UnBreaking Birth

I recently watched this video "UnBreaking Birth" - a lecture by Ryan McAllister. It is basically a version of the lecture I have given a couple of times as a guest lecturer undergraduate women's/sexual health classes.

"How you're born affects the rest of your life, and can affect the rest of your mother's life, too"

"There are a host of values at play beyond safety"

He says our birth care system is broken for at least 4 reasons:

1. There isn't a sufficient amount of space and time to build an adequate relationship between the mother and the caregivers
2. Our interventions have become routine, instead of based on the mom and baby's best interests
3. Those interventions are often opinion-based
4. There are conflicts of obligation within the hospital that systematically cause behavior that is out of alignment with the mom and baby's best needs

"Even when they know that practicing a different way would be better for their clients, they have some reason to practice differently. That means that there are conflicts of obligation in the hospital. At times, when the hospital's best interest is over here, and the patient's best interest would mean you behave this way, the hospital's best interest wins."

"Obstetrics has been organized around handling high-risk, emergency surgical births. and they may do this well. But treating all births this way actually derails well-birth, which is the vast majority of births. So I think we need to keep the good of this system and pair it with another approach that doesn't break well-birth."

"How could we possibly find or create highly trained experienced professionals who have evidence based practices, who work within a strong relationship wit h the mother, compassion for newborns, and don't experience conflicts of obligation with a large institution?... Those practitioners already exist. They are independent midwives."

The video does not have ALL of the information on the topic, but is a nice overview for consumers. It covers:

• Why birth is broken (evidence that we spend more on maternity care in the U.S. but have worse outcomes; evidence that c-sections are too high and it is not caused by women being in worse health)
• The 4 reasons he believes our maternity care system is broken 
• A system that would work better for well-birth (certified professional midwives, birth centers)
• What YOU can do to help improve the system

This would be a great video to share in a class, because it is only 32 minutes long.

"Being aware of and making available these other options, especially independent midwives, but also including other birth assistants such as doulas, is key to unbreaking birth in the U.S."

I like the way the UnBreaking Birth says about the indicators that we have a serious problem. It is basically a run-down of why I do what I do as a public health professional and a doula/childbirth educator:

there are terrible health disparities by race and socioeconomic status

infant and maternal mortality rates are higher than in 45 other nations

the maternal mortality rate has risen every year since 1995 while in most other countries it has decreased

only 25% of obstetric practice guidelines are based on good scientific evidence, many are overtly contra-indicated

common hospital policies are not in the best interest of moms and babies

and we spend more than any other nation on healthcare

True Dat

Nicole at Bellies and Babies blog has a series of pictures she calls "True Dat" which I find very amusing and true!

"So, let me get this straight... I hire YOU but you can't "let" me...

You Learn Something New Every Birth

artwork (c) Amy Haderer mandalajourney.com

I'll admit, I don't usually back my doula bag until my client's are 40 weeks. I know this isn't perfect doula practice, but there are two reasons: 1. My bag stays almost entirely packed with my doula tools all the time anyway (I just have to add things like toiletries, snacks, medications, phone charger, sweater, etc), and 2. My clients never seem to go into labor before 40 weeks.

This is another reason that I find the whole "40 weeks is your due date and then after that you're late" thought-process to be completely flawed. Nearly all my clients have gone into labor AFTER their 40 week mark. There is no timer to go "ding!" that means you are "done" at 40 weeks! (but for more on estimated due dates, see this other post, or this one)  And not just first time moms!

Back when I was a brand new doula, my bag used to be packed at exactly at the 38 week mark. I was also more paranoid in general - not a single drink during my on-call period, no foods with onion or garlic (so my breath wouldn't smell bad), obsession with checking my phone all the time and with every single plan I made (can I go to the movies?), and so forth. I remember each birth that occurred prior to the due date:

I had a first time mom go into labor before 40 weeks, but that was an effort on her part - she asked her midwife to sweep her membranes at around 39 weeks (see bottom of post for an explanation if you don't know what this is), and it worked the very same day. I knew in advance why she wanted to go into labor earlier than her due date and she kept me informed of her techniques.
A third time mom went into labor at 38 weeks, a week after I met her and she hired me.
I also had a first time mom go into labor on her exact due date, which is so rare that it was shocking.

And then just recently, with no warning at all, I got a phone call in the middle of the night from a mom who had no major warning sign that she would give birth before 40 weeks (other than the fact that she really didn't want to be pregnant anymore, which is like most women), and had to scramble around and pack my bag! I found out that she was taking evening primrose oil capsules, on her midwife's advice. I'm not sure why she was taking them, or why the midwife advised her to take them, prior to her estimated due date. Perhaps the midwife always prescribes it. Perhaps the mom was incredibly impatient and so that's why the midwife suggested it.

Evening Primrose Oil is a supplement that can ripen the cervix because it is high in prostaglandins. Prostaglandins are sometimes administered directly in the vagina by a doctor to prepare for a labor induction. Semen also contains prostaglandins, which is one reason why they say sex can start labor! Evening primrose oil doesn't exactly induce labor; it helps soften the cervix in preparation for labor. I don't know much about EPO so I asked about it on twitter.  Respondents said that it can have side effects and should not be used routinely and perhaps not unless an induction is looming for post dates, and that there is not a lot of research on EPO. Apparently side effects can include upset stomach and headaches.

A quick survey of the literature came up with a retrospective quasi experimental study of 108 low-risk nulliparous women that found:

Findings suggest that the oral administration of evening primrose oil from the 37th gestational week until birth does not shorten gestation or decrease the overall length of labor. Further, the use of orally administered evening primrose oil may be associated with an increase in the incidence of prolonged rupture of membranes, oxytocin augmentation, arrest of descent, and vacuum extraction.

Another article on midwives' use of herbal preparation for stimulation of labor found that there were no reported complications in the use of evening primrose oil or red raspberry leaf tea and that evening primrose oil was the most efficacious herbal preparation for cervical ripening. Most else of what I could find just says that there is a lack of evidence. Basically, that more research is needed.

Anyway! She went into labor prior to 40 weeks and the labor and the birth went well. I always tell my clients that I will come when they feel they need me. Sometimes in the middle of the night I really hope that even though they're calling me, they'll see that their contractions are still "early labor" contractions and they won't "need me" right now. With this one, I did end up getting to her house a bit before an active labor pattern was established. This has happening to me a couple times. This is hard for a couple reasons: First, now everyone feels like we're in active labor mode and it's hard to not feel rushed once the doula is there and you feel like everyone is waiting on you and watching you labor. Second, it would be nice if everyone (mom, partner, and doula) all got some more sleep, but now sleeping arrangements are awkward. And third, several other things are also awkward - instead of needing active help all the time, we're hanging around at home watching TV and making lunch, etc. But the second ones are more about me, and so... see number one!

