Saturday, February 28, 2009

Hospital tour

Today I went on a tour of my local hospital's maternity center with another couple. He is a colleague of my husband's, and his wife is expecting their first a few weeks after me. We are both planning to give birth at home, but we wanted to check out our local hospital to see what it's like if we needed to transfer. We didn't specifically mention our home birth plans to the nurses giving the tour, since we wanted the tour to focus on the hospital's policies. I would have mentioned it if they had asked, but they assumed that we were seeing one of the hospital-based midwives or OBs.

Some numbers and stats:
Our hospital serves a town of 15,000 and any neighboring communities. It sees at most 300 births per year. The hospital doesn't have a NICU. The physicians and anesthesiologists are both on-call rather than in-house. There are two OBs and one nurse-midwife who rotate call, so you have a 1:3 chance of having your care provider present at your birth.

The hospital has six LDRP suites. They all have about the same setup and decor, but some of the rooms are larger than others. If they're really busy, some women will be shunted off to another area for their postpartum stay.

Between 90-95% of the maternity patients labor with epidurals, and almost all of those women also are on Pitocin. I asked the nurses what the hospital's c-section rate was, and they said it was definitely higher than average--"higher than ACOG standards" was what one nurse said. They couldn't give me any specific numbers, though. The second nurse explained that they are more likely to cut than not if they see anything funky on the monitors since they don't have a NICU in the hospital. They do not allow VBACs anymore, and a high number of the patients have elective inductions. The nurse said the hospital is trying to lower its c-section rate, but agreed with me that the no-VBAC policy and the high rate of inductions makes that difficult to change. They also see a lot of scheduled cesareans (I assume for women with previous c-sections, since VBACs are not allowed). Breech presentations are an automatic c-section.

I asked the nurse what would happen if a woman with a previous cesarean presented at the hospital in labor and refused a repeat cesarean. The nurse said, "Well, you can't do surgery without her consent. That said, we'd probably try to talk her into a c-section." They've never faced this particular situation, though.

Both the physicians and anesthesiologists live close by the hospital. I asked the nurse about their decision-to-incision time for an emergency situation, and she said it's 30 minutes or less. However, they can do it in less than that. For example, she remembered a recent cord prolapse that took 10 minutes from decision-to-incision, and that was with both the OB and the anesthesiologist having to travel to the hospital. That's pretty impressive for a small rural hospital, considering that neither the OB or the anesthesiologist are in-house. It makes me wonder why they won't allow VBACs with the ability to assemble an OR team that quickly. I mean, I know why--ACOG's 1999 policy of "immediate" availability that was interpreted to mean 24/7 in-house availability--but still...

Admittance and labor policies:
I asked the nurse what were the standard admittance procedures, and she was fairly vague. 20 minute admission strip? It sounded like it's a standard routine, and I wasn't able to get a good answer if it's easy to decline it or not. IV/saline lock? She said that's something to discuss with your midwife or OB and put on your birth plan. They do try to work closely with a woman's birth plan, so if it's signed off, it shouldn't be too much of an issue. That said, 90% + of women have Pit & epidurals and/or IV pain medications, so it's pretty rare that a woman won't have an IV. Monitoring? They do intermittent monitoring if the woman requests it and, obviously, if she doesn't have Pit or an epidural. They do not have wireless monitoring (telemetry) or waterproof telemetry. Eating and drinking in labor? Both nurses said "don't let me see it, and don't tell me you've done it!" Sounds like we have a "don't ask, don't tell" policy here! They can't provide the laboring woman with anything but ice chips and popsicles (and IVs, of course). But they said to go ahead and eat/drink when they're not around; that way they won't have to report it to the anesthesiologist, who doesn't like women to eat or drink during labor. They emphasized that they encourage women to eat freely for as long as they're home, since food intake is restricted in the hospital.

LDRP room.
Infant warmer & fetal monitor to the left of the bed.
Notice the spotlights on the ceiling--those always creep me out for some reason.

View from the bed.

The hospital has birth balls and (smallish) jacuzzi tubs for laboring in. The first nurse we talked was very encouraging about laboring unmedicated. I got the feeling that she likes working with moms who want to be upright and mobile, especially with the high rate of epidurals at this hospital. She said that if you wanted to go without drugs, they'd encourage you to use the birth ball or the tub, to walk the halls, and to move around. You have to get out of the tub once you're pushing, though. The tubs are fairly small: standard length and perhaps a bit deeper than a typical tub, so there isn't a lot of room to stretch out and move around. Showering might be a more comfortable option at this hospital.

Jacuzzi tub & bathroom
(tub is to the left on the bottom photo)

The nurse-midwife is more used to women laboring and pushing in non-conventional positions, whereas the two OBs will likely request that you lie on your back, especially as the baby is getting closer to being born. I asked about how often they do episiotomies, and both of the nurses said "we don't do them any more." One of the nurses got a piece of paper and did the standard demonstration of how it's so much easier to tear once you already have a cut. (She also teaches the hospital's childbirth classes.) Instead, the OBs and midwife are fairly hands-on with the perineum. The nurse said the OBs will typically apply pressure to the baby's head and the woman's clitoral area, while "ironing out" the perineum. (Doesn't that sound fun!? I'd rather have nothing done to me at all, thank you very much).

They have Stryker maternity beds, which are my least favorite among the varieties of maternity beds. Some of the other brands such as the Hill-Rom can adapt into a nearly sitting position with a U-shaped cutout, so it's almost like a birthing chair. The Stryker, though, is pretty much only set up for the stranded beetle position. The first nurse got out the squat bar and also mentioned that unmedicated women often like to labor on their knees, resting their arms on the elevated back of the bed.

