New midwifery program in Canada

My mother-in-law just sent me a link to this article, Calgary college plans midwifery degree. There will finally be another four-year midwifery degree program in Canada by as early as 2010! This is much-needed, as there are currently only six midwifery education programs in the entire country. In addition, demand for midwives vastly outnumbers supply, so many Canadian women wanting midwifery care are unable to access it. The degree program will be offered through Mount Royal College in Calgary, Alberta.

Canadian midwives are required to obtain a university-level degree in midwifery. In provinces where they are legally recognized, they attend births at the location the woman chooses (home or hospital or, if available, freestanding birth centers). For more information on midwifery in Canada, visit the Canadian Association of Midwives.

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Cesarean section and VBAC, again

Here are a few recent articles that are worth reading given recent discussions about VBACs, cesarean sections (elective or otherwise), and the ever-climbing cesarean rate.

The first is an excellent, thorough article in The Poughkeepsie Journal covering the trend to perform cesareans more and more often: Birth by Surgery: The Skyrocketing Cesarean Rate. The author did quite well in covering the salient issues in depth. The article begins with the story of a woman who had an "elective" cesarean for a large baby that turned out to be 2 1/2 lbs lighter than the ultrasound estimate:

Two weeks before Kristi Ashley gave birth to a son in 2007, an ultrasound exam estimated the baby at a hefty 12 pounds, 10 ounces — too big, her doctor believed, for a safe vaginal delivery. After the child weighed in at 9 pounds, 4 ounces in the delivery room, Ashley came to believe that the planned cesarean section she had, with its attendant pain, long recovery and what she called "emotional damage," may have been a rush to judgment.

"It's very hard to go up against your physician, especially at the 12th hour," said Ashley, 38, of Hopewell Junction. "I think doctors are very quick these days to get scared. They would rather opt for the surgical solution."

Determined to avoid another surgical birth and aided by a supportive doctor, hospital and birthing coach, Ashley last month did something that has become increasingly rare for post-cesarean women today: She gave birth vaginally, to another son.

In an era of soaring malpractice premiums, technology that sometimes sets off false alarms, physicians pressed for time and mothers-to-be conflicted by fear, cesarean-section birth is soaring to its highest levels ever. Read the rest of the article here.

The next article by the same author, Modern medicine increasingly intervenes in the birth process, discusses many of the same issues, in addition to the increasing medicalization of childbirth.

In the decade through 2002, something momentous happened to babies in the wombs of American women, especially white women. The average time fetuses spent there decreased from 40 weeks to 39.

The decline, reported in a 2006 study in the medical journal Seminars in Perinatology, appears to have little to do with nature.

Instead, earlier births may be the outcome of “increased use of induction (of labor) and other obstetric interventions such as cesarean delivery,” said a January report by the U.S. Centers for Disease Control. Prematurity rose 20 percent since 1990, the report said, and the rate of low birth-weight babies hit a 40-year high.

“We are shortening the gestational age,” said Dr. Carol Sakala, program director for the research and advocacy group Childbirth Connection. “That is a big interference with mammalian evolution, human evolution.”

Researchers, midwives, birth coaches and mothers point to such data as symptoms of a flawed system of birthing in America, one they say over-manages, over-medicates and over-monitors labor and delivery, often leading to unnecessary cesarean-section births. Read the rest of the article here.

The last article is a glimmer of hope amidst the gloom of our contemporary obstetrical culture. In C-section births fall, one hospital has lowered its cesarean rate (18% last year, usually around 16%). Some of the key practices the hospital has adopted are taking a midwifery approach to childbearing with a focus on facilitating spontaneous, natural births, minimizing the routine use of technology and interventions, and offering and encouraging VBACs.

While more and more women choose to undergo Cesarean section births despite a national push by the federal government to decrease the number, the local rate has declined and is well below the state average.

North Adams Regional Hospital performs significantly fewer c-sections than other hospitals around the state — an average of 18 percent of all births at the hospital compared to the state average of 34 percent, according to reports released by the state Department of Public Health.

The hospital also has a better prenatal care record, according to the reports: 94 percent of women giving birth have had nine or more prenatal care visits versus the state average of 87 percent having that many visits.

"I think what is being reflected in our numbers is that we are taking a more 'midwifery' approach with our practice then before," Robin Rivinus, a certified nurse midwife with Northern Berkshire Obstetrics & Gynecology at the hospital, said last week. "It means that we do fewer unnecessary interventions — inductions, Cesarean sections, episiotomies. We treat childbirth as the normal, natural thing that it is. We only step in when it's medically necessary, which is much better for both the mother and the baby." Read the rest of the article here.

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Belly shot: 35 weeks pregnant

35.2 weeks from LMP. After my sleepless night a few days back, I decided I needed something to pick me up, so I got my hair cut. I was trying to recreate the original hair cut from a few months ago and it's close, but not quite the same. Still not bad, though.
I finally found a family doctor in town and he's only 1 1/2 blocks away, right next door to the dentist's office and video rental store. I brought Zari in today for a meet & greet and to ask him about selective/delayed vaccinations. Zari hasn't had any yet and I'm still trying to figure out what, if any, I will give her. He was upfront that he strongly supports vaccinating, but respectful of whatever I wanted to do. So he said to do some reading & research and let him know my plan at our next visit.

I'd like to check out Dr. Sears' Vaccine Book. I find that the literature on vaccinations is usually either so rabidly pro or against that they both turn me off and make me skeptical. There are some I most likely will not do (chicken pox, Hepatitis B) and several that I'm on the fence about (MMR, DTaP, polio). Rubella, for example, is something to be concerned about when a woman enters childbearing age. At that point, it would be prudent to run an antibody titer and, if it's negative, accept the vaccine before trying to get pregnant. We don't live on a farm or near livestock so tetanus is quite unlikely to be an issue. Hmmmm...

I also gave him a prescription request from the CNM I'm seeing. In my state, there's a loophole that doesn't allow independently practicing CNMs to write prescriptions for certain pharmaceuticals (things such as antihemorrhagic meds like Pitocin & methergine & cytotec, abx for GBS+ moms, lidocaine for suturing, etc). She carries these medications with her but technically/legally can't administer them without a prescription signed by a physician. It can be any licensed physician in our state--even a dentist (but unfortunately not a chiropractor, otherwise I know one who most likely would sign it). He said he'd look over the request, consult with his OB colleagues, and get back to me. I hope it won't be a problem.