But it is also highly beneficial for me to come early in several instances. Once, it was because mom and dad had me meet them at the hospital and mom was only about 4 cm dilated. They walked around trying to decide what to do: Be admitted and be in the hospital the entire labor, being pressed for time and to adhere to the ridiculous "1 cm per hour" rule? Or go home and try to sleep, and hope that in their own environment labor would move along at a comfortable, un-stressed pace. Perhaps if I hadn't been there at the hospital to discuss things they wouldn't have gone home (and ended up having a great labor!)

Most recently, I was glad to sacrifice my time/comfort/sleep/whatever to be with mom and dad early in order to reassure them and keep them at home. This is a big one. I have been told so many times, "if it weren't for you, we would have just gone to the hospital at [2 am, 4 am, etc]!" And mind you, this is JUST after labor contractions start. You really shouldn't go to the hospital at the start of labor, for a multitude of reasons. 1. they might send you home if you're not 4 cm or more anyway, 2. hospitals can be stressful places where labor actually slows, 3. if you want a natural labor, the longer you are in the hospital the more likely things will be done that make this harder (i.e. stay in bed the whole time, pressure to get pain meds, you aren't allowed to [eat, drink, pee, use the shower for pain relief, etc], let's manage this labor a bit more with drugs, etc), 4. you will be rushed for time (it's been ___ hours since ___ so we need to do ___) even though there is no medical reason to do so, and 5. I could probably think of more if I wanted but I'll stop there.

Several times if I hadn't showed up right away mom and dad would have just listened to some direction (that always changes) like, "come in when contractions are 5, 1, 1" or "come in when your water breaks" or "come in so we can see how far you've progressed" which have no basis other than they just want to manage labor. I have been told a million times, "I am so glad we labored at home," and "this is really great laboring at home," and "I'm glad we didn't go to the hospital right away." And even from hospital midwives, who are impressed that the mom comes in at 8 cm or 10 cm because that is so rare for them (and I've even got a "way to go, doula!"). But it is hard, especially for first time parents, to want someone there with them to can reassure them about what is normal and answer a million questions about labor positions, eating and drinking, whether or not they should try sleeping or walking, and of course the big one - when should we go to the hospital? [And in this instance, interestingly, many a question was answered along the vein of "is this going to make the contractions worse? Such as "Is a cold beverage going to make the contractions worse?" and "Is a shower going to make the contractions stronger?"] I have witnessed many many more labors than they have and I know what a contraction pattern or mom's temperament means.

Just as an aside, I always let the couple decide when it is time to go to the hospital. I give advice if asked, but if they feel it is time, we go. The only instances in which I say "ok it's time to go now" are when mom says her first "I feel the urge to push"! And I should also add, here, that we've left while mom felt like pushing many times and always made it to the hospital in time (even with a third time mom); They have all still had to actively push for a period of time in the hospital. This is always a big worry, but the stories you hear about babies being delivered in the car are rare (though I'm not denying that is possible to wait too long to go, or to have an exceedingly fast labor).

Talking about doula self-sacrifice - my body was really aching after my last doula labor! Whoever thought that becoming a doula was all fun and babies, you should really recognize how hard being a doula can be, sometimes.

I also wanted to mention that a recent labor was attended at a Baby Friendly Hospital. I want to share this experience, because it wasn't quite what I thought it would be. Firstly, the nurses asked the mom immediately after delivery if she would be bottle feeding or breastfeeding. This is interesting in two ways:  1. I did actually think it odd that a hospital with the highest support for breastfeeding there currently is is even asking a mom if she is breastfeeding, instead of assuming that she would do the norm (and yes, wanting to breastfeed is the 'norm' - 75% of women in the U.S. initiate) and only require formula in case of complications (which is what formula should be used for), but...  2. For the people who say that going baby friendly hurts moms who want to bottle feed because it pushes breastfeeding on everyone, clearly if they are asking moms, this isn't true.

Secondly, I was under the impression that BFH's do uninterrupted skin-to-skin and make sure mom has help in trying to initiate breastfeeding in the first hour after birth. I was under that impression... (Perhaps you see where I am going with this?) This mom had her baby on her maybe 20 minutes of the entire first hour and twenty minutes of baby's life. They were doing the usual - weighing, measuring, drawing blood, eye ointment, letting dad take photos, etc in the baby warmer instead of letting all that wait and giving mom the chance to warm and feed and bond with the baby, all of which is good for both the baby's blood glucose levels and the breastfeeding relationship. Oh, and they did the typical swaddle the baby and we had to un-swaddle him to put him back on mom, and then they took him off a second time. And the entire time no one was helping with breastfeeding but me! Until finally a baby nurse came back in and then repeated EVERYTHING I had just been saying and doing. Grr. So frustrating. I do think this nurse was trained in lactation, luckily, but I don't know if all the nurses are, because all she said is "you can ask any nurse for help with breastfeeding." Which is what they all say everywhere, even if the nurses aren't trained in lactation.

The point of all this is... you learn something new every birth. Or many somethings. For instance, I also learned that if a mom is GBS+ she should really get the IV antibiotics in her system at least 4 hours before delivery (so don't wait too long to go to the hospital with a GBS+ mom).

Or sometimes, many things are affirmed. For instance, you really can't tell if a mom is going to take one hour or several hours to go from ___ cm to 10 cm. Or like how sometimes L&D nurses are all the same. And sometimes they're idiots (Sorry, just really annoyed at an L&D nurse who told my client to tell her if she had a continual urge to push,  even in between contractions, which is NOT how it works. And then wouldn't let mom stand beside the bed when she felt pushy because she was afraid she'd have the baby on the floor, even though she had just checked her and she was only 8 cm and was not going to push a baby out that fast. Ok, rant over).

Ok, POST OVER! Thanks for sticking with it til the end :)


--> A membrane sweep, or stripping the membranes, is not the same as breaking the bag of waters (amniotic sac). It is done by inserting a finger between the membrane that goes around the amniotic sac and the wall of the uterus to loosen the membranes from the wall. Sometimes this stimulation of the uterine wall can help to start labor. It doesn't work for everyone, may or may not be uncomfortable, and can sometimes cause the water to break.

