Amy Romano, a CNM who blogs at Lamaze's Science & Sensibility, has written a great response to two New Yorker articles by physician Atul Gawande. I've been wanting to discuss his articles, but haven't had the time to write up my thoughts. Mom's Tinfoil Hat, an OB-GYN-in-training, agrees that Romano's analysis is worth the read.
First, read his two articles, How Childbirth Went Industrial (2006) and The Cost Conundrum (2009), then read Romano's response: The Maternity Conundrum: One Thing Atul Gawande Doesn’t Get About Health Care Reform.
Breech: what to do next?
From Robin Guy, co-founder of the Coalition for Breech Birth:
Dear friends of CBB,
Well, here we are. Women's voices are finally getting heard -- the Society of Obstetricians and Gynaecologists of Canada has issued new breech guidelines that above all, advise that women need to be offered the choice of vaginal breech birth. What is the most important about these guidelines is not the nitty-gritty of candidate selection and techniques of delivery, but rather that they have tackled the ethical issue of forced surgery and come down firmly on the side of not obliging women to have surgery they neither want nor need.
Here is a link to the new guidelines and commentaries (please especially read Andrew Kotaska's commentary).
For those of you not in Canada, this is a great opportunity to approach your own organizations and present this example of progressive movement towards recognizing women's autonomy over their own bodies and ownership of their birthing.
So one battle is won, but the next is beginning. The guideline change will offer those doctors and midwives who were willing to catch, but afraid of professional censure or litigation, the excuse they need to start catching openly and helping to train their colleagues. The SOGC is also launching training initiatives that will help the care providers currently in school to gain these skills and graduate competent to include vaginal breech in their practice.
However, as always, the real change must come from us. The real change must come from women and their families expecting better care. Expecting to be offered unbiased informed choice discussions and for our choices to be respected and supported. Expect referrals to competent attendants when our own midwife or doctor legitimately doesn't have enough experience to safely catch our breech babies.
Please. Tell your friends what has happened. Shout it to the rafters. Watch for the International Breech Conference registration announcement (it will be October 15-16, in Ottawa), and do whatever you can do to be here.
Let's make some noise.
Blessings, Robin
Dear friends of CBB,Well, here we are. Women's voices are finally getting heard -- the Society of Obstetricians and Gynaecologists of Canada has issued new breech guidelines that above all, advise that women need to be offered the choice of vaginal breech birth. What is the most important about these guidelines is not the nitty-gritty of candidate selection and techniques of delivery, but rather that they have tackled the ethical issue of forced surgery and come down firmly on the side of not obliging women to have surgery they neither want nor need.
Here is a link to the new guidelines and commentaries (please especially read Andrew Kotaska's commentary).
For those of you not in Canada, this is a great opportunity to approach your own organizations and present this example of progressive movement towards recognizing women's autonomy over their own bodies and ownership of their birthing.
So one battle is won, but the next is beginning. The guideline change will offer those doctors and midwives who were willing to catch, but afraid of professional censure or litigation, the excuse they need to start catching openly and helping to train their colleagues. The SOGC is also launching training initiatives that will help the care providers currently in school to gain these skills and graduate competent to include vaginal breech in their practice.
However, as always, the real change must come from us. The real change must come from women and their families expecting better care. Expecting to be offered unbiased informed choice discussions and for our choices to be respected and supported. Expect referrals to competent attendants when our own midwife or doctor legitimately doesn't have enough experience to safely catch our breech babies.
Please. Tell your friends what has happened. Shout it to the rafters. Watch for the International Breech Conference registration announcement (it will be October 15-16, in Ottawa), and do whatever you can do to be here.
Let's make some noise.
Blessings, Robin
Saturday, June 27, 2009
2 months old!
Dio turned two months old yesterday. I'm still a bit stunned that I've already given birth and now all of a sudden I have a chubby 2-month-old. With a toddler to take care of as well, I haven't had time to just sit for hours on end, gazing into Dio's eyes and thinking about how cute my newborn is and how in love I am. It's more like jumping on a bullet train and you're gasping for breath and trying to take in the view before it disappears.
Dio's crankiness is getting better. He started smiling when he was 6 weeks old, and we're getting more grins out of him every day, although none on camera yet. We've discovered that he likes being held facing outward looking at things, rather than facing my chest. But the absolute best thing is setting him underneath a quaking aspen on a windy day. (And here in southern Alberta, most days are windy). He'll lie there contentedly, looking around, waving his arms and legs, for 20-30 minutes at a time. 
Eric, his dad, and his sister ran a 10K this morning. Maybe I'll be up for running that distance again in a few months, but not right now! I started running a bit this week and had to take it very easy, and it was more walking than running. Eric was disappointed because he ran it in 46 minutes--the longest he's ever run a 10K. I was rolling my eyes a bit because I think that's pretty impressive, especially for someone who's more of a sprinter than a distance runner.
Eric, his dad, and his sister ran a 10K this morning. Maybe I'll be up for running that distance again in a few months, but not right now! I started running a bit this week and had to take it very easy, and it was more walking than running. Eric was disappointed because he ran it in 46 minutes--the longest he's ever run a 10K. I was rolling my eyes a bit because I think that's pretty impressive, especially for someone who's more of a sprinter than a distance runner. 
Zari put on her grandma's zip-up jacket and wouldn't take it off for much of the day. 
Wednesday, June 24, 2009
Postpartum bodies
As shallow or trivial as it might sound, I need to admit something: I am feeling dumpy and frumpy in my postpartum body right now. For the first few weeks after giving birth, I feel incredibly attractive. Every day, especially during the first week, I look thinner and more shapely. My breasts get bigger, my stomach gets smaller, and when I see myself in the mirror each morning, I think, "Wow! I look good!"
I find newly postpartum bodies incredibly beautiful. Very feminine--or perhaps the better word is womanly. I love the empty, rounded belly; the soft bread-dough skin; the flush of hormones.
Then the swelling and the shrinking slow down and that's where the postpartum frumpiness sets in. It doesn't help when celebrities shrink back to their pre-pregnant bodies in record time. If you want to make yourself feel bad about your post-baby body, then definitely DON'T look at this 24-page slideshow of magical shrinking celebs! Last year, MSNBC reported on how Celebrity mamas fuel post-baby body blues:
Other mothers have recently shared their thoughts about their postpartum bodies: Jill at Keyboard Revolutionary talks about her cesarean scar bothering her years after her surgery. Housefairy talks about diets and how "this is me, and there is not one iota of room in this Mama for added stress of self hate." In another post, she mentions her post-cesarean (x3) body. And I'm still waiting for her to finish her post about 34 years of body image. (Hint hint!)
Thoughts? Comments? Any other good posts or articles about postpartum bodies you'd like to share?
I find newly postpartum bodies incredibly beautiful. Very feminine--or perhaps the better word is womanly. I love the empty, rounded belly; the soft bread-dough skin; the flush of hormones.
Then the swelling and the shrinking slow down and that's where the postpartum frumpiness sets in. It doesn't help when celebrities shrink back to their pre-pregnant bodies in record time. If you want to make yourself feel bad about your post-baby body, then definitely DON'T look at this 24-page slideshow of magical shrinking celebs! Last year, MSNBC reported on how Celebrity mamas fuel post-baby body blues:Perhaps the most painful part about the new celebumom standard is that it’s managed to infiltrate the last bastion of the female experience. Years ago, moms got a pass — even moms with movie deals. Now even motherhood — the great equalizer — has gotten a brutally hot makeover.In fact, the Institute for Quality and Efficiency in Health Care (IQEHC) recently advised that new mothers should take 6-12 months to gradually lose their pregnancy weight. An article discussing the IQEHC's recommendations reported:
Wilson says standards have become so distorted that a “normal” mom body is now viewed as “unattractive.”
“The tabloids and TV make it seem like it’s not normal that your body looks different after you’ve had a baby,” she says. “It’s like there’s something wrong with you physically — or you’re lazy — if you’re not able to get back to the exact same shape and size that you were prior to conceiving a child. And that’s impossible.”
Impossible, that is, if you don’t happen to have a personal trainer, personal chef, nutritionist, nanny, night nurse, and three or four full-time assistants.
“Celebs have 24-hour ‘round the clock care,” says Suzanne Schlosberg, mother to 13-month-old twin boys and co-author of The Active Woman’s Pregnancy Log: A Day-to-Day Diary and Guide to a Fit and Healthy Pregnancy. “They’ve got somebody to take care of baby while they do their workouts with their $250-an-hour trainer. They’ve got a fancy personal chef creating their perfect 200-calorie meals. It’s not an even playing field. They have all these advantages that real people don’t have.”
The IQEHC said celebrities who are back at their normal weight within weeks of giving birth are not necessarily a good example for other mothers.Nicole Kidman was back in her skinny jeans weeks after her daughter's birth last year, and model Heidi Klum was back on the catwalk shortly after giving birth. Unlike most new mothers, these women usually have a collection of nannies and housekeepers on call, leaving them extra time to work on their figures.
The institute said gaining weight in pregnancy is normal and necessary to support the unborn baby. Taking that weight off again should take some time.
“Having a new baby is a major change in lifestyle,” the IQEHC guidelines state.