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Ethics of refusing to perform elective cesareans

A few recent posts by Mom's Tinfoil Hat--Reply turned post, three way mirror style and
Reply turned post, tired-of-pushing style--got me thinking about the ethics of refusing to do a non-medically indicated cesarean section. If a woman requests to have a c-section with no medical reason, are physicians justified in refusing to perform one? Does refusal or promotion of elective cesarean section (ECS) have ethical implications for other birth choices, such as VBAC or homebirth? Is ECS a "choice" that is an essential part of women's reproductive rights? If a physician defends a woman's right to choose ECS, should he/she also be obliged to defend her right to choose homebirth, waterbirth, etc? Is it ethically/morally justifiable to refuse a woman an ECS but to argue that VBACs should not be banned?

Here's how I see the issue: Refusing to perform a non-medically indicated cesarean is ethically justifiable. Refusing to allow VBAC is not. What's the difference between the two situations?

1) Elective cesarean section is a medical procedure that cannot happen without the physicians and staff to perform it. On the other hand, a vaginal birth after cesarean is not a medical procedure, but rather the spontaneous and inevitable conclusion of pregnancy. It will occur whether or not there is someone doing something.

2) As I understand it, patients have the legal right to informed consent, which includes the right to decline/refuse medical treatment and to bodily autonomy* (provided they are in a state to make competent decisions). Patients do not have the legal right to demand medically unnecessary procedures; they only have the right to decline procedures that are offered/indicated. Refusing to perform an ECS does not violate a patient's right to informed consent and refusal. If a physician feels that there is no good reason to perform a cesarean section (or any other medical procedure), they can refuse to do it and/or refer the patient to another care provider. However, banning VBACs does violate a woman's legal rights, in that it does not allow the woman to refuse a repeat cesarean section.

What are your thoughts on this issue?

* For additional reading on this topic, see:
The Right to Refuse Treatment: Ethical Considerations for the Competent Patient in the Canadian Medical Association Journal
The NHS' explanantion of the right to refuse treatment
Informed Consent and the Right to Refuse Treatment by Valerie Goodwin Larcombe, Esq.

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Help with breathing issue

At the end of my last pregnancy, I had two sleepless nights in a row due to, for lack of a better term, nasal engorgement of late pregnancy. As soon as I would start falling asleep, my nasal passages would constrict and I'd begin to snort/snore/gasp, which would wake me up with a startle. I was pretty miserable, but luckily I went into labor and it went away.

Well, it has started again. So, here are some burning questions I have:

1) Is there an official name for this? I searched nasal engorgement late pregnancy and there are lots of mentions of it, but nothing about treatments or comfort measures
2) Can I do anything to make it go away? Seriously, if I have several more weeks of this, I don't know how I will survive. Really. As in, last night I only got 2-3 hours of sleep total because of this issue.

I'm not congested at all. I's just that with the increased blood volume, the mucous membranes are swollen and engorged, and this can lead to this kind of snoring/airway obstruction. I phone my midwife about it today and she said she'd ask around for suggestions. She also commiserated with me, since she's dealing with the same thing right now (she's pregnant and due in June)

Help!!

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Eating and drinking during labor

A recent RCT of eating and drinking during labor found that it is safe to do. A lot of us would go "well, duh!" but many hospitals still restrict laboring women from anything but ice ships or sips of water.

This is the case with the two local hospitals I recently toured, although there are ways to get around this rule. In one hospital, you need to do it on the sly when the nurses aren't watching. In the other, they said they'd document that they discussed their policy of nothing but water/ice chips, then it would be up to the woman to decide if she wished to eat or drink. Still, most women are probably not aware that they do not have to follow hospital policies.

The study, Effect of Food Intake During Labour on Obstetric Outcome: Randomised Controlled Trial, concluded that:

Consumption of a light diet during labour did not influence obstetric or neonatal outcomes in participants, nor did it increase the incidence of vomiting. Women who are allowed to eat in labour have similar lengths of labour and operative delivery rates to those allowed water only.

For a more thorough look at the historical restriction on eating and drinking during labor, visit the Cochrane Database's review (PDF). Below is the background information from the review:

Background
Restricting oral food and fluid intake of women in active labour in hospitals is a strongly held obstetric tradition. A survey of labour ward policies in England in 1985 revealed that over a third of consultant maternity units allowed no fluids whatsoever during labour (Garcia 1985). In a more recent survey of 351 units in England and Wales, one third allowed some form of food and drink and over ninety per cent allowed some form of oral intake, usually water (Michael 1991). Restriction of oral intake is not a common practice in home births or birth centers (Rooks 1989) nor is the practice consistent across hospital sites (Haire 1991). Few if any centers have policies that are reflective of women's preferences (Pengelley 1998). Most are based on historical, but important concerns, related to the risks of gastric content regurgitation and aspiration into the lungs during general anaesthesia, a risk first identified by Mendelson in the 1940s. Though rare with modern anaesthetic techniques, the syndrome is potentially fatal.

The rationale for withholding food and fluid during labour is to decrease the risk of maternal morbidity and mortality from Mendelson's syndrome if a general anaesthetic is required, as fasting will ensure small gastric volumes. Recent reviews suggest that there is no evidence to support this belief (O'Sullivan 1994). Interventions to reduce stomach contents or the acidity of the content, both by pharmacological means and by restriction of oral intake, have not proved successful (Taylor 1975). Gastric emptying is delayed during labour (Davidson 1975). Irrespective of whether a woman has been starved or not during labour, anaesthetic precautions are necessary to reduce the risk of gastric content aspiration. These include reducing unnecessary operative interventions; using regional rather than general anaesthesia; and using rapid sequence induction with airway protection for general anaesthesia (Am Soc Anesth 1999). With modern techniques, particularly the use of regional analgesia, the risk of gastric content aspiration has become extremely small (McKay 1988).

Fluid and nutrient needs during labour are not well studied. Glucose metabolism and need are accelerated during pregnancy and labour. Many believe that elevated levels of ketone bodies, which accumulate during exercise or starvation (Williamson 1971), is a physiological response with little clinical significance. However, associations between ketone levels and longer labours and maternal psychological stress have been reported (Chang 1993; Foulkes 1985). It is difficult to determine whether ketone production contributes to the longer labour or whether it is a consequence. The presence of ketonuria should be considered a signal for metabolic imbalance, though the effect of the imbalance is not known (Johnson 1991).

Intravenous therapy instead of oral hydration is common practice during labour. Historically, practitioners administered high dose glucose solutions to combat the development of ketones (Ketteringham 1939). More commonly now, intravenous fluids are isotonic or low dose glucose as high dose glucose solutions are associated with increased incidence of neonatal hypoglycemia (low blood sugar levels) (Mendiola 1982; Grylack 1984). Dextrose only solutions cause a fall in serum osmolality and sodium concentration (hyponatraemia) (Begum 1999). Regardless of solution type, intravenous therapy predisposes women to immobilization, stress, increased risk of fluid overload, and does not ensure a nutrient and fluid balance for the demands of labour (Simkin 1986a; Simkin 1986b). The value and safety of routine intravenous fluid therapy has been questioned (Begum 1999).

