3 years old!

Zari is three years old today! Halloween is the best day for a birthday. We've gone to two different Halloween parties this week, plus the regular trick-or-treating tonight. We're having a very informal birthday party tomorrow night. Zari requested a soccer ball cake again. I think I'll make it out of ice cream this year instead of cake.

This morning we opened presents--or rather, a present (Adidas Samba soccer shoes, which is what we got for her last year) and three cards from friends and family. Then we looked through her baby scrapbook, made foot & hand prints in the book, and marked her height on our closet doorway. She's grown about 6 inches in the past year! I think I'll read through her birth story tonight before I go to bed. Here are pictures from her first and second birthdays.

Halloween was insanely busy again this year. Our entire street was closed off to traffic for about 14 blocks. We bought about 1,000 pieces of candy and ran out after two hours. I was glad to be done early because it was quite cold this year.

I was going to make Zari a dragon costume, as she'd requested, but then I found this used one for $3. There are wings and a tail and spikes down the back. She's been wearing it for the past two weeks. Whenever anyone would say, "oh, what a nice dinosaur," she'd reply, "I'm not a dinosaur. I'm a green dragon!"

We've been talking a lot about food that is good for your body. While we were trick-or-treating tonight, she told me, "If I eat all of the candy, I will feel sick. That's why you just eat a little." Smart girl!

Our next-door neighbors built a pirate ship off the end of their porch. Zari's standing on their porch next to the pillar.

I tried to get her to lie down in the graveyard next to the ship, but she didn't want to. She said it was too windy.

I just noticed that the kids match. I didn't do that on purpose. Their jackets (both secondhand) are even the same brand.

Happy birthday Zari!

Ghouls and Doulahs

Halloween is just a few hours away. Are you scared yet? If not, here's something to shiver your timbers.

This sign is from a clinic in a town where I went to university. I am SO glad I didn't get pregnant when I was living there. It was before I knew anything about birth and I could easily have gone to such a place and not known any better. Anyway, the internet has been buzzing about this sign. Here's just a few pieces to whet your appetite:

• Dou-la-la in Signs, Signs, everywhere there's signs asks what's next--forbidding women to look at certain websites, books, or movies?
• Radical Doula wrote about Signs you don't want to see at your ob-gyn's office
• Organic Birth asks What's next?
  
• Bellies and Babies commented on this in Posted Refusal and Black Lists, and corresponded with a CNM who uses one of the clinic's doctors for their backup physician. This midwife explained that the sign isn't quite as bad as it seems.

Still, even if there's a back story and the docs aren't really that bad, they certainly could have come up with a better sign! Like actually spell "doula" right for starters..

If you're not already scared by the "no doulah" sign, then read this OB's Birth Plan. It's so bad that I wonder if it could possibly be real. I read through the original thread and it does seem legit--as legit as something can be on the internet! 

Siblings

 

 

Be scared...be very scared

If you're not already spooked by health care, you will be if you read the Change of Shift Carnival over at Wretched Reality Rounds. The theme is: "What's so scary about health care?" Read it if you dare!

If that's not enough blood and  gore for you, then go to the carnival at Weird Science & Sensibility* and read about the Lamaze Deathly Birth Practice #2: Lie down, don't move, and be very scared throughout labor.**

* Science & Sensibility
** Lamaze Healthy Birth Practice #2: Walk, move around, and change positions throughout labor

A tale of two doctors

Sharon Astyk's post A Tale of Two Hospitals inspired me to write this post about two physicians' wildly different recommendations for the same problem.

About two months ago, I visited a vein clinic for my varicose veins. I developed spider veins when I was pregnant with Zari, but during Dio's pregnancy varicose veins popped all over both legs. I had to wear thigh-high compression hose every day, and one of the varicose veins even developed a blood clot.

I met with Dr. F, a distinguished looking gentleman in his sixties with graying hair and a neatly trimmed beard. His vein clinic, located in a wealthy suburb of a very large metropolitan area, was filled with glossy advertisements for cosmetic procedures of all kinds: legs, face, skin, breasts.

My first visit with Dr. F was a very short consultation. I told him the history of my vein problems, that I wanted to have several more children, and that I was hoping to address the varicose veins now so they wouldn't be such a problem in future pregnancies. I'm especially concerned about getting blood clots again in my veins, since it happened when I was about 7 months pregnant with Dio and is likely to reoccur. I was able to schedule an ultrasound examination of my veins and a longer consult for the same day.

When we met again after the ultrasound, he presented his findings: both of the great saphenous veins had malfunctioning values and blood was flowing backwards as a result (no surprise). He recommended a minimally invasive vein surgery for both legs. In his practice, this involves undergoing two outpatient surgeries under general anesthesia, one surgery for each leg. They collapse the top of the vein with a catheter that emits radio waves, then remove all of the smaller branches through tiny incisions. He said they only do one leg at a time because the risks increase the longer you're under anesthesia. Insurance would cover the treatment, but with my 20% copay it would still be quite expensive. I'd have to pay for everything twice: anesthesia, surgery center, physician's fees, etc. In addition, he charges a cosmetic fee of $400 per leg "because we're very meticulous with our surgery and take great pains to get all the small veins out."

I asked Dr. F if other therapies would be effective, such as sclerotherapy (injecting a small amount of solution into the vein, which causes it to collapse). He said that there's a high likelihood of recurrence with sclerotherapy and my best bet is to remove the great saphenous veins entirely. Sclerotheraphy is also not covered by insurance, even if it would correct a medically indicated problem--and I wondered how much that had to do with his recommendation. I asked him what the chances were of getting varicose veins in future pregnancies if I did the surgery, and he said it was not likely to reoccur.

Dr. F said I'd need to wean my baby before the procedure, or pump & dump for three days, because of the general anesthesia. I was quite surprised to hear this, since I had read that it's safe to breastfeed after GA. I mentioned this to him, and he said "if your pediatrician or midwife says it's okay, then go ahead. But I tend to be conservative and recommended weaning, just to be safe." (I later asked my CNM, who is also an IBCLC, and she said that I was absolutely correct. You can breastfeed after general anesthesia as soon as you're awake enough to hold your baby.)

***Is it "conservative" to recommend weaning before general anesthesia, even when the medical literature indicates that you can safely continue breastfeeding right after the surgery? I'd call it "dangerous"and "radical" to recommend weaning, not "conservative."***

And here's where my visit got really weird. He kept patting me on the shoulder, in a grandfatherly "don't worry your pretty little head, we'll take care of you" manner. It seemed very much like an act to me. And then Dr. F said that he would--this is an exact quote--"work hard to preserve the youthful appearance of your legs."

I replied: "I don't care at all about that."

He had committed a grave miscalculation, assuming that I was distressed by the appearance of my legs. I don't care one bit about how they look. I just want them to stop hurting. I don't want to have to wear support hose during every future pregnancy. I don't want to get blood clots again.

I went home to think about his recommendations. I was glad to know that insurance would cover the treatment, although not happy about having to go under general anesthesia twice, let alone the cost and hassle of two procedures. But I was also under some time pressure; if I was going to do something about my veins, I wanted to get it done before the end of this year. If not, my insurance deductible would kick in again at the start of the year and it would be even more expensive.

I was talking about this visit--especially the "preserving the youthful appearance of my legs" part--with a friend. She recommended talking to her OB, Dr. W, who recently became specialized in varicose veins. She told me he was really upfront, matter-of-fact, and wouldn't try to sell you on anything. I could use some of that after being patted on the shoulder by Dr. F. I scheduled an appointment and had my records sent over.

Yesterday was my visit with Dr. W. His clinic had dark plum colored walls, floral upholstery on the chairs, and no advertisements or brochures except one TV monitor displaying women's health advice and occasional ads for things like breast pumps or flu shots. I met with Dr. W first in his office. Dio came with me, while Zari was playing with her cousins at the children's museum. While I was waiting for him to arrive, I scanned his bookshelves. I noted the familiar obstetric classics such as Williams Obstetrics and laughed at the thought of adding Holistic Midwifery to his collection. He came in and said hello, reaching and touching my shoulder. Not again! I thought. I quickly extended my hand to shake his.

