Down to Birth
Join Cynthia Overgard and Trisha Ludwig once per week for evidence-based straight talk on pregnancy, birth and postpartum --- beyond the clichés and beyond the system. With 40 years' combined experience in midwifery, childbirth education and advocacy, publishing, research and postpartum care, we've guided thousands of families toward safer, more empowered choices. Down to Birth is all about safe childbirth, while recognizing a safe outcome isn't all that matters. We challenge the status quo, explore women's rights in childbirth, and feature women from all over the world, shining shine light on the policies, culture, and systemic forces that shape our most intimate and transformative of life experiences. You'll hear the birth stories of our clients, listeners and numerous celebrities. You'll benefit from our expert-interviews, and at any time you can submit your questions for our monthly Q&A episodes by calling us at 802-GET-DOWN. With millions of downloads and listeners in 90 countries, our worldwide community of parents and birth professionals coms together to learn, question and create change, personally and societally. We're on Instagram at @downtobirthshow and at Patreon.com/downtobirthshow, where we offer live ongoing events multiple times per month. Become informed, feel empowered, and join the movement toward better maternity care in the United States and worldwide. As always, hear everyone, listen to yourself.
Down to Birth
#357 | Back to Basics: Birth Planning 2.0
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Six seasons later, we are revisiting one of our first episodes of this podcast: Using evidence-based care to plan your birth.
Much of what happens in labor is presented as standard, routine, or unavoidable—but that doesn’t mean it’s evidence-based. Birth care hasn’t become more complex because women need more intervention. It’s become more complex because intervention has become the default. If you’ve ever wondered whether what’s happening in labor is truly backed by research—or simply “standard protocol”—this episode is for you.
In this conversation, we get back to the basics, examining how modern birth is typically managed, where that approach aligns with evidence, and where it too often doesn’t. This episode gives you an evidenced-based framework, so you can better evaluate the care offered and recognize when something supports physiologic birth or when it may quietly interfere with it.
Listen with your partner, take notes, and use this episode as a guide for thinking more clearly about the choices that shape your birth.
#9 | Birth Plan 101: Evidence Based Birth as the Safest, Smartest Approach
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I'm Cynthia Overgard, birth educator, advocate for informed consent, and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Show. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.
Back to basics. Six years in, I think it’s time that we revisit some of the most basic, core principles of a good, safe, satisfying birth.
Way back when, when we first started the podcast—episode number nine in 2020—we did Birth Planning 101: the most evidence-based methods for your safest, most satisfying birth. I actually listened to that episode this morning, and I was delighted by how excellent it was. I expected to cringe and think, “Oh my gosh, we’ve learned so much in six years of podcast recording,” but it really was very good. So if you haven’t listened to that, you might want to go back and start with episode number nine.
But I think it’s time to revisit this in the current stage of birth, and I know we have a lot to add and expand on. So here we are with birth planning 2.0, or whatever we want to call this.
The key thing to first understand is that there are two models of care in birth. There is the obstetrical model, and there is the midwifery model. We fall pretty squarely into supporting the midwifery model of care, but it’s important to revisit what the distinction is.
The main distinction is that in the midwifery model of care, birth is viewed as normal and healthy—a normal, healthy physiologic process that sometimes goes off course. That’s why we have skilled care providers there to help, support, guide, and redirect when something becomes a complication or a variation of normal.
The obstetrical model of care views birth as a pathologic event that sometimes goes right. Birth is seen as inherently prone to problems, needing to be managed, protocolized, and intervened upon in order to go right most of the time.
The only caveat—the thing that gives me pause—is that I don’t want women to hear this discussion and think “OB bad, midwife good.” There is overlap. If you think of two circles, there is overlap. There are wonderfully supportive, evidence-based OBs. I do think they are few and far between, particularly because they must practice within the medical model of care. They have to adhere to revenue targets, hospital administrators watching over their shoulders. Even those with the best intentions are constrained.
What surprises and disappoints me endlessly is how medicalized many midwives have become. In just the past few days, I’ve seen this. I have a client in California planning a home birth with totally normal blood pressure but high protein in the urine. Her home birth midwife said she would not attend the birth and told her she had to go in for an induction. Even ACOG says high protein in urine alone is not a reason for induction.
Just before recording today, I received a message from someone who conceived via IVF. Her midwife is saying, hard stop induction at 39 weeks because they don’t want the placenta to die.
So this isn’t black and white. It’s not OBs are bad and midwives are good. It’s the distinction between how providers are educated. Obstetrical education is rooted in everything that can go wrong with birth and how to fix it, which we need. Birth does go off course sometimes, and you need providers who know how to correct it.
The midwifery model is based on the natural physiology of birth. Midwives are trained to trust birth differently. That doesn’t mean every practitioner practices that way. You can have OBs who truly understand physiology, and midwives who practice in a highly medicalized way.
When ACOG was established many decades ago, the board made a conscious decision about how obstetricians would practice in the United States. They opted for active management of labor instead of expectant management. That decision changed everything. They study and practice active management, not expectant management, which is what midwives practice. This is factual, not opinion.