Despite these risks, and lack of evidence of benefit, routine restriction of foods and fluids in labour has persisted. This policy is not reflective of women's preferences or cultural expectations (Broach 1988a; Broach 1988b). This systematic review may assist in resolving the clinical uncertainty, which is currently apparent.

Article citation:
O’Sullivan G, Liu B, Hart D, et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. Br Med J 2009; 338:b784.

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Belly shot: 34 weeks pregnant

34.4 weeks from LMP. I changed shirts in part because I wanted to compare this with pictures from my last pregnancy.
For kicks, here's a picture of me at 35 weeks from LMP with Zari (33 weeks gestation):
Yeah, quite the difference--and I still weigh less this time around! Blame it on my (lack of) transverse abdominals, eh?

I started cleaning out our upstairs room, where I plan on having the baby. It's a large bedroom with a small full bath attached. It's really quiet up there and feels totally separate from the rest of the house, almost like I'm up in a nest or a treehouse, so I think it will be perfect for getting away from everyone & everything else during labor. I blew up my La Bassine birth pool and cleaned it out. I'm going to give it a trial run soon. My pond/fountain pump just arrived, which will make emptying the pool a breeze. Pictures coming soon once the room is organized.

We did a fun project yesterday: making a sandbox. I scavenged the 4x4s from a nearby abandoned lot where a house had been torn down a few months ago. The play sand (250 lbs) and screws cost $18 total. I still need to make a cover to keep the neighborhood cats out. Zari was thrilled.

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A L&D nurse's fantasy land

A L&D nurse's blog that I follow, 10 centimeters and beyond, has an excellent post called Nurse Fantasy Land. I'm taking the liberty of reposting it here (and I hope you don't mind--please let me if you do!).

In a perfect world, we would never be short-staffed. There would always be enough nurses so that you could do one-on-one labor support for each mom, and you had plenty of time for teaching. Gone are the days of juggling 3 labor patients. Charting would be minimal, as each nurse is equipped with a device that electronically (magically) charts every intervention that is done/heart tones/etc as it is being done, automatically. No more staying after your shift for an hour, looking at strips and charting - it's already done as you go! (Man, wouldn't that be wonderful!). Decisions about how patient care would be carried out would be made by people who actually are at the bedside...not people who haven't done patient care for decades, or ever. There would always be working equipment that was easy to use. Patient scanning devices for medications/labs/etc., would be user friendly. Call lights would become unnecessary because you would have plenty of time to care for your patient and so you are able to anticipate her needs. All members of the healthcare team: Nurses, Techs, Doctors, etc., would all treat each other with respect that everyone deserves. Communication would be exceptional. No one would ever feel left out of the loop or show up at work and find that something has changed without warning. Leadership would actually listen to the staff, value their opinions and run the unit/hospital/etc well. In OB, there would not be elective inductions - those patients would go into labor on their own and progress as nature intended. No continuous monitoring for healthy mama's, and in those who need continuous monitoring, there is an abdominal girdle that picks up baby constantly, regardless of movement and position. So, no need for internal fetal monitors. There would always be an OB and anesthesiologist in house for those emergencies (I know some hospitals have this, but mine does not). C-sections would only be done if there really was a need and VBAC's would be the norm instead of repeat c-sections. Medical inductions would be successful and episiotomies would be a thing of the past. Every breastfed baby would come out of the womb and latch right on. Aaaahhh, a nurse can dream, can't she!?

Interestingly, implementing the Baby-Friendly and Mother-Friendly childbirth initiatives, along with Lamaze's recommendations for six practices that promote normal birth, would bring hospitals close to many of these ideals.

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Heating a birth pool

A common question among women planning to use a birth pool in labor is how to heat enough water to fill the pool reasonably quickly, and then maintain the water temperature once the pool is full. Most of us here in North America have 30-50 gallon tank water heaters, rather than the tankless gas heaters that much of Europe uses, so we run out of hot water before the pool is full. This is especially challenging if you're using an inflatable pool, rather than one that comes with a built-in heater.

Rather than boiling pots of water on the stove and then hauling them to the birth pool, I have come up with another solution that is portable, fast, and relatively inexpensive. You will need a 5-gallon bucket (plastic or metal), an electric outlet (preferably close to your birth pool), and a bucket heater (the kind used to heat water for livestock tanks). You can find these at a vet/livestock supply store.


These heaters are quick and powerful; they will bring the water to a boil if left in the bucket long enough. This definitely beats boiling water on the stove in relatively small pots and then hauling it to the birth room. Instead, you just put your bucket & bucket heater right near the birth pool, plug it in, and you're good to go!

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Well I'll be darned

I just got back from a chiropractor's appointment, followed by a visit with my midwife. We chatted the first hour about the upcoming birth, preparing for labor, giving birth to breech babies, etc. She bought some moxibustion sticks, so we planned on doing that at the end of the visit. We then went to palpate, measure my belly, listen to heart tones with a fetoscope, etc. The midwife's assistant palpated first and thought the baby was breech, perhaps kneeling, facing mostly posterior with its back on my right side. The midwife felt around next, closing her eyes as she moved her fingers and hands around my belly.

"This baby is direct OP. Feel that part down in your pelvis and travel upwards."

I did so, my fingers outlining the part that I had always thought was the butt.

"That is definitely a head," she said.

"But it feels too lumpy to be a head," I said.

"There's an arm or elbow in front of the head, but that's definitely a head. I can ballot it back and forth. And there is not a head anywhere in the top of your fundus."

This is what this baby is up to right now, except it also has an arm in front of its face (illustration comes from Spinning Babies' section on fetal and maternal anatomy). Even when the baby was breech, it was almost always posterior, so I've been feeling movement primarily along the front of my belly, from the pubic bone to the top of the fundus, for the past several months.

The assistant said something about this teaching her not to rely on her assumptions about the baby's position when she is palpating.

The funny thing is, we're still finding heart tones right about the same place as usual--about 2" below my belly button (which is entirely possible for both a vertex baby or a very well engaged frank breech).

Huh. So this baby has found the exit sign and turned around after all. I would never in a million years have guessed it had flipped to vertex. It feels just the same as it has all along. I never noticed any drastic heaving or lurching sensation when the baby flipped around. And I am officially abandoning all faith in my palpation skills!

