Thursday, May 31, 2012

"Just in Case" Something Goes Wrong

The hospital doesn't always reduce fear. Many times it creates it, amps it up, takes it to the Nth degree. Women choose to birth in a hospital because there is that nagging fear that something bad will happen to them or the baby and they want to be near an emergency facility that can provide immediate assistance... "just in case." Society has told them that birth is painful and risky, and television and movies constantly show the doctor swooping in to save the day.

Sometimes being in the hospital is what a woman needs to have their ideal birth, because if they weren't in the hospital they would not have a good birth experience. Worrying about the health of the baby. But much of the time a hospital just takes that feeling of fear and runs with it. It will start with the nurse telling her that they have to keep her on the continuous fetal monitor so that they can make sure the baby's heart rate is where they want it to be. Now the mom is worried about the baby's heart rate, and dad can't stop staring at the monitor (instead of his partner). Then, even if the baby's heart rate is fine, they still insist on monitoring it all the time, "just in case." So the whole experience becomes ruled by "just in case." Never mind the fact that continuous external fetal monitoring is not evidence based. Hospitals are scared, doctors are scared, nurses are scared, women are scared, and families are scared. You are being told that you have to be on the monitor so you are too afraid to take them off to urinate without permission. You are too afraid to stand beside the bed instead of lay down.
http://www.mybirth.com.au/where.html

We expect our bodies to nurture and grow our baby for 9 months while we are pregnant, and if something bad happens we would go to the hospital. Same goes for birth. It is a normal process that generally goes right. And it something happens, we can go to the hospital. Bad things don't just happen during birth, they can happen during pregnancy, too. And postpartum! and throughout the baby's whole life! And we'd go to the hospital if something happened.

I have been in more than 8 different hospitals, and a few more than once. I know what this creation and growth of fear feels like. You can feel the shift in the room when the nurse or doctor explains something to the parents that makes them freak out. Baby's heart rate indicates the baby is sleepy, so that means constant monitoring in the bed (why?). They go into detail about how the baby is going to have a shoulder dystocia if they let her labor any longer on the epidural (what?), how if she hasn't had the baby by now it is probably too big for her pelvis because she is not following Friedman's curve (also not evidence-based, see note below for an explanation if you don't know what this is). They freak mom out with stories of how a shoulder dystocia means doctor has to pull on the baby and sometimes it causes nerve damage or break the baby's clavicle (shoulder dystocia does not always mean that. There are maneuvers mom can do to help the baby out). Wouldn't that affect your decision? How could you not make a decision based on fear for the baby after hearing something like that?

I consider myself highly informed about birth, and in such a situation I may be able to call that BS and refuse whatever they are trying to talk me into. Which is why I am a big proponent of women being as informed as possible! But even a highly educated, empowered woman becomes vulnerable and emotionally malleable during labor. And she may freak out when she hears that and not be able to advocate for herself. It's hard! It really is. I just hope that many women think back on their birth experiences later, when the baby comes out healthy and happy from a vaginal delivery during which they were making her fear for the baby's health the whole time, and thinks "what the hell were they talking about?"

And women aren't just asking for freedom of movement and intermittent monitoring or drug-free births or even just vaginal births because they "care more about the experience than the baby," as many jaded providers might believe. It is because the evidence shows 1. that these things make a labor less painful, less likely to stall, or are more healthy for the baby or the mother, and 2. that a woman's birth experience is remembered for the rest of her life. Research proves all of this. But many times nurses or doctors will have seen too many (true or iatrogenically created) emergencies and they are scared, so they want to make the mom scared, too.  When a mother makes a request to not have an epidural, the care providers feel they have to scold the mom, use their authority, get defensive, and create fear by saying they are going to do whatever has to be done for the baby. Obviously the woman would do anything to assure the health of the baby! She never said she would refuse a c-section if the baby's life was in danger, or that she would choose her preferences for a drug-free birth over her own or the baby's safety. A mother would certainly consent to birthing her distressed baby quickly, even if it meant a c-section.