“After childbirth, weight loss is complicated by the extra stresses the mother is facing, and her need to provide nutrition for her baby if she is breastfeeding. Women are exposed to many unrealistic images of female body size, and body size around pregnancy or after birth is no exception. That makes it difficult for many women to be satisfied with their figures, and it can damage their self-image and enjoyment of their body. You do not have to be movie star thin to be happy, healthy and have a healthy baby.” Read more here.
I know, I know. But it's still hard to not fit into some of my clothes, to have that extra thickness, and to feel frumpy in addition to being tired from taking care of a newborn and a toddler!
Other mothers have recently shared their thoughts about their postpartum bodies: Jill at Keyboard Revolutionary talks about her cesarean scar bothering her years after her surgery. Housefairy talks about diets and how "this is me, and there is not one iota of room in this Mama for added stress of self hate." In another post, she mentions her post-cesarean (x3) body. And I'm still waiting for her to finish her post about 34 years of body image. (Hint hint!)
Thoughts? Comments? Any other good posts or articles about postpartum bodies you'd like to share?
Tuesday, June 23, 2009
Review of Your Best Birth
After the release of their documentary The Business of Being Born in 2007, Ricki Lake and Abby Epstein wrote a book called Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience. I have written a lengthy summary, followed by my own brief commentary, of Your Best Birth.
Abby comments on learning how to surrender to what birth brings:
Chapter 1: Not Your Mama’s Birth Plan
The chapter begins with the story of Jennifer Jilani’s pregnancy and birth. An American living in the Netherlands, she was initially skeptical about using a midwife—something that all healthy Dutch women do—but came to enjoy the personalized, laid-back care. She had planned a hospital birth but, late in labor, decided to stay home (something that the Dutch system allows for; women don’t have to decide until the day of labor where they want to give birth). Ricki and Abby remind women that even in the US, a similar positive, empowered experience is possible if you do your homework and assemble the right people to be with you. It’s up to you to advocate for your best birth. One major step in that process is overcoming your fears, both external (ones from Hollywood depictions of birth or “horror” stories that women often tell each other) and internal (fears that you create in your own mind). They encourage you to approach fear as your friend; use it as a starting place for education and growth. Another major step is looking carefully about your attitude towards pain. They encourage their readers to think about it in a new way: not as something awful and terrifying, but as something that is healthy and that can help your body move and shift around just the right way. They include several useful excerpts, such as the top 10 non-narcotic pain relievers (from laboring in warm water to movement to vocalizing) and Penny Simkin’s Pain Medication Preference Scale.
Chapter 2: Your Best Birth Place
In this chapter, Ricki and Abby discuss the pros and cons of the four main choices of birth place: hospitals, hospital birth centers, freestanding birth centers, and home. This section contains great advice for how to ask the right questions when you’re taking the hospital tour. It’s not enough to ask things like “do you have showers or tubs for laboring in?” or “can I use different positions for laboring and birthing?” The answers to those types of questions will almost invariably be yes. However, whether or not those things actually happen once a laboring woman arrives is another story. (For example, during her first birth my sister-in-law was not even allowed to go into the shower because her water had broken and her doctors told her that it was too dangerous because of the risk of infection!) So you need to ask follow-up questions and sleuth around, so to speak, to see how often women actually are allowed to be in the shower or in the tub, or whether the nurse or physician will actually be okay with you squatting on the bed to push. They write, “As you walk around the hospital on the tour of the maternity ward or attend an orientation session at a birth center, you need to remember that this is a sales pitch. The people conducting the tour are going to show you all the pleasant features of their establishment….The style of rooms means far less than the attitudes and behaviors or providers. The hospital’s cesarean rate is a better indicator of these than its room décor. Hospitals can use style to co-opt substance.” They include a list of questions to ask on the hospital tour, ones that should reveal attitudes, routines, procedures, and practices common at that hospital.
The rest of the chapter overviews the pros and cons of the other three birth locations (hospital birth center, freestanding birth center, and home). It includes questions to ask for each location and information about water birth and helpful positions for labor & birth.
Section II: Putting Your Dream Team Together
Your birth team is key to having the kind of birth you want, even more than the location of birth. Choose your care provider carefully; when you decide on a particular physician or midwife, you’re essentially agreeing to his or her philosophy of intervention and pain management. The next two chapters overview the general differences in philosophy and management between obstetricians and midwives.
Chapter 3: Obstetricians: Finding Dr. Right
This chapter begins by discussion the pressures obstetricians face that limit the kind of care they are able to give. OBs have to keep a high volume of patients in order to pay for their (increasingly expensive) malpractice premiums. Many practice defensive medicine by actively managing labor and intervening sooner rather than later, in the hopes of avoiding a lawsuit. They comment:
Although this chapter mainly discusses obstetricians’ training and style of practice, it does include a brief section about family physicians, who usually practice with a more integrative style and tend to have lower intervention rates than their OB colleagues. Family physicians attend about 8% of all births in the US, similar to the percent of births attended by midwives.
Ricki and Abby advise women to use pregnancy as a time to stop being people pleasers. Don’t hesitate to “fire” your caregivers, even if it’s late in pregnancy, if they are not the right fit for you. One way to find out if your physician is “Dr. Right” is by asking the right questions—a list is included in the book.
Chapter 4: Midwives: Not Just for Hippies Anymore
Ricki and Abby begin by outlining the midwifery model of care (keeping in mind that midwives, like physicians, can vary dramatically in their practice style depending on where they were trained and their personal philosophy of care). In general, midwives view birth as a normal, healthy process that usually needs little or no intervention. They spend much more time with women than OBs do during both prenatal visits and during labor. They outline the various types of midwives available in the US, including primarily hospital-based CNMs and home-based CPMs. They also discuss the historical turf wars between physicians and midwives that still exist today in battles over midwifery licensure and autonomy. They also include lists of questions to ask when you’re interviewing midwives.
Chapter 5: Doulas: Labor’s Love
This chapter discusses what a doula is and how she can help the birth process through education, advocacy, and encouragement. You will learn what doulas do at a birth and how to pick the right one for you.
Chapter 6: The Guest List: Birth as a Private Party
Pregnancy and birth are opportunities to develop trust in yourself and deepen your knowledge of what you want and what is best for you—not a time to be “nice” or to do what other people tell you to. With that in mind, whom should you invite to be at your birth? Ricki and Abby feel that it should be “only people whom you trust completely, who approve of your birth plan, and who you don’t mind seeing you naked.” They comment: “that certainly shortens the list. Particularly the naked part….Birth is not a party, like a wedding, where you have to worry about offending those who were not invited.” Don’t worry about hurting people’s feelings when you’re in labor; you need to focus on clearly stating your needs and on feeling completely uninhibited with the people around you.
Chapter 7: For Sexual Abuse Survivors, a Healing
This chapter discusses the ramifications that labor & birth can have on sexual abuse survivors. For some survivors, labor can bring up old traumas. But it can also be a profound healing experience, as Ricki found. She was abused as a child and, after giving birth the second time, finally learned how to fully accept her body. She writes: “Then I totally looked at my body in amazement, like look what I’m capable of. It is amazing that we can carry children and give birth. After Owen was born, I started to lose weight easily. Well, it definitely didn’t fall off. I made a decision, but it was the easiest time I’d ever tried….I don’t know how to explain it other than it just felt like this purging of that pain and trauma from the past.” The chapter discusses how to help abuse survivors plan for their birth and how care providers can avoid bringing up past traumas.
This is a rambling, somewhat disorganized chapter about the birth process, different types of childbirth education classes (such as Bradley, Birthing From Within, Lamaze, and Hypnobirthing), and tips to help labor go more smoothly.
Chapter 14: Bonding with Baby
This chapter discusses the routine newborn procedures typical in hospital births and stresses that they can be delayed, leaving the first hour or two for breastfeeding and snuggling. Ricki and Abby discuss the astounding hormonal adjustments your body goes through as you give birth and begin breastfeeding and remark upon the newborn’s ability to crawl to the breast and self-attach (if the mother had an unmedicated labor). They mention the role of postpartum doulas and emphasize the importance of rooming-in and uninterrupted contact with your baby.
Your Best Birth is written in a chatty, conversational, informal tone—the kind of things that a good friend might tell you. Ricki and Abby speak favorably of natural birth and midwifery and other alternatives to conventional obstetrical care, but they do not present these choices as The Only Right Way To Give Birth. At times I found the writing style somewhat rambling and disorganized; the book could benefit from another round of editing and polishing.
I was glad to see an entire chapter devoted to birth after sexual abuse. It's something that isn't written about very often, but should be. With a large minority of women experiencing sexual abuse in this country, it's important to know how labor and birth might affect abuse survivors.
The weakest part of the book was the section on interventions—not because the information was incorrect, but because Ricki and Abby did not provide references to back up their claims. This book was not written as a reference text or guide to the medical literature, of course, but providing some information about their sources and giving suggestions for further research—the Cochrane Reviews or Lamaze’s Research Summaries, for example—would have greatly strengthened Section III.