It's funny--I was becoming so resigned to the idea that this baby was breech that now I find myself a bit at a loss for what to do next!

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Guest Post: Learning to Breastfeed

I asked my good friend, Nutrition Momma, to write a post about Learning to Breastfeed. Her baby is a few weeks old, and she has already faced and overcome some breastfeeding challenges. I've taken the liberty of reposting her thoughts here.

As I said earlier breastfeeding did not come super easy for me or Princess. In fact after the first two days home both of my nipples were covered in blisters. I cried every time I tried to nurse, and the baby was also frustrated. The midwife had shown me a good latch at the birthing center on Friday. Monday I had a lactation specialist over for about 30 minutes that also showed me a good latch, but both of these women basically just latched the baby on for me and said "See that's how it works,"and then they were on their way. (I do not blame them for being busy or for not being able to stay longer.) It seemed so easy when they did it. I thought for sure I would be able to figure it out. But once they were gone it seemed that I could not figure out the right position and my nipples at this point hurt no matter what so I couldn't tell if it was a good latch or not.

On Tuesday after she was born my milk had come in, I still was not feeding her well, and I was at my wits end. I decided to call a fellow La Leche League member (as I mentioned in an earlier post) On her blog she is Top Hat. She discusses all about attachment parenting, breastfeeding, and unassisted birth if you are interested. She is really an amazing person. Anyway, when I called I was almost in tears yet again and she offered to come over immediately. She came with her daughter and stayed from 11 am-3pm. She even brought me some lunch. The most important thing she did was stay and observe me while I tried to latch the baby on. She was here for multiple feedings and reminded me of certain keys things each time I began to feed my baby. She did not do it for me. These are a few of the things I learned while she was here.

1. Be patient and relax. I was so anxious and frustrated that I was not being patient and watching for Princess to open her mouth wide enough for a good latch. She told me that sometimes when she was trying to latch her daughter on at first it would take 45 minutes. This realization that I did not need to be in a hurry, nor was my daughter going to starve if we waited for the best latch.

2. Position of the body is everything!! I thought I was belly to belly, but actually part of Princess's body was turned wrong sometimes, or as I tried to latch her on she would squirm and then be out of alignment. In both the cross cradle hold and side football hold your babies whole front of her body (think belly to chin) is supposed to be flush with your body (mom's stomach for cross cradle, mom's side for football hold - the baby's knees/legs curl around your back). I needed to learn to look at the alignment of both me and the baby each time I prepared to latch her on. This made it easier to bring her body to my breast, instead of me trying to put my breast into her mouth. It was interesting that if Princess was aligned correctly if the latch was incorrect she would automatically fall off the breast. This made it so I didn't have to unlatch her over and over, she did it herself because it didn't feel right.

3. The position of the babies mouth on the breast is different depending on the hold. The baby will take in a different part of the areola depending on what hold you are using. As she sucks on each of these different parts, different milk ducts are being emptied. I had not realized this. For some reason from the books I had read and things I had learned I thought the baby's mouth had to have the bottom of the areola in it all the time. The bottom of the areola only goes in the mouth if you are doing a front football hold or a lap sitting hold. I was trying to do it with a cross cradle hold. Once I realized that you go up and over the nipple helping the baby take in part of the areola closest to her bottom lip, while you make sure the lip is down. Made the whole thing make more sense. It is important to nurse in different positions so that you drain all the ducts and don't get plugged ducts or mastitis (or you can do massage while nursing if one hold is easiest for you and make sure you empty the milk from the different parts of your breast)

4. The less complicated you make it the better. At first I was using a bunch of pillows plus the boppy to try and get the position perfect. I actually kind of figured this out after Top Hat left. You can't take all of these things with you, and after the first two weeks you will probably usually be nursing in a lot of places where having 5 pillows and a boppy is inconvenient. I started really practicing having control of Princess's whole body and head as I held her. I started putting her on the breast with only my arms and hands as support. At first this was difficult, but after a day it actually seemed a lot easier than it was with all the pillows (this is for the cross cradle hold, I still need pillows for the football side lying hold to keep her mouth at breast level, I only do this one once or twice a day, usually at night.) I am happy to say that now at 3 1/2 weeks we can nurse quite well without any pillows, though at night it is nice to have something to rest my elbows on as she nurses and I fall back to sleep.

I hope that this has been helpful for someone. I don't pretend that I am great at explaining things, but I hope that you could follow and visualize what I was trying to say. I am so grateful to La Leche League and especially Top Hat. If you are trying to breastfeed and are frustrated get help before you give up!

Now that we have a good latch breastfeeding is much easier, but it is not perfect, Princess and I are currently dealing with possible thrush for both of us... I will ask my doctor to prescribe Doctor Newman's All Purpose Nipple Ointment on Monday and hopefully we will get it taken care of quickly. As my mother always says "Something to keep you humble." Even though breastfeeding is not simple, I really enjoy it. I feel very connected to my daughter and needed by her. I am also grateful that I don't have to pay for formula which at this time would have been a major strain on finances. I think that the way our bodies and all female mammals have been created to provide for our young is amazing. What a miracle and a blessing.

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Homely stuff

I'm getting a major case of nesting--not the hormonal type, just the mental kind in which I want to get everything done NOW because I know there's not that much time left. So we finally finished painting the dining room. While Eric was out of the country during spring break, I made an executive decision and picked paint colors. I knew if I waited until he got back, we'd never decide on something. I wanted to get the whole room done before he got back, but it took a lot longer than I expected. So late night we put on the final coat of red paint. The top is a warm champagne color with a Ralph Lauren topcoat called "Candlelight," which gives the walls shimmery, iridescent look when the light hits right, kind of like crushed velvet. You can see it a little bit on the first picture, although the camera doesn't pick it up very well.

Spring is finally here, and we've been spending a lot of time outside.
My neighbor gave me the tumbling composter that you see behind Zari. She noticed I was composting and said "Do you want ours? We don't use it any more." Yes please!

Goofing around

Recent thrift store finds: baby sweater for $2 (I couldn't pass up on the giraffe)
A vintage embroidered luncheon set (4 place mats and 4 napkins) that just screams 1960s. Still in the original box and wrapping. It was a bit of a splurge at $20 but I couldn't resist. The picture is a bit washed out, but it's cream linen with robin's egg blue embroidery.