I think its also important to note that even if there was an emergency situation that required surgery as fast as possible, most hospitals don't have that emergency staff always on-hand. Especially at night and on weekends, there is not always an anesthesiologist or an available obstetrician in-hospital. Many times they have to call the doctor, who just has to live within 30 minutes of the hospital come to perform the surgery. This isn't something we think about when we are birthing in the hospital, where we assume there will always be emergency care on-hand to take care of a situation within a 1 minute or 5 minute space of time. Unfortunately, this isn't true (and is one of the main reasons why doctors won't do VBACs). As Stephanie writes,
"I know you like to advertise yourself as being ready for an emergency at any moment…you say that being 15-30 minutes away from a hospital can be the difference between life and death! And yet….you ban VBAC’s because you don’t feel you are capable of dealing with the 0.1% chance of a uterine rupture since you don’t have an anesthesiologist as well as surgeon standing by immediately? If that’s the case…how are you prepared for ANY obstetrical emergency??"
One of the things that also bugs me about all of this is that the hospital is not only creating fear, but creating the emergency. That's what iatrogenic means - resulting from the activity of physicians. All the monitoring, staying in bed, not being able to move, eat, having to always "do something" like rupture membranes, pressing for pitocin for a faster labor, active management of the third stage... all of that causes harm for the baby and mother. Now I know that there are situations where the pitocin helped not hindered, the epidural was perfect and the baby was born easily through the vagina with no major adverse effects, etc, but more often than not they are associated with negative effects.

Additionally, many care providers encourage their patients to labor at home as long as possible, or until their contractions get to a certain point (like the 3/1/1 rule, which I hear all the time from parents). This is especially recommended if the mom wants a natural birth, and sometimes even told to women who want to successfully VBAC.  But doesn't this seem contradictory? Physicians say you have to be in the hospital to have your baby just in case something goes wrong, but then they say to labor at home? Is is not labor, then, that's dangerous, but just the birth? And if it is just the birth, then why monitor so much in the hospital? But isn't laboring at home the same as a home birth? And wouldn't that be better to do with a trained midwife who can recognize a need to transfer to the hospital?


Now if you DO want pain medication, obviously some of these points don't refer to you. For pain medication you do have to be in the hospital. But if you want a drug-free birth, being in the hospital can just cause a lot of increased fear and increased risk in many ways, and may the benefits may not outweigh the risks compared to a home birth. Or even just laboring at home as long as possible.

Much of the monitoring, etc occurs because hospitals fear for their own liability, not because it is evidence-based or best for the patient. I encourage you to keep that in mind when a doctor or nurse is trying to explain to you why you "have" to do something (you never HAVE to do anything, you can always say "I do not consent" even if they use the phrase "have to"), that it may be mostly motivated by protecting their assess ("look, we monitored! we can't be held responsible!"), and not your health or comfort. Or even by their schedules (doctor has somewhere to be at 6pm, has another woman in labor at another hospital that he has to get to, etc).

I know we live in a "just in case" world, and it's hard to shake. We lock our doors and install alarm systems "just in case," and it makes sense. But there are other things we can do for that "just in case" instinct that we are not. It is not recommended by physicians that a woman have a birth kit ready at home in case she has the baby faster than she can get to the hospital and she has to catch her own baby. We don't tell women to have all these things on hand in case the baby is born in the car or on the toilet, and we don't train partners how to catch or resuscitate babies. But maybe every mom should learn how to resuscitate a baby, "just in case."

This post has been a little bit all over the place, but I wrote it to express my frustration over what I see in hospitals and the way women are spoken to while in labor. This isn't necessarily advice or gospel, but just how I'm feeling lately!



Friedman's Curve - A depiction of the progress of labor used to facilitate detection of dysfunctional labor. Basically it is cited as a woman must dilate 1 cm/hour.
A study found that a wider range of "normal" was found, and that primiparous women remained in the first stage of labor for up to 26 hours with no adverse effects to mother or infant.
A recent systematic review found that 1.2 centimeters per hour is the mean, not the slowest, and that nulliparous women with spontaneous labor onset have longer "active" labors and therefore slower dilation rates than are traditionally associated with active labor.
Research and many professionals in obstetrics agree that Friedman's curve is an obsolete approach to labor assessment. But I just heard it cited 5 days ago as a reason a mom wasn't laboring fast enough.

Monday, May 21, 2012

Certified Lactation Counselor Training

A couple weeks ago I did my training to become a Certified Lactation Counselor. I knew probably about 80% of it already (since I am a voracious reader of birth/breastfeeding blogs and academic studies on evidence-based practices, and I have worked with breastfeeding moms), but I also learned a lot, too.