I’ve been thinking about the core message of consumer empowerment in Your Best Birth: the idea that, as consumers, you have a right to demand options for your birth and to “vote with your pocketbook.” It’s a very individualistic message—it’s up to you to create the kind of birth you want. Sometimes I wonder whether it sets women up for failure, because it isn’t always so simple as asking for and then receiving the things you want. There are things like hospital culture, malpractice insurance regulations, and physicians’ fear of litigation that strongly limit the options available to women. Simply asking for change on an individual level might not be enough to overturn these deeply entrenched forces. On the other hand, individual advocacy on a massive enough scale translates into a powerful force for change. I’m thinking back to the days when husbands weren’t allowed in birth rooms. It was individual women and men demanding change, persistently, over and over, that gradually led to a dramatic reversal of policy. Nowadays, it’s expected that the woman’s husband or partner will be present at the birth—something that was fairly unthinkable just a few decades ago. In sum, I find Ricki and Abby’s message of consumer empowerment a pragmatic one. If you know you want a certain kind of birth—whether it’s at home or in a hospital, under water or on an operating table—you need to speak up and work hard to get what is right for you. It won’t happen by itself.
Summary
Foreword by Jacques Moritz, OB-GYN
Dr. Moritz, the obstetrician shown with Abby during her prenatal visit in The Business of Being Born, wrote an introduction to Your Best Birth. Instead of paraphrasing his comments, I will include some excerpts from his foreword:Foreword by Jacques Moritz, OB-GYN
On a recent, beautiful fall day in New York City, my family and I went for a walk around Gramercy Park. It was a walk we had taken a hundred times before, but this time, as we passed by a brownstone, we all noticed a National Parks Foundation sign that read “The Birth Place of Theodore Roosevelt.” My fourteen-year-old son asked if Theodore Roosevelt was actually born in this house or if it was just the place where he grew up. I thought it was a great question. Of course the year, 1858, meant that he was actually born in this house. My daughter’s response was “cool!” At that time, Mrs. Roosevelt didn’t have a choice. Giving birth at home was her only option.
A lot has changed in the 150 years since Mrs. Roosevelt delivered. If you were to walk into the coincidentally named Roosevelt Hospital’s labor and delivery floor, where I’m the director of the gynecology division, the first thing you would see is two sixty-inch plasma monitors displaying an array of data such as fetal heart rate, intrauterine pressure readings, blood pressure, pulse oximetry readings, and the list goes on. In front of these monitors would be a group of well-minded physicians and nurses that are all “managing” the laboring women. It reminds me of air traffic controllers at JFK trying to get a 747 on the ground in one piece. And patients love it. They say, “The care must be good—look at all that high-tech equipment they are using.” But is all this high tech a good thing? Have we now entered the day of “high-tech, low touch” deliveries? And if we have, what are the risks and benefits? These are all questions that expecting mothers should ask themselves. These questions and more are answered in Your Best Birth....
The state of obstetrics in America is in a crisis mode….Women must understand this crisis and how it will affect their birth options. Physicians and midwives are being squeezed between the dual constraints of rising malpractice premiums and increasing lawsuits. The record numbers of OB-GYNs who are voluntarily stopping obstetric practice and of midwives who are unable to find backup physicians or get malpractice insurance are signs of a major crisis. Even more importantly, there are increasing limitations imposed by insurance companies that introduce restrictions on how OBs can practice. In Oklahoma, for example, OBs are not covered by their malpractice provider for VBAC….Obstetrics training itself is questionable, in my opinion. In my four years of residency at Columbia University, the only natural childbirth I ever
saw was done by midwives.
The days of pregnant women interviewing their doctor (as seen in the film Knocked Up) may be a thing of the past. I know doctors who now interview patients to see if they will accept them in their practice, or “fire” patients if they have too many questions. The days of your health care provider’s being the person who attends your birth are also over….And this new trend goes one step further with the “laborist,” a physician who is now commonly hired by a hospital or large obstetrical group exclusively to deliver babies. Laborists often have twelve-hour shifts. You will never meet the laborist before you start labor and you won’t see the laborist again after delivery, and if your labor is a long one, you may have more than one laborist
taking care of you. Welcome to the new world of obstetrics.
Preface: Ricki and Abby: Our Best Births
In the preface, Ricki Lake and Abby Epstein tell the stories of their sons’ births: Ricki’s first birth began as an unmedicated birth in a hospital birth center and ended in the L&D unit with Pitocin and epidural. Her second birth took place at home with a CNM. Abby saw Dr. Moritz until 30 weeks into her pregnancy, when she changed to a home birth CNM. However, she went into premature labor at 35 weeks with a breech baby, which meant a transfer to the hospital and an unplanned cesarean section.
Ricki discusses how when she was pregnant, everything seemed beautiful:
Ricki discusses how when she was pregnant, everything seemed beautiful:
The birth center took up part of a floor of St. Lukes--Roosevelt Hospital in New York City. When Abby saw it later she thought the big birthing tub and the blocky, impersonal furniture made it feel like a cheesy hot tub suite in a slightly run-down Las Vegas hotel. The sheets on my bed at home had a much higher thread count. At the time, I thought it was beautiful. Right then, though, I thought everything was beautiful. Even my 210-pound ass was beautiful to me.
Abby comments on learning how to surrender to what birth brings:
Although the dash to the hospital and the emergency C-section were traumatic, I never felt Matteo [her son] and I were in any real danger or that my little birth team of Cara, Ricki, and Paulo couldn't handle the situation. In truth, I really did feel empowered. I had information and wasn't going to do anything unknowingly or be railroaded into a certain kind of birth. I surrendered to the birth Matteo needed, and I don’t feel disappointed. I think it’s almost impossible, in that moment when you have a new baby, to feel disappointed about anything. In some ways, it was a perfect entry into parenthood—these little people arrive and make their own path beyond your control. They start teaching you lessons before they are even born.
Introduction: Your Birth Is Your Business
Ricki and Abby emphasize that this book does not tell other women how they should birth their babies. Instead, their goal is to help women learn what the range of choices are and how to “decide what kind of birth is best for you….Your best birth is one where you feel empowered because you know all your options and are confident in the decisions you have made about the birth.” They believe that the goal of a healthy mother and baby isn’t incompatible with an optimal, empowering experience. The write, “we believe that you can place the health and well-being of your newborn as your highest priority and still have an optimal, empowering experience that is right for you both—whether that is in your bed, in your bathtub, in a hospital room, or on an operating table. All the choices are yours and we want to give you some information and encouragement to resist and question the current trend toward more medicalized births that are not appropriate for everybody.”
The main goal of Your Best Birth is to “demystify the natural options that [many] doctors didn’t present as viable and that would offer these options in a straightforward and comprehensive format that could educated and empower women….In this book we will be looking to a wide array of experts to educate you about the possibilities that generally don’t come up in discussions with doctors and in hospitals.”
The main goal of Your Best Birth is to “demystify the natural options that [many] doctors didn’t present as viable and that would offer these options in a straightforward and comprehensive format that could educated and empower women….In this book we will be looking to a wide array of experts to educate you about the possibilities that generally don’t come up in discussions with doctors and in hospitals.”
Section I: Know Your Options
In the introduction to this section, Ricki and Abby describe a “typical hospital birth” to educate women about procedures and practices that commonly occur in hospitals. After stressing that hospital practices can vary widely, they overview common hospital practices that many laboring women will encounter: when you’re advised to come to the hospital, what happens in triage before you’re admitted, consent forms, meeting with the anesthesiologist, epidurals, Pitocin, artificial rupture of the membranes, episiotomy, and standard newborn procedures.Chapter 1: Not Your Mama’s Birth Plan
The chapter begins with the story of Jennifer Jilani’s pregnancy and birth. An American living in the Netherlands, she was initially skeptical about using a midwife—something that all healthy Dutch women do—but came to enjoy the personalized, laid-back care. She had planned a hospital birth but, late in labor, decided to stay home (something that the Dutch system allows for; women don’t have to decide until the day of labor where they want to give birth). Ricki and Abby remind women that even in the US, a similar positive, empowered experience is possible if you do your homework and assemble the right people to be with you. It’s up to you to advocate for your best birth. One major step in that process is overcoming your fears, both external (ones from Hollywood depictions of birth or “horror” stories that women often tell each other) and internal (fears that you create in your own mind). They encourage you to approach fear as your friend; use it as a starting place for education and growth. Another major step is looking carefully about your attitude towards pain. They encourage their readers to think about it in a new way: not as something awful and terrifying, but as something that is healthy and that can help your body move and shift around just the right way. They include several useful excerpts, such as the top 10 non-narcotic pain relievers (from laboring in warm water to movement to vocalizing) and Penny Simkin’s Pain Medication Preference Scale.
Chapter 2: Your Best Birth Place
In this chapter, Ricki and Abby discuss the pros and cons of the four main choices of birth place: hospitals, hospital birth centers, freestanding birth centers, and home. This section contains great advice for how to ask the right questions when you’re taking the hospital tour. It’s not enough to ask things like “do you have showers or tubs for laboring in?” or “can I use different positions for laboring and birthing?” The answers to those types of questions will almost invariably be yes. However, whether or not those things actually happen once a laboring woman arrives is another story. (For example, during her first birth my sister-in-law was not even allowed to go into the shower because her water had broken and her doctors told her that it was too dangerous because of the risk of infection!) So you need to ask follow-up questions and sleuth around, so to speak, to see how often women actually are allowed to be in the shower or in the tub, or whether the nurse or physician will actually be okay with you squatting on the bed to push. They write, “As you walk around the hospital on the tour of the maternity ward or attend an orientation session at a birth center, you need to remember that this is a sales pitch. The people conducting the tour are going to show you all the pleasant features of their establishment….The style of rooms means far less than the attitudes and behaviors or providers. The hospital’s cesarean rate is a better indicator of these than its room décor. Hospitals can use style to co-opt substance.” They include a list of questions to ask on the hospital tour, ones that should reveal attitudes, routines, procedures, and practices common at that hospital.