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The Case Against Breastfeeding

Hanna Rosin's recent article in The Atlantic, The Case Against Breastfeeding, has drawn a lot of attention, comments, and criticism. Read the original article, then visit the following sites for a host of responses to her article:

• Mom's Tinfoil Hat argued that breastfeeding shouldn't be framed as a benefit, but as the biological norm for feeding babies.
• Alas, A Blog talks about Bottles, Breasts, and Mothering "Choices"
• As the Citizens for Midwifery blog noted, both the Academy of Breastfeeding Medicine and the AAP (American Association of Pediatricians) have issued responses to Rosin's article.
• US Food Policy has an in-depth critique of the Rosin article
• Adventures in (Crunchy) Parenting feels that Rosin is a bit to focused on herself
• Mama-Is's cartoon, Unbelievable Hypocrisy!, is probably the first of many on this topic.
  

Have you come across any other interesting commentary on this article?

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Dr. Fred Duhart, St. Louis home birth physician

I just saw that Dr. Fred Duhart, a family physician in St. Louis who attended home births for 38 years, recently passed away. Read more about his life and career catching babies here.

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Hospital tour #2

I just got home from touring another hospital in my area that is about 30 minutes away. Like my home town C., the town of L. is the county seat and has a population of around 15,000. The hospital is fairly new--perhaps 6 years old. The Maternity Center in L. has four LDRP rooms, two with jacuzzi tubs and two with large showers. It sees about 400 births per year. There are four OBs who attend births at this hospital. They usually attend their own patients' births, although they do rotate call after-hours so there is a small chance you might not get the OB you have been seeing during pregnancy.

The hospital has a lower than average cesarean rate; in was 21% in 2008 (compared to the 2007 national rate of 31.8%). The hospital has 24-hour anesthesia and offers VBAC (vaginal birth after cesarean). I forgot to ask the nurses how many VBACs they see per year, but they sounded quite supportive of them. They couldn't think of any special policies or requirements for VBAC labors, but instead said they would be treated like any other labor.

Standard admittance procedures are a 20 minute monitoring strip and, once they've made sure the woman is in active labor, a saline lock (done in conjunction with the standard blood draws). They say the physicians usually don't require actual IVs, so women just have saline locks unless there's a specific indication for an IV drip, such as antibiotics for GBS+, Pitocin, epidural, etc. I asked about how hard it would be to refuse the saline lock, and they said they'd advise you why they suggest a saline lock and then give you a form to sign saying you declined the procedure. So it seems that if you have a strong preference about not having a saline lock in place--I've had one before for a non-birth-related issue and it HURT constantly--you can assert your wishes and simply sign any necessary paperwork.

The official policy for eating and drinking in labor is ice chips or sips of water only, but the nurses all emphasized that it is your body and your choice. They would simply document that they explained why they suggest not eating or drinking. Then it's up to you if you want to eat or drink. One of the nurses, when we were chatting about this and other topics, said, "I remind people in my childbirth education classes that you don't check your rights as an individual when you walk in the hospital door." There is a small kitchenette stocked with food and drinks by the nurse's station: milk, juice, pop, yogurt, cereal bars, etc. The nurses said that if you wanted healthier choices, be sure to bring your own snacks and drinks with you.

I asked about how common inductions and epidurals were. The nurses replied that they do see a lot of both, but they are definitely not pushed on the women. Instead, a lot of women insist on being induced or on having anesthesia. It's not the physicians pushing induction or the nurses pushing medications. They didn't give me any hard numbers, but I got the sense that the epidural and induction rates were probably lower than in the hospital in C. The nurses talked for a while about how inductions and epidurals are so common everywhere now and how they're most often patient-led. I got the feeling that they liked working with women who want unmedicated births and spontaneous labors.

If a woman doesn't have an epidural or Pitocin running, they encourage her to walk around, to have intermittent monitoring, and to use the jacuzzi tubs. They usually do intermittent monitoring via a strip every hour (usually 15-20 minutes I think) but if you want intermittent auscultation rather than going on the monitors periodically, you can request that. They do not have wireless monitoring (telemetry); I encouraged them to get a wireless & waterproof unit so women could get closer monitoring if needed, but still be completely mobile and even in the shower or tub.

I wasn't able to take pictures of the rooms due to security reasons (which I've never heard of before), but they were fairly typical for a new hospital. The labor room has a delivery bed, rocking chair, couch, baby warmer, monitor table, wooden cupboards, and handwashing sink for the staff. The bathrooms are a good size with either a jacuzzi tub or a large shower. They have Hill-Rom beds, which are a lot more adaptable than the Sryker beds at C. Hospital in my town. The nurses mentioned using the squat bars, and I saw birth balls in some of the rooms. The jacuzzi tubs are large corner units, roomier than the ones in C. Hospital. There's also a showerhead in the tubs if you'd like to take a shower. The two rooms with showers only at least have large showers, probably 5x3 feet. There's a shower chair in there, so you can sit down and rest while you're showering. All rooms, of course, have private bathrooms--pretty much standard in modern maternity wings.

Of the four OBs, Bob and Ted were recommended as being more used to women birthing in less conventional upright positions than the two newer physicians Sara and Joseph, who are more accustomed to the semi-sitting position for giving birth (aka the "stranded beetle" position). Bob and Ted did their OB training in a hospital that had a lot of midwives, so they are used to more flexible, less conventional care of laboring women. However, the nurses said to be clear about your preferences with your physician, and they will all work with you to honor your preferences.

The Maternity Center in L. is currently working on becoming Baby-Friendly certified. They don't have a well-baby nursery, so babies always stay with their mothers. I asked about what happens immediately after the birth. Unlike C. Hospital, where babies go immediately to the nursery for weighing and measuring and where they have a 3-4 hour stay in the nursery a few hours after the birth, the Maternity Center keeps the babies right with the moms the whole time. They ask the mother what she would prefer--baby skin-to-skin on her chest, baby on a towel on her chest, or baby cleaned off a bit in the warmer and then put on her chest--and they follow the mother's wishes. There is a small room with two warmers and one incubator for special cases where the baby is having medical issues and needs constant monitoring, but otherwise there is no mother-baby separation (except briefly towards the end of the stay for the newborn metabolic screening, etc). They said their breastfeeding rates have gone up quite a bit recently, probably due to the baby-friendly practices that they follow.

Like C. hospital, the Maternity Center in L. does not have a NICU. If the baby is severely ill, it would be transferred to a larger tertiary care center about 1/2 hour away. Both hospitals refer out high-risk cases to larger medical centers, so if you went into labor before 35 weeks, for example, you probably wouldn't be able to give birth at either C. hospital or L. Maternity Center.