Active Management of Third Stage

Third Stage

The third stage of labor lasts from when the baby is born to when the placenta is birthed. Once the baby is expelled, the uterus generally continues contracting. Stimulation of the nipples by the baby helps the uterus contract down to pre-pregnancy size. The contractions and the hormones cause the placenta to detach from the uterine wall. The mother may feel another urge to push, but pushing out a squishy placenta is much easier than pushing out another baby!

The third stage generally lasts about an hour. It can last more than that, but generally the hospital won't even wait more than 30 minutes. If the placenta is taking a long time to detach and come out, there is a fear that it is a "retained placenta," and they may manually remove it. If the placenta is retained, or if pieces of it are retained, there is a risk for postpartum hemorrhage (excessive bleeding). This is why 1. the doctor or midwife will check to make sure the placenta is intact, and 2. the doctor or midwife may administer a shot or a bolus of pitocin to get the uterus to continue to contract.

Active Management 

Postpartum hemorrhage is the biggest childbirth complication and maternal killer worldwide. The World Health Organization recommends pitocin for all women to prevent postpartum hemorrhage and maternal mortality. They refer to this as "active management."

Many women want to avoid pitocin, even postpartum, because of it's potential side effects.  Normal expulsion of the placenta is possible without pitocin. We also have the luxury, in the United States, of having immediately available emergency care. If you begin to bleed excessively after birth, either your care provider would notice and take steps to stop it, or you would be able to call 911 and have an ambulance with you in a short time.

If you don't see a problem with receiving pitocin after birth, go for it. It is preventative, and recommended. And if you don't want it but end up needing it because of a suspected retained placenta, don't worry too much about it - it is a life saver in many instances!

The midwife at Midwife's Thinking Blog wants you to know something important:

Physiological placental birth is an option and possible if you manage to avoid induction, augmentation, an epidural or complications – but be aware of how difficult it may be, and don’t beat yourself up if it doesn’t happen.

Some medical interventions can mess with a physiological placental birth because they interrupt your body's natural production of oxytocin (your labor hormone!). Just something to keep in mind, and another bonus to a natural birth. Another thing that interrupts this - stress.

Keeping baby skin to skin and on the breast immediately after birth is a great way to help that placenta out!

In a world where the majority women are having inductions, pain medication, anesthesia, augmentation, and stressful birth environments in the hospital, active management of the third stage might be the best idea for most women. 

Cord Traction

I do have to add here that I don't think cord traction is a good idea. I'm not a doctor or a midwife, but cord traction seems like a terrible idea, yet one that is done ALL THE TIME. This is when the care provider pulls on the umbilical cord to help the placenta out (sometimes in conjunction with the pitocin). This can cause additional problems - a placenta that hasn't separated from the uterus yet can cause a partial detachment (adds to hemorrhage), you can snap the umbilical cord (not a huge deal), or worst case scenario, pull the uterus out!

Even though this is "faster," which doctors like, it doesn't seem to do much good. I really wouldn't want to risk making things worse by pulling on the cord, especially if the third stage hasn't been that long, yet! 



How long did it take for your placenta to come out? What are your thoughts on the active management of the third stage?

 

 

 

 

"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.

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.

Weekend Movie: Waterbirth in a Hospital

Waterbirth in a hospital - It's possible!

Listening to Mothers

Have you read the findings of the 2002 and 2006 national U.S. surveys of women's' childbearing experiences? The Listening to Mothers and Listening to Mothers II surveys are a great look at U.S. maternity care and mothers experiences in birth.


I have read an referenced these findings before, but here is a summary of the findings. I encourage you to download the Pdf's, read through the complete findings, view the graphs and charts, and develop a better sense of what childbirth is like in America.

The 2002 Listening to Mothers study was the first national U.S. survey of women’s childbearing experiences. 136 mothers of singletons were interviewed by telephone, and 1,447 completed an online survey within 24 months of their birth (Declerq et al, 2002). The survey was repeated in 2006 in Listening to Mothers II (Declerq et al, 2006).

In the 2002 survey, mothers were pleased with the care they received during birth. The majority of mothers felt that they understood what was happening, felt comfortable asking questions, that they got the attention they needed, and were as involved as they wanted to be in making decisions. Technology-intensive labor was the norm, with high numbers of women receiving an IV, epidural, pitocin, artificial rupture of membranes, or stitching. Almost half of women reported that their caregivers tried to induce labor. One third reported a non-medical factor as part of the reason for induction. Five percent of women chose labor induction to be able to give birth with the birth attendant of their choice. 

The women surveyed in 2002 reported that obstetricians delivered 80% of babies. This was the same in Listening to Mothers II (2006). Midwives attended 10% of births and family physicians attended 4% of births. 97% of births took place in hospitals. Doulas and midwives were most highly rated providers of labor support, but used only 5% and 11%, respectively. These findings were the same in Listening to Mothers II (2006). Three in ten women had never previously met the person who delivered their baby. Four percent of women had a nurse or assistant deliver their baby (not a doctor).

Nearly two-thirds of women received epidurals and most rated them highly. However, most couldn’t answer questions about side effects of epidurals. Use of the tub, showering, and birth balls was rated high for help with labor pain, but used by only eight percent of women.  71% of mothers did not walk around because they were hooked up to instruments, had pain meds, or were told not to by caregivers. Only twelve percent of women had anything to eat during labor, 31% had something to drink. Most were told by caregivers that it was not permitted. Three quarters of women gave birth on their backs.

Two-thirds of mothers had an unassisted vaginal birth; one fourth of mothers had a cesarean delivery. In LTMII (2006), one-third of mothers had a cesarean delivery. In the 2002 mothers who had a cesarean delivery, 51% were planned (predominantly repeated cesareans). 26% of mothers with previous cesareans had a VBAC (LTMII: 11%). 42%- 58% were denied the option of VBAC. (LMTII: only 1 mother out of all the 1^st time c-secs requested her c-section with no medical reason).

By a margin of more than 5 to 1 mothers thought it was unlikely that they would choose a cesarean for non-medical reasons for a future birth. Women who had given birth more than a year prior to the survey were more likely to express willingness of caregivers to permit VBAC, compared to women who had given birth within a year of the survey.

           

Compared to women with vaginal births, those with c-sections were less likely to ‘room-in’ with the baby and be breastfeeding at one week, more likely to experience several health concerns after birth. Experienced mothers (compared to 1^st timers) were less likely to attend CBE, use pain med and other interventions, report negative feelings during labor, have a physician as a birth attendant, give birth by cesarean.