The rest of the chapter overviews the pros and cons of the other three birth locations (hospital birth center, freestanding birth center, and home). It includes questions to ask for each location and information about water birth and helpful positions for labor & birth.
Section II: Putting Your Dream Team Together
Your birth team is key to having the kind of birth you want, even more than the location of birth. Choose your care provider carefully; when you decide on a particular physician or midwife, you’re essentially agreeing to his or her philosophy of intervention and pain management. The next two chapters overview the general differences in philosophy and management between obstetricians and midwives.
Chapter 3: Obstetricians: Finding Dr. Right
This chapter begins by discussion the pressures obstetricians face that limit the kind of care they are able to give. OBs have to keep a high volume of patients in order to pay for their (increasingly expensive) malpractice premiums. Many practice defensive medicine by actively managing labor and intervening sooner rather than later, in the hopes of avoiding a lawsuit. They comment:
The financial and legal pressures on obstetricians are enormous. Every minute they spend answering your question s is a minute they aren’t spending with money-making patients in the other rooms. This is probably why many doctors trained in obstetrics and gynecology only practice obstetrics for a few years and move in mid-career to the better hours and more manageable risks of plain gynecology. For many it’s a terrible disappointment. They started in this specialty because they loved helping women have their babies. The way obstetricians are trained and the legal environment they practice in gets them further and further away from their original expectation of being a doctor.LA Obstetrician Stuart Fischbein bemoans what he calls the “coercive” business of medicine: “Hospital risk managers and insurance companies are making the decisions that affect the lives of patients who they never have to look in the eye. We are training doctors to be sheep, not shepherds. One successful lawsuit can devastate the hospital’s bottom line for years, so there is pressure to protect the hospital from liability, despite what the hospital’s television commercials tell you.”
Although this chapter mainly discusses obstetricians’ training and style of practice, it does include a brief section about family physicians, who usually practice with a more integrative style and tend to have lower intervention rates than their OB colleagues. Family physicians attend about 8% of all births in the US, similar to the percent of births attended by midwives.
Ricki and Abby advise women to use pregnancy as a time to stop being people pleasers. Don’t hesitate to “fire” your caregivers, even if it’s late in pregnancy, if they are not the right fit for you. One way to find out if your physician is “Dr. Right” is by asking the right questions—a list is included in the book.
Chapter 4: Midwives: Not Just for Hippies Anymore
Ricki and Abby begin by outlining the midwifery model of care (keeping in mind that midwives, like physicians, can vary dramatically in their practice style depending on where they were trained and their personal philosophy of care). In general, midwives view birth as a normal, healthy process that usually needs little or no intervention. They spend much more time with women than OBs do during both prenatal visits and during labor. They outline the various types of midwives available in the US, including primarily hospital-based CNMs and home-based CPMs. They also discuss the historical turf wars between physicians and midwives that still exist today in battles over midwifery licensure and autonomy. They also include lists of questions to ask when you’re interviewing midwives.
Chapter 5: Doulas: Labor’s Love
This chapter discusses what a doula is and how she can help the birth process through education, advocacy, and encouragement. You will learn what doulas do at a birth and how to pick the right one for you.
Chapter 6: The Guest List: Birth as a Private Party
Pregnancy and birth are opportunities to develop trust in yourself and deepen your knowledge of what you want and what is best for you—not a time to be “nice” or to do what other people tell you to. With that in mind, whom should you invite to be at your birth? Ricki and Abby feel that it should be “only people whom you trust completely, who approve of your birth plan, and who you don’t mind seeing you naked.” They comment: “that certainly shortens the list. Particularly the naked part….Birth is not a party, like a wedding, where you have to worry about offending those who were not invited.” Don’t worry about hurting people’s feelings when you’re in labor; you need to focus on clearly stating your needs and on feeling completely uninhibited with the people around you.
Chapter 7: For Sexual Abuse Survivors, a Healing
This chapter discusses the ramifications that labor & birth can have on sexual abuse survivors. For some survivors, labor can bring up old traumas. But it can also be a profound healing experience, as Ricki found. She was abused as a child and, after giving birth the second time, finally learned how to fully accept her body. She writes: “Then I totally looked at my body in amazement, like look what I’m capable of. It is amazing that we can carry children and give birth. After Owen was born, I started to lose weight easily. Well, it definitely didn’t fall off. I made a decision, but it was the easiest time I’d ever tried….I don’t know how to explain it other than it just felt like this purging of that pain and trauma from the past.” The chapter discusses how to help abuse survivors plan for their birth and how care providers can avoid bringing up past traumas.
Section III: Interventions: The Slippery Slope
To summarize the third section of Your Best Birth, I will quote from the introduction to Section III. “Things happen pretty quickly in the hospital and informed consent isn’t always the staff’s highest priority, even if getting you to sign the release form is. If you don’t know the risks, how are you supposed to weigh them against the benefits? In this section, we’re going to speak candidly about different kinds of interventions so that now, as you sit calmly reading a book and are not in labor, you can think these things through and talk them over with your partner and your caregiver. That way, if you find yourself in a situation where things are moving quickly and there is pressure for you to decide, you can say, ‘Wait! There is a reason I decided against this. Everybody, let’s just slow down and give me a minute to think this over.’”
Chapters 8-12 cover several main interventions and procedures that might be proposed during the course of a woman’s labor: epidurals, inductions and Pitocin, electronic fetal monitoring, episiotomies, vacuum extraction, forceps, cesarean section & VBAC. These sections focus more on the potential risks and drawbacks, since the authors assume you’re already informed about the possible benefits. Their main approach to interventions is that they can be useful and even life-saving in certain circumstances. However, every intervention or medication has potential risks and drawbacks, which are important to be aware of. They write: “every attempt to interfere or interrupt the natural process of birth has to be considered very carefully. Even though your baby is strong and resilient, a little super hero making the journey down the birth canal, every intervention, every drug, carries with it some risks. You need to know those risks.”
Chapters 8-12 cover several main interventions and procedures that might be proposed during the course of a woman’s labor: epidurals, inductions and Pitocin, electronic fetal monitoring, episiotomies, vacuum extraction, forceps, cesarean section & VBAC. These sections focus more on the potential risks and drawbacks, since the authors assume you’re already informed about the possible benefits. Their main approach to interventions is that they can be useful and even life-saving in certain circumstances. However, every intervention or medication has potential risks and drawbacks, which are important to be aware of. They write: “every attempt to interfere or interrupt the natural process of birth has to be considered very carefully. Even though your baby is strong and resilient, a little super hero making the journey down the birth canal, every intervention, every drug, carries with it some risks. You need to know those risks.”
Section IV: Take Back Your Birth
This section emphasizes the care practices that will help you have “your best birth.” Ricki and Abby include the World Health Organization’s recommendations that support and protect normal birth. These are similar to the Mother-Friendly childbirth Initiative and Lamaze’s 6 Care Practices That Support Normal Birth. They reiterate that it is up to you to seek out the birth that you want and that you feel is best for you and your baby:We’ve been describing a kind of childbirth throughout this book that, we hope, is centered on you and your baby and exactly the situation in which both of you would feel the most supported and the most comfortable. This idea of labor and birth insists that you think things through for yourself and decide what you believe to be best. In addition to that, we want you to go out and get exactly what you want, like a good consumer. Once you’ve examined all your choices, talked them over with your partner, and surrounded yourself with an environment and a team that you believe can handle whatever comes up, you have the right and, in fact, the responsibility to completely relax and simply birth your baby.Chapter 13: Loving Your Labor
This is a rambling, somewhat disorganized chapter about the birth process, different types of childbirth education classes (such as Bradley, Birthing From Within, Lamaze, and Hypnobirthing), and tips to help labor go more smoothly.
Chapter 14: Bonding with Baby
This chapter discusses the routine newborn procedures typical in hospital births and stresses that they can be delayed, leaving the first hour or two for breastfeeding and snuggling. Ricki and Abby discuss the astounding hormonal adjustments your body goes through as you give birth and begin breastfeeding and remark upon the newborn’s ability to crawl to the breast and self-attach (if the mother had an unmedicated labor). They mention the role of postpartum doulas and emphasize the importance of rooming-in and uninterrupted contact with your baby.
Epilogue
Ricki and Abby have noticed that our birth culture is beginning to shift. In order to have a VBAC, women are driving over one or more state line to find a provider, or they are laboring in the parking lot until birth is imminent. “Midwives all over the country have reported that demand for their services is growing….Medical students and nursing students are demanding rotations in midwifery and more training in the physiological process of birth. The system has swung so far out of control that attitudes are shifting back toward respect for the natural process.”
They encourage women to speak with their pocketbooks—one of the only ways to get our for-profit health system to take notice. “After reading this book,” they write,” we hope that you will begin to demand more choices in childbirth in your community….If you used a fantastic OB-GYN or midwifery practice, tell other women to seek them out….If your local hospital doesn’t have a birth center or offer midwifery services, make a big fuss about it.”
They conclude by reiterating their core message of education, empowerment, responsibility, and action: “Many parents are starting to understand that the birth of their child is something that can be ‘taken away’ from them. It takes a lot of research and guidance to make sure you are with providers who will respect your family’s birth plan….At the end of the day, we feel that the true mark of a ‘best birth’ is when the mother is respected, informed, and treated as a participant in every decision about her pregnancy, labor, and delivery.”