*** Is there something in my demeanor that inspires older men to pat my shoulder?***

I introduced myself and my vein issue briefly, and we moved to an exam room. He took a look at the veins in both legs, then spent several minutes reading through my records from Dr. F's clinic. He looked up and said, "This is going to sound cynical, but..." He gave a long explanation of how insurance only pays for certain varicose vein treatments, and that physicians often look for a problem with insurance reimbursement in mind. He said my case was a classic example of that. Yes, both my legs DO have varicose veins and hence the malfunctioning values, back flow of blood, etc. But the bundle of veins behind my left leg--the ones that got the superficial blood clot--is most likely not part of the greater saphenous vein. He saw nowhere in Dr. F's report any procedure that would have fixed that area at all--the part that gives me the most grief! There's a bundle of nerves right behind the knee, and in order to avoid hitting those nerves, vein specialists will usually avoid vein ablation in that area in favor of sclerotherapy (which, if you remember, isn't covered by insurance even if it is medically indicated).

It kept getting better. Dr. W said, "You said that you could live with this if you knew you weren't having any more kids. But honestly, I'd advise you get get it fixed once you're done having kids. There's a very high chance of reoccurence. Even if you remove the entire vein, the compensatory veins might very well develop varicosities." Darn. And he told me: "I know you're not going to want to hear this, but you'll probably need to wear compression hose every time you're pregnant." Double darn.

And then he asked about what procedures the vein clinic had suggested. I told him that it would involve minor outpatient surgery, under general anesthesia, in a surgery center, and that I'd have to do both legs separately. Dr. W seemed about ready to fall off his chair. "Really? There is NO way I'd do general anestehsia for this kind of thing! We do a similar procedure right here in our office with tiny injections of local anesthesia. And going under general incresases the risk of deep vein thrombosis!"

I asked him what he'd suggest doing next. He wants to take another look at the varicosity behind my knee and see how/where it inserts into the venous system and then we can go from there. He also said to go ahead and get a 3rd, 4th, or 5th opinion if I wanted. I scheduled the ultrasound for next week and am curious to see what he suggests. It seems, though, that I might just need to live with my varicose veins until my childbearing years are over. Which really stinks because it is no fun wearing compression hose. It was bad enough in the winter and early spring, but I simply cannot imagine wearing those and being pregnant in the summer.

The icicng on the cake, though, was when I glanced at my records from Dr. F's office. I was reading them upside down, and one particular phrase caught my eye:

"...the patient came to me in acute distress..."

Seriously? Acute distress? Those of you who know me personally can vouch for the fact that I am very level-headed and not inclined to overt displays of emotion.

Sorry, Dr. F, but I am not your damsel in distress.

6 months old!

Dio is six months old today! So what's new with him? He can sit up quite well without any support.

He topples over every so often.

When he gets really excited or worked up, such as in a noisy crowd, he yells/grunts at the top of his lungs--kind of like a weightlifter. He likes to scratch things over and over by opening and closing his fists. He likes to wave his right arm up and down repeatedly, hitting his leg or whatever surface is available. He's super strong and wiggly. The other, as I was trying to swaddle him for a nap, I thought "this is like trying to swaddle a python!" He's having fun with Zari. I tell her: "your job is to play with Dio and bring him toys." When I need to get some sewing done, I'll bring both kids upstairs and put them on the bed with educational videos (French language DVDs or Signing Time) while I work next to them. Dio will watch for quite a while and sometimes smile or laugh at what he's seeing.

Babies often change their sleep patterns, and at the moment Dio is waking up more frequently. I haven't had a long first stretch for a while; it's pretty much every 3 hours or less all night. He still wakes up just as often even when he's in another room with a fan running...but I am not complaining, really, since I love snuggling with him at night. There are worse things than nursing a baby a few times at night. And it's the best to wake up every morning and see his huge grin. It's as if every morning is the most exciting day of his entire life and he just can't stand it.

I'll try to get some pictures taken soon. We have family visiting for a few days. Zari and Dio are loving all of the cousins. Tomorrow we're going to the children's museum that's an hour away. I also have an (second opinion) appointment with an OB/vein specialist about my varicose veins...more about that later.

Thinking, no conclusions yet

I like reading things that make me think, hard. That make me examine my assumptions and evaluate what I'm doing and why. Things like one day in a life by Sweet & Salty Kate. I have a lot of complex responses to her post.

I fall somewhere inbetween the "you can't plan or control anything; birth is just one day and mothering the baby afterwards is the most important thing" camp and the "your birth is the most important event in shaping your life as a mother" camp. I think it's because birth itself is so complex and multi-faceted. There's the unpredictable, wild, ferocious nature of birth--sometimes generous, sometimes harsh and unforgiving--that we can never adequately plan or prepare for. That's where Kate, and many of her fabulous commenters, are coming from.

But there's also the reality that certain choices generally--not always, but often--lead to certain consequences. If you choose an elective induction at 38 weeks with a closed cervix...chances are you'll end up with a highly interventive labor and a c-section because of the failed induction. If you seek care with a midwife or physician who has a low cesarean and intervention rate...chances are you'll have a smooth, uncomplicated, spontaneous labor and birth. If you seek care with a busy OB practice with an assembly-line approach to pregnancy and birth...chances are you'll be sent down that assembly line too.

But in all of those cases, there will always be exceptions and surprises. And there's where it can be so hard to make any kind of generalization about birth. Because there are women who have elective inductions at 38 weeks with a closed cervix and their baby pops out after a quick labor. Because some women will have highly complex, complicated births even when they're planning for it to be as natural as possible. Because some women are extremely satisfied with their assembly-line care and rave about how fantastic their OB was. So whenever you try to say anything definitive about birth, someone will always pop up with an exception.

In Jan Tritten's case, the sentence that prompted Sweet & Salty Kate's post was poorly worded. I understand, though, why she might have said something like this. After all, her life's work surrounds birth. She's a midwife and editor of Midwifery Today. In her world, birth is highly significant, often the pivotal event in a woman's life.

I was wondering: how would I say that my children's birth ranks in importance in my life? It's hard to quantify. My own journey wasn't just about "the birth," but the entire process of thinking and researching and planning--not just for the tangible, physical birth itself, but also for the spiritual process of becoming a mother. I deeply treasure the memories of my children's births. I love that my labors were experiences predominantly of love, peace, and calm. I love that I was able to meet and overcome the challenges of labor and birth and find strength in other areas of my life, knowing that if I could give birth to a baby I could certainly do ___ (run a half marathon, finish my dissertation, etc).

Making a woman's birth as positive and empowering and enriching as possible is important. Why not strive to make every birth as good as it can be? Why make anything unnecessarily difficult or painful or traumatic? But of course giving birth isn't the one definitive moment for all women, even though for some women it is. If you speak to the women at Solace for Mothers, you'll learn how a traumatic birth experience can haunt someone for years. If you were at the International Breech Conference, you heard women still deeply affected by their birth experiences, years after the fact.

So how do we reconcile the complex natures of birth--the parts that you can't plan for, and the parts that you can?

Things that make me smile

I came across three things today that made me smile.

First, NursingBirth's post How one mom “Walked, moved around, and changed positions” to a successful hospital VBAC! This was written as part of Science & Sensibility's Healthy Birth Blog Carnival #2 on moving, walking, and changing positions during labor.

Second, the National Advocates for Pregnant Women have announced the winners of their writing contest. The contest "asked law students to address the statutory, constitutional, and/or human rights arguments that can be made to challenge the trend of banning pregnant women from having a vaginal birth after a caesarean section (VBAC)."