Worldwide, the research is clear that the safest births are on the side of midwives when you look at local statistics. But your work as a woman is always difficult. You must interview your provider very well. It’s not enough to say, “I’m having a midwife.” You have to evaluate them continuously through prenatal care to make sure they remain the right provider, so you don’t end up in a crisis at the end over something that isn’t evidence-based.
That’s why we’re going to talk about evidence-based methods of care that are overused and underused. Regardless of whether you’re with a midwife or an OB, many methods are being overused, and many are being significantly underused. Once you understand these concepts, you can determine whether your provider aligns with evidence-based care.
We have a lot to cover, so we need to move.
This could be a three-hour episode, and we’re going to make sure it’s not.
Nobody wants a three-hour episode.
One person gets away with that. His name is Joe Rogan.
And Huberman. His are always three hours. He repeats himself a lot.
We’re going to be efficient.
The first and most underutilized evidence-based supportive measure in birth is oral nutrition and hydration—drinking and eating in labor. This is simple and profoundly underutilized.
Women in hospitals have long been labeled NPO—nothing by mouth. Ice chips only. Maybe a popsicle if you’re lucky. How do we expect the body to go through an incredibly demanding physiologic process without fuel?
The concern historically was aspiration during emergency cesarean under general anesthesia. That dates back to when women routinely birthed under general anesthesia. Modern reviews, including a major Cochrane Review, find no justification for restricting food or fluids in low-risk labor.
Restricting food can lead to ketosis, maternal exhaustion, longer labor, and failure-to-progress diagnoses. Our advice: bring your own food, hydrate, eat at will. Don’t worry about hospital policy.
And don’t sneak food. I have strong feelings about this. Sneaking food is two unempowered women conspiring. A woman has the right to eat, full stop. She can order steak and potatoes and eat them sitting upright. No one can stop her.
The research shows a woman in labor needs the caloric equivalent of a marathon runner. Stand tall in caring for yourself.
In November 2015, the American Society of Anesthesiologists released a statement saying women benefit from small meals in labor. They explicitly stated this. There is no need to “check with your provider.”
Another risk of food and fluid restriction is fetal distress. This affects both mother and baby.
The second underutilized evidence-based practice is intermittent fetal monitoring instead of continuous monitoring.
Continuous monitoring means a strap and constant recording of the baby’s heart rate, looking for problems. Intermittent auscultation means listening at intervals with a Doppler or fetoscope.
For low-risk pregnancies, intermittent monitoring is as safe or safer. Continuous monitoring increases unnecessary cesareans and interventions.
Women often think constant listening is safer. It’s not. We don’t want to catch every transient cord compression. Intermittent monitoring significantly reduces cesareans and instrumental births.
If you’re induced, on Pitocin, or have an epidural, continuous monitoring makes sense. If you’re having a physiologic birth, it does not.
At home birth, monitoring is always intermittent. Protocols are about every 15 minutes in active labor and every 5 minutes during pushing.
The third underutilized practice is immediate skin-to-skin contact after birth.
This has improved in hospitals but is still not taken seriously enough. Skin-to-skin is not a “nice to have.” It is essential.
There is no incubator better than the mother. Separation is harmful. Babies are taken away unnecessarily for weighing, measuring, bathing, and procedures.
Immediate skin-to-skin regulates heart rate, breathing, temperature, and blood sugar. Many NICU admissions for low blood sugar could be prevented.
Dr. Nils Bergman’s research shows infants separated from mothers exhibit protest-despair responses, while infants kept skin-to-skin cry ten times less and stabilize faster.
Skin-to-skin is about brain maturation and neural imprinting. It sets the foundation for emotional regulation and social development.
Women should ask providers exactly what happens after birth and whether gentle resuscitation can occur with the baby on their body, cord intact.
The fourth underutilized practice is VBAC. For most women with one prior cesarean, VBAC is safe and appropriate, with success rates of 60–80%, higher with supportive providers.
Repeat cesareans carry increasing risks. Uterine rupture risk is under 1%, while surgical risks accumulate.
The fifth is upright and mobile labor. The bed should not be the focal point. Gravity helps descent, dilation, and pelvic opening. Upright positions can increase pelvic diameter by up to two centimeters.
The sacrum must be free to move. Lying flat restricts normal physiology.
The sixth is continuous emotional support. Continuous support, especially from doulas, reduces cesareans, increases vaginal birth, reduces pain medication use, improves satisfaction, and improves newborn outcomes.
Women have always supported women in labor. This aligns with hormonal physiology and safety.
Finally, we discussed seven overused, non-evidence-based interventions, including routine IV fluids, continuous electronic fetal monitoring in low-risk labor, routine induction, strict labor time limits, routine episiotomy, amniotomy, and directed pushing.
Birth requires trust—trust in the body, trust in physiology, and trust in the people chosen to support you.
That is where we begin.
Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.