Things I forgot to ask:

• if there's a limit on how many people can be with the woman during labor & birth
• can you photograph or videotape the birth
• what is their typical and their fastest decision-to-incision time for a truly emergency cesarean
  
• what happens to the baby after a c-section (since they don't have a nursery, I'd guess that they baby would be with the mom ASAP in most cases)
• when standard newborn procedures are usually done (such as weighing and measuring, bathing, etc)
  

I would definitely choose the Maternity Center in L. over the hospital in C. as my backup hospital unless I needed immediate care. The 30-minute drive would be worth it for two main reasons: the hospital's lower cesarean rate and their Baby-Friendly policies. Not to mention their bigger tubs and, it seems, physicians who are a bit more used to working with "unconventional" birthing practices. For women planning a hospital birth, there is more continuity of care, since the physicians usually attend their own clients' births.

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Obama Organic Victory Garden

Can the Obamas get any cooler? I just learned that they're planting an organic vegetable garden on the White House grounds. Michelle Obama told Oprah's O Magazine:

We want to use it as a point of education, to talk about health and how delicious it is to eat fresh food, and how you can take that food and make it part of a healthy diet. You know, the tomato that’s from your garden tastes very different from one that isn’t. And peas - what is it like to eat peas in season? So we want the White House to be a place of education and awareness. And hopefully kids will be interested because there are kids living here.

To read more about their garden plans, visit Crunchy Domestic Goddess' post.

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2007 C-Section Rate Hits Record High

The 2007 U.S. cesarean rate has hit yet another record high: 31.8% of all births. The CDC has just released the preliminary birth data for 2007 (PDF download). From the report:

The preliminary cesarean delivery rate rose 2 percent in 2007, to 31.8 percent of all births, marking the 11th consecutive year of increase and another record high for the United States. This rate has climbed by more than 50 percent over the last decade (20.7 percent in 1996). Increases between 2006 and 2007 in the percentage of births delivered by cesarean were reported for most age groups (data not shown), and for the three largest race and Hispanic origin groups: non-Hispanic white (32.0 percent in 2007), non-Hispanic black (33.8 percent) and Hispanic (30.4 percent). The rise in the total cesarean delivery rate in recent years has been shown to result from higher rates of both first and repeat cesareans.

What are you going to do about it?

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International Breech Conference: Call for Speakers

International Breech Conference
Ottawa, Canada - October 15-16, 2009

Call for Speakers

The Coalition For Breech Birth is hosting the second International Breech Conference in Ottawa, Canada, continuing the important work that began at the first conference in March 2006.

The International Breech Conference seeks to draw on the expertise of birth professionals, while accessing the voices of women who have become keenly aware of the lack of skilled breech care providers, and the impact it has had on them and their reproductive health.

We are seeking speakers and session leaders who have experience with and/or have done research in the area of vaginal breech birth.

Please submit:

• The working title for your presentation(s)
• 150-300 word abstract of the paper/research you are presenting
• The anticipated format of your presentation (i.e. plenary presentation, breakout/workshop session, or both)
• A brief biography (60 words), relating to the conference content.

Please submit your proposal to conference@breechbirth.ca, not later than May 30, 2009.

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Currently reading

I love Interlibrary Loans. Right now I'm reading:

• Birth and Power: A Savage Inquiry Revisited by Wendy Savage
• The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia by Penny Simkin and Ruth S. Ancheta
• Square Foot Gardening by Mel Bartholomew
• Blessingways: A Guide to Mother-Centered Baby Showers--Celebrating Pregnancy, Birth, and Motherhood by Shari Maser
• Mother Blessings: Honoring Women Becoming Mothers by Anna Stewart
• Playhouses You Can Build: Indoor & Backyard Designs by David & Jeanie Stiles
• The Urban Homestead: Your Guide to Self-sufficient Living in the Heart of the City by Kelly Coyne & Erik Knutzen

I also requested the two books on breech birth that I reviewed a few months ago: Breech Birth by Benna Waites and Breech Birth Woman-Wise by Maggie Banks.

I'm quite enjoying Wendy Savage's 2007 book Birth and Power. Dr. Savage was an obstetrician and Senior Lecturer in Obstetrics and Gynaecology and Honorary Consultant at the London Hospital Medical College. After 25 years of practice, she was accused of incompetence by her obstetrical peers in 1985. (If you've read Benna Waites' Breech Birth, you'll remember that she was one of the physicians and midwives interviewed about vaginal breech birth.) She had a highly publicized trial and was acquitted of all charges a few months later. This spurred her to write a book in 1986 about her trial called A Savage Enquiry: Who Controls Childbirth?. She retired in 2000.

Birth and Power is an updated look at the issues she raised in her first book. It includes six sections focusing on birth and power, accountability, incompetence, disciplining doctors, academic freedom, and what women want. Each section is introduced by Savage, along with several chapters authored by midwives, physicians, and consumer advocates. Birth and Power also reprinted the original text of A Savage Enquiry.

Some of the chapters in Birth and Power are heavily focused on details specific to the UK obstetrical and medical systems, so I skimmed when they became too dense or unfamiliar. I thoroughly enjoyed reading A Savage Enquiry, which outlines Wendy Savage's path to becoming an obstetrician, how she gradually became more woman-centered in her care, and the five infamous cases her obstetrician colleagues used to assert that she was medically incompetent.

A few quotes from Dr. Wendy Savage:

From the section "What Women Want" p. 171

From my own experience of caring for pregnant women I believe that the majority of women want a normal birth cared for by people they know and trust. They need peace and quiet in order to concentrate on the instinctive nature of giving birth. If one looks at animal behaviour, cats and dogs tend to go into a quiet dark place to give birth, and cows and sheep may stop labouring if moved. We are mammals, and it seems likely that we instinctively want to behave in the same way. It therefore seems plausible that the underlying reason for the increase in intervention in hospital practice is that we have set up a system which is antipathetic to the needs of women, for peace, quietness and privacy.

The modern British labour ward, where women hear the sounds of other women giving birth and of telephones and bleeps going off, and where the lighting is usually harsh fluorescent strips, could almost be designed to interfere with the natural process of labour. Add to these the frequent interruptions by midwives coming to "get the keys" to the drug cupboard (often without knocking on the door), changes of midwifery staff, the doctor's round when five or six people enter the woman's room and discuss her "case," and it is hardly surprising that in some hospitals almost half the women require labour to be strengthened by a synthetic version of oxytocin, the natural hormone with makes the uterus contract.