And finally, this lovely short film Too Big For My Skin. Thanks to TopHat!

Conference pictures

I didn't have a camera with me, but Lisa Barrett snapped a few photos of me trying to keep Dio occupied during the International Breech Conference. Be sure to read her writeup of the conference (and photos too!)

Advice and information needed

I've received several requests for information and resources about VBAC, VBAMC, twins, Bandl's Ring, and shoulder dystocia. I can't personally respond to all of these requests but I didn't want to just let them go unanswered. So I'm asking for your help! Several of the questions are fairly brief and it's hard to answer them without more specifics and background information. Nevertheless, let's see what we can do when we all put our heads together.

Request #1:
I have a friend that I'm trying to help. She is due in December with her third child. She's had 2 prior c-sections and is coming to find out that she does not want a third. I have some questions about what resources I should help her with and what she should look for in hospital policy.

Request #2: 
My best friend is having twins. She is currently 33 1/2 wks. Both babies are breech. Dr's of course want to section her bc of it. She is wanting true info on the safety of section versus breech birth. (I don't think there are any good studies on CS vs vaginal birth for breech twins. I mean, the Hannah Term Breech Trial was the biggest of its kind and that was only applicable for term, singleton breech babies.)

Request #3:
I have been curious about VBAMC for obvious reasons...Also, Rixa. Do you know where I might find info about Bandl's Ring? (if she is who I think she is, she's had 2 c-sections, and during the last one they discovered a Bandl's ring)

Request #4:
I have a question for you regarding shoulder dystocia. I have had 2 natural births, and both of them my daughters shoulders got stuck, it seemed they never rotated properly. The second time it happened I was in a hands and knees position though slightly upright leaning into an inclined bed. I was wondering if you could give me any information as to the best way to deal with this if it happens again (I'm pregnant with my 4th baby and a little worried about it happening again). Could it be that I am pushing to urgently and not giving the baby enough time to rotate before the shoulders pass? Thank you so much for your time!

Request #5:
I am interested in what the recent research shows about Pitocin administration and risk of uterine rupture in patients attempting a VBAC. For some reason, I thought that Pitocin was contraindicated for VBAC moms, but my OB tells me that she is comfortable administering Pitocin to augment (but not induce) labor. I'm not sure how I feel about this. I've done some of my own research, but find mostly mixed reviews. So, I thought I'd ask you since you are very familiar and up to date with obstetric research.

In case you were wondering about my background, I am expecting my 2nd child, in about 3 weeks. And I'm preparing and hoping for a VBAC. I had a c-section with my first for "failure to progress". It's a long story, so I'll try be concise: my water broke spontaneously 8 days before my due date; I waited for 12 hours for labor to start and had no contractions; was started on Pitocin-- labored on Pitocin for 12 hours and dilated to 1/2 centimeter; turned down the offer to do a c-section (since it had been 24 hours and they worry about infection risk), but I wanted to give labor a real chance; had Cervidil placed on my cervix and waited for 12 more hours-- no contractions; after 12 hours of Cervidil, I was dilated to 2.5 centimeters and "soft"; labored on Pitocin for 12 more hours and got to 5 centimeters when I stopped dilating. I never got an epidural and was up and moving during all the laboring; and by the time I got to that point, I was exhausted and it had been over 48 hours since my water broke, so I opted for a c-section. It was a tremendous disappointment and I felt like I never really got to do what I was preparing for. I still have no idea why my water broke, why my body didn't labor on its own, or why it didn't respond favorably to Pitocin. But, my doctor is very supportive of a VBAC. And I feel very lucky to be delivering at a hospital that does support VBACs.

Anyway, I guess the reason why I'm so worried about Pitocin is because I can't help but wonder what I'll do this time around if that situation happens again-- it's the only frame of reference that I have, you know? I've heard other doctors and other CNMs say that Pitocin can help VBAC moms, but I'm not necessarily interested in an opinion, I'd like to know what the research says. I am still just hoping and praying that I will go into labor on my own and that my water won't break until I'm far along, but I want to be prepared in case labor does slow down and/or stall. In fact, I just checked out some books on Acupressure because I've been told that it can help during labor. Do you have any other suggestions, I'd like to have more cards to play than just the Pitocin card.

I spoke with this last woman on the phone and gave several things to look into if this same situation arises, including nipple stimulation/breast pump, waiting a bit longer for labor to start on its own, asking her doctor about the possibility of low-dose pitocin, etc. We also talked about things that are theorized to make the amniotic sac stronger or prevent PROM. I wasn't able to find my files on UR rates and Pitocin administration during a VBAC, although I know that information is out there.

International Breech Conference: Day 2 continued

Friday, October 16, 2009

After the German physicians spoke, the morning concluded with two panels. The first panel, "Fear and Faith: The Breech Experience," was made of five women who had breech births. Almost all of them were forced/coerced/cornered into cesareans at some point. They spoke eloquently about their desperate search for a care provider. Of being told at the last minute that no one was willing to attend their baby's birth unless they agreed to a cesarean. Of being strapped down to a table, legs tied together and told they were killing their baby, pushing their baby out to the hips, then having the baby pushed back inside them and an emergency cesarean performed under general anesthesia. The midwife who attended Dio's birth was on the panel, and that last situation happened to her first breech baby. She's had three breech babies total, of five children. Hearing these women speak, and at times break down in tears over their treatment, was eye-opening for the physicians present. They tend not to see the back story of women's pregnancies and births.

Some notable comments from women on the panel:

• “Women get the birth that their trusted care provider thinks they ought to have.” Robin Guy
• “Women do not belong on the alter of obstetric convenience.” Robin Guy
• "Cesareans are not the root of all evil, the manipulation of the cesarean is what we struggle with."
• “When it’s the care provider’s lack [of skills or experience], it is not a choice.”
• "I tried to create choice for myself because my midwife was unable to provide it."

The next panel had five physicians (4 OBs and 1 family doctor) discussing "Challenges and Solutions for Offering Vaginal Breech Birth in the Hospital." Panel participants were: Dr. Stuart Fischbein of LA, Dr. Michael Hall of Colorado, and three Canadian physicians whose names I can't remember. The panel was moderated by Canadian midwife Betty-Anne Daviss, which was great fun, since she gave them some very challenging/uncomfortable questions. Some emerging themes: Canadian solutions won't work in the US, with our fractured, private system of hospitals and health care. For example, one of the Canadian physicians remarked that he's on salary and has an academic appointment, so there is absolutely no financial incentive for him to do a cesarean. There was widespread agreement that simulation will need to be a part of breech training in the 21st century. There was discussion of the pressures to practice a certain because of litigation. And two of the doctors mentioned that parenting was as important as being a doctor; at times the lifestyle of always being on call is hard for them and their families. I won't even try to summarize everything they said, but I will include this lovely quote from Dr. Hall:

"You can pull the breech into trouble, but the mother can’t push the breech into trouble.”

After lunch were another series of breakout sessions. Julie and I presented our research about women's experiences of breech birth. More on our conclusions later. Because I was presenting, I missed the sessions on simulation training, but I talked with other people who went. They said it was great, and the breech birth simulator can do hands & knees, not just on-the-back.

The last speaker was Ina May Gaskin. Her presentation was supposed to be about "Breeches at The Farm," but it was mainly a rambling, train-of-thought talk about birth. It would have been great as a story-telling session, but it wasn't appropriate in the context of a conference on breech birth with a mixed audience. I wanted to know more about how they do breeches and came away disappointed. I don't want to dismiss her important role in the renaissance of midwifery and home birth in the States, but her presentation was very disappointing. Julie leaned over to me and said, "No wonder doctors don't listen to midwives. They're not even speaking the same language!" Jane Evans' presentation epitomized the very best of midwifery, while, frankly, Ina May's was quite lacking. If I had been a physician, I would have come away from her presentation with a very poor impression of midwifery.