           

In the 2006 version of the survey, researchers found that first-time mothers identified books as their most important source of information. More mothers were exposed to childbirth through TV than through childbirth education.

           

The greatest concern with the care received during birth was feeling “rushed.” In 2002 and in 2006, about half of women agreed that giving birth is a natural process that should not be interfered with unless absolutely medically necessary. One-third of women had limited understanding or none about her legal right to full information about any procedure and her right to refuse. More than one-third reported she would have liked to know about this during maternity care.

“What happens to childbearing women, infants and families matters deeply. A vast body of evidence is accumulating about lifelong implications of the medical, physical, and social environment during this crucial period. Growing evidence also supports the long-term impact on maternal well-being of conditions at this time.” (LTMII, 2006, p 8)

“Large segments of this population experiencing clearly inappropriate care that does not reflect the best evidence, as well as other undesirable circumstance and adverse outcomes.” (LTMII, p 8)

References:

Declerq, Eugene, Carol Sakala, Maureen P. Corry, Sandra Applebaum, Risher P. (2002) Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences. New York: Maternity Center Association, 2002.

Declerq, Eugene, Carol Sakala, Maureen P. Corry, Sandra Applebaum (2006) Listening to Mothers II: Report of the Second National U.S. Survey of Women's Childbearing Experiences. New York: Childbirth Connection.

 

Meconium

I've done a post on vernix, and one on the "ring of fire," among other useful things to know about childbirth that you may not know about, and now its time to do a post all about meconium!

Meconium is the first poo of a newborn. It is thick, sticky, brown and sometimes dark greenish. It is made up of what the baby was ingesting inside mom's uterus (like water, amniotic fluid, cells, vernix, etc) and is pretty sterile. It usually passes after the first couple days of the infant's life, turning into the more liquidy poop of a milk-fed baby.

If you're going to be a parent, you'll be seeing a lot of this!

I also just learned this interesting information:

The term meconium derives from ancient Greek meconium-arion, or "opium-like." Aristotle developed the term because he believed that it induced fetal sleep.

I've been asked a couple times about whether the baby poops or pees inside the uterus before being born. The answer is generally "no," but also "sometimes."

Occasionally, the meconium will be present in the amniotic fluid when the membranes rupture (a.k.a. when the water breaks). About 15-20% of babies are born with meconium in the fluid among term-pregnancies, and is increased to 30-40% among post-date pregnancies.

There are a few reasons why this would occur:

1. Women who are truly post-dates are more likely to have a baby that has "meconium-ed" in-utero. This is because their digestive system and bowels have reached maturity and started working.
2. Cord or head is being compressed during labor, which can cause heart rate decelerations, and is a normal physiological response and can happen without fetal distress.
3. True fetal distress. One theory is that the baby either isn't getting oxygen (hypoxia) or is stressed for another reason and poops in response.

Fetal distress can be present without meconium, and meconium can be present without fetal distress. The best indicator of fetal distress is abnormal heart rate, especially if coupled with meconium, and especially if the meconium is thick rather than thin.

Unfortunately, any presence of meconium in the amniotic fluid is cause for alarm among hospital staff. If meconium is discovered in the fluids, the laboring woman will be confined to labor attached to the monitors, with her movement restricted, which reduces her ability to move with her contractions to help the baby down through the pelvis and also restricts her ability to walk or use the shower for comfort. A time limit is also placed on the labor, and the risk of augmentation, c-section, or instruments to speed along the birth are increased. Once the baby is born, the cord will be immediately clamped and the baby will be whisked away from mom, rather than placed on her chest, to be vigorously suctioned.

The suctioning is done for fear of meconium aspiration. Meconium aspiration is when the baby inhales her own meconium, which is extremely rare but can be fatal. It is unlikely that the baby will inhale meconium in utero, unless the baby is extremely hypoxic, in which case they are gasping for air and might inhale their own stool. So, once again, meconium alone may not be a problem, but an oxygen-deprived baby showing other signs of distress may have a problem.

So, if this newborn poo during labor and birth is such a cause for concern, don't you think that care givers would do everything they could to reduce this occurrence? Unfortunately, in the U.S. at least, they do not. It is common practice to do procedures that have been scientifically shown to increase the chance of hypoxia, fetal distress, and meconium aspiration syndrome. For example, (via Midwife Thinking blog):

• Inducing labour if the waters have broken (with meconium present) and there are no contractions or if labour is ‘slow’ in an attempt to get the baby out of the uterus quickly.
• Performing an ARM (breaking the waters) to see if there is meconium in the waters when there are concerns about the fetal heart rate.
• Creating concern and stress in the mother which can reduce the blood flow to the placenta.
• Directed pushing to speed up the birth.
• Having extra people in the room (paediatricians), bright lights and medical resus equipment which may stress the mother and reduce oxytocin release.
• Cutting the umbilical cord before the placenta has finished supporting the transition to breathing in order to hand the baby to the paediatrician.

To reduce chances for complications from meconium, try to avoid the above. For more suggestions on what to do when there is meconium in the amniotic fluid during labor, click over to the post linked above! She has even more information about how the airways are cleared during vaginal birth as the baby is squeezed through the birth canal!

The biggest piece of advice I would give is to avoid artificial rupture of membranes early on in labor unless there are other serious indications of fetal distress. Once meconium is discovered, the whole birth plan changes, even if the baby is doing fine!


References:
http://www.sciencedirect.com/science/article/pii/S1751721410001120
http://www.hon.ch/Dossier/MotherChild/labor_complications/birth_meconium.html
http://midwifethinking.com/2010/10/09/the-curse-of-meconium-stained-liquor/

Informed Choice and the BRAIN Acronym

I vary my prenatal visit topics depending on my client's experience and knowledge, but one of the things I talk about with every doula client is Informed Choice and Informed Consent. Specifically, we discuss what it will be like to exercise their right to informed choice during the sometimes highly emotional experience of pregnancy and childbirth in a medicalized setting where informed consent is not always practiced (sad, but true).  An excellent tool to use to talk about this topic and help clients see what this looks like, especially during labor, is the BRAIN acronym. 

Use Your BRAIN! 