Baby care:
Right after the birth, the baby is taken to the nursery for weighing and measuring, then brought back to the mother. The baby spends a few hours with the mom, then goes to the nursery for about 3-4 hours for glucose heel pricks, blood pressure checks, bathing, etc. After that the mother can request either rooming in or nursery stays for the baby. This is an improvement over the mandatory 24-hour nursery stay that the hospital used to have several years ago, but the mother is still separated from her newborn twice in the first several hours.

Things I forgot to ask about:
- What happens to baby & how long is it separated from the mom if she has a c-section
- If they have TENS units for laboring or for post-cesarean pain relief
- If they have lactation consultants available
- Breastfeeding policies (do babies get sugar water, bottles, and/or pacifiers while in the nursery?)
- Number of people allowed in the room while the woman is laboring
- If photographs/videos are permitted during the birth

Overall impressions:
A woman's labor experience at this hospital will depend on several variables, some of which she controls (whether or not she chooses an induction or epidural) and others she does not (which nurse is on duty, which OB or midwife is on call). There was a noticeable difference even between the two different nurses we talked with. The first one we met seemed a lot more accommodating of individual women's requests, while the second one who joined us halfway through our tour kept saying things like, "well, safety does need to come first" and "we feel that a healthy mom and baby are more important than a vaginal delivery." Of course, you can request a different nurse if you don't mesh well with the one you're assigned to (assuming there's more than one on duty, which might not be the case in such a small hospital), but most women don't know that.

The hospital still has room for major improvements in its baby care policies, especially its initial separation of mother and baby and the later 3-4 hour long nursery stay (which you can refuse, but it would take some negotiating).

I was glad to know that the decision-to-incision time can be fairly rapid, even though the OB and anesthesiologist have to be called in to do a c-section. If I were needing to transfer for something like a prolapsed cord or placental abruption, we'd call the hospital and tell them to assemble an OR team while I was en route from home (5 minutes door-to-door going the speed limit). I'd make sure someone remained on the phone with L&D as we were driving in (or taking an ambulance, but transporting ourselves would be faster).

The hospital's high induction and cesarean rates are concerning. It's partly patient-led (via elective inductions) and partly hospital-led (via its no-VBAC policy and quick-to-cut approach). Small rural hospitals generally should have lower-than-average cesarean rates, since they transfer high-risk patients to larger teritiary hospitals that are better equipped to deal with certain complications of pregnancy and birth. If you're interested in avoiding an unnecessary cesarean, this might not be the best hospital for you, especially since they mandate that you have repeat cesareans after your first one.

With a 90-95% epidural/Pitocin rate and a higher than average c-section rate, I would be concerned that the staff is not used to working with unmedicated, spontaneous labors. Only 15-30 women give birth without anesthesia per year here, so the hospital is perhaps not the best place for women wanting to give birth without Pitocin or an epidural. Still, it is doable, if not optimal. Going into labor spontaneously, laboring without Pitocin or an epidural, hiring a doula, having a signed birth plan, laboring at home for as long as possible, and requesting a nurse who is supportive of your wishes will all increase your chances of a vaginal birth at this hospital.
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Friday, February 27, 2009

Closet organization

And now for something totally non-serious and non-birth related: my closet. We have one L-shaped walk in closet shared between the two downstairs bedrooms. I forgot to take before pictures, but it was a mess. I blame it on poor closet/shelving organization. Our shoes were heaped up on the floor. All of my husband's pants, sweaters, and t-shirts were piled on top of the waist-high shelf above the lower closet rod, which meant we couldn't hang anything on the upper rods.


I finally decided to remedy the situation this week. I removed an 18" wide shelf/rod unit (which was on the right side where the shelves now are) and moved it to an empty spot at the back of the closet. You'll see winter coats hanging on it now; it's to the left of the hanging shoe rack. Then I put in floor-to-ceiling shelves.


I got the shelf brackets and supports for next to nothing at a clothing store that was going out of business, and the shelves are from Home Depot. I cut them down to size last night once Zari was sleeping and had a great time putting everything away in its proper place. I really enjoy seeing neatly folded, orderly rows of shoes and clothes. And I love being able to see our closet floor for the first time in 6 months!

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Breastfeeding as sexual deviancy?

Jane of What About Mom sent me this 2003 report from the Dallas News, 1-hour Arrest, about a couple who were arrested on felony charges for supposed child pornography. The evidence of their crime? A photo of the mother breastfeeding her infant son that she had sent to a photo developing lab. The couple's two boys were removed and placed into foster care. Several months later, the state of Texas finally dropped the case, and the 1-year-old son was finally returned to his parents.

Cultural attitudes towards breastfeeding, especially breastfeeding in public, aren't just a trivial matter of "covering up" and "being discreet" versus "letting it all hang out." They can cause real harm when, as in the Mercado case, a family's private photo of a mother nursing her son can be interpreted as child pornography.

From the article:
The service was fast, the judgments even hastier. Never did Jacqueline Mercado imagine that four rolls of film dropped off at an Eckerd Drugs one-hour photo lab near her home would turn her life inside out, threaten to send her to jail and prompt the state to take away her kids.

For Mercado and her family, last fall was a happy time, one they wanted to record and save in the venerable tradition of the family photo. Johnny Fernandez, Mercado's boyfriend, had just emigrated from Lima, Peru, ending a yearlong separation, and on top of that, it was their son's first birthday...

In one--the photo that would threaten to send Mercado and her boyfriend to prison--the infant Rodrigo is suckling her left breast.