From the introduction to A Savage Enquiry p. 217

Pregnancy is not an illness. I belong to the school of thought which believes that every pregnancy is normal unless there are indications that something is wrong. Those at the opposite end of the obstetric spectrum believe that no pregnancy is normal, except in retrospect. This attitude, together with the labelling of women as high risk on the basis of statistical, rather than individual information, leads to a situation where too many women are forced to attend hospital clinics, rather than having the more personal care of the midwife or a general practitioner closer to home. I feel that as the risks in childbirth become smaller, statistical methods of predicting (on the basis of her age, number of children or income) which woman will lose her baby have limited use. In my view, if you look at each woman as an individual, and plan her care with her, you will get the best result.

And one from Dr. Marsden Wagner's essay "Birth and Power" in Savage's book (p. 40):

Half of informed choice is information: the information provided to pregnant and birthing women has been most inadequate and always very carefully monitored by doctors. I've often heard doctors say that we must not "scare" pregnant women, as an excuse for not sharing information. If sharing the information does elicit concern or fear in women then, rather than withholding this information, doctors must be prepared to work with women to cope with this anxiety--as well as their own. Sharing information also means sharing power.

The other half of informed choice, of course, is choice. To give women choice is to give up power on two levels. Firstly, the doctor loses control over what happens with that particular woman. Secondly, the doctor implicitly acknowledges that the woman also has valid information and should control her own body and life. Such an acknowledgement by the doctors would shift the ultimate power from the doctor to the woman. Rather than choice, the literature today is filled with discussions on patient compliance. To comply means to obey and is the opposite of choice.

The results of the power of doctors over birth might well be summarised by saying that the doctor has written the obstetrical drama so that he is the star, rather than the woman.

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Belly shot: 33 weeks pregnant

33.2 weeks from LMP. Fundal height at 34.5 cms, all vitals are normal. I'm not too uncomfortable except when I'm trying to sleep at night--but that's normal at this stage.


Physically I feel good. But emotionally--another story. It seems that this pregnancy has been a long, hard episode of constant anxiety and fear, punctuated by occasional moments of calm and peace. I worry worry worry all the time: will this baby make it? will I end up with a c-section? Those two are the Big Ones for me. I am absolutely positively terrified of having a c-section. I know it's not really a big deal for some women but it's basically my personal worst nightmare. I'm tired of this fruitless worry and constant fretting but haven't quite figure out how to shake it for good.

I have to admit that the baby's position plays into my current fears right now. The baby is still happily head-up with its butt firmly wedged in my pelvis. I find it so hard to mentally or emotionally prepare for the birth because I don't know how or what to visualize. I don't know who will be there or where I will be, necessarily. I don't know what it will feel like if a butt is coming out, rather than a head. I just want to be able to settle in and enjoy the anticipation during these last weeks and get ready for the baby, not to have so many unanswered questions--all due to the possibility of a breech presentation.

Anyway, here's my plan of action over the next few weeks:

• From now until 36 weeks, see a chiropractor who does the Webster technique (I've already seen her once) and do some gentle things to help baby turn around: pelvic rocks, knee/chest or breech tilts (although I can only hold these for a few minutes at most--don't know how some people can do them for 15-20 minutes!), and perhaps swimming or handstands in the water. And things like prayer and visualization, etc.
  
• After my home visit and Mother Blessing at 36 1/2 weeks, if the baby is still butt-down, schedule an external version for the following Monday. There's a physician who is very skilled at doing versions about an hour away; she has done a few for my midwife's other clients.
• If the version doesn't work, start planning for a hands-off vaginal breech birth, ideally at home. I would probably need to find another breech-experienced midwife to be present. Breech births are within my midwife's legal scope of practice, and she has attended quite a few during her training (mostly at home, I think). However, she doesn't feel she has enough experience as a primary midwife to do it on her own. So I guess we'd have to start calling around to find someone close enough to travel in when I go into labor, or bring someone in to stay for a few weeks if there's no one within about 4-5 hours from me.
  
• Traveling to The Farm is another possibility, but as I've mentioned earlier, it's 8 hours away so I'd have to go there before labor began and wait. I don't know if Eric would be able to come along and I really would not want to have the baby completely by myself (as in, even though I like laboring in private, I don't want Eric to be 8 hours away!). I'd also rather not have to leave home to have the baby. Or take care of Zari by myself for several weeks. Etc.
  
• See how things go the day labor begins. Really, the biggest deciding factor for me will be asking Eric for a blessing once labor has started. If he feels inspired to say that all will go well, we'll go ahead with my plans. However, if the blessing indicates that I need to change my plans--whether that means having a vaginal breech birth in a hospital or even going in for a surgical delivery--I'll accept that change of plans. Probably with a lot of tears and a good amount of trepidation, but hopefully with the courage to do what is best. And of course there are a few situations that would indicate the need for a transfer: a stargazing breech baby is a pretty much universal indicator for surgical delivery of breech babies, as well as a slow, long, difficult labor.

Now of course I really hope that this baby finds a way to turn, whether by itself or with help during an external version! I'm trying not to be overly aggressive about doing too much stuff in the meantime. How do I find the balance between helping the baby flip around and just letting things be, since there may or may not be an underlying reason for the baby's positioning?

I've never had such an emotionally challenging experience before. It's like a heavy weight has been around me much of this pregnancy. I want to be able to feel excitement about becoming a mother and having a newborn again but it's all been dwarfed by this ever-present sense of fear and dread. I don't feel that it's some kind of intuitive foreknowledge that something bad is going to happen. It's just plain old fear and worry, the non-productive kind that gets you nowhere.

Now I feel like I'm whining a bit too much...so here's a picture of Zari from this morning. How is so much cuteness possible?

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Natire Enchantee: vocalization during birth

Thanks to Pamela for bringing this lovely birth video, Naitre Enchantée, to my attention. It's a recent birth of a French woman named Magali Dieux--a home birth most likely, since I see a cat wandering around at the bottom of the screen. I love the reverent atmosphere that never breaks even after the baby is born. (I could do without the multi-lingual voiceovers, though). I wish there were more background information about the birth. I have done a quick and somewhat rough translation of the two commentaries supplied with the movie. If anyone has a better translation, please send it my way!

A method of gentle birthing by using sound and vocalization

“To me, utilizing the power of sound and vocalization are indispensable for easing pain and for enhancing the progression of labor during a birth. Magali Dieux shows us how birth can unfold in the best possible conditions." Corinne Adler, midwife.

“At a time when, in France, 90% of births are anesthetized and totally controlled by medicine, Magali is one of the pioneers of the future of birth—one who reveals the formidable powers hidden within each of us as human beings. Powers that can be tapped, if you desire them and work to access them.” Patrice van Eersel, Mettre au monde éd Albin Michel Essai Clé.

You can watch the video here.