That said, I was interested to learn that The Farm midwives gradually came to use a kneeling or hands & knees position for breech. They used to do breeches with the woman sitting down, leaning back slightly, but now they have come to prefer all fours. They don't dictate this position, though, and some women will choose to move into other positions as they push the baby out.

Right after the conference, Julie and I caught a bus back to the airport. (I LOVE public transportation.) We got sent from kiosk to kiosk, and finally were directed to a check-in desk. At this point we were exactly 3 minutes past the cut-off time to check in for international flights. Julie was told by one particularly mean clerk that it was too bad, we'd have to miss our flights and stay overnight. Luckily I had Dio with me and he charmed the woman at my check-in desk and she let us through. It's nice to travel with babies!

International Breech Conference: Day 2 (The Germans)

Friday, October 16, 2009

My co-presenter and I hurried to arrive on time in the morning, because Dr. Frank Louwen was speaking about "Breech Delivery in the 21st Century." He is a German OB from Frankfurt who is doing breeches with the mother in a hands & knees position, rather than on her back. At the start of his presentation, he expressed thanks for being invited to this conference and hoped that it would help change minds. He commented that it's better for women to give birth in upright positions--but quite uncommon from obstetricians to acknowledge this.

When he first came to his hospital, no one had done vaginal breeches for 30 years. So first he had to convince his maternity unit to start doing breeches again. They did a pilot study of primip vs multip vaginal breeches and, so far, have found that primips do just as well.

He started with the story--which at some point will probably reach semi-mythological status!--of how he first thought of doing breech births upright. One day he had his obstetric textbook open to vaginal breech birth. He was on the phone, walking around, when he glanced at his book from the other side of the desk. He saw the woman giving birth turned 180 degrees--almost a picture-perfect of hands & knees birthing. He had an "aha!" moment. It's fairly common for women to give birth to vertex babies in Germany in upright positions, but not breeches. So the first thing was to see if any woman was willing to humor him. He approached one with a breech baby and said "I'd like to try this, but I've never done it before. Are you on board?" She said "sure! let's give it a go!" He didn't have to do any manipulations on the baby at all, and the birth turned out wonderfully. Several hundred upright breech births later, he's convinced that it's a much better way to birth a breech.

During his presentation, he showed slides and videos of women in his hospital birthing breeches on hands & knees. They were pretty mind-blowing. I've seen this sort of thing before, but only in home birth videos. To see women doing this in a hospital setting, with a kind, calm, supportive staff, was beautiful.

Upright breech births in his clinic are done with very few maneuvers, if any. Except for very unusual cases--for example, a trapped head or nuchal arms that don't resolve on their own--the only time they might touch the baby at all is to do "Frank's Nudge" or the "Louwen maneuver." If the body births but the head seems to need a bit of assistance, he presses in at the baby's shoulders well beneath the clavicle, which causes flexion of the head and the baby delivers. It appeared that he used very little pressure. The technique is to press the shoulders back toward the mother's symphysis pubis (which is behind the occiput) and this causes the head to flex. There is no downward traction and the technique is so fast it is hard to catch it on some of the videos until you know exactly what you're watching for.

He commented that it's great to see those nice, easy breech births that happen 80% of the time. But what about those scary situations that give breech birth a bad name? He then showed us videos of some very complicated breech births in H&K: nuchal arms, or the baby born to the umbilicus but then stuck there, despite strong maternal pushing efforts. And it was amazing to see how easily and gracefully he was able to resolve these complicated situations, with a minimum of manipulations (thanks to the maternal positioning). Remember stillbirth #1 from Day 1 of the conference--the baby in the TBT that was born to the umbilicus, then got stuck, so the doctor pushed the baby back up and did a c-section? Well, he showed us this same situation in his clinic, except with a few very gentle maneuvers he was able to deliver the baby vaginally. He remarked, "in the Hannah trial, this baby died."

A few other things from his presentation: he never does episiotomies with breeches (vigorous cheering and applause from the audience). You must keep your hands off the baby. No touching--it will just complicate things. And hands off the mother's bottom, unless she already has a laceration, at which point some gentle counterpressure might help her from tearing farther. I loved watching the videos, because they did a lot of touching--gentle, reassuring touch on the mother's back or legs. If the baby hasn't been born within 4 hours after the mother has reached complete dilation, they will move to cesarean section, since a prolonged pushing stage is a risk factor for vaginal breech birth. (This is more generous than the new Canadian guidelines. The SOGC notes that a passive stage between full dilation & pushing can last up to 90 minutes. Then, after the mother has been actively pushing for an hour and birth is not imminent, the SOGC recommends moving to cesarean.) Don't break the mother's amniotic sac--that offers the best possible protection for a breech baby.

Dr. Louwen has been studying the results of breech births in the hands & knees position and these are his preliminary findings (of over 300 births):

• Hands & knees seems to reduces fetomaternal complications
• Umbilical cord is less influenced by compression in stage II
• Incidence of maneuvers is reduced, with less perinatal and maternal morbidity

He's working on planning a multicenter RCT of maternal position (hands & knees versus on-the-back) in vaginal breech birth and has invited interested midwives or physicians to participate. This, he hopes, will reveal the real complication rate of vaginal breech birth, when women are birthing in the best position for themselves and their babies.

I know this is already turning into a novel, but I also wanted to comment on Dr. Louwen's demeanor and personality. I would describe him as jovial, kind, and gentle. This comes from watching him speak, of course, but also from seeing him in action (or rather, non-action most of the time) in the birth videos. Being gentle, patient, and calm are intangible qualities, but probably just as important in the success of a birth than any newfangled method or technique.

After his fantastic presentation, his colleague Dr. Anka Reitter discussed whether prenatal pelvic MRI for primips can help reduce the incidence of emergency c-sections in vaginal breech births. Dr. Reitter was trained in the UK before the Hannah trial and saw lots of vaginal breech births. She has found that, in their unit, primips can birth breeches as well as multips. They also do vaginal breech births for primips with twins (one or both breech). If ECV is not successful, they offer MRI scans to primips or "functional primips" (i.e., a woman who has never had a vaginal birth before) with full-term breech babies and recommend surgical delivery for mothers with an obstetric conjugate of less than 12 cms (pretty sure it was the obstetric conjugate, but don't take that as gospel!). From their preliminary study, they've found that MRI for primips may help reduce the number of emergency cesareans during an attempted vaginal breech birth. She also cited some other breech studies currently underway. When comparing H&K to on-the-back positions, they found that H&K significantly shortens the 2nd stage (pushing). The average 2nd stage for H&K was less than an hour, while the average for on-the-back was twice as long!

International Breech Conference: Day 1

Thursday and Friday were a whirlwind of listening, learning, and speaking. I went to every plenary session and then had to make the hard choice of which breakout sessions to attend. I'll give a short summary of each presentation I attended on the first day of the conference.

Thursday, October 15, 2009:

Dr. Andre B. Lalonde, Executive Vice-President of the Society of Obstetricians and Gynaecologists of Canada (SOGC) since 1991. He discussed how we came to the current approach to breech birth. I don't have notes on this presentation so I can't give much more specifics (they're all running together in my head at this point).

Dr. Marek Glezerman spoke about "How to Save a Vanishing Obstetric Skill: Vaginal Breech Delivery." He emphasized the immense challenge in bringing back vaginal breech birth, since with the deskilling of obstetricians and residents, it will take a long time and a lot of births for physicians to re-gain the appropriate skills and volume of births. He spoke of the importance of simulation training for breech birth; since opportunities to witness and assist at "real" vaginal breech births are fairly scarce, simulation training can help birth attendants gain the necessary skills and practice in order to keep calm and know what to do. He also explained the weaknesses and flaws of the Hannah Term Breech Trial.