After Mercado dropped off the film for processing, a technician viewed the images and decided they were "suspicious," according to a police report. As required under Texas law, he immediately contacted local police. Mercado says that when she went to pick up her pictures, the clerk told her there would be a delay, and then only returned three of the four sets of prints.

To Richardson police, who arrived at the store that afternoon and apparently made up their minds from the content of the pictures alone, this was nothing short of a felony case of child pornography. "We thought they contained sexuality," says Sergeant Danny Martin, a Richardson police spokesman, explaining why two Richardson police detectives began pursuing a criminal case. "If you saw the photos, you'd know what I mean."

With nothing else to support their contention that the photos were related to sex or sexual gratification, the police and the Dallas County District Attorney's Office presented the photos to a grand jury in January and came away with indictments against Mercado and Fernandez for "sexual performance of a child," a second-degree felony punishable by up to 20 years in prison. The charges centered on a single photo, the breast-feeding shot. Fernandez and Mercado say they took it--although the child had ceased breast-feeding--to memorialize that stage of their baby's development.

Read the rest of the article here.
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Thursday, February 26, 2009

Review of "Breastfeeding With Comfort and Joy"

Several blog readers recently recommended Laura Keegan's new breastfeeding book, Breastfeeding with Comfort and Joy: A Photographic Guide for Mom and Those Who Help Her. I contacted Laura, a Family Nurse Practitioner in private practice at Lifeforce Family Health Care, to see if she would send me a copy to review. Just a few days later, the book arrived at my house!


This book is unlike any other breastfeeding book I've read. It is primarily a visual guide to breastfeeding, rather than a textual guide with the occasional picture or illustration. Laura Keegan's photographs are stunning in their beauty, detail, and ability to capture the essence of proper positioning and latch. There is at least one full-size photograph at every page turn. The book's text supplements and clarifies the photographs, often with a very poetic quality.

A main theme interwoven throughout the book is that women in our culture have been imprinted with bottlefeeding behaviors, and this affects how they hold their newborn babies and how they bring them to the breast. Unless we have had extensive exposure to breastfeeding, we unconsciously hold babies in a manner appropriate for bottlefeeding: cradled deep in the crook of our elbow, body and head facing upwards. When brought to the breast in this position, babies (and their mothers) often experience difficulty attaining a deep, comfortable latch, which affects milk supply, brings pain to the mother, and frustrates both parties. Keegan's book illustrates the postures and positioning, done unconsciously by women in breastfeeding cultures, that facilitate proper positioning and a painless latch. She comments about her book:
You will learn ways of holding your baby and bringing your baby to the breast that are imprinted early in life in women in other societies where breastfeeding is the norm. The steps are simple but may take a little time to learn because women automatically hold their babies and their breasts in ways that work for bottle-feeding since that is what most of us have imprinted in our minds.
For example, Keegan points out how the natural shape of our unclothed breasts facilitates comfortable and effective nursing. Our cultural norms of what breasts should look like, especially breasts contained in bras, can mask the function of a breast's normal shape:
It is interesting to note that when most women look down at their unclothed breasts, the nipples point outward, instead of straight ahead. We unconsciously push our breasts to the center of our bodies to make our nipples point straight ahead as they do in bras. We don't want to push our breasts in this way when we breastfeed.
The natural position of the nipple pointing outward allows for the nipple to point to the roof of the baby's mouth when bringing the baby to the breast. Indeed, nature has an ingenious design to ensure painless, efficient feeding at the breast, when holding the baby in a way that is not affected by bottle-feeding imprinting.
Breastfeeding with Comfort and Joy focuses on the basics of positioning and latch that solve or prevent most breastfeeding difficulties. She writes:
There are usually simple reasons for the problems mothers have encountered that lead to varying difficulties, such as sore nipples, babies fussy at the breast, sleepy babies, frequent feeds, babies not being satisfied, and colic. The purpose of this book is to emphasize certain key points that provide for an enjoyable breastfeeding experience for both mother and baby.
Although there is much less written text than in most of the other breastfeeding books I have read, Breastfeeding in Comfort and Joy covers a remarkable range of information, from achieving a proper latch to nursing twins and working with sleepy or premature babies. Keegan accomplishes this by relying on photographs to communicate the bulk of her message, while the text clarifies and emphasizes the photographs' key points. This certainly makes sense with how many of us learn--it is much easier to understand what a proper asymmetrical latch looks like by seeing multiple pictures of it, rather than just reading about it.

The book is wider than it is tall, so it stays open easily--a plus for moms who are holding one or more nursing babies! The pages are all high-quality glossy paper with either color or black-and-white photographs.

I highly recommend Laura Keegan's book. It would make a vital addition to a nursing mother's personal collection, as well as to hospital maternity wards, NICUs, pediatrician/OB/midwife/family physician offices, and public libraries. If you are involved with a birth- or breastfeeding-related organization, you may also place a bulk order for a reduced price. In addition to buying a copy for yourself or a pregnant friend or family member, I suggest you contact your public library and request that they order a copy. I did this yesterday; it only took 30 seconds to fill out a purchase request slip at the circulation desk.

Breastfeeding with Comfort and Joy is available for sale only at www.TheBreastfeedingBook.com. You can read testimonials and book reviews on that website, as well as view excerpts from the book. Laura Keegan has also created a blog with more information about and reviews of her book.
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Wednesday, February 25, 2009

Spring apron giveaway

One of my sisters is holding a spring apron giveaway. See her selections of aprons here. She's very creative and crafty and has dedicated a blog to her projects--anything from handmade leather books to amazing cakes (3-D fish cakes, wedding cakes, you name it) to funky cufflinks. Check it out!
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Tuesday, February 24, 2009

Bumbleride stroller giveaway

If anyone is in the market for a stroller, there's a giveaway at Supermom Central!
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Belly shot: 30 weeks pregnant

30.2 weeks from LMP. Fundal height is around 31/31.5 cms. No unusual physical complaints or discomforts.