They encourage women to speak with their pocketbooks—one of the only ways to get our for-profit health system to take notice. “After reading this book,” they write,” we hope that you will begin to demand more choices in childbirth in your community….If you used a fantastic OB-GYN or midwifery practice, tell other women to seek them out….If your local hospital doesn’t have a birth center or offer midwifery services, make a big fuss about it.”
They conclude by reiterating their core message of education, empowerment, responsibility, and action: “Many parents are starting to understand that the birth of their child is something that can be ‘taken away’ from them. It takes a lot of research and guidance to make sure you are with providers who will respect your family’s birth plan….At the end of the day, we feel that the true mark of a ‘best birth’ is when the mother is respected, informed, and treated as a participant in every decision about her pregnancy, labor, and delivery.”
Appendix
The appendix provides information about the following topics:
- Making Your Birth Plan
- Making Your Wishes Known
- A sample birth plan
- Resources (including midwives, doulas, consumer advocacy & birth resources, childbirth education, Baby-Friendly hospitals, cesareans, books, magazines, videos, breastfeeding, low-income and teen parent resources, intimate partner violence, lesbian and gay parenting, research, waterbirth, alternative medicine, and postpartum depression)
My thoughts on Your Best Birth
Your Best Birth was written for women who have little or no knowledge about their birth options, rather than for those who have already begun that journey. I think this is why I liked the book more the second time I read it. This last time, I tried reading through the lens of a woman whose only knowledge about birth came from the media or from casual conversations with friends or co-workers—you know, “just get the epidural!” or “I had to have an episiotomy because the doctor said I was going to tear.” This book opens your eyes to the many possibilities and options surrounding childbirth, from conventional OB-GYN care and medicated hospital births, to midwives and doulas, to waterbirth and thinking positively about the sensations of labor. I would guess that many women do not even know there are other ways of giving birth. This book is most valuable for presenting the many options for pregnancy & birth, urging women to carefully research their options, and encouraging them to take action and work hard to create the best possible birth experience.Your Best Birth is written in a chatty, conversational, informal tone—the kind of things that a good friend might tell you. Ricki and Abby speak favorably of natural birth and midwifery and other alternatives to conventional obstetrical care, but they do not present these choices as The Only Right Way To Give Birth. At times I found the writing style somewhat rambling and disorganized; the book could benefit from another round of editing and polishing.
I was glad to see an entire chapter devoted to birth after sexual abuse. It's something that isn't written about very often, but should be. With a large minority of women experiencing sexual abuse in this country, it's important to know how labor and birth might affect abuse survivors.
The weakest part of the book was the section on interventions—not because the information was incorrect, but because Ricki and Abby did not provide references to back up their claims. This book was not written as a reference text or guide to the medical literature, of course, but providing some information about their sources and giving suggestions for further research—the Cochrane Reviews or Lamaze’s Research Summaries, for example—would have greatly strengthened Section III.
I’ve been thinking about the core message of consumer empowerment in Your Best Birth: the idea that, as consumers, you have a right to demand options for your birth and to “vote with your pocketbook.” It’s a very individualistic message—it’s up to you to create the kind of birth you want. Sometimes I wonder whether it sets women up for failure, because it isn’t always so simple as asking for and then receiving the things you want. There are things like hospital culture, malpractice insurance regulations, and physicians’ fear of litigation that strongly limit the options available to women. Simply asking for change on an individual level might not be enough to overturn these deeply entrenched forces. On the other hand, individual advocacy on a massive enough scale translates into a powerful force for change. I’m thinking back to the days when husbands weren’t allowed in birth rooms. It was individual women and men demanding change, persistently, over and over, that gradually led to a dramatic reversal of policy. Nowadays, it’s expected that the woman’s husband or partner will be present at the birth—something that was fairly unthinkable just a few decades ago. In sum, I find Ricki and Abby’s message of consumer empowerment a pragmatic one. If you know you want a certain kind of birth—whether it’s at home or in a hospital, under water or on an operating table—you need to speak up and work hard to get what is right for you. It won’t happen by itself.
Sunday, June 21, 2009
A father's birth stories
In honor of Father's Day, I wanted to post the birth stories of Zari and Dio, as told in Eric's journal. He has been--and is--a wonderful father to our children. I especially like how he loves to play with them. I remember back to when we were engaged, and I was over at my mom's friend's house. She was playing around with my hair, coming up with ideas for the wedding. Her daughters got hold of Eric and proceeded to do his hair too. He got the works: hairclips, elastics, gel, and hairspray. My mom's friend saw him enjoying the makeover and commented that he was going to be a great father.
Zari's Birth:
So. I am a father. As of 11:23 this morning, I have earthly posterity, a beautiful daughter. We haven’t named her yet, probably won’t until we find something that suits her. What an experience! I think this calls for exclamation points! Rixa woke me up around 6:30 this morning saying that she had been having regular contractions since about 1:30. She told me to cancel my classes, which I did. And take out Zeke, which I did. After a brisk run, Rixa continued to have regular contractions and they got stronger and stronger until about 9:30 when she started pushing.
So. Saturday night. Rixa was acting a little strangely; we were trying to get to bed and we had just finished watching a semi-scary movie, Disturbia, and she started getting contractions. She had mild contractions during the day as well. We did a bunch of planting and shopping and getting these screen boxes over our square-foot gardens and I think that the exertion may have pushed her over the edge. She didn’t really get to bed much and stayed up until almost 1 AM.
The next morning, she was still having regular contractions but they weren’t strong enough for her to stop everything. She kept saying that with Zari it was boom, she couldn’t do anything else but labor. But with these, she was more relaxed and she could talk through them, etc. She was getting to the point, though, that she needed to move around a little so she opted to not go to church, so I took Zari and faced a gazillion questions about how Rixa was doing while I was there. I called in between meetings to see how things were going and then hurried home with Zari in tow. Thanks to the Madsens for helping watch Zari during church while I had to play the organ and for the great nursery leaders who amuse her so much that she could’ve cared less that momma and papa weren’t around.
So, after church we ate and Rixa started having stronger labor. I put Zari to bed and we could hear Rixa making a little noise, mostly just heavy breathing and the occasional drawn-out “oohhhh”. Soon after I put Zari down, though, Rixa was having stronger and stronger contractions. She called Penny (the midwife) and we filled up the birth tub and headed upstairs. I was pretty busy from the get-go for this birth. No time to play Scrabble (especially with Zari to take care of and then put down for a nap). Before we went up, I gave Rixa a blessing and I blessed her that she would be able to trust her body during the labor and that the baby would be healthy. I felt very strong impressions that everything would be fine, but that Rixa was feeling less confident about her body for some reason. Turns out that’s about what was happening. Not exactly a lack of confidence, but the labor, especially pushing, was much stronger than the last time around. She felt more overwhelmed but she trusted her body and birthed baby Dio very smoothly.
I was with her through the whole thing this time. She wanted something to grab onto, so she would hold my arms in a kind of arm wrestler’s grip and she would pull on me when the contractions would come. The pushing was very quick, around fifteen minutes or so of strong pushing. Penny was there but she was very unobtrusive and only took heart tones a couple times and otherwise didn’t say or do anything (except take pictures once the baby was coming out). It was a beautiful birth and Rixa was so strong through the whole thing. Very self-assured and cogent. I took a few videos and helped get towels and transfer Rixa to the bed. The midwives (she had an assistant there by the end) were pretty chill and they left us alone for much of the time to spend time with Dio. Zari got up after everything was over and awoke to a new baby brother. I’m going to have to cut this short and fill in the rest tomorrow, but things have been good and people’s outpouring of friendship has been phenomenal.
Zari's Birth:
So. I am a father. As of 11:23 this morning, I have earthly posterity, a beautiful daughter. We haven’t named her yet, probably won’t until we find something that suits her. What an experience! I think this calls for exclamation points! Rixa woke me up around 6:30 this morning saying that she had been having regular contractions since about 1:30. She told me to cancel my classes, which I did. And take out Zeke, which I did. After a brisk run, Rixa continued to have regular contractions and they got stronger and stronger until about 9:30 when she started pushing.
Pushing took much longer than she thought it would—the baby’s head took a while to mold and move down the birth canal. I did my part by giving Rixa a blessing when she needed it and basically by staying out of the way and helping only when she needed it. She really was amazing. Rixa spent most of her time on the toilet but she also went on the floor and used the birth ball for stability or she went in the tub. I was sitting in the bedroom most of the time, trying not to focus too much on the loud vocalizing that Rixa was doing. Like from the belly of the beast. They were about a minute apart for most of it and when she got close to the end I thought labor was stalling. She wasn’t making as much noise but breathing heavily. Then I heard, “OK, the head is out” and I came in to help catch the baby. She came out smooth and slick, bright pink with a full set of lungs. She cried for about a minute or so but calmed right down when we put her on Rixa. Her head was very molded from the birth but already it looks round and normal. She has a full head of hair and the little Freeze nose crinkle. She looks very much like Freeze babies usually do. Same eyes and forehead going on. Still, it is hard to distinguish characteristics from newborns.