Betty-Anne Daviss, an Ontario midwife, researcher, and professor at Carleton University, gave an entertaining presentation about "Choosing the Myths and Fears We Live By"--part scatterbrained comedy, part sound & light show (complete with a gigantic pelvis & Homer Simpson "baby" doll sitting breech in said pelvis), and part call to arms. She challenged the SOGC's position that breech birth is best conducted in a hospital setting. She spoke of the 4 "Ps": Pelvis, Passenger, Power, and Psyche. She noted that in Europe, obstetricians tend to focus on the pelvis. MRI scans of the pelvis are fairly common there, whereas they're rarely done over here. North American obstetrics places most emphasis on the passenger: estimating the baby's weight on ultrasound, intervening for suspected fetal macrosomia, etc.

So what did she say about breech specifically? Quite a bit, so I'll try to cover the main points.

• She first learned about breech in upright positions decades ago from Guatemalan midwives. 
• She has traveled to many European countries to learn about breech birth and found that many medical centers there declined to participate in the Term Breech Trial because the study's protocols did not match their evidence for successful vaginal breech birth. 
• She is quite skilled in vaginal breech birth and recently attended 20 vaginal breech births with Dr. Frank Louwen in Frankfurt (who was the "star" of this conference with his research on the hands & knees position for vaginal breech birth). 
• She noted that it has traditionally been--and still is--very hard for obstetricians to listen to midwives. Midwives, for example, have been doing breech births in upright positions for, well, probably as long as midwives have been around! And they've published and spoken about it in the Western world for the past two decades or so (Mary Cronk, Jane Evans, Maggie Banks, etc). But--and these are my observations here, not her words--it wasn't until a German OB began doing upright breech births in a medical center that other doctors paid notice. 
• Despite the de-skilling of midwives and physicians in vaginal breech birth, mothers themselves have never been de-skilled. Their bodies still know how to give birth to breech babies.  

At the Panel on Complementary Therapies and Breech Turning Techniques, I particularly enjoyed CNM Jay MacGillivray describing how she melds technology and intuition when doing ECVs. She uses ultrasound to visualize fluid pockets, see where the cord is, and find the location of the placenta, which she draws on the woman's belly. She does ECVs in a darkened, quiet room in her clinic where the mother is warm and comfortable. After she has mapped out the baby, placenta, and fluid pockets, she closes her eyes and gently turns the baby around, following the path of least resistance. When she's trying to turn a frank breech, she'll feel for the legs and gently tickle the baby behind its knees, causing the baby to fold its legs. She doesn't see ECV as a procedure done to the woman, but as a cooperative effort between mother, baby, and practitioner. She'll often do multiple ECV attempts, starting at around 35-37 weeks. I think the most she ever did on one baby was 6!

Her comments led me to wonder if the so-called divide between technology and intuition (you know, the discourse of "artificial/natural") is really a false distinction. I love how she melded the use of technology with indefinable, intuitive, hands-on skills.

After lunch, we had a choice of five different breakout sessions. I went to Michael Hall's presentation "Breech Vaginal Delivery: Tips, Tricks, Techniques." He's an older OB near Boulder, Colorado and has always done vaginal breech birth, in large part because of continued demand for his skills within his community. He remarked the Boulder is a particularly progressive community, with large numbers of doulas, midwives, and educated women who demand options. He trained in Oregon, where he says he learned how to do normal vaginal births with a midwife. He's also married to a hospital-based CNM. He's well known as a breech-friendly doctor, so most of the breeches in his area get funneled down to him. Which is great, because doing 20-30 breeches a year keeps his skills intact.

I had to laugh when he prefaced his presentation, almost apologetically, with the caveat that this was the "traditional" way of doing breeches (i.e., the woman on her back with legs up in stirrups), since that was the way he was taught. He mentioned the new way of doing breech births on hands & knees. My paraphrase: "well, this is the old way of doing vaginal breech, since that's what I know, but we'll be learning all about the new way tomorrow."

Dr. Hall's criteria for vaginal breech birth include: EFW between 2000-3500 grams, frank or complete breech, pelvimetry to determine an adequate pelvis (he emphasized that it's extremely rare to come across a contracted pelvis), flexed head, progressive labor loosely aligning with Friedman's curve, normal fetal monitoring with good variability (so I assume that means cEFM), an experienced operator with good forceps skills, and true informed consent. He emphasized that there is always room for flexibility in these criteria and that it's important, as a provider, to trust your instincts and to respect your own comfort zone.

So I'll walk you, very briefly, through the mechanics of how he does VBB. The mother pushes the baby out on her own with no traction or episiotomy, until the baby is out to the umbilicus. Dr. Hall rarely does episiotomies and, in those rare occasions, never when the baby is rumping or coming out to the umbilicus; if you do an episiotomy at those points, it will just create more problems. He kept emphasizing over and over: don't touch the baby, keep your hands off and be patient. When the mom is on her back, you'll see the baby come out, back up, almost straight upwards. The legs will fall out on their own if you're patient. If the baby comes out to the side, rather than back up, that means it has a nuchal arm. If the arms do not emerge spontaneously, he gently releases the anterior arm, rotate the baby, and release the other arm. At this point he papooses the baby's body in a warm towel and holds it slightly elevated. The last step is to gently push down on the perineum (i.e., with your fingers inside the vagina, pushing down towards the rectum) and the head will release as he guides the baby's body following the pelvic curve. 99% of breeches will come out with no further assistance. Low 1-minute Apgars may be common; just be patient and let the baby get its blood (which means the cord needs to stay intact) and it will perk up. You also need to train your nursing/pediatric staff to be patient, as they'll want to get their hands on the baby, while it just needs some time and a nice pulsing cord!

If the head is truly stuck, Piper forceps may be needed (he has used them 3 times in 30 years). The application and traction should be easy, with no resistance. If it's hard to do, then you're not doing it right! Dr. Hall lamented on the lack of forceps training among new OBs. Many OB residents are only trained to use a vacuum, which of course isn't of any use for a breech baby.


Dr. Hall's hospital recently made him start doing all vaginal breech births in the OR--mostly a push from anesthesia--which he doesn't like because, in his experience, you'll have plenty of warning that a c-section is necessary with a breech baby. If the baby is out halfway and is stuck, you can't do a c-section at that point anyway. (In the next presentation, Dr. Menticoglou gave an example of one physician who did just that, with disastrous results.)

Dr. Hall sees vaginal breech birth as an art: you have to be facile with your fingers, maintain humility, and keep from getting overly excited. That means someone in the room needs to maintain a quiet, calm atmosphere. Sometimes he'll send an overly anxious nurse or pediatrician "to get the Piper's forceps" but really it's just to get them out of the room! He concluded his presentation with strong support for simulation training for vaginal breech birth.

One thing that made me laugh was his hands-on demonstration of the mechanics of breech birth, using Betty-Anne's oversized pelvis and Homer Simpson doll!


After that interesting breakout session (sadly, I missed Lisa Barrett's presentation on "The Physiological Face of Breech Birth" because it was at the same time), we listened to Dr. Savas Menticoglou talk about "The Term Breech Trial: Perspectives from participating units." He reviewed the initial and 2-year followup data from the Hannah trial, as well as several commentaries (Keirse, Glezerman, Kotaska, etc). He analyzed all of the deaths reported in the TBT, especially those within developed countries. For example, there were 3 reported stillbirths. In stillbirth #1 (Canada), a primip was induced at 41+5. She had an epidural and pushed the baby out to the umbilicus, but could not get the baby out any farther. At that point, the attending physician made no efforts to do traction or any kind of assisted breech delivery/extraction--instead, the physician pushed the baby back into the uterus and performed a cesarean. The baby was dead by time the surgery was done. Stillbirth #2 was twins (and should not have been included, since this was a study on singletons) and, if I remember correctly, the first twin was a very small baby, quite macerated, and breech. Stillbirth #3 took place in Romania, where they could not do a cesarean within 10-20 minutes as per the Hannah requirements. It was a primip who went into spontaneous labor at 41 weeks with a frank breech. For the last 20 minutes of pushing (48 minutes total), the attendant could find no heart tones and they did not know if the baby was alive or dead until it was born. 