I'm feeling good (aside from the emotional anxiety over the baby's presentation, or rather about the practical ramifications of a non-vertex presentation). I am usually a very calm, level, rational person not prone to worrying about things, and I have to say this pregnancy has been quite a challenge for me in that regard. My last pregnancy was so joyful and peaceful and this one has been one set of worries after another, to the point that I feel it's been stealing away the enjoyment of being pregnant and the anticipation of having another baby. Is it because I'm not doing it unassisted this time around? I know some UCers might suggest that, but I am hesitant to adhere to that simplistic explanation. I would really like to just enjoy the moment but it seems those moments have been all too brief.

I wrote that last part, and then I just got off the phone with my midwife and feel a million times better. I told her all about my recent worries about breech I've written about here and how all of the stuff I know--everything I've told other women when I've been on the other side of the fence--still isn't making it any easier for me. She reassured me that yes, it really is too early to fret about it and that there are a lot of resources and options if, worst case scenario, the baby is persistently breech at term. She's attended a lot of breech births herself, but just not as a primary midwife. There's a great chiropractor who specializes in pregnancy & the Webster technique who I can see if, in a few weeks, baby is still heads-up. The chiro is at least an hour away, so I really hope I won't have to do that--but she's had fantastic success with getting babies to turn. My midwife also says there are a lot of options for breech birth that she knows about--there are one or two physicians who still attend breeches and many more supportive/sympathetic ones that she knows, there's a doctor who is great at doing versions, there's the option of inviting another experienced midwife to come up and assist, or even of traveling down with me to The Farm, etc. In any case, she reassured me that she is totally committed to making sure I'm not having to face a last-minute panicked scramble and that she has a lot of resources that she didn't know about when, four years ago, she had a breech baby and was dropped by her midwives at the last minute.

I'm glad I called. I'm trying hard to open up more and accept help or reassurance when I need it. I'm usually so independent that it's a bit strange to be on the receiving end, and to be okay with feeling vulnerable and letting other people care about me.
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Monday, February 23, 2009

Musings on breech

I had an enjoyable meeting with my midwife this week. When we were checking fundal height and heart tones, I asked her to palpate and see where/how she thought this baby was lying. Baby was definitely breech: a nice round wobbly head up near my ribcage, a butt/hip above my pubic bone, and lots of arms & legs on my right side. (And today, it's all over the place--I'm feeling movement in my cervix & on my left side, possibly a head or a butt on my right side.) Having a confirmation that the baby was that dreaded "B" word--breech--left me with lots of thoughts. So here goes:

I find myself more prone to anxiety and worrying during pregnancy, and more this time compared to last pregnancy. My logical brain knows that fretting about a baby's positioning at 30 weeks gestation is fairly pointless, and that the vast majority of breech presentations resolve themselves by term. But does that make any difference to my emotional self? Not really! Here I am, knowing all of these things and having reassured many other women about breech presentations, and I still can't stop fretting about the future: what if the baby stays breech? what would happen then? what would I do?...

It's not that I am worried about a vaginal breech birth per se. I feel quite confident that I could give birth to a breech baby, and I have read extensively about the controversies surrounding breech management. But I am quite afraid of birthing a breech baby in the current medical & legal climate. Going into labor with a breech presentation would mean the following for me:
  • No continuity of care, as my midwife cannot attend a breech at this time. She really wants to add breeches and twins to her practice in the next five years, but she does not have enough training yet to attend a breech birth.
  • A last-minute desperate search for someone to attend me, or a last-minute unassisted birth with no midwife backup. I live about an hour away from a very large city with a total metropolitan population of 1.7 million. There may (or may not) be one or two physicians who still attend breeches. There used to be more, but almost all of them have stopped attending vaginal breeches, some of them against their will. My midwife used to work as a L&D nurse in a large tertiary hospital in that city, and she said they used to do vaginal breeches all the time until a change in medical opinion declared a vaginal breech to be malpractice. She remembers one OB letting off the F-bomb because he was so upset he'd have to start doing c-sections for all breeches. She knows of a few physicians who, although they currently don't officially do vaginal breeches, might be able to attend a woman if she into labor on a day they happened to be on call and insisted on a vaginal birth at the hospital. She'd have to know that this option even existed and who to ask for, of course.
  • Or, if I wanted to stay at home, I could try to find a direct-entry midwife who has skills with breech births. There are one or two, but there is a complicated back story that makes me more hesitant about that option. In brief: my midwife's third baby was breech. She was abandoned by those midwives the day before she went into labor because of the breech presentation, leaving her to do it on her own.
  • A massive amount of stress and worry, because I could not simply carry on with my birth plans. Instead, the days or hours leading up to the birth would be characterized by extreme upheaval and uncertainty. And there's still no guarantee I could find someone willing to attend a vaginal birth.
  • And of course, if I did go to a hospital and manage to find a doctor to attend me in this hypothetical situation, I wonder if that would be a very good setting for a vaginal breech: unknown physician, probably a lot of anxiety and fear, unknown amount of manipulations or interventions in the process. Not a very good setting for a smooth vaginal breech birth. The best possible atmosphere for a successful vaginal breech birth is one that is the least disturbed, one with low levels of stress and adrenaline, one with laid-back hands-off providers with lots of skill and experience seeing physiological breech births. Basically the opposite of what I would be able to find if I found myself faced with a breech presentation at term.
The problem with breech in this country isn't the actual presentation and birth--it's the hostile climate that makes a vaginal birth nigh to impossible.
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Sunday, February 22, 2009