After she was born we took pictures and a couple videos. Rixa went probably prematurely to the bed because it took her a couple hours to get the placenta out. She continued to have strong contractions like she did during labor, but these were for the placenta which stubbornly would not come out. Rixa didn’t want to force it because that could cause unnecessary hemorrhaging so we waited it out. We decided to cut the cord and then Rixa went to the bathroom to labor and get it out, which she did after a short prayer. She even had a small chunk of it to chew on to help stop the bleeding, etc. She really felt great, looks great, and has been recovering nicely. We had Bernice over at the end to help stitch Rixa up and do some blood work. It was very nice to have her just to verify that we did everything right (which we did). Rixa has had pretty minimal bleeding and she can walk, etc. Very functional for a woman who just gave birth.
So. Saturday night. Rixa was acting a little strangely; we were trying to get to bed and we had just finished watching a semi-scary movie, Disturbia, and she started getting contractions. She had mild contractions during the day as well. We did a bunch of planting and shopping and getting these screen boxes over our square-foot gardens and I think that the exertion may have pushed her over the edge. She didn’t really get to bed much and stayed up until almost 1 AM.
The next morning, she was still having regular contractions but they weren’t strong enough for her to stop everything. She kept saying that with Zari it was boom, she couldn’t do anything else but labor. But with these, she was more relaxed and she could talk through them, etc. She was getting to the point, though, that she needed to move around a little so she opted to not go to church, so I took Zari and faced a gazillion questions about how Rixa was doing while I was there. I called in between meetings to see how things were going and then hurried home with Zari in tow. Thanks to the Madsens for helping watch Zari during church while I had to play the organ and for the great nursery leaders who amuse her so much that she could’ve cared less that momma and papa weren’t around.
So, after church we ate and Rixa started having stronger labor. I put Zari to bed and we could hear Rixa making a little noise, mostly just heavy breathing and the occasional drawn-out “oohhhh”. Soon after I put Zari down, though, Rixa was having stronger and stronger contractions. She called Penny (the midwife) and we filled up the birth tub and headed upstairs. I was pretty busy from the get-go for this birth. No time to play Scrabble (especially with Zari to take care of and then put down for a nap). Before we went up, I gave Rixa a blessing and I blessed her that she would be able to trust her body during the labor and that the baby would be healthy. I felt very strong impressions that everything would be fine, but that Rixa was feeling less confident about her body for some reason. Turns out that’s about what was happening. Not exactly a lack of confidence, but the labor, especially pushing, was much stronger than the last time around. She felt more overwhelmed but she trusted her body and birthed baby Dio very smoothly.
I was with her through the whole thing this time. She wanted something to grab onto, so she would hold my arms in a kind of arm wrestler’s grip and she would pull on me when the contractions would come. The pushing was very quick, around fifteen minutes or so of strong pushing. Penny was there but she was very unobtrusive and only took heart tones a couple times and otherwise didn’t say or do anything (except take pictures once the baby was coming out). It was a beautiful birth and Rixa was so strong through the whole thing. Very self-assured and cogent. I took a few videos and helped get towels and transfer Rixa to the bed. The midwives (she had an assistant there by the end) were pretty chill and they left us alone for much of the time to spend time with Dio. Zari got up after everything was over and awoke to a new baby brother. I’m going to have to cut this short and fill in the rest tomorrow, but things have been good and people’s outpouring of friendship has been phenomenal.
Saturday, June 20, 2009
(je vais) Au Canada!
We arrived in the Great White North this evening after 14 hours of traveling (2 car rides, 1 shuttle bus ride, 2 plane rides, a 2-hour layover, and a 2-hour wait at the border). It's nice to be "home" at my in-laws'. I am so glad we didn't drive the whole way; it would have been three 12-hour days in the car each way. Most of Eric's siblings and their children are arriving this week, so we'll have a house packed full of kids for the next few weeks. I'm so excited to see all of my husband's siblings and spouses. They are some of my closest friends and we always have a great time together.
Friday, June 19, 2009
More on breech & the SOGC
There's a lot of conversations about the new SOGC guidelines on vaginal breech birth. If you'd like to read the complete text of the new guidelines, an editorial by Dr. Lelonde, or commentary by Dr. Kotaska (one of the physicians featured in Pushed; he traveled to Europe to obtain training in vaginal breech birth), visit the SOGC's Media Advisory site on breech birth. Those documents, and more, are available as PDF downloads near the bottom of the page. Be sure to read the editorial and the commentary!
A few more links discussing the SOGC guidelines.
A few more links discussing the SOGC guidelines.
- Public Health Doula has included excerpts from Dr. Kotaska's commentary. He is one of my physician heroes with his strong advocacy for woman-centered care.
- Lamaze's Science and Sensibility, a research blog, discusses the research that spurred the SOGC's new breech policy.
- Dr. Denise Punger, a family physician who had a surprise footling breech at home with her third baby, shares her thoughts on her blog Permission to Mother.
- The ACNM blog Midwife Connection briefly mentioned the policy change.
Wednesday, June 17, 2009
Canada does a 180!
The Society of Obstetricians & Gynecologists of Canada (SOGC) has made a dramatic about-face this week. In a reversal of its earlier prohibition of vaginal breech birth, the SOGC just announced its new recommendations: to offer vaginal breech birth and to establish nationwide training programs so that physicians can learn the necessary skills. From The Globe and Mail: C-section not best option for breech birth:
Physicians should no longer automatically opt to perform a cesarean section in the case of a breech birth, according to new guidelines by the Society of Obstetricians and Gynecologists of Canada.
Released yesterday, the guidelines are a response to new evidence that shows many women are safely able to vaginally deliver babies who enter the birth canal with the buttocks or feet first. Normally, the infant descends head first.
“Our primary purpose is to offer choice to women,” said André Lalonde, executive vice-president of the SOGC.
“More women are feeling disappointed when there is no one who is trained to assist in breech vaginal delivery,” he adds....
The new approach was prompted by a reassessment of earlier trials. It now appears that there is no difference in complication rates between vaginal and cesarean section deliveries in the case of breech births....
This article also highlighted the SOGC's position on normal birth:
The new decision to offer vaginal breech birth aligns with the SOGC promotion of normal childbirth – spontaneous labour, followed by a delivery that is not assisted by forceps, vacuum or cesarean section. In December of 2008, the society release a policy statement that included its recommendation for a development of national practice guidelines on normal childbirth.
“The safest way to deliver has always been the natural way,” said Dr. Lalonde.
“Vaginal birth is the preferred method of having a baby because a C-section in itself has complications.”
Cesarean sections, in which incisions are made through a mother's abdomen and uterus to deliver the baby, can lead to increased chance of bleeding and infections and can cause further complications for pregnancies later on.
“There's the idea out there in the public sometimes that having a C-section today with modern anesthesia and modern hospitals is as safe as having a normal childbirth, but we don't think so,” said Dr. Lalonde.
“It is the general principle in medicine to not make having a cesarean section trivial.”
The SOGC believes that if a woman is well-prepared during pregnancy, she has the innate ability to deliver vaginally.
Another article in The Vancouver Sun, Canadian docs to stop automatic C-sections for breech babies, covers much of the same information about the change in breech policy:
In a major shift in medical practice and another assault on Canada's rising cesarean section rate, Canada's delivery doctors are being told to stop automatically scheduling C-sections for breech babies and attempt a normal delivery instead — something significant numbers of obstetricians aren't trained to do.
New guidelines issued Wednesday by the Society of Obstetricians and Gynaecologists of Canada say women carrying babies in the breech, or bottom-first, position should be given the right to choose to attempt a traditional delivery when possible.
The society says that women in Canada want the choice, and that some women with breech babies are delivering at home "because they knew if they went to hospital A, B or C it would not be offered," says Dr. Andre Lalonde, executive vice-president of the obstetricians' group and an adjunct professor of obstetrics and gynecology at McGill University and the University of Ottawa.
Lalonde says the group is working aggressively to ensure future specialists are trained in breech vaginal deliveries and is organizing courses across Canada for practising doctors to refresh their training.
I am somewhat stunned at this dramatic shift in policy. The ACOG could definitely take some hints in listening to women and looking closely at the evidence from their friendly northern neighbors...This makes me want to go outside and sing "O Canada" at the top of my lungs!
ps--I love Unnecesarean's illustration!
Tuesday, June 16, 2009
Update: weeks 6 & 7
We've hit a few milestones, some big and some small, this week.
Zari stopped wearing diapers and has been accident-free in her new underwear for the past two weeks. She could probably have gone into underwear a while ago, but I never got around to buying it until now. We've been working with her to tell us before she needs to go to the bathroom. For the past several months, she's been really good at telling us immediately after she went, but not before! I think we've got that down now. She gets a potty treat--either a sticker or small pieces of chocolate or candy--whenever she goes. Works like a charm. I'm not one to allow sugar normally, but she is very motivated by the promise of a chocolate chip or an M&M.
Dio switched diaper sizes, from newborn (6-12 lbs) to small (10-20 lbs). He probably could go another week or two in the newborns, but since we'll be out of town much of the summer, I had to switch over before we leave. I've been doing elimination communication with Dio, like I did with Zari, and he is so good about going when I cue him. I usually sit backwards on the toilet and cradle is body in one arm and support his feet with the other. When I cue him with the poop sound (little grunting noises) he'll look at me and grunt back and, more often than not, poop.