Some of the new and awesome things that I learned in CLC training:

1. Babies can detect breast cancer (WTF): There is something called Goldsmith's sign, which is when a baby might be detecting undiagnosed breast cancer. The baby refuses to nurse on one breast. If other reasons such as ear infection, teething, birth trauma, etc are ruled out, breast cancer might be a possibility! And cancer may be diagnosed as late as 5 years after this sign from baby.

2. Breastfeeding provides protection for LIFE: When mothers who breastfed their baby donated a kidney to their adult child later in life, the adult child had less organ transplant rejection (compared to mother-child pairs that had not breastfed). The same protection was afforded when there was a sibling --> sibling organ or tissue transplant, if they had breastfed.

3. Powdered formula is not a sterile substance:  It must be prepared at a temperature of at least 158 degrees F (and then cooled) before being fed to an infant, and you should not prepare a large amount ahead of time. A powder cannot be sterilized, and formula has been found to contain harmful microorganisms from time to time.

4. Colic = crying for more than 3 hours/day for more than 3 days/week, for greater than 3 weeks. I didn't know that definition!

5. Great resource! How to Safely Co-Sleep: The UNICEF UK Baby Friendly Initiative have a helpful pamphlet on how to safely sleep or co-bed with your baby. This is more than the U.S. provides, as they just say "don't do it," but people do it anyway, and do it unsafely.

Of course I learned a lot of other things, too, but less new and less awesome (and thus not worth sharing here). But in case you're interested in what the training covered...


On the first day we covered: International and national breastfeeding policy context, evidence-based practice, lactation credentials, examination of factors influencing success at breastfeeding, national perspectives on breastfeeding rates, anatomy and physiology of lactation, hormones of lactation, composition of human milk, gastrointestinal hormones of lactation, distinct weight gain patterns of breastfed babies, and myths about milk supply.
On the second day we covered: The effect of substances and objects on milk supply, the effect on milk supply of hypoglycemia, jaundice, latch-on, engorgement, implants, effect of milk supply of discrepant breast size, breast surgery, inverted nipples and others, counseling women with fears about milk supply, approaches to use in patient education with different types of learners, health outcomes associated with infant feeding choice, safer use of infant formula, and donor milk banking.
On the third day we covered: Application of social psychology theory to lactation counseling, influencing the infant feeding decision, men's concerns about breastfeeding, enhanced effectiveness through lactation counseling skills, supporting the mother's desire to breastfeed exclusively, the impact of maternity care practices on breastfeeding outcomes, parameters of feeding assessment, and strategies that have been found to be effective in assessing breastfeeding.
On the fourth day we covered: Strategies for dealign with the challenge of breast problems, milk expression, milk storage and handling, supplemental feeding methods for the breastfed baby, working women and breastfeeding, strategies for building or maintaining a milk supply under challenging conditions, galactogogues, strategies found effective for assisting babies with special challenges, effect of breastfeeding on amenorrhea and fertility, the effect of foods in the mother's diet on the infant, the effect of alcohol, caffeine, and environmental contaminants on mother's milk, the impact of medications on the infant, and contraindications to breastfeeding.
On the fifth day we covered: Early support in the "zone of professional unavailability," common concerns after the early weeks - ages and stages, vitamin supplementation, complementary feeding, weaning, nursing older babies, nursing strikes, ethical issues in lactation care, and the Baby-Friendly Hospital Initiative


A lot of people in my course were new to working with breastfeeding moms - many people from the community, some people in public health, a few from Healthy Start-type positions, a handful of doulas, but only one nurse. I have realized this is not the normal audience for this type of class, which is generally mostly people from medical backgrounds. Elita at Blacktating writes about her course, which had a different audience, but was structured similarly to mine.

The organization that runs the course, The Center for Breastfeeding, has claimed that the CLC certification is equal to the IBCLC training in that both are "entry level." You can read more about their opinion here: Position Paper on the Comparative Roles and Training of the IBCLC and CLC. Basically they believe that since the CLC course has not only an exam that must be passed, but also several competencies, that it is just as good a training as the IBCLC, where "anyone can take the exam" and there are no competencies. I beg to differ. The IBCLC certification requires over 1000 clinical hours, in addition to certain pre-requisite education on anatomy/physiology, etc, and the CLC training does not require any. I imagine this is all part of a political rivalry between the two certifying organizations.