Okay, sorry for all these gory details but he used these examples to show how, in all 3 cases of stillbirth from the TBT, they should not have been included because they all violated one or more Hannah protocols, particularly the one calling for experienced, skilled physicians prepared to deal with breech births.

Next, he spoke about other recent studies of breech births from different European countries, including the PREMODA study from France and Belgium. Finally, he discussed the process of coming to the 2009 SOGC Breech Birth Guidelines and the various committees it had to go through. There were 10 physicians working together to come up with the new guidelines, coming from widely varying perspectives. Some felt that VBB was quite safe, while others felt strongly the other way.

Finally, he reviewed some of the historical literature and statistics on breech birth, trying to figure out the intrinsic risk of vaginal breech birth. He also had some fascinating commentary about our cultural expectation of perfection: if we want to believe that no "normal" baby should ever die or be damaged during labor, we are going to have to accept an extremely high cesarean rate.

The next presentation was a delight after the more somber, numerical approach of Dr. Menticoglou. We listened to Jane Evans, a British midwife, talk about the "Mechanisms of Spontaneous Vaginal Breech Birth." Of all of the midwives' presentations I attended, hers was the most compelling, most eloquent, and most adept at addressing the very wide range of attendees (OBs, medical students, nurses, midwives, doulas, and lots of parents). She defined spontaneous breech birth from a midwifery perspective: spontaneous onset of labor, no induction or augmentation, labor progresses smoothly (contractions become longer, stronger, and closer together), the presenting part is accompanied with dilation of the cervix, and, in second stage, the expulsive efforts of the mother, together with the baby's movements, result in the baby being born without traction or manipulation from the attending practitioner. She stressed that women have been delivering their babies in upright positions since, well, forever, until we started interfering in the last few hundred years.

Jane Evan's presentation covered the mechanism for how the baby negotiates the pelvis in a breech presentation. She used a life-size pelvis and doll to illustrate, step by step, along with videos and pictures of women birthing breech babies in upright, hands & knees positions. It was fascinating to learn how the baby rotates through the pelvis, step by step, with each movement optimizing the shape of its body with the shape of the pelvis. I won't go into too much detail with each of the intricate movements through the pelvis, but there were a few lovely phrases that I just have to mention. 

• "The pelvic floor is a lovely, beautiful valley”: said as the presenting part hits the pelvic floor and begins rotating
• "Rumping": the term for when the breech baby appears at the perineum ("crowning" for a vertex baby) 
• "Oozy births": Jane Evans mentioned that you'll likely see lots of baby meconium and possibly some maternal poop as well. Don't wipe anything, because you don't want to trigger the mother's anal sphincter to close at the moment when she's pushing out her baby. Also used to describe how the baby's body often oozes out of the mother's vagina.  

The last speaker on Thursday was Dr. Robert Gagnon discussing the SOGC's new breech guidelines. He was one of those physicians who completely abandoned vaginal breech birth when the preliminary results from the Term Breech Trial first came out. Now he wants to reintroduce vaginal breech birth, after being persuaded by the 2-year followup to the TBT, by several publications discussing problems with the TBT and the preliminary analysis, and by more recent studies such as PREMODA that don't show an elevated mortality or morbidity rate due to VBB. He noted that at his hospital, 20% of cesarean sections are done for no other indication than breech presentation. He discussed some of the potential risks of VBB (increased risk of asphyxia, birth injury due to head entrapment, cord prolapse), stressing that these risks are about the same as with vertex births. He discussed the years of controversy and conflicting findings following the end of the TBT. He also stressed that cesareans are not without risk, especially multiple repeat cesareans (including higher rates of placenta previa, accreta, hysterectomy, and maternal death).

One comment I found particularly interesting, given my academic and personal interest in unassisted birth, was that if we require all women to have cesareans for breech presentation, "patients who refuse cesarean may give birth at home unsafely and unattended." This is theme that kept cropping up. I am glad that unassisted birth has made it on the Canadian obstetrical radar. While I am hesitant to make any blanket statements about the safety of unassisted birth, I strongly feel that no one should make that choice because of a lack of options.

Another poignant comment was that some women will refuse a cesarean, no matter what the official policy or guidelines are. "Should we abandon these women?" he asked. The answer is no, and the new SOGC guidelines stress in several points that women who refuse a recommended cesarean should not be abandoned or coerced, but rather should receive the very best care in accordance with their stated preferences.

The absolute best thing of the day, I think, was one of Dr. Gagnon's very first remarks. He thanked Jane Evans for her presentation and said something to this extent: "after seeing her presentation, I finally understand why the upright position for breech makes so much sense! I am excited to go back to my hospital and start doing breech births on hands & knees." He was visibly enthusiastic about this new way of doing breeches. It was wonderful to see an OB so convinced by a midwife! Of course, the fact that upright breech births are now being done by an OB in a medical center had a lot to do with the reception of this "new" approach.

Simply Give Birth

I invited Heather Cushman-Dowdee to do a guest post about her new book Simply Give Birth.This was supposed to be published while I was at the Lamaze conference, but it never showed up! I'm trying again...

The other day I walked up to a group of mothers carrying a new book, Simply Give Birth, under my arm. I had just received the first copy and was hoping to show it off a bit, in the way that I do. Hey, if I don't beep my own horn, who will? The mother that noticed the book first and asked me about it, isn't someone who cares much about my comics. Actually it would be better to say that she doesn't care at all about them. Deep breath, pant pant. She gave birth both times in what I call a "long emergency." Hospital births are like that, an emergency from conception through birth. She's grateful that the docs saved both of her children's lives, and those experiences have colored the way that she views birth, and me. The one time that we came close to talking "birth" was when I was asking another acquaintance who was newly pregnant if she was going to have a homebirth, the acquaintance said no, and named her hospital choice. Well, this mother said, "Oh great!" and then waxed poetic about the cookies they serve. I kid you not. I made a comic to commemorate the moment:

Well, this time, her eyes alighted on the book and she asked in a oh-you're-always-pushing-an-agenda way, "so, it's a book about homebirths?"

And in my pushing-an-agenda way I said, "no, it's just about normal, simple births."

Because I'm just so in outrageously pushy like that.

And how did I know about the "long emergency" of her births? Because after I showed her the book and told her about some of the stories, we talked about birth for an hour at least. It was a lovely beginning to a new relationship.

Simply Give Birth is not a book about homebirth, though all except one birth takes place at home. It's not about unassisted birth, though most of the stories are unassisted. It doesn't compare homebirths to hospital births; it has no statistics, footnotes or expert opinions. It isn't in your face about anything at all. It's just some really great birth stories told in a matter-of-fact, simple way. These are the stories that I wanted to read when I was pregnant, and when they're read all in a row you start to get the gist of what happens in a normal birth. So in a way it's also a how-to book, but with absolutely no directions. It could even be a textbook for birth education, just without any "teaching" and "lessons." It's just stories. Simple.

Here's a few things it does have:

• at least one husband's point of view.
• a retained placenta.
• surprise twins.
• some comics.
• a birth on a bucket.
• a whole bunch of vbacs.
• births that are post-due.

So, anyway, the new book is ready, and though Rixa hasn't been given a copy yet to read (sorry about that! this self-publishing is brutal!) hopefully you can take my word for it, because maybe you can tell, but I think it's great (and I'm not just tooting my own horn, there's 28 other authors in this book!)

http://www.simplygivebirth.com/

Love,
Heather Cushman-Dowdee, aka Hathor, aka Mama, long-time creator of the comic, theCowgoddess.com, and the comics over at http://www.mama-is.com/.