Dio is still quite grumpy, but I think it's getting somewhat better. I'm not sure if we're just getting used to it or if he's growing out of it. Probably a little bit of both. We've figured out that swaddling really helps calm him down. That, in combination with him sucking on my upside-down index finger, is usually a surefire combination for getting him calmed down. Of course, it doesn't leave any hands free! He's most happy in the morning and gets progressively fussier throughout the day. So evenings often find us holding a "Dio burrito" with our finger stuck in his mouth. He doesn't care for the pacifier much and will only take it once he's sucked on our fingers for a while.
I've started exercising again two weeks ago. I go in the morning around 8 am. Right now Eric isn't teaching, but when school starts again in the fall he'll be going up to campus at 9, so I can keep the same schedule for the most part. I do ellipticals 3x/week for 30-40 minutes and weight training 2x/week. We're lucky to live only a 5-minute walk away from the campus athletic facilities, which I can use for free. I'll probably start running while we're gone this summer, since I won't have access to a gym. I've got to fine a good sports bra first, though. My current exercise top is fine for the elliptical machine, but there's way too much bouncing going on when I run!
Nights are so-so. Dio usually sleeps 4 hours (from about 9 pm-1 am), then 3 hours (1 am-4 am). Then, around 4 am, he often has avery restless period where he's either half-awake and grunting and stirring, or fully awake. Often he won't really go back down to a deep sleep until 6 am or later. So that makes me a bit tired. He and Zari both wake up for the morning around 8 am.
Our typical summer day looks like this:
Zari stopped wearing diapers and has been accident-free in her new underwear for the past two weeks. She could probably have gone into underwear a while ago, but I never got around to buying it until now. We've been working with her to tell us before she needs to go to the bathroom. For the past several months, she's been really good at telling us immediately after she went, but not before! I think we've got that down now. She gets a potty treat--either a sticker or small pieces of chocolate or candy--whenever she goes. Works like a charm. I'm not one to allow sugar normally, but she is very motivated by the promise of a chocolate chip or an M&M.
Dio switched diaper sizes, from newborn (6-12 lbs) to small (10-20 lbs). He probably could go another week or two in the newborns, but since we'll be out of town much of the summer, I had to switch over before we leave. I've been doing elimination communication with Dio, like I did with Zari, and he is so good about going when I cue him. I usually sit backwards on the toilet and cradle is body in one arm and support his feet with the other. When I cue him with the poop sound (little grunting noises) he'll look at me and grunt back and, more often than not, poop.
Dio is still quite grumpy, but I think it's getting somewhat better. I'm not sure if we're just getting used to it or if he's growing out of it. Probably a little bit of both. We've figured out that swaddling really helps calm him down. That, in combination with him sucking on my upside-down index finger, is usually a surefire combination for getting him calmed down. Of course, it doesn't leave any hands free! He's most happy in the morning and gets progressively fussier throughout the day. So evenings often find us holding a "Dio burrito" with our finger stuck in his mouth. He doesn't care for the pacifier much and will only take it once he's sucked on our fingers for a while.
I've started exercising again two weeks ago. I go in the morning around 8 am. Right now Eric isn't teaching, but when school starts again in the fall he'll be going up to campus at 9, so I can keep the same schedule for the most part. I do ellipticals 3x/week for 30-40 minutes and weight training 2x/week. We're lucky to live only a 5-minute walk away from the campus athletic facilities, which I can use for free. I'll probably start running while we're gone this summer, since I won't have access to a gym. I've got to fine a good sports bra first, though. My current exercise top is fine for the elliptical machine, but there's way too much bouncing going on when I run!
Nights are so-so. Dio usually sleeps 4 hours (from about 9 pm-1 am), then 3 hours (1 am-4 am). Then, around 4 am, he often has avery restless period where he's either half-awake and grunting and stirring, or fully awake. Often he won't really go back down to a deep sleep until 6 am or later. So that makes me a bit tired. He and Zari both wake up for the morning around 8 am.
Our typical summer day looks like this:
- 8 am: wake up, exercise, shower, eat breakfast, get dressed, etc
- 10 am: Eric leaves to write in his office, the rest of us play together
- noon: lunch, then get both kids down for naps by 1 pm
- 1-3 pm: naptime, which means writing/blogging/email checking time for me. Or sling sewing time. Or house cleaning time time. etc.
- 3 pm: kids wake up, Eric comes home, we play together
- 5 pm: make dinner, eat
- evenings until 7:30 or 8 pm: do thing together--take walks, go to the park, watch movies, etc
- 8-9 pm (or later): get kids to bed
- 9-10 pm: check email, read books, write in my journal, or watch movies. Around 10-10:30 pm I usually go to bed and Eric stays up a few more hours reading or writing
Monday, June 15, 2009
6 & 7 week pictures
almost 6 weeks old
A few vacation pictures from last week:playing on a cannon
climbing
time for a nap
7 weeks & 1 day old today!
Sunday, June 14, 2009
Non-compliance
Within a few days of each other, two fascinating viewpoints on patient non-compliance have gained widespread attention. The first is the AMA's Resolution 710: "Identifying Abusive, Hostile or Non-Compliant Patients." Jill at Unnecesarean has posted both the full text of the AMA Resolution and ICAN's response. Here are a few excerpts from the Resolution:
This brings me to the second viewpoint about patient compliance/non-compliance. In an interview with the New York Times, Dr. Donald M. Berwick, a Harvard pediatrician, discusses his recent article “What ’Patient-Centered’ Should Mean: Confessions of an Extremist.” Some excerpts from the interview:
Whereas, Many patients are becoming more abusive and hostile toward physicians for many reasons not limited to the economy, increasing co-pays and deductibles, unreasonable expectations and demands, a lack of instantaneous cure, arrogance and/or the belief that they “own” their physicians; and...The internet has been abuzz over this resolution, so much that posting all of the links would be too time-consuming for me. I have several concerns with this resolution. I agree with ICAN that it could open up doors for insurance companies to deny claims for patients labeled "non-compliant." And, at least in the birth world, I fear that the label would be applied to women who want VBACs or home births or even just wish to decline standard labor interventions such as routine IVs or continuous fetal monitoring.
Whereas, The stress of dealing with ungrateful patients is adding to the stress of physicians leading to decreased physician satisfaction;...
RESOLVED: That our American Medical Association ask its CPT Editorial Panel to investigate for data collection and report back at Annual 2010 meeting: 1) developing a modifier for the E&M codes to identify non-compliant patients and/or 2) develop an add-on code to E&M codes to identify non-compliant patients. (Directive to Take Action)
This brings me to the second viewpoint about patient compliance/non-compliance. In an interview with the New York Times, Dr. Donald M. Berwick, a Harvard pediatrician, discusses his recent article “What ’Patient-Centered’ Should Mean: Confessions of an Extremist.” Some excerpts from the interview:
The notion of "patient non-compliance" is a very complex one, in large part because one person's "non-compliant" patient is another physician's dream patient. Some people refuse treatment for ethical or religious reasons. Some might refuse treatments simply because they aren't evidence-based, such as an elective primary cesarean for suspected fetal macrosomia). Some patients come to office visits with a long list of questions and preferences, behavior that might annoy one physician but delight another. I don't doubt that there are many patients who truly display hostility or abusive behavior towards their health care providers, and that is not acceptable in any setting. But grouping non-compliance in with hostile, abusive, and "ungrateful" patients? Highly problematic.Q. Do you think “patient-centeredness” exists in current health care practice?
A. If you are interested in quality, you have to be interested in patient-centeredness. Good doctors and nurses do try mostly to focus on every patient as an individual. But we have built a system around clinicians that makes it impossible to customize care the way it needs to be. We don’t have a standard of services or processes that are comfortable for patients. We have built a technocratic castle, and when people come into it, they are intimidated.
Patients keep having to repeat their name because the system has no memory. We dress them in silly-looking gowns. We give them the food we make instead of the food they want. We don’t let them look into their medical records unless they have permission. Health care keeps telling patients the rules instead of asking patients about their individual needs. What is said is, “This is how we do things here,” not “How would you like things done?”
People get accustomed to this. They are trained to be passive, and passivity is not a good idea. Studies have shown that people who are trained to be proactive do better and feel stronger. They have more pride and trust in their own capabilities.
When you make someone helpless, in a funny way you make them sicker, even if all you cared about was just the body.
Q. What if a patient’s preference is in conflict with recommendations grounded in evidence-based medicine?
A. I would treat it as a challenge of information exchange. Human beings have got to have the ability and the responsibility to make their own decisions. As long as they know everything they need to know, they should be able to make the decision. If we doctors feel a person is going to make unwise choices, we have to take on the responsibility of being teachers, educators and informers. We need to give people all the knowledge and information so they can make their decisions well.
And we don’t do that well at the moment. It’s often done as a relatively pro forma matter.
Q. Tell me about your views on “noncompliance.”
A. I think “noncompliance” is a control word, a power word, and we need a slightly different one. “Compliance” means I order and you either do it or not; you obey. Patients live in their bodies and may know more than the person who prescribes or does their procedure. They may know better about what is going on in their body and about the optimization of their own life. I think people who aren’t taking their own medicine are telling us valuable information about their medications and their life, and we need to listen to them.
I solemnly swear...
...that I am up to no good.
No, actually, I solemnly swear that I was in fact pregnant and had a real baby, unlike this blogger who fabricated a pregnancy and birth. Her "baby" had defects incompatible with life, yet she chose to carry her to term. She had a home birth and her baby died several hours later. Only it turns out it wasn't a real baby but a doll and she was not pregnant.