I'm glad to have added this training to my skill set, and anxiously await the results of my exam!


Sunday, May 13, 2012

Breastfeeding in the News

So, I'm a little late in writing about some of these stories, but I did want to post about them.

1. Beyonce breastfed! And she "endorses" it! This is a great thing for black breastfeeding moms everywhere - a great role model. She says
"I lost most of my weight from breastfeeding and I encourage women to do it; It's just so good for the baby and good for yourself."
 Unfortunately, she only breastfed for 10 weeks, but that's still GREAT. We won't know what contributed to her decision to stop, but every mom has the right to make that choice. Any breastfeeding is better than no breastfeeding!

It does seem odd that the message she (or her representatives) wanted to send was that it helped her lose a lot of weight. She could have been such a great breastfeeding cheerleader!


2. New York City Mayor Bloomberg is bringing the Baby Friendly Hospital Initiative to NYC hospitals, and for some reason this has perpetrated a lot of misunderstanding and disapproval of the initiative. Many people think that it means that hospitals are going to force moms to breastfeed:

THAT IS NOT WHAT THE BFHI DOES.

Unfortunately, Whoopi Goldberg led a heated attack on the initiative on The View. She told Mayor Bloomgberg "This is not your place. Back Off" and said that "Not all women can breastfeed."


I think it is really a shame that we have a good black breastfeeding role model situation followed by terrible black breastfeeding role model. Build it up, Break it down.

Here are 10 reminders about the 10 Steps to a Baby-Friendly Hospital, inspired by Whoopi Goldberg:

  1. Baby-Friendly represents a set of maternity practices that improves breastfeeding outcomes. 
  2. Baby-Friendly is NOT about coercing women to breastfeed. 
  3. Baby-Friendly is about assuring women have the information they need to make an informed feeding choice. 
  4. According to the Surgeon General, 75 percent of women start out breastfeeding. Baby-Friendly is about helping these women realize SUCCESS in their breastfeeding goals. 
  5. The benefits of Baby-Friendly practices extend to bottle feeding families too. For example, all babies benefit from skin-to-skin contact with their parents. 
  6. Baby-Friendly is also a call to action to improve the safety of formula feeding through enhanced education to families who choose to bottle feed. 
  7. Baby-Friendly hospitals provide formula for families who choose to use it while in the hospital. However, a physician order is required before supplementing a breastfeeding baby’s feedings with formula. 
  8. Successful breastfeeding is a public health issue. The benefits extend to both mothers and their babies, and breastfeeding is recommended by the American Academy of Pediatrics as a way to help prevent Sudden Infant Death Syndrome (SIDS). 
  9. With our growing understanding of brain health, neuroplasticity and how the brain is “wired” from an earlier age than we ever before realized, we may even conclude that parent-infant bonding is a public health issue as well as a significant social issue. Feeding choice aside, Baby-Friendly practices facilitate bonding. 
  10. Mayor Bloomberg is not alone in promoting the Baby-Friendly Hospital Initiative. He is joined by the Surgeon General, The Joint Commission, the American Academy of Pediatrics, the Association of Women’s Health, Obstetric and Neonatal Nurses, the American Congress of Obstetricians and Gynecologists, the CEOs of approximately 500 U.S. hospitals and nearly 20,000 hospitals worldwide.

3. This divisive TIME magazine headline is just meant to fuel the Mommy Wars... Just in time for Mother's Day. I had a problem with the headline, which pits moms against each other, but apparently most people took issue with the "hot" mom breastfeeding her 3-year-old son. They are calling it "sick" and "perversive."
I posted a ton about this on my facebook page, but in case you weren't able to keep up with all that...