Why breech matters

At the International Breech Conference, Dr. Marek Glezerman spoke about how to save the vanishing skill of vaginal breech birth. Dr. Glezerman is chair of OB/GYN at the Women's Hospital of the Rabin Medical Center, which does about 8,500 births per year. Breech presentation is directly or indirectly responsible for approximately 40% of his hospital's cesarean sections. (Keep in mind that his hospital's c-section rate is much lower than US or Canadian rates, so in North America the effect of breech presentation on direct and indirect c/s rates will be less dramatic)

• Directly: 20% of all cesareans at his hospital are for breech presentation. 
• Indirectly: 37% (give or take a percentage point--I don't have my conference notes with me right now) of cesareans at his hospital are repeats, and he estimated that over half of them are due to the primary c/s for breech.

Vaginal breech birth matters!

Heads up!

Having a fantastic time at the International Breech Conference in Ottawa! It's late and I really need to get to bed but here are some of the highlights of the day:

• Meeting Lisa Barrett, a Welsh midwife currently practicing in Australia. I was sad to miss her presentation because it was full by time I got to the sign-up table. She had red striped socks, flowery Birkinstocks, pale purple capris, and was doing quite well despite her luggage being sent to Toronto
• British midwife Jane Evan saying "The pelvic floor is a lovely, beautiful valley." 
• Betty-Anne Daviss and her gigantic pelvis and the Homer Simpson doll and the dry ice coming out of the statue's head (one of those "you needed to be there" moments)
• Old-time OB from Colorado, Michael Hall, using said pelvis and Homer Simpson doll to demonstrate vaginal breech birth techniques. 
• All the OBs talking excitedly about this amazing new breech technique, how it just makes so much sense, how they really want to start doing it. What is it? Birthing on hands & knees. (More later on how it took a German OB doing this in a hospital setting to finally make a blip on the obstetrical radar--even though midwives have been doing this, and writing about this, for a while). But I'm loving the buzz.
• Getting oohs and aahs from passers-by over Dio in the MamaPoncho

More later, must get some sleep! 

Epic birth story, and a tribute

I've heard women say that getting in the car was the worst part of their labor. Well, if you think your 30 minute drive was bad, think again. One woman I've been corresponding with, Shaye Miller, drove across two state lines in order to birth with a supportive care provider. In the winter. On icy roads. But it worked out well for her, and she was able to give birth vaginally for the first time after having two cesareans (the first for "failure to progress" and the second an "elective" repeat cesarean). Read her epic birth story here.

For National Midwifery Week, she wrote a tribute to the CNM who attended that birth. An excerpt from her article:

Over a series of hour-long meetings, we discovered that the focus of a midwife isn’t solely on my uterus and vagina. A midwife seeks to assist, educate, and collaborate WITH the mother to achieve the healthiest birth possible. My mind was just as valuable to her as my pregnant body. On my couch we’d sit discussing the birth literature my husband and I were reading each week. She readily listened to my concerns and offered options for consideration. We discussed safety measures and what would happen if the need arose for a hospital transfer. In due course, I learned to listen to my body and to recognize when something wasn’t right. The power of posture and attitude was revealed to me as I worked through optimal fetal positioning methods. Our skeptical minds opened significantly during those hours of preparation and I loved it…every minute of it.

I also enjoyed the hour or two-hour long visits with the CNM who attended Dio's birth. I loved having someone to talk with about all of my concerns, fears, and hopes for the birth. And this kind of care isn't restricted to home birth midwifery. Remember, for example, Ruth Lubic's midwifery clinic for low-income women in Washington D.C. Doctors can also practice the midwifery model of care (and earn the title of MD--Midwife in Disguise).

The Midwives Model of Care can--and should--be found in any birth setting: home, hospital, or birth center.  Don't settle for anything less.

How many midwives...?

...does it take to change a lightbulb?

None, according to Erik Lee in Bossy Midwives. Sometimes we just need to lighten up a bit when we talk about birth. I think you'll enjoy his thoughts. A teaser:

An anesthesiologist, an OB, and a midwife walked into a bar. The anesthesiologist ordered a pitcher of stout and a double burger; the OB ordered a Reuben and a bottle of red wine; the midwife ordered their biggest plate of steak and fries with a margarita. They all sat in a booth and shared war stories.

A long time passed, and the three realized something had gone wrong with their order. They decided to find out what the problem was. They found the busboy just behind the swinging double doors to the kitchen. He was struggling to get their overloaded cart from the tiled kitchen to the carpeted dining area. The wheels kept catching on the bump.

The anesthesiologist kneeled down and examined the tires. “You just need to inject something here in the back,” he announced. “Then everything will go better.”

The OB leaned down to look at the carpet. “This part of the carpet is blocking the cart,” he announced. “Give me a knife and I’ll just give it a little cut to help it along.”

The midwife leaned over to the busboy and whispered loudly in his ear, “You can do this! Just PUSH!”

Read the rest here.

Sanctum/Surveillance

I went to Amy Romano's presentation at the Lamaze Conference about "Optimizing Labor Progress: What the Research Does and Does Not Tell Us." She cited a recent book that proposed a theory of birth territory. In Birth Territory and Midwifery Guardianship, Kathleen Fahy, Maralyn Foureur, & Carolyn Hastie discuss "sanctum" and "surveillance rooms" for giving birth. An excerpt from the book (the language is sometimes a bit dry, but the ideas are very compelling):

“Birth territory” is comprised of a physical terrain of the birth space over which jurisdiction or power is claimed for the woman. The terrain denotes the physical, geographical and dynamic features of the individual birth space impacting on women and babies. Jurisdiction refers to power and how it is used in the birth space and beyond, including the way maternity services are organized and managed. Birth territories affect how women feel and respond as embodied beings; either they feel safe and loved or fearful and self-protective. The aim for the midwife is to skillfully create optimal environments within which women feel safe and where normal labor and birth physiology remain undisturbed.

In particular, birth territory refers to the features of the birth room, here termed the “terrain,” and the use of power within the room, here termed “jurisdiction.”


Terrain
“Terrain” is a major sub-concept of birth territory. It denotes the physical features and geographical area of the individual birth space, including the furniture and fittings that the woman and her attendants use for labor and birth. Two sub-concepts, “surveillance room” and “sanctum,” lie at opposite ends along this continuum called “terrain.”

Sanctum
“Sanctum” is defined as a homely environment designed to optimize the privacy, ease and comfort of the woman; there is easy access to a toilet, a deep bath and access to or a view of the outdoors. Provision of a door that can close and lock from the inside meets the woman’s need for privacy and safety. The more comfortable and familiar the environment is for the woman, the safer and more confident she will feel. And experience of “sanctum” protects and potentially enhances the woman’s embodied sense of self; this is reflected in optimal physiological function and emotional wellbeing.

Surveillance room
“Surveillance room” is the other sub-concept of “terrain.” It denotes a clinical environment designed to facilitate surveillance of the woman and to optimize the ease and comfort of the staff. This is relevant to the concept of “jurisdiction” (discussed below) and it is consistent with Foucault’s notion of disciplinary power. A “surveillance room” is a clinical-looking room where equipment the staff may need is on display and the bed dominates. It has a doorway but no closed door, or the door has a viewing window so the staff can see into the room (not so the woman can look out). The woman has no easy access to bath, toilet or the outdoors.

Proposition
The more a birth room deviates from a “sanctum,” the more likely it is that the woman will feel fear. This deviation from the “sanctum” will in turn reduce her sense of self—it will be reflected in inhibited physiological functioning, reduced emotional wellbeing and possibly emotional distress.

Jurisdiction
“Jurisdiction means having the power to do as one wants within the birth environment. “Power” is an energy which enables one to be able to do or obtain what one wants. Power is essential for living; without it we would not move at all. Power is ethically neutral; this is consistent with Foucault’s notion of power which he argued was productive; not necessarily oppressive. Power can be used to get others to submit to one’s own wishes. Health professionals who want women to submit to their authority (to be docile) normally use a subtle form of coercive power that Foucault called “disciplinary power.” The concept of jurisdiction is directly relevant to “midwifery guardianship” which is the topic of the next chapter in which the theory of birth territory continues to be developed.