In most instances, there is time to discuss every treatment or procedure with the care provider. This includes the nurses, too, not just the doctor or midwife. The reason this is a great tool is because everything that happens to a patient should include an informed choice, which includes both the option of informed consent and informed refusal. Yes, the doctor has been to medical school, but that doesn't mean that everything she says or proscribes is based on scientific evidence, or that it is your only option.

Benefits - What are the benefits of this procedure? How will this help me/my baby/my labor?

Risks - What are the risks of this procedure? How might this negatively affect me/baby/labor?

Alternatives - Are there alternatives to this procedure? Are there other options?

Intuition - What is my gut feeling about this?

Need Time, or Nothing - Can I delay this procedure and take some time to think about it/Discuss it with my partner? What will happen if I choose to do nothing for now?

The BRAIN acronym and Informed Consent exercise may seem obvious, but for many people, especially pregnant and laboring women, it doesn't always occur. Many people don't realize that they have the right to ask these questions or even to refuse certain procedures when they are being told they "have" to by a physician with authoritative knowledge. There is a social power play going on, and it is going on while a woman is nervous for her and her baby's health.

I recently had a client use the BRAIN acronym for informed consent/refusal that I had taught her and her partner! Her doctor started talking about induction at her 40 week prenatal visit, and then scheduled some dates for her at the hospital, even though he told her at 2 check-ups that she and baby were doing well. She felt very nervous about it, but also nervous because of the way the doctor talked about "what could happen" to the baby. So she went home and talked to her partner about the Benefits, Risks, Alternatives, Intuition, and Need Time aspects of the decision to induce. Then she called me and told me that the only benefit they could think of was seeing the baby sooner! Which wasn't enough to make them feel comfortable with inducing, so they decided to tell the doctor they'd like to wait until 42 weeks. So awesome!

• No person should give you a pelvic exam or manipulate your cervix without your prior consent.
• No person should pressure you into attempting induction unless it is medically necessary.
• No person should pressure you to dilate faster for his or her own convenience.
• No person should break your water or cut your perineum without consulting with you first and gaining your permission.
• You have the right to refuse a course of treatment that you feel is not in your or your baby’s best interest.
• No person should rush you to make a decision.

These things are true, and childbirth educators and doulas say these sort of things all the time, but they still happen. I see them happen. So it is an important thing to pass on to our clients -  YOU HAVE A RIGHT TO CONSENT TO AND REFUSE ANYTHING THAT INTERFERES WITH YOUR BODY OR THE BODY OF YOUR CHILD.

There are some great informed consent role plays out there, where mom and partner can practice asserting their rights. I really like these (via Prep for Birth), because these are very difficult situations that almost every woman birthing in a hospital will find herself in:

You are laboring along slow but sure. Early labor is taking awhile. Your contractions change and seem stronger. You go to the hospital and are 5 centimeters. Baby looks good on the monitoring in triage, so you are assigned a room. The labor and delivery nurse would like you to stay in bed and not move around or get into the shower/tub. That is ALL you want to do.

What would you do?

 Hopefully, you would use your BRAIN! Let's practice:

B: What are the Benefits of staying in the bed? Well, your labor has been normal and the baby looked healthy on the monitor. Your body is telling you that you would be more comfortable moving around. So why would the nurse ask that of you? There are benefits for the nurse - he/she can keep you securely hooked up to the electronic fetal monitor, the blood pressure cuff, possibly an IV, and all the other gadgets being used to record your vitals. That way she can leave the room to do other things but you are still being "monitored" by the equipment. The nurse has also been told in training that birth must occur in the bed and that the monitor is the best and only way to detect fetal stress, which in her experience happens all the time.

R: What are the Risks associated with staying in bed? Well, you would be extremely uncomfortable the whole time, especially if getting out is all you want to do. Another risk is that staying in bed may make your labor more painful and possibly slower. Moving in response to labor contractions and change of positions makes use of gravity and changes the shape of your pelvis, helping baby make his/her way down. The freedom to move and to use pain coping techniques like the shower gives you an increased sense of control and lessens your anxiety. (For more about the proven benefits of movement during labor, click here).

A: Are there alternatives to this procedure? Can we get more information about why the nurse wants you to stay in bed? If its to keep the baby on the monitor, you can request intermittent monitoring (every 45 minutes or so)? Or maybe something that is portable, like a fetoscope or a telemetry unit, and that way you can even get into the shower. If you have done your research, or if the nurse/doctor does theirs, you will know that routine continuous EFM provides no benefit for babies and increases the risk of cesarean for mothers.

I: What is my Intuition telling me? Well, that's easy - its I WANT TO MOVE! 

N: Its ok to Need some time to think about it. You might choose to stay on the monitor for a bit and see if you can get comfortable with that. Or, after you gathered all the information you can from your nurse and or doctor on the benefits, risks, and possible alternatives, you just want a few minutes to talk to your partner and your doula about what you're thinking and feeling. There is no rush to decide.

Here's another scenario:

You have been assured that after your push out your baby, he will be placed right on your belly or chest for assessments even if he needs oxygen without separating you two. After you birth your baby, he is making good effort to breathe, is vocalizing, and his color is just right. The baby nurse wants to take him right away. You ask her to do all his assessments on you and she says no and without your consent takes him off to the warmer.

What would you do?

(Some may recognize this in a different form - BRAND. I like BRAIN better because it includes Intuition, and also because the "Nothing" and the "Delay" of BRAND seem too similar to me, and are encompassed well under "Need time.)

Hospital L&D Tour

Yesterday I went with my doula client on the tour of her hospital's labor and delivery unit. I've wanted to do this in the past, so I was excited to do it, especially at a hospital I hadn't been a doula at yet.


Unfortunately, both my client and I had heard that this particular hospital was not majorly doula-friendly. I had also heard that it was not a natural birth-friendly place, and had a high cesarean section rate. Oy. 

The first thing we did was sit around a table in a classroom while she told the group what procedures they could expect during labor, during and after delivery, and postpartum. The nurse leading the tour spoke in the most patronizing way - like she had a lifetime of experience of talking down to her patients. This wasn't just my opinion - my client agreed that we were being spoken to like we were children! And the voice and mannerism never let up - it was like the nurse talked like this all the time without realizing it. Very odd.

She also spent a lot of time on strange details like how any cameras or laptops that we brought had to be battery-powered because although there were outlets in the room, we can't use them in case they were needed in an emergency. I found that an odd 3 minute rant... She also spent time talking about how if you have a dog at home, you need to take home your baby's first hat (the one covered in vernix) and give the hat to the dog so they can get used to baby's smell. It makes sense, I guess, but relevant to knowing what the labor and delivery experience will be like? Nope.