My brother rocks

A few weeks ago my little brother (well, at 21 years old and 6 feet tall, he's not really so little) wrote me this quick note from Russia. He's currently serving a mission for our church in Vladivostok, Russia. Some translations of LDS lingo:
sister = female missionary, usually ages 21-23
elder = male missionary, usually ages 19-21
senior missionaries = usually retired couples
There is one sister that loves that you gave birth at home, you breastfeed, and that Zari breastfeeds her stuffed animals. Also, I brought up the whole birth thing with the senior missionaries with us (around the dinner table at a restaurant), and they were all weird about it, but I loved it--they were so shocked, but I was thinking the whole time, "If you want shocked, I could tell you about the placenta, or the various uses of garlic*." Then some other elders were talking about how they will force their wives to give birth at a hospital, because they "don't want to take any chances," but I turned that one down. It's true--people treat birth as something inherently wrong, that it should be medically treated. True, there are other options other than unassisted at home (Joss [my younger sister], in a hospital birthing center). So I was telling them all about it, even though I'm male, will never have birth, and still am single.
He is hoping to go into radiology, so he should have lots of opportunities to talk about birth & breastfeeding when he's in medical school. I love that he occasionally uses Russian-isms when he's writing in English ("will never have birth," for example). My brother is awesome!

* Referring to its use for treating yeast infections--my family just can't get over how weird they think this is, so it's become a family joke
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Saturday, February 21, 2009

The back story to the Times article

Pamela Paul, author of the Times article The Trouble With Repeat Cesareans, wrote another article in The Huffington Post: Childbirth Without Choice. This piece gives the back story of the Times article, including her own fight to have a VBAC in a supposedly "pro-VBAC" hospital.

She writes:
I wrote an article in this week's issue of Time magazine called "The Trouble With Repeat Cesareans" on the subject of women's diminishing patient's rights. I won't repeat the story here, since you can link to it here, but will give some of the back story for those who want more:

This was a story I've been wanting to write for a long time. The short version is, doctors and hospitals are no longer allowing many women to have a vaginal birth after cesarean (or VBAC, pronounced "vee-back") because the "medicolegal" costs are too high. Or, as one ob-gyn put it when I asked why she and other doctors no longer allow VBACs, ""It's a numbers thing. It is financially unsustainable for doctors, hospitals and insurers to engage in a practice when the cost of doing business way exceeds the payback. You don't get sued for doing a C-section; you get sued for not doing a C-section."

Read the rest of the article here.
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Friday, February 20, 2009

Share your VBAC stories here!

In light of the recent Time article on the difficulty of obtaining a VBAC, I'd love for my blog readers to share their VBAC stories (including those who wanted a VBAC but were unable to attain one for whatever reason, or those who are currently planning a VBAC). How hard was it to find a hospital and/or provider who would attend a VBAC? Were there certain conditions you had to meet, such as going into labor on or before a certain gestational age, continuous EFM, or having to have the baby during daytime hours? How far did you have to travel to find a VBAC-friendly provider? What were your biggest challenges in planning for a VBAC? What were some of the supportive or not-so-supportive things you heard from your providers about VBACs? If you were ultimately unable to have a VBAC, what happened?

Please share your stories!
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Thursday, February 19, 2009

Time article on VBAC and Forced Repeat Cesareans

I am excited to announce that Time magazine just released an article about VBAC and forced repeat cesareans, called The Trouble With Repeat Cesareans. It will hit newsstands tomorrow morning. I was privileged to play a (very small) part in helping the International Cesarean Awareness Network (ICAN) phone hospitals all across the US to determine whether or not VBACs were allowed in their facilities.

With a few exceptions, ICAN has contacted every American hospital that has a maternity ward. As you'll see in the article, 28% of U.S. hospitals have an outright ban on VBACs, and another 21% have a "de facto" ban: while VBACs are technically allowed at the hospital, no doctor will attend them. To find out the VBAC policies in your local hospitals, visit ICAN's VBAC policy database (it might not be up and running until tomorrow).

I feel that access to VBAC is one of the most pressing maternity care issues in this country, along with the disturbingly high cesarean rate (31.1% as of 2006). Please advertise this article widely, making sure to link to the original article on Time's website. The more traffic it gets, the longer it will remain online.

From the article:

For many pregnant women in America, it is easier today to walk into a hospital and request major abdominal surgery than it is to give birth as nature intended. Jessica Barton knows this all too well. At 33, the curriculum developer in Santa Barbara, Calif., is expecting her second child in June. But since her first child ended up being delivered by cesarean section, she can't find an obstetrician in her county who will let her even try to push this go-round. And she could locate only one doctor in nearby Ventura County who allows the option of vaginal birth after cesarean (VBAC). But what if he's not on call the day she goes into labor? That's why, in order to give birth the old-fashioned way, Barton is planning to go to UCLA Medical Center in Los Angeles. "One of my biggest worries is the 100-mile drive to the hospital," she says. "It can take from 2 to 3 1/2 hours. I know it will be uncomfortable, and I worry about waiting too long and giving birth in the car."

Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that "once a cesarean, always a cesarean"--an axiom thought to be outmoded in the 1990s--is alive and kicking. Indeed, the International Cesarean Awareness Network (ICAN), a grass-roots group, recently called 2,850 hospitals that have labor and delivery wards and found that 28% of them don't allow VBACs, up from 10% in its previous survey, in 2004. ICAN's latest findings note that another 21% of hospitals have what it calls "de facto bans," i.e., the hospitals have no official policies against VBAC, but no obstetricians will perform them.
Read the rest of the article here.
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Wednesday, February 18, 2009

Wednesday wrap-up

I might start doing a weekly wrap-up of miscellaneous news & articles that I find interesting. If I wait much longer than week, they start piling up rather quickly:

Speaking of upright/vertical birth...
Home birth
  • The "Authorities" Resolve Against Home Birth: a recent editorial by Nancy K. Lowe, editor of the Journal of Obstetric, Gynecologic, & Neonatal Nursing ( Volume 38, Issue 1, Pages 1-3). Click on the article title for the full text. An excerpt from her editorial: "The point is that we have no system of maternity care in the United States that provides a healthy woman the choice of giving birth at home and if she needs to transfer to a different type of care during labor, the transfer is easy. We do not have a system in which this woman is treated with respect and kindness, and her provider either maintains responsibility for her care or professionally and respectfully is able to transfer responsibility to another provider. Interestingly, while ACOG and AMA have declared that hospital grounds are the only safe place to give birth in the United States, the National Perinatal Association (NPA) adopted a position paper in July 2008 titled, 'Choice of Birth Setting.' The paper supports a woman's right to home birth services....Further, in Canada following the model of British Columbia, the province of Alberta has recently expanded its health care system to include women's access to midwifery services 'in a variety of locations including hospitals, community birthing centers, or in their homes.' "
  • Two Charleston Gazette articles: Midwife delivers babies in mothers' homes and Home delivery: After three hospital births, fourth-time mom was determined to deliver the old-fashioned way
  • A Herald Tribune (FL) article narrates how a home birth unfolds in Home Delivery
  • An article featuring Womancare Midwives of North Idaho
  • Tribute to Maude Callen, a nurse-midwife serving rural South Carolina for over 70 years. Make sure you click on the Life photo archive for lots of fantastic pictures!
  • Adventures in (Crunchy) Parenting wishes to move beyond binary views of safety
  • Future Search Conference on Home Birth currently being planned. From the description:
  • It will be a multi-disciplinary consensus conference of key stakeholders around the provision of home birth services in the United States, to be convened by the University of California San Francisco and various organizations, including the American College of Obstetrics and Gynecology the American Academy of Pediatrics, the Association of Certified Nurse Midwives, Mothers and Midwives Associated, Lamaze International, Association of Women Hospital Obstetric and Neonatal Nurses, and the International Center for Traditional Childbirth. Further, it is hoped that public health practitioners and students, insurers, government agencies, health economists, medical anthropologists, state and national legislators, and women who have given birth will be among the eventual participants. The purpose of the conference is to start to bridge the "divide" between the medical and midwife communities over out-of-hospital births in the United States. Safety of birth in any setting is of utmost priority. Rights to choice and self-determination and culturally appropriate healing are also core values in American discourse that influence this issue. The purpose of this multidisciplinary conference of key stakeholders will be to craft a consensus policy and strategy on provision of home birth services. The project may also inform regulatory discourse, alternative funding structures, and the required modifications of curricula to prepare physicians and midwives in urban, rural and remote settings to provide maternity services across birth settings.
Research studies & articles
  • Evidence-based labor and delivery management. Berghella V, Baxter JK, and Chauhan SP. Am J Obstet Gynecol. 2008 Nov;199(5):441-2. From the abstract: "Evidence-based good quality data favor hospital births, delayed admission, support by doula, training birth assistants in developing countries, and upright position in the second stage. Home-like births, enema, shaving, routine vaginal irrigation, early amniotomy, "hands-on" method, fundal pressure, and episiotomy can be associated with complications without sufficient benefits and should probably be avoided." (Email me for full text).
  • Born in the USA: Exceptionalism in Maternity Care Organisation Among High-Income Countries by Edwin van Teijlingen, Sirpa Wrede, Cecilia Benoit, Jane Sandall and Raymond DeVries. Sociological Research Online, Volume 14, Issue 1. From the abstract: "In lay terms, childbirth is regarded as a purely biological event: what is more natural than birth and death? On the other hand, social scientists have long understood that 'natural' events are socially structured. In the case of birth, sociologists have examined the social and cultural shaping of its timing, outcome, and the organization of care throughout the perinatal period. Continuing in this tradition, we examine the peculiar social design of birth in the United States of America, contrasting this design with the ways birth is organised in Europe."
  • Postnatal quality of life in women after normal vaginal delivery and caesarean section. Behnaz Torkan, Sousan Parsay, Minoor Lamyian, Anoshirvan Kazemnejad, and Ali Montazeri. BMC Pregnancy Childbirth 2009; 9: 4. From the conclusion: "Although the study did not show a clear cut benefit in favor of either methods of delivery that are normal vaginal delivery or caesarean section, the findings suggest that normal vaginal delivery might lead to a better quality of life especially resulting in a superior physical health. Indeed in the absence of medical indications normal vaginal delivery might be better to be considered as the first priority in term pregnancy." (full text available by clicking on article title).
  • Health Care Reform in the U.S. Organisation for Economic Co-operation and Development Working Paper #665, Feb. 6. 2009 by David Carey, Bradley Herring and Patrick Lenain. From the abstract: "In spite of improvements, on various measures of health outcomes the United States appears to rank relatively poorly among OECD countries. Health expenditures, in contrast, are significantly higher than in any other OECD country. While there are factors beyond the health-care system itself that contribute to this gap in performance, there is also likely to be scope to improve the health of Americans while reducing, or at least not increasing spending. This paper focuses on two factors that contribute to this discrepancy between health outcomes and health expenditures in the United States: inequitable access to medical services and subsidized private insurance policies; and inefficiencies in public health insurance." Full text PDF available by clicking on the article title.
VBAC & Cesarean Section
Birth Centers
For Expectant Moms, a Happy Medium Between Hospital and Home Births: profiles the struggles of one birth center to obtain permission to open

Breastfeeding
Pedialyte Alternative recipe (not necessary for breastfeeding babies, but great for older children & adults)

Gardening
25 plants you should consider growing
Read more ...

