant: Right.

Dr. Suzanne: But like a nuchal cord. Are you kidding me?

Schuyler Grant: Like a third of babies have a wrapped cord.

Dr. Suzanne: Or not? It doesn't mean death. Do I have, unfortunately have I had horrible situations and that was there. Yeah. Was that the reason? We'll never know. So that's the big ... there's such a huge question mark and then we put this culture of like, "Well everything has to have an explanation and a reason." So that's going to drive you toward more technology, which is not necessarily better for anybody.

Dr. Suzanne: Oh, if you know you're going into this and you're thinking you really want to do this as intervention free as possible, I mean just be upfront about that. If you, for instance, if you've heard about seating the nasal cavity, right? So in a sc-section we're not supposed to do this. Some institutions do it routinely. Some institutions you can't do it. 

Some people will, like if my patients ask me and they're like, "Look, if I have a sc-section," or let's say they're planning a primary sc-section, you can swab the vagina. I will do it. If their GBS negative, if they don't have some specific bacteria or they don't have an infection, swab the vagina, sterilely right. Put it on some little sterile q-tips and then I'm like, "This is for you. I'm not doing this. But here it is. It's in a glove. You can put it in the baby's nose.

Schuyler Grant: Nose. Yeah, I've heard about that. You could ask that and just even your doctor's knowledge of it would tell you something.

Dr. Suzanne: Right. Oh yeah. Again, there's ways to do this. I'm sorry to make it sound like you have to be on the down low, but you might. You might have to be on the down low. Then you might find out your doctor is the coolest hippie you've ever met and you didn't know. Or like, "Whoa, this person who presents as like super open-minded is very rigid." Right? And then you have to decide, is that going to work for you?

Schuyler Grant: Right. Gut. Cool. Wow. There's so many things I could ask you. We can go on forever.

Dr. Suzanne: I know. A ten-hour podcast.

Schuyler Grant: All right, my darling. Well, I know you, you are going to send your daughter off to college this weekend.

Dr. Suzanne: Yeah, yeah.

Schuyler Grant: That's another kind of delivery, out a different canal.

Dr. Suzanne: Crazy. I burst into tears at dinner last night, just I had, didn't even feel it coming. Then all of a sudden I just started. Yeah. That's okay.

Schuyler Grant: Yeah.

Dr. Suzanne: It's part of it. Her birth was effing amazing.

Schuyler Grant: You'll have to tell that one.

Dr. Suzanne: Oh yeah.

Schuyler Grant: We haven't gotten you on the birth story.

Dr. Suzanne: Oh yeah. I'll tell you both my birth stories. They're interesting.

Schuyler Grant: Okay. We'll see you very soon.

Dr. Suzanne: Well, to me.

Schuyler Grant: To me. All right, my love.

Dr. Suzanne: Thanks for having me.

Schuyler Grant: Thank you. Go ahead.

Schuyler Grant: Holy Moly. How much do you wish Dr. Suzanne was your OB, or your backup doc if you are having a home birth? She's lucky that I didn't have my home birth here because I would have corralled her into being there, too. You can plumb the depth of her knowledge even further by joining me for the empowered birth course on onecommune.com.

For the launch of this course, we are offering the program free from August 12th to September 1st, so don't miss out, even if you're not sure when or even if you want to get pregnant, you can be the crazy expert in your group of friends. Dr. Suzanne is joined by 10 other pre and postnatal experts I regard most highly, including midwife Elizabeth Bochner, from last week's podcast, Nina Plank, Laura Cohen Thompson, Erica Chidi Cohen, Shafia Monroe, Britta Buschnell, Kimberly Snyder, Kimberly Durban, the list goes on.

I guide you through all the expert content day by day and I lead a 20 to 30 minute physical practice that will support you through your pregnancy and into postpartum. These are super diverse classes that take inspiration from yoga and physical therapy. They range from rigorous to deeply restorative, focusing on strengthening and opening all parts of your body with a special emphasis on core and pelvic floor work.

All the experts in this course share my two abiding philosophies about childbirth. One, the best place for a woman to have her baby is the place she is most comfortable, and two, an empowered birth is not a state of knowing. It is a state of inquiry. Please join the journey into Empowered Birth at onecommune.com/birth. That's one, O-N-E, commune.com/birth.

Thanks for joining me on The Commune podcast. You're going to get Jeff back next week. He won't be talking about childbirth. This is his better half, Schuyler, wishing you an empowered life.