To illustrate, here are photos of my own sanctum and a surveillance room in my local hospital.

Sanctum checklist: 

• homely, comfortable and familiar environment
• room designed to optimize privacy, ease and comfort
• easy access to a toilet (there's a small full bath, which you can see in the bottom photo)
  
• a deep bath
• access to or a view of the outdoors (I can look out the window or just walk downstairs and go outside)
• a door that can close and lock from the inside

Surveillance room checklist

• a clinical environment designed to facilitate surveillance of the woman 
• optimizes the ease and comfort of the staff
• equipment the staff may need is on display
• the bed dominates (note the bed's central location, framed by the linoleum inlay)
  
• It has a doorway but no closed door, or the door has a viewing window so the staff can see into the room (not so the woman can look out). You can't lock the door to the room, or the door to the bathroom, which has been the case with every hospital birth room I've been in.
  
• The woman has no easy access to bath, toilet or the outdoors (this hospital room has a bath and tub. The window looks out on a parking lot. There are some trees off in the distance, but I don't think we can argue this constitutes "access to the outdoors.")
  

I have some questions and requests:

• How can we create a sanctum within a clinical/institutional environment--for all those women who can't/don't wan't to give birth in an out-of-hospital setting?
• Do you have any photos that illustrate a sanctum or a surveillance room? If so, please email them to me (stand.deliver @ gmail.com) and I will repost the best ones.
  

Watching, listening, and reading

Today I am watching a montage about one woman's journey to a VBAC. I'm enjoying it of course--it's made to inspire and motivate. But the academic part of me is also intrigued by this video in particular, and birth videos/montages in general. There's a definite formula to this type of media--the narration about a woman's journey to birth, intersersed with photos and sometimes videos in rough chronological order, the background music that becomes more upbeat as it gets closer to the moment of birth.

My Journey to a VBAC from Lindsey Meehleis on Vimeo.

I'm listening to an interview with Jill of The Unnecesarean about Informed Consent and Informed Refusal. Well, technically I'm downloading it right now.

And I'm reading NieNie, a blog I first learned about thanks to Jane of Seagull Fountain. (Her dad is cool, too!) She, like me, is LDS and a mother of several young children. She survived a near-fatal plane crash a year ago and spent several months in a coma. She was burned terribly and is learning to live with a new body and a new face (and her kids, too, had to become re-acquainted with their mother). I just found out today that she is also a home birth mama--how cool is that? Anyway, she'll be on Oprah tomorrow and I'd really like to watch it. I don't have cable or antennas, so I'll have to see if I can watch it online.

Lamaze Conference

We're home, both kids are sleeping, and it's time to update about the Lamaze conference. I met several bloggers face-to-face for the first time, including Amy Romano of Science & Sensibility, Mom's Tinfoil Hat, and Reality Rounds. I also met some amazing LDS women at the conference. We had lots to talk about and I left wishing that we all lived closer. One of them had an idea for a book that I loved and now I have yet another project I'd love to work on--once I get my other ones done, that is.

Can I just say that I love Lamaze's focus and mission? The Lamaze Six Healthy Birth Practices, all based on the best available evidence, should be what every woman in labor receives. They are a great place to start in our efforts to improve maternity care: simple, clear, evidence-based, and universally applicable to all laboring women.

Dio was a real trooper and made it through almost the entire four days with very little fussing. By the end, though, I could tell he was really bored. He'd played with all of his toys, he'd been in the same rooms for days on end, and he was ready for it all to end! After the last speaker, we went into our hotel room and he had a nice long afternoon nap and we all felt better after that.

A camera phone picture of Dio on a makeshift "bed" (two chairs pushed together). He had just woken up from a nap.

Here are some things I noticed at the Lamaze conference.

• Widespread frustration with the lack of evidence-based care at hospitals
• Sentiment that often the only way to have a normal birth nowadays is to go to a birthing center or have a home birth
• Frustration that childbirth educators can talk to pregnant women, get them informed of their options and the best evidence-based research, help them make a birth plan—and then it all falls apart in the hospital and they keep seeing these “train wreck” births where the woman gets every intervention she didn't want and the woman seems stunned by how nothing she asked for happened
• A desire to have physicians working on the same page as them, but a deep cynicism that that would ever become a reality—sense of hostility between CBEs, doulas, and other birth workers and physicians/hospitals, even as they would like to work cooperatively, not antagonistically
  
• Frustration with hospital protocols, routines, and guidelines that hamper what women are “allowed” to do and often compromise good mother-friendly and baby-friendly care
• A sense that we’re still facing the same problems and frustrations we were 2 or 3 decades ago, that little has changed overall
• Agreement that many hospital-based providers have never even seen a truly normal, natural, physiological birth at all (and many of the attendees, themselves nurses, agreed on this one)

It's getting late and I feel like my brain is shutting down. Read more specifics about the conference by Mom's Tinfoil Hat's Highlights of the Lamaze Conference and Reality Rounds' Reflections. 

Blogger heaven

Guess who I'm having lunch with tomorrow?

Reality Rounds
Mom's Tinfoil Hat
Amy Romano of Science & Sensibility

Woohoo!

I also met Penny Simkin (briefly).

It is a very surreal experience to be walking down the hallway and have total strangers call out to me, "Hey Rixa, nice to see you! How's Dio?"

Elective(?) repeat cesareans

If a woman is forced to have an Elective Repeat Cesarean Section (abbreviated ERCS in the medical literature), but vigorously protests against it and does not agree to the surgery, can it really be called "elective"? One Arizonian woman says no. She is pregnant with her fourth baby. Her hospital, which allowed her to have a VBAC with her third child after her second was born via c-section due to placental abruption, has informed her that she will not be allowed to give birth vaginally. If she shows up in labor and refuses surgery, the hosital's CEO has told her they will seek a court order for a cesarean section. From the Lake Powell Chronicle:

A pregnant woman’s pleas not to have an unnecessary caesarean are being ignored by Page Hospital administrators.

Joy Szabo, 32, said she is upset with Page Hospital’s general ruling in June prohibiting vaginal births after cesareans (VBAC). The mother of three children, she has given birth to all of her children at Page Hospital, the only hospital in the immediate area. A placenta eruption caused her to have an emergency cesarean delivering her second child, but the hospital allowed her third child to be delivered naturally two years ago.

Now pregnant with her fourth child, she is being forced to have a caesarean due to lack of hospital staffing.

“Page Hospital is, as many small communities are, challenged with resources,” said Chief Executive Officer Sandy Haryasz. “Page simply does not have the physician resources to respond to an emergency."...

Joy thinks it is against her legal rights to force her to have unnecessary surgery that might place her and her baby at greater risk of harm than delivering naturally. Her only option to having natural birth is to travel to a women’s care clinic in Phoenix or have unassisted home delivery....

Joy said she voiced her concerns at a board of directors meeting and has met twice with Haryasz.

“I asked Sandy what would happen if I just showed up refusing a c-section and she said they would obtain a court order,” Joy said. “They don’t want to allow VBACs because she said they aren’t equipped for emergency c-sections, but if they can’t do emergency c-sections, they shouldn’t be having labor and delivery at all. That’s why women go to the hospital to have their babies – in case there is an emergency....
The Szabos think that lack of staffing is not sufficient cause for Joy to be forced to undergo unwanted, unnecessary surgery.

“My doctor doesn’t have a problem with me having natural delivery, but said that the hospital does,” Joy said. “The fact that I successfully had a VBAC two years ago lowers my risk for rupture, but that doesn’t matter since the hospital has decided that all VBACs have to have an ‘elective c-section.’ I think my definition of ‘elective’ differs from theirs because I don’t want this.”

Read the rest of the article here.