  • TIME wanted attention. They have gotten that. via the Huffington Post piece "No I am not Mom Enough": "Breastfeeding is not a macho test of motherhood, with the winner being the one who nurses the longest. In fact there ARE no macho tests of motherhood. Motherhood is -- should be -- a village, where we explore each other's choices, learn from them, respect them, and then go off and make our own."
  • Anthropologist Katherine Dettwyler weighs-in on extended breastfeeding and the TIME cover at USAToday "Breast-feeding a 3-year-old is normal, anthropologist says": "Dettwyler, who has published studies on breast-feeding, found that most children around the world are breast-fed for three to five years or longer."
  • The Academy of Breastfeeding Medicine writes a great piece "TIME cover sells out moms to sell magazines":"The cover not only castigates mothers and children who practice extended nursing, but it also lends legitimacy to strangers who assail moms for nursing any infant in public as “nasty” and “indecent.” Recent stories of nursing mothers ejected from big box stores, courtrooms and churches demonstrate that it is not easy to be a breastfeeding mother in America. When you follow medical recommendations, you face public humiliation."
  • A dad/comedian writes a piece called "From Breasts to Boobs and Back Again":  "Let’s remember that the child is 3. Don’t forget how litte 3 year olds are. It’s why the photographer had him stand on a chair. Otherwise, he’d be sucking his mother’s knee"
  • Celebrities Who Breastfed Toddlers, but not on the Cover of Time:
  • "Because breastfeeding past one year is often hidden from view, it might appear that children such as the one on the Time cover just don’t exist . . . but they do. Best for Babes collects and shares celebrity stories to increase the cultural acceptance of breastfeeding. The celebrity stories below show that this “uncommon” act of nursing a toddler might be more common than you think."
  • On Breastfeeding past infancy by an evolutionary Anthropologist: "Extended breastfeeding is the norm in most human and primate societies. So why are we the weird ones?" 

  
Many, many moms who enjoy breastfeeding breastfeed their children past infancy, they just may not tell anyone about it. But they are following the American Academy of Pediatrics and the World Health Organization recommendations, which recommend breastfeeding up to a year and beyond, as desired.

This post at Motherwear Breastfeeding Blog explains some of the misconceptions about extended breastfeeding!


Wednesday, May 2, 2012

The Learning Never Stops



Happy May! I meant to post more than I did in April, but the end of my semester completely overwhelmed all my time! The good news is that I've been doing a lot of doula prenatal visits for my clients who are due this month and next month. Prenatal visits are so great! I love talking birth. This is why I should really become a childbirth educator, so I can just talk birth all the time.

In one of my recent prenatal visits my client taught me a few new things. First, she pointed out that the longer she is pregnant, the more her fundal height matches her gestation length! Fundal height is measured from the top of the pubic bone to the top of the fundus which is the top part of your uterus (the highest part of your baby bump, under the breasts) Fundal height is measured in cm, gestation length in weeks. So, for example, when she was 25 wks 5 days, her fundal height was 26 cm, and when she was 30 weeks, her fundal height was 30 cm! I had no idea that this occurred, but it is so cool. Unfortunately, it's not an exact science, but it does give a good indication of fetal growth. If for some reason the measurement was not as expected, an ultrasound may be useful!

The second thing, which I have been exploring a bit more on my own, is that she wants to drink at least a pint of very strongly brewed red raspberry leaf tea once she is in labor. It is known that raspberry tea has an effect on the uterus, by relaxing the smooth muscles while it is contracting, and many women drink it late in pregnancy to "prepare" their uterus for labor by toning and strengthening it. Anecdotally, women have said that it can ease labor or even make it shorter. This is why my client wants to try it. She has heard that just drinking it leading up to labor is not enough; some women have noted that when they downed a large amount of it in early labor that their labors were shorter. Since there have been no noted side effects for the woman or the baby with raspberry leaf tea late in pregnancy, we all agreed she can go ahead and try it if she likes! So, I will let you know how that goes ;)  When I asked some doulas on twitter what they thought about this, many different responses came up. Some said red raspberry leaf tea is good to get contractions going, some said it can slow them out and make them more regular, that it strengthens contractions, and that she shouldn't be disappointed if it doesn't work exactly as she was hoping. What do you think? Do you have any experience with raspberry tea for labor? Would you try this method? 

Additional good news is that next week I'll be doing the Certified Lactation Counselor (CLC) training. Has anyone taken that before? I am wondering what CLC's go on to do after they become certified. In addition to working with a local non-profit that supports breastfeeding, or just adding it to my doula services repertoire, what else can I do with my CLC? Do CLC's do independent work that they charge for? Do you run peer support groups, La Leche League style?


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