She did not leave an open atmosphere for questions, or solicit questions.

We visited the labor and delivery floor to see a room, and I noticed the floor was totally empty. Not one room's door was closed. The place was totally empty! The nurse emphasized how "homey" the room felt, with all its wood instead of metal. The L&D room looked just like the room I had seen in one other hospital, which happened to contain the most irritating L&D nurses yet (yelling and "if you're breathing you're not pushing!" kind of thing). I wonder if there is a correlation between the hospital's effort to make the room feel "homey" and worse L&D experiences. 

Then we went up to the nursery on one of the postpartum floors. The nursery only had 2 babies in it! Granted, the hospital practices rooming-in, which is great, but only 2 babies in the nursery and 0 women laboring on the delivery floor made the hospital seem like a ghost town. The postpartum room was small, just like all the postpartum rooms I've been in, with an uncomfortable couch for the partner to sleep on.

Luckily, the hospital seemed very pro-breastfeeding. She repeated several times that they want the baby to be skin-to-skin as soon as possible because it helps with breastfeeding success. Unfortunately, who knows how long the skin-to-skin will last, and how helpful the postpartum nurses and lactation counselors will be. Someone asked about Lactation Consultants and the nurse said you could "request" one. I'm guessing that means its not standard that everyone see one, and that the LC is not there all the time.

At the end of the tour we asked if the newborn procedures (APGAR, heel prick, eye gel, vitamin K, etc) could be done with the baby on the mother's chest. The nurse thought for a really long time and said she really didn't know, no one had ever asked before and she had never seen it done (not good odds that it will occur then). She assured us it all gets done in "a blink of an eye" while mom is going to the bathroom anyway, so we won't even notice. I've never seen it happen in a blink of an eye, I've seen mothers and fathers peering sadly over at the other side of the room wanting to see and hold their newborn that they worked so hard for and who just got whisked away. It usually takes as long as it takes for the doctor to stitch the mom's perineum if she has torn, which is a while. We also asked about rooms with showers and tubs, which the nurse said are only in two of the room, and are reserved for the mother's who want to go natural. This makes me sad.

I was nervous to ask irritating questions about epidural and cesarean section rate, as I was there with my client, and I didn't want to further give doulas a bad name.

What questions should we have asked? Have you been on a hospital tour with your doula clients?



A blogger at Science and Sensibility just posted a blog about taking a hospital tour - If you'd like to check it out, click here.

Choosing a Hospital Birth? How to make it AWESOME

I practice my doula services from the perspective that every woman has the right to choose, and that I am here to help her achieve her ideal birth. Whatever that means to her, I am here to support her. It is HER birth, not mine. Even though I do a lot of research and I've developed a lot of opinions over the last year, I would never tell a woman what she should or shouldn't do, or that her choices are wrong. If she asks, I tell her everything the evidence has to say about every option, and I try to uphold her wishes.

Though I do not think a hospital birth is right for myself, I know that it is where doula support is needed most. I will continue to help women labor and deliver in hospital settings, especially because 99% of women in the USA choose to do so in a hospital.

Every birth is unique, and while the presence of a doula or other factors can't guarantee a wonderful hospital birth (as some things are out of my control), there are a few common factors that can help women have the best chance at the birth they hope for.  

Having an AWESOME hospital birth

via Vita Mutari

1. The first thing is to hire a care provider that they love and that has a reputation of being respectful. It is so important to go into this with the attitude that you are a TEAM working towards the same goal…not that the doctor/midwife and hospital are the enemy to be conquered. Having a great RELATIONSHIP with your care provider and trusting them to respect you and your baby is the best start to a joyous pregnancy as well as a birth free of animosity and stress.

2. Take a good childbirth preparation class! What makes a good class? One that’s not in the hospital. I know that there are good classes that may be in the hospital…but those are the exception rather than the rule. It’s not the instructors’ fault, they are often restricted in what they can teach by the hospital. The class should run a minimum of 12 hours….not a quick little 2-4 hour class.

3. Hire a doula that you (and your partner) trust and adore. Interview with several – in many ways it’s like dating again! When you go out on a date with “the one”, you should know it. It should be someone you look forward to seeing! Someone you are excited to share this experience with. Someone you trust…someone that makes you feel good when you are around them. It’s also super important that your partner have the same level of trust, as many find that the doula helps dad MORE than she helps mom through this process!

4. Only invite people to your birth for YOU…not for them. Don’t invite someone because you feel obligated, or because you think it would be neat for them. The only people who should be at your birth are people with a PURPOSE! They should be there to photograph, or to rub your back, or because they make you feel safe…it should be for you, not as a gift to them.

5. Regardless of where you intend to birth – go into this rested!! The worst thing a mom can do if she thinks labor is beginning is to “try to help it along”. I saw mothers who would walk the neighborhood or mall, scrub the floors, make love with their husband…not because they wanted to but because they want to encourage labor to keep going. If it’s labor…IT DOES NOT NEED YOUR HELP!! We have a hard time STOPPING labor when you don’t want it! If you think labor has begun, then this is the beginning of your baby’s birth story!! Make it the BEST story you can by filling it with pampering and joyful things for you – take a bath, sip some tea, watch the sunset, watch your favorite movie…but most of all, take it easy!

6. Stay in the moment! Did you know that pain relief is not the most common reason that epidurals are requested? The most common reason for a first time mom is 1) fatigue (see #3 above) and 2) fear of what’s to come. They get an internal exam and are found to be 5cm and they think, “I can’t do this for another 10 hours!! I’ve been doing this for 10 hours and I’m only halfway there!” or they think, “If it feels like this at 5cm, how will I do 9cm??” They can do *this*…they can do *here* and *now*….but they want an epidural because they fear what is to come. Stay in the moment…take each one as it comes! STAY here and now…don’t jump ahead in your labor.

7. Pick and choose your battles. I often see frustration when someone chooses a hospital birth but rejects all that a hospital means. If you want to avoid everything a hospital does, then why are you birthing in a hospital? If you feel a hospital birth is safer, then why are you demanding that they don’t do the things that they do with hospital births? And how can you possibly be making it safer by taking them out of their routine, out of their comfort level, and trying to demand that they abandon all of their protocols and procedures? And if you think that all of the protocols and procedures aren’t helpful, then why are you birthing there? If you choose a hospital birth then I hope that you also understand that the hospital is doing what they feel will make your birth safer. If there’s nothing you want from the hospital….then again I ask, why are you there? You are there for a reason so why create animosity for them trying to do their job?