Some people are very upset over this incident, feeling angry and betrayed and calling her all sorts of bad names. Here's my take on it: I'm married to a fiction writer. His job is to tell lies. More or less. So if someone wants to fabricate a pregnancy and a birth and can tell a compelling story, it really doesn't bother me all that much as long as no one gets hurt in the process.
So back to my original point: I really am in fact who I claim to be. (Or maybe not--perhaps I have exceedingly good photoshop and CGI skills and wrote a fake 300+ page dissertation...evil laughter)
No, actually, I solemnly swear that I was in fact pregnant and had a real baby, unlike this blogger who fabricated a pregnancy and birth. Her "baby" had defects incompatible with life, yet she chose to carry her to term. She had a home birth and her baby died several hours later. Only it turns out it wasn't a real baby but a doll and she was not pregnant.
Some people are very upset over this incident, feeling angry and betrayed and calling her all sorts of bad names. Here's my take on it: I'm married to a fiction writer. His job is to tell lies. More or less. So if someone wants to fabricate a pregnancy and a birth and can tell a compelling story, it really doesn't bother me all that much as long as no one gets hurt in the process.
So back to my original point: I really am in fact who I claim to be. (Or maybe not--perhaps I have exceedingly good photoshop and CGI skills and wrote a fake 300+ page dissertation...evil laughter)
Saturday, June 13, 2009
Online again
We just got back from a week vacation. Eric had a week-long writer's retreat and the rest of us came along. We stayed in a state park about 10 minutes outside the town where the retreat was held. No internet access, of course, but no phone access, either. No signal for my emergency cell phone and the closest pay phone was about a 5-10 minute walk away. It was a little strange being so cut off from everything.
It was a bit more stressful than I had anticipated. I would have to take multiple trips back and forth from our cabin and town whenever the children got tired and fussy. It was a challenge keeping everyone happy and amused with no home I could easily walk back to, no toys or play things for Zari, no stroller (so when Zari decided she was done and not moving another foot and laid down on the sidewalk and refused to move, I had to literally drag her, kicking and screaming, to the next place we needed to go), lots of bugs and occasional bad weather. But when Eric had time off, we had a blast. The state park had a huge swimming pool with a big waterslide, so we spent most afternoons swimming and splashing. We also were able to eat out one night at a fantastic restaurant. Amazing flavors and tastes, lots of locally grown and seasonal ingredients. Mmmmm...
More updates tomorrow once I wade through all of my emails and bills and packages.
It was a bit more stressful than I had anticipated. I would have to take multiple trips back and forth from our cabin and town whenever the children got tired and fussy. It was a challenge keeping everyone happy and amused with no home I could easily walk back to, no toys or play things for Zari, no stroller (so when Zari decided she was done and not moving another foot and laid down on the sidewalk and refused to move, I had to literally drag her, kicking and screaming, to the next place we needed to go), lots of bugs and occasional bad weather. But when Eric had time off, we had a blast. The state park had a huge swimming pool with a big waterslide, so we spent most afternoons swimming and splashing. We also were able to eat out one night at a fantastic restaurant. Amazing flavors and tastes, lots of locally grown and seasonal ingredients. Mmmmm...
More updates tomorrow once I wade through all of my emails and bills and packages.
Friday, June 05, 2009
6 week visit
We had our 6-week visit (a few days early) at the midwife's house today. I was amazed to find that Dio has grown quite a bit. He's now 23" long and weighs 11 lbs 4 oz! No wonder he's been looking so big!
We've been quite busy around here, and we're getting ready to go on some fun trips. I'll be out of town next week so the blog might be a bit quiet. Time to nurse Dio and get him to sleep for the evening...
We've been quite busy around here, and we're getting ready to go on some fun trips. I'll be out of town next week so the blog might be a bit quiet. Time to nurse Dio and get him to sleep for the evening...
Wednesday, June 03, 2009
Midwife, nurse, and doctor blogs
I've come across a few new nurse blogs recently:
1) Nursing Birth. You've got to read her "Don't Let This Happen To You" series!
2) The Man-Nurse Diaries. Be sure to read his recent post about nearly bleeding to death from a cesarean section. The cesarean was scheduled because of a breech presentation. As I've been preparing to do research for a presentation at the International Breech Conference, I've been thinking a lot about the ramifications of having a breech baby in today's medical and legal climate. Universal cesarean section is not the best solution to breech babies. I hope that this conference will result in more doctors and midwives offering vaginal breech birth.
Anyway, here's my current list of birth-related midwife, nurse, and doctor blogs (taken from my sidebar). Are there any other good ones that I'm missing? Are any of my links outdated? I haven't had time to check them all recently.
10 centimeters and beyond
A midwife's muse
Andrea's Diary
At your cervix
Australian College of Midwives SA branch
Babycatcher
Babycatcher33
Belly tales
Birthfriend's place to ponder
Close to the root
Gloria Lemay
Homebirth happens
Homebirth: Midwifery Mutiny
Hospital birth debate
Midwife with a Knife
Midwife: Sage Femme
Midwifery ramblings
Midwifery world
Missionary midwife mama
Missions of a baby catcher
Mom's tinfoil hat
My journey
N is for nurse
Navelgazing midwife
Nursing Birth
Permission to mother
PinkyRN
Radical midwife (in the making)
Rebirth
Rural doctoring
Somewhere south of the equator
Tales from a future OBGYN
The Man-Nurse Diaries
Village Midwife
Women in charge
1) Nursing Birth. You've got to read her "Don't Let This Happen To You" series!
2) The Man-Nurse Diaries. Be sure to read his recent post about nearly bleeding to death from a cesarean section. The cesarean was scheduled because of a breech presentation. As I've been preparing to do research for a presentation at the International Breech Conference, I've been thinking a lot about the ramifications of having a breech baby in today's medical and legal climate. Universal cesarean section is not the best solution to breech babies. I hope that this conference will result in more doctors and midwives offering vaginal breech birth.
Anyway, here's my current list of birth-related midwife, nurse, and doctor blogs (taken from my sidebar). Are there any other good ones that I'm missing? Are any of my links outdated? I haven't had time to check them all recently.
Tuesday, June 02, 2009
Three down
Last night's death toll: 3 (mice, that is). We have an infestation. I keep finding mouse poop in more and more places, some of which I can't figure out how a mouse could even get there. I first saw a mouse less than a week ago, and I finally bought glue & spring traps yesterday. Eric felt really bad when we caught the first mouse on a glue trap. "Can't we take it out into a field or something? It's so cute," he said. But I had been cleaning mouse poop for several hours, armed with bleach spray and old rags. I didn't feel very sentimental about its eventual demise. I showed Zari the other two (caught on the same glue trap) in the morning. She was fascinated.
Some 5-week-old pictures:
Some 5-week-old pictures:
I'm allowed to do that?
A hospital's birth policies and routines can vary dramatically from one to another, as Rebirth, a nurse-midwife blogger, illustrated in My Last Shift. She is a L&D nurse who recently became a CNM and just found a new job working as a midwife rather than as a nurse.
On her last day at her old job, she took care of a laboring L&D nurse who worked at another hospital with a more old-style approach. This laboring mother was constantly surprised that she was "allowed" to do things like drink juice, avoid frequent vaginal exams, "labor down" (when you have an epidural and wait for the baby's head to descend to the perineum, rather than begin pushing as soon as the cervix is 10 cms dilated), sit or squat to push, or keep her baby with her after the birth. Her post illustrates the importance of doing your research and asking lots of questions before you choose a provider or a location for your birth. There is no generic or universal hospital experience. Or, for that matter, birth center or home birth experience.
For example, contrast some of the policies and intervention rates at two of my local hospitals, C. Hospital and L. Hospital. Both are small, rural community hospitals with similar populations, doing about the same number of births per year, and serving mostly lower-risk women with full-term (35 + weeks) babies. Here's a brief overview of some of the differences between the two hospitals:
C. Hospital:
On her last day at her old job, she took care of a laboring L&D nurse who worked at another hospital with a more old-style approach. This laboring mother was constantly surprised that she was "allowed" to do things like drink juice, avoid frequent vaginal exams, "labor down" (when you have an epidural and wait for the baby's head to descend to the perineum, rather than begin pushing as soon as the cervix is 10 cms dilated), sit or squat to push, or keep her baby with her after the birth. Her post illustrates the importance of doing your research and asking lots of questions before you choose a provider or a location for your birth. There is no generic or universal hospital experience. Or, for that matter, birth center or home birth experience.
For example, contrast some of the policies and intervention rates at two of my local hospitals, C. Hospital and L. Hospital. Both are small, rural community hospitals with similar populations, doing about the same number of births per year, and serving mostly lower-risk women with full-term (35 + weeks) babies. Here's a brief overview of some of the differences between the two hospitals:
C. Hospital:
- C-section rate is "above the national average" of 31.8%--so perhaps 35% or higher?
- VBACs not allowed
- the 3 doctors and midwives rotate call, so you have no guarantee of continuity of care
- mothers and babies are routinely separated: right after birth for weighing and measuring, and then again a few hours after birth for a 3-4 hour stay in the nursery
- 2008 C-section rate was 21%
- VBACs allowed (although I learned from someone who used to work there that very few actually happen there--not sure if that's patient-led or physician-led)
- during office hours, your doctor will attend your birth. After hours, they rotate call.
- the hospital is working toward its Baby-Friendly certification, so there is no routine separation of mother & baby and in fact, no nursery at all!