Tuesday, February 17, 2009

Marvelous makeup giveaway

If you're feeling a bit pale and washed out after the long winter, you might enjoy this Marvelous Makeup Giveaway. You will receive:
  • CoverGirl Aqua Smoothers Tinted Moisture SPF 15 in #805 "fair to light"
  • CoverGirl Aqua Smoothers Pressed Powder in #710 "translucent light"
  • Revlon Age Defying Spa Foundation SPF 18 in #003 "light"
  • Revlon Matte lipstick in #001 "nude attitude"
  • Revlon Creme Gloss lipgloss in #080 "mischievous mocha"
  • Sally Hansen Maximum Growth Plus nail polish in #07 "profound pink"

Giveaway rules:
1) For 1 entry, leave a comment.
2) For 2 entries, do #1 and link to this giveaway on your blog, Facebook, website, etc. Paste the link in your comment.
3) For 3 entries, do #1-2 and subscribe to my RSS feed, letting me know you've done so in your comment.
4) Lower 48 US residents only
5) Giveaway ends Friday, February 20th at 5 pm EST
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Monday, February 16, 2009

Belly shot: 29 weeks pregnant

29.2 weeks from LMP. Fundal height is right around 30 cms, FHTs usually in the mid-140s, lots of movement as usual. I think I'm getting close to the "ack! this baby is really coming soon" stage of pregnancy. I have all these things I want to get done before the baby arrives: sending my book proposal to publishers, doing a belly cast, having a Mother Blessing ceremony, making a silk painting to hang in my birthing room, painting the dining room...

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Teleseminar tonight with Dr. Sarah J. Buckley

You're invited to attend a free teleseminar (via phone or webcast) tonight featuring Dr. Sarah J. Buckley, an Australian physician with specialization in GP obstetrics. Dr. Buckley gave birth to all four of her babies at home, the last unassisted and a surprise breech. Visit MyBabyBelly blog for more details. Dr. Buckley just released a new edition of her 2005 book Gentle Birth, Gentle Mothering. It's one of my favorites as it combines scientific research into the hormones of birth and mothering with her personal experiences of pregnancy, birth, and breastfeeding. I am excited to read the new edition, which contains several new chapters and updated medical evidence.
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Sunday, February 15, 2009

Eduador's vertical maternity ward

In an effort to lower maternal and infant mortality rates, one Ecuadorian hospital has implemented a "vertical maternity ward" in which traditional practices--including upright or "vertical" birth, medicinal teas, bathing & massage during labor, and indigenous spiritual rites--are encouraged. Read more about it in the article 'Gravity Birth' Pulls Women to Ecuador Hospital. Some excerpts from the article:
Gravity is the invisible midwife in indigenous birthing rituals, says Rosa Colta, a traditional midwife and intercultural health promoter in Otavalo, a town in the Andean highlands of Ecuador.

For that reason a maternity ward in the dimly lit hospital of San Luis de Otavalo calls to mind a small yoga or ballet studio.

Six horizontal bars covered in colorful rope hang on the back wall, forming a gradient, or "chakana," in Kichwa, the dialect of the Quechua language spoken here.

In a room right around the corner from the hospital's emergency room, laboring women move down the chakana's rungs during delivery, transitioning from almost standing before contractions, to kneeling with their palms on the lowest rung, back curled like a cat, posterior high and ready for birth.

The practitioners believe the downward abdominal pressure as a woman moves down the steps or switches from standing to squatting helps push the child out and speeds up dilation of her cervix.

Part of a model effort to lower maternal and infant mortality and attract more women to hospital deliveries, San Luis de Otavalo is the first public hospital in Ecuador to provide a so-called vertical maternity ward that connects indigenous birthing practices with access to modern medicine. The ward opened in April 2008.

"It was a hard fight for us to get into the hospital and care for women with our ancestral wisdom and practices, with our teas and waters, our sacred cleansing rites," says Colta. "Everyone has bad energy. But we shoo it out at birth."

I particularly enjoyed this gynecologist's commentary about vertical versus horizontal birth:

Pedro Luna, the chief gynecologist at the ward, attributes the speed of ... vertical deliveries to the use of a natural position. "Vertical birth-delivery, adapted by the Kichwa tradition, is a natural and instinctive process that makes physiological sense," says Luna. "Horizontal birth is an occidental practice brought by the conquistadors with zero medical logic."

First chosen mostly by indigenous women, vertical births are becoming more common among mestizas as well. Vertical births have also lowered the hospital's cesarean rate from 18% to 8%.

Read more ...

Used Hypnobabies Home Study Course


Update--set has been sold.

