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My journey into natural birth began late in my training as an obstetrician. My residency occurred within a classic, heavy-intervention obstetrics program, although I had attended a very open and liberal medical school which informed many of my core beliefs regarding patient autonomy and the role of medical intervention and alternative medicine. In my last year of residency, I found myself in the uncomfortable role of the patient, pregnant with my second child. I had given birth to my first child via cesarean section and was determined to avoid a second surgery. I quickly realized how few options I had for a vaginal delivery, even within my own hospital, where I was a senior resident. I began researching both medical and lay literature in an effort to identify any strategies that might increase my chances of a successful VBAC. In doing so, I discovered an entirely different philosophy toward childbirth and the very loud outcry from women who were unhappy having babies in the manner in which I had been taught. Although I had delivered over a thousand babies by this point in my career, I was completely ignorant about natural birth practices and the large movement away from medically managed birth. I also discovered that the medical evidence in support of the standard labor management I performed on any given day was lacking. I learned natural birth techniques, many of which made perfect sense from my knowledge of anatomy and labor physiology and applied them to my own birth. My son was born vaginally 2 months prior to my graduation.

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As a new attending, I found myself eager to support women who wanted to have babies in a different way. I continued reading as many books and journal articles that I could find regarding alternative approaches to labor management and attended workshops and conferences given by midwives, childbirth educators, doulas, and other “birthworkers” in order to learn better techniques for supporting naturally laboring mothers. My own mother also completed training in doula support, childbirth education, and lactation support and helped to expand my knowledge base as she worked with patients and began to support my practice. She also helped me to understand how much resistance naturally laboring women faced when the doctor left the room.

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Word of the young obstetrician supporting natural birth and VBAC quickly spread throughout my community and within a year of graduating residency, I found myself with a very busy, primarily natural birthing practice. Within 2 years, I had opened a solo medical practice, dedicated to helping women achieve unmedicated deliveries and VBACs, which included childbirth education, doula support, prenatal yoga, and lactation counseling and support groups. However, as I attempted to help my patients reach their goals, I frequently found myself in conflict with the institution that had trained me, mainly the nurses and other doctors who were uncomfortable with my patients ambulating, eating, and spending more time in labor. The goal of my literature searches rapidly transitioned from self-education to defense of my management and my patients’ labor plans. I spent many hours in the hospital library pulling articles in order to support how I was caring for a woman laboring upstairs. I began to wish for a better resource that I could draw upon when these challenges arose. This recognition of the need for a single, evidence-based resource for natural birth practices was furthered over the years by the increasing number of colleagues who began to reach out to me for information and article links to help them care for their own patients.

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The aim of this book is to make the case for natural labor as a reasonable, evidence-based, alternative to aggressive labor management in a way that is valuable to both women exploring their birth options and the doctors, midwives, nurses, doulas, and other individuals caring for them. It does this through a thorough, scientific examination of each of the points of a typical natural birth plan. It also offers alternative, nonmedical strategies for common labor challenges and a framework for care providers and patients to work together toward satisfying birth processes and outcomes. At times, this goal was frustrated by a lack of evidence regarding common natural birthing requests; however, in these situations I made a strong effort to also demonstrate, if applicable, the lack of evidence for denying a certain birth request. I approached this project from the ethical viewpoint that, as most natural birth requests constitute the avoidance of intervention and maintenance of normalcy in the birth process, the burden of proof should fall to the intervention, not the other way around.

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I am extremely grateful to McGraw-Hill Education for taking on this unusual project and considering it an important addition to the body of educational resources regarding childbirth. I am especially appreciative of my editor Andrew Moyer, who believed in this lofty idea of mine and helped it become a reality, patiently guiding a novice author and busy doctor through the writing process. I would also like to acknowledge the teachers and mentors throughout my medical training who have encouraged me to continue striving to learn more and be better for my patients. To the staff of Saint Barnabas Medical Center and Mountainside Medical Center, despite our moments of conflict, I know without your willingness to be open to new ideas, as well as challenge them, this book would not exist and I will always be appreciative for your support of both me and our shared patients. Finally, I would like to express my love and gratitude for my husband and children, who have unconditionally loved and supported me even when they have had to share me far too often with this calling, and my mother, Catherine Galle, who has always nurtured my every dream and built the vision that truly enabled us all to become wombkeepers.

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MICHELLE ARISTIZABAL, MD, FACOG

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