8. Remember that this is YOUR baby! May seem silly to you that I say that…but it always amazed me how easily “ownership” of the baby is handed over to the hospital. I hear women complain that the baby will be taken from them immediately….but they can’t TAKE the baby, you must GIVE them the baby. I’ve seen a healthy baby laying in the warmer, nurse leaves the room, and a cleaned up mom say, “When can I have the baby?” only to have dad say, “Want me to go get the nurse?” Why would he need to get the nurse?? It’s HIS baby…he can pick his baby up anytime he wants! Why would he need permission to pick up his baby and hand his baby back to the mother?

9. If this is your first time breastfeeding….schedule an appointment to see a lactation consultant. Make sure it’s actually a lactation consultant, not a nurse who likes helping moms breastfeed. Is she an IBCLC? (stands for International Board Certified Lactation Consultant) That’s a good question to ask….”are you an IBCLC?”  See if you can find an IBCLC who will come out to your home a few days AFTER the birth to evaluate how things are going.  And while we’re at it…I wouldn’t have ANY formula in the house!! You can buy formula 24 hours a day in a store – and a baby is NOT going to starve to death in the 30 minutes it takes for dad to run down to a store and buy it if you fear for the baby’s safety or if your IBCLC believes formula is needed – there’s no reason to have it. That’s like getting married but having the divorce papers drawn up ahead of time “just in case”.

10. Enjoy your blessings!! Your gorgeous baby, the beauty of having your family together…

 

My Thoughts on Hospital Birth vs. Home Birth

On the heels of a 21 hour birth with a client, my longest yet (and also finally a birth that counts as my last birth for certification! yay!), I am going to share some thoughts.


Here are a few things about Hospitals Births that solidify my desire to have a Home Birth:

1. I HATE directed pushing. Hate it. You do not need to be told when and how long and how strong to push in order for your baby to come. You also do not need to "know" that you are 10 cm and then be "allowed" to push. You will know when it is time to push. You will feel the urge!

I think women push much more effectively when they follow their bodies. They breathe more than they do with directed pushing, which gets more oxygen to the baby and themselves. They do not push so hard that they are not letting their perineum tissue stretch, and so they tear less. They tend to push in more effective positions, especially if they are not in a hospital confined to the bed (which is more convenient for the doctor).

I told my client recently who was experiencing a nurse who was telling her not to push during a strong pushing contraction because she had to "give the baby a rest, she's having her head compressed a lot," that this was HER show. She needs to push and breathe when she feels it is right.

2. Monitors. Constantly attached and tethered, constantly beeping and squeezing, constantly readjusted. I think they are so freaking obnoxious. They also haven't been shown to identify and prevent what they are "supposed" to (see my post Where's the Evidence Based Medicine?) How can I labor effectively if I am so profoundly irritated?

I don't think the blood pressure cuff, thermometers, contraction monitors, heart rate monitors, etc etc really help my baby have a safer labor and delivery. I think they hinder that which creates a healthy birth, namely, a mother who is at peace and as comfortable as possible, a mother who can get up and more around and be in any position she likes, a mother who doesn't feel encumbered or worried.

3. Not being able to eat or drink whatever I want. Again, there is no evidence that eating and drinking during labor is bad, but its certainly true that not being able to eat or drink lowers your energy level and also makes your labor unpleasant. I'd much rather eat and drink what I want for energy than be attached to a painful IV.

I also think its ridiculous that we withhold such a thing from a laboring woman. Its like its some power trip to be able to control their eating (and their peeing, too, if mom has to have a urinary catheter).  All part of the Rite of Passage (see: Robbie Davis-Floyd).

4. People telling me where and how and in what position I can labor/birth. Uh uh, no. I am going to labor how I damn well please. I am not going to stay still in that bed just so YOU and the hospital record room can have a "nice strip on the monitor." I am not going to lay here and suffer pain that would be alleviated by moving or a hot shower just so you can fill in your charts with my blood pressure. That's bullshit.

I'm also going to push in whatever position feels the most comfortable for me. I don't care if its hard for you to catch the baby that way - I don't actually need you! I can catch my own baby! Or my husband can do it! One does not need a medical degree to catch a baby. That baby is coming whether we like it or not, and its coming in whatever position I choose at that moment.

5. The hospital atmosphere. Strange smells, weird sounds, the fact that hospitals are full of illnesses and germs, and being in someone else's territory. I've never liked the sterilization smells of doctors offices and hospitals. They just remind me of being sick and uncomfortable. I don't think I could fully relax in an atmosphere where people can come and go as they please, touch me and tell me what to do whenever they please, and me and my family have to "ask" to be able to do things or go places. I also don't want to feel embarrassed during my labor, and I don't want people there that I don't know. That atmosphere can stall a labor, and I've seen it happen.


I should emphasize, also, that all of these things also solidify my decision to have a home birth because I want a natural birth. If you want a natural birth, STAY OUT OF THE HOSPITAL.


What about you, what do you think? Other than the "safety" or "fear" aspect of the hospital vs. home birth debate, tell me what prompted you to make the decision you did!

Re-Blog: Eating and Drinking during Labor from a Medical Anthropologist's Perspective

In this article, we see Robbie Davis-Floyd's explanation for the restriction of food and drink during labor as reinforcing the liminal status of pregnant women during her rite of passage into motherhood.


Re-Blog: Restriction of Food and Drink in Labor from a Medical Anthropologist’s Perspective via Birth Activist Blog

 

The recent Cochrane review, Restricting oral fluid and food intake during labour, analyzed five studies and concluded that women should be free to eat and drink in labor at will.

Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women.

The rationale behind denying laboring women food is that the danger of aspiration and the potentially lethal complication known as Mendelsohn’s syndrome while under general anesthesia is greatly reduced.

Medical anthropologist Robbie Davis-Floyd wrote extensively about the cultural myths about non per os and childbirth in the 1992 book, Birth as an American Rite of Passage. Mendelsohn’s original 1946 article reported several cases of aspiration and subsequent pneumonia, but no deaths. Davis-Floyd cites Baggish’s 1974 study which showed that at most 2 percent of maternal deaths were caused by aspiration under general anesthesia and Scott’s 1978 work that placed the risk of death at 1 in 200,000 women.