I also appreciated Pamela's commentary about not wanting to make women feel bad if they don't birth quite as "calmly" as this woman. She wrote:

Sometimes I hesitate to post birth videos that are so romantic and calm and quiet and what we all deem to be “perfect with the woman in control”; simply because few women actually birth this way and it creates a feeling sometimes of “why can’t I birth like that? there must be something wrong with me!”. However, I wanted to post this birth video for the simple fact that the midwife in attendance is so respectful of this couple’s privacy, their need for quiet and calm, and a gentle entrance for their baby.

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Solace for Mothers

We are pleased to announce the Solace for Mothers Friends and Advocates Online Community which provides a forum for those who support mothers who have experienced birth trauma, have been impacted by witnessing birth trauma, or want to connect with others to advocate for gentler birth practices.

Solace for Mothers is committed to providing resources and support to professionals and loved ones supporting women through the difficult emotions following a disappointing, hurtful, or violating birth experience. Spouses, family, and friends of mothers who have experienced traumatic births are offered a space to find information, support, and resources through participation in the Friends and Advocates Forum. Birth attendants are also provided with the opportunity to process their own emotions in response to births they have attended. Birth professionals and birth advocates are provided a space to discuss the causes of birth trauma, how policies and programs can be enacted to prevent trauma from occurring to childbearing mothers, and methods of treatment when trauma has occurred.

The Solace for Mothers Friends and Advocates Online Community welcomes birth activists, mothers, families, and professionals, all of whom are stakeholders in providing healthy, safe, and empowering births that enable families to successfully transition to parenthood. Users of the online community are invited to contemplate and discuss the current state of birth and what evidence based practices best support childbearing women, their babies and families. Advocates who are interested in becoming involved in organized efforts to promote these practices are encouraged to participate and share their thoughts.

The Friends and Advocates Online Community can be entered from www.solaceformothers.org/advocates-forum.html. The forum is made public for browsing and registration is required to post and respond to topics. To view the online community, go to: http://forums.solaceformothers.org/mb/birthtrauma.

Mothers are welcome to participate in the Friends and Advocates role but they are invited to register and participate in the Online Community for Healing Birth Trauma, which provides peer support to women who have had traumatic childbearing experiences. Birth professionals, family members, and friends please respect the privacy of the Community for Healing Birth Trauma and register only for the Friends and Advocates Community.

If you have something to say regarding childbirth and want to be a part of a larger conversation, please join us. We are interested to read your stories, thoughts, hopes and goals for the future! Please also feel free to pass this invitation on to organizations and individuals who would be interested in the topics of birth trauma and improving maternity care.

Warmly,
Sharon Storton, Founder of Solace for Mothers, Inc.
Jenne Alderks, Creator and Moderator of Online Communities
Jennifer Zimmerman, Creator and Moderator of Online Communities

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Belly shot: 32 weeks pregnant

32.4 weeks from LMP. Fundal height is 32.5 cms. I've gained another 2-3 lbs since last week, which is good. I've seen a jump in weight gain over the last 4-6 weeks, which I hope reflects an expanded blood volume in addition, of course, to a growing baby.

The last few belly pictures have been self-portraits with my camera's timer function. Eric is in Canada this week at a conference and was able to go skiing at Banff on Monday. Lucky him!

Zari helped pose when I was setting up the camera.

Snuggling with her snake and dragon

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Cesarean morbidity

I just received this from Gretchen Humphries, Advocacy Director of ICAN (International Cesarean Awareness Network). Please participate if you are able.

I have been contacted by a reporter who is doing a story on maternal mortality. He would like to speak with women who suffered a serious or life-threatening complication related to a cesarean surgery. If you or someone you know experienced such a complication (it doesn't have to be related to malpractice, a mistake, nor does the cesarean have to be either necessary or unnecessary) and you would be willing to speak to a reporter, please contact me as soon as possible. Please feel free to distribute this request to other email lists or forums.

Gretchen Humphries
Advocacy Director, ICAN
advocacy@ican-online.org

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Conversation with the ultrasound tech

I had a very interesting conversation with the ultrasound tech during yesterday's scan to rule out DVT. She asked, probably to make small talk, if I had already had my pregnancy ultrasound. I said, "I'm not having an ultrasound unless there's a specific indication." We moved on to other topics, such as whether or not I work. (I'm never entirely sure how to answer this; I usually end up saying "I just finished my PhD.") I told her that I was in American Studies and that I focused on childbirth and maternity care.

After the exam was done, she turned to me and asked why I wasn't having an ultrasound. I briefly explained that, based on the medical evidence, I had decided not to have a routine ultrasound. I mentioned several RCTs comparing routine versus medically indicated prenatal ultrasounds; they concluded that routine ultrasounds for low-risk pregnancies brought no significant improvements in neonatal outcomes. (For example, one meta-analysis of several RCTs concluded that "There is no evidence from RCTs of routine ultrasonography that it has any effect on the outcome of live births from low-risk pregnancies. Until there is further information from RCTs about possible subtle effects of ultrasonic scanning, exposure of fetuses to ultrasound scans should be minimised by performing them only where the clinical benefits are established. More research is needed to follow-up children of mothers taking part in RCTs.")

She replied, "Well, you can look at RCTs all you want, but they don't really matter when you've seen what I've seen." She mentioned lots of rare and potentially fatal conditions that ultrasound scans can detect in women with totally healthy pregnancies. One of them was anencephaly--which is 100% fatal, so I am not sure how that would be reason to have an ultrasound. She said, "In this day and age I cannot imagine anyone not choosing to have an ultrasound." She also told me, "I cannot understand how someone as educated as you are would choose not to have an ultrasound."

She kept repeating these things to me; I could tell she was having a really hard time wrapping her mind around the fact that some women would choose not to use this technology. Her comment dismissing the research evidence about routine ultrasounds was particularly fascinating. In her case, no amount of evidence-based medicine would change her views; she had simply had too many first-hand anecdotal experiences to be able to accept the conclusions of the medical research.

I think that personal experience plays a tremendously influential role in those who work with pregnant and birthing women. It's partly our human tendency to remember the (numerically small) scary, unusual, and exceptional situations rather than the more common "normal" pregnancies and births. For example, you can cite literature about the safety of VBAC all you want, but some OBs will still insist that they are too dangerous and too risky, perhaps because they have witnessed first-hand the rare case of uterine rupture. It's fine to have personal opinions and even certain preferences based your first-hand experiences. However, it is highly problematic when a care giver allows their personal biases to overwhelm or even erase the medical evidence or to dictate what a pregnant woman can or cannot do. I would hope that every health care provider would be able to separate their personal experience and emotional preferences from both the medical evidence and the woman's autonomy in decision-making.

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