So what purpose would denying food and drink to all laboring women serve more than six decades after Mendelsohn’s work and with the great improvements made to regional anesthesia? Davis-Floyd wrote:

According to Feeley-Harnik, “persons undergoing rites of passage are usually prohibited from eating those highly valued foods that would identify them as full members of society” (1981:4). In rites of pregnancy and birth across cultures, food tabus serve the purpose of marking and intensifying the liminal status of the pregnant woman. The pseudo-foods (ice chips and lollipops have no nutritional value) allowed in the hospital are often fed to the laboring woman by her partner as if she herself were the baby, a symbolic process that can heighten her own sense of weakness and dependence.
In a recent article in Birth, Broach and Newton (1988) address the question of why laboring women are still prohibited from eating and drinking in labor in spite of mounting evidence that such prohibitions are medically contraindicated. Pointing out that this custom started in the 1940’s when general anesthesia was widely used for childbirth and the danger from aspiration was therefore higher, they posit that its continuance is the result of “culture lag”—that is, of “culturally patterned behavior that continues to be practiced long after the reasons for doing so have disappeared” (1988:84).

Davis-Floyd views denying food in labor as indicative of the confirmation of a woman’s initiate status as a dependent of the institution.

On the contrary, I would suggest that this custom forms an integral part of the technocratic tapestry of birth in the United States, continuing as routine procedure not because of culture lag but because it serves so well to legitimate and further necessitate the technocratic interventions we investigate here as transformative rituals. To deny a laboring woman access to her own choice of food and drink in the hospital is to confirm her initiatory status and consequent loss of autonomy, to increase the chances that she will require interventions, and to tell her that only the institution can provide the nourishment she needs—a message that is most forcefully conveyed through the “IV.”

Restriction of food and liquids in labor was the subject of many discussions last year following the American Congress of Obstetricians and Gynecologists’ press release that women should be allowed “modest amounts” of water and clear liquids in labor, with physicians defending IV use and telling women to calm down their rhetoric and fight for things that matter.

A Doula for Your Cesarean Section

Yesterday I had an extremely awkward conversation with my pregnant professor. It was one of those moments where I maybe should have kept my mouth shut, and refrained from spewing the birth-related word vomit all over someone who didn't ask for it. It happens! Especially when the topic of elective cesarean sections come up.

An elective cesarean section is one that is schedule ahead of time by the doctor and mother.

Reasons for this are:
1. suspected macrosomia (big baby)
2. mother and doctor want the convenience of picking the date and time of delivery
3. mother is tired of being pregnant
4. mother is "overdue"
5. baby is breech
6. medical conditions for the mother (hypertension, etc)
7. medical conditions for the baby (suspected deformity, etc)

Birth workers get very touchy when the idea of an elective cesarean section comes up if it is not for reason 6 or 7, above. The first 5 reasons (with some grey areas, like going past 42 weeks) generally create more dangers for mom and baby when compared with spontaneous vaginal labor and delivery.

Having a Cesarean before labor begins on its own increases the chance that a baby will be born premature (as due dates are merely estimates and can be wrong, and ultrasounds in the third trimester are known to be off by up to 3 weeks and 2 pounds). Premature and low birth weight infants, especially those born by cesarean section, have respiratory and sucking problems and spend more time on the ventilator and in the NICU. They also cost billions of dollars in health  care.

When cesarean is elective with no emergency present, the woman's chance of dying from the procedure it self is nearly three times that of a vaginal birth. Moreover, the mother has a much longer recovery period from the major abdominal surgery, which makes caring for her newborn much harder.

When an elective cesarean section occurs for a medical reason, such as fear of uterine rupture (after considering VBAC!), one can still create a Cesarean Birth Plan and Bring a Doula!


Yes, thats right, A DOULA CAN HELP YOU WITH YOUR PLANNED CESAREAN SECTION.
Which is what my birth-related word vomit was all about yesterday - the support a doula can provide for a mom and her partner during a cesarean section.

Informational Support
For a planned or even the possibility of an emergency c-section, a doula can provide a ton of informational support. The biggest of which is helping you to create a cesarean birth plan. How can I plan for a surgery in which I will play little to no part? you might ask. Many people do not know that they have many options and a doula can inform you of these.

Would you like to specify a double suture as opposed to a single suture? Or have your urinary catheter placed after your spinal epidural? 
Would you prefer that the surgeons keep the chit-chat to a minimum? (I have heard stories of women lying there scared and uncomfortable while the doctors and nurses talk about things completely unrelated to the procedure)
Would you prefer that your baby be brought to you (if baby is healthy) as opposed to immediately placed on the warmer?
For more help with cesarean birth plan options, see this post (or talk to a doula! :)

Additionally, a doula can help you and your partner know what to expect with a cesarean section, and also inform you of the newborn options that you are allowed to decline if you wish, and so on.


Emotional Support
The doula can help allay fears before, during and after the surgery. If you are disappointed that you have to have a cesarean section rather than a vaginal birth, the doula is there to discuss your feelings with you and your partner She can help you practice relaxation techniques, and talk to you during the procedure to keep you calm. She can help keep partners calm, especially during prep time, so that they are effective support for mom as well. She can still be your advocate in the ER - remind the surgeons to please describe, or not describe, the procedures as they are doing them, that mom would like to do skin-to-skin as soon after birth as possible, etc.

After the birth, the doula is there for you while you process your feelings about the birth. While in the recovery room, the postpartum room or at home, its great for moms to have someone to talk to. She can recommend resources like ICAN and other support groups.


Physical Support
Just having someone else there can be a bigger help than is realized. If dad wants to photograph and touch his baby while the baby is in the warmer, the mother is left alone on the surgery table. If the baby must go immediately to the NICU, and dad goes with the baby, the mother is also left alone. This can be a scary time to be alone - the procedure continues for around 45 more minutes as the surgeons suture you back up, and you continue to feel discomfort and concern for your baby. The doula can stay by your side throughout all of this, if the obstetrician allows. This varies from doctor to doctor and must be discussed ahead of time.

The doula can also help with breastfeeding after birth. This is no small feat after having abdominal surgery! The doula can help you figure out how to hold the baby and get the baby to latch, in addition to all the regular breastfeeding support typically provided postpartum.


You will be surprised how much having this kind of support can really help with your recovery!

photo: doula network of fort wayne, which also has on their webpage a story written by a mom who was glad she had a doula at her cesarean section!

So, who knows if I positively informed my professor, and helped her consider the support a doula can provide even for a c-section, or if I just annoyed her with unsolicited advice. Its a fine line we walk sometimes!