I have a nearly-new Hypnobabies Home Study course (5th edition) for sale. The set is complete except for the sample-sized Luna Bar, which I ate. (It was good!) The set includes:

1) 170 page Hypnobabies Workbook
2) Birth Partner's Guide Booklet
3) Quick Reference Booklet for Labor
4) 12 Advanced Hypnosis for Childbirth Scripts on CD
5) Prenatal Perineal Massage booklet
6) Various handouts
- Positions for laboring out of bed
- Various signs/handouts for hospital staff
- Midwives Model of Care
- The Rights of Childbearing Women
- Instructions for ipod users
- Introductory letter
- List of other Hypnobabies products
- Bumper sticker
- Pen

Price is $90. Shipping to U.S. or Canada included. Email me if you're interested or have any more questions.
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Friday, February 13, 2009

Heads or tails?

Still trying to figure out how/where this baby is lying. For the past month or two I've been feeling intense activity around and sometimes right on my cervix, which can be REALLY annoying after a while. I suspect the baby was heads up and tails down, based on how strong the movements were down there compared to the gentle flutters and swishes near the top of my fundus. So last week I decided to encourage this little one to move. I gently lifted the baby up away from my cervix with one hand and kind of nudged whatever was on top off to the side with the other. I've been having a hard time making heads or tails (ha!) when I am palpating since the baby is small enough that the landmarks aren't familiar to me yet. But I think it did the trick. I've been feeling lots of big kicks and stretches in my upper fundus, nice polite little punches and waves around my lower abdomen right above the pubic bone, and really nothing at all right on my cervix. Ahhhhh, much nicer. Thanks baby!
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Zari pictures

A few pictures from the past couple of weeks...

Horsing around in the mei tai, which I haven't used for a while. I was trying to get pictures of us using the Mamaponcho but I couldn't get any good ones by myself.
She asked me to take a picture of Baby Bear.
Snuggling with her menagerie.
Ready to get wet in swim gear that my mom sent
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Thursday, February 12, 2009

Belly shot: 28 weeks pregnant

28.3 weeks from LMP. I've noticed a lot of breast changes over the past few weeks: they're fuller, the areolas are getting darker (which didn't really happen my first pregnancy), and I've been able to express colostrum recently.

I got some very sexy (not!) thigh-high compression hose for the varicose veins that have been popping up all over my legs. My midwife was quite impressed with how extensive they were. Another thing that didn't really happen the first time around. I wish I'd had the compression hose during all of our Christmas road trips. They feel quite good once I wrestle them onto my legs.

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Wednesday, February 11, 2009

Arrived, resting

We got off to a soggy start this morning. The Amtrak station and waiting area were submerged under several inches of water. We had to decide between waiting outside in the pouring rain or going inside the (underwater) waiting area. We chose the latter, parking all of our bags on the chairs and standing up on the seats until the train came. Zari enjoyed the train ride, although after the first two hours she started asking to "get off train" and "go to mama and papa's house." We made it to Chicago with only one brief crying episode (involving her wanting to bring her baby doll to the bathroom and I didn't know that at first). Our room wasn't ready when we arrived at the hotel, so we left our bags at the front desk and ate lunch.

Zari's napping now--thank goodness, because I really needed her to take a nap for my own sanity. She was totally wired and crazy from exhaustion. We're going to the Field Museum after she wakes up. It's a free day today--woohoo! Then we'll look for a good pizza place for dinner. There's a Giordano's only a few blocks away, so we might try that out.
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Tuesday, February 10, 2009

Going to Chicago!

We'll be in Chicago this Wednesday through Saturday. We're going to take the train up there--much easier than trying to drive through the nightmare of Chicago traffic. Anyone have suggestions for fun things for Zari and me to do while Eric is attending his conference?
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Sunday, February 08, 2009

TENS and cesarean recovery

I checked out physical therapist Elizabeth Noble's Essential Exercises for the Childbearing Year last month. She wrote about using TENS for post-cesarean pain relief (p. 203):
TENS (Transcutaenous Electrical Nerve Stimulation)
This physical therapy modality works on the same principle as scratching an itch. Another message gets to your brain before the pain, traveling over nerves with faster transmission speed. Electrodes are taped above and below your incision. These electrodes are then connected to a hand-held unit with adjustable controls. You can choose the type and speed of electrical current to meet your needs. Patients who use TENS after any kind of abdominal surgery require less or no pain medication, an important advantage to breastfeeding mothers. The stimulation also reduces the incidence of paralytic ileus (intestinal distention and symptoms of obstruction). I also believe it helps to prevent the formation of a dead zone around the scar. A dead zone occurs from pain, disuse, and the mother’s reluctance to examine or palpate this area. The tissues are like dough, many women feel “cut off” from that part of the body, and nerves to the skin may indeed be injured and take many months to recover.
Another (older) book also mentioned TENS for post-cesarean recovery and pain relief. In Adrienne B. Lieberman's Easing Labor Pain, she wrote:
Transcutaneous electrical nerve stimulation (TENS), occasionally used to alleviate labor pain, also offers many benefits to the woman who is recovering from a cesarean delivery. Russsel Foley, TENS expert, comments, “Taking patients’ pain away with TENS gives them better mobility, and that’s important because the most traumatic thing to the body after an operation is immobilization. The longer a person is immobilized, the harder it is to recover.”

Using TENS can mean you’ll need fewer narcotic painkillers after your surgery. Indeed, a study published in Physical Therapy in 1986 showed that women who used TENS following cesarean birth used significantly less Demerol for pain relief. Narcotics such as Demerol, says Russel Foley, “suppress gastrointestinal motility, change respiration, and alter heart rate. If you remove the need for medication by using TENS, you can also remove the side effects of medications.”

If you use TENS for your post-cesarean recovery, the electrodes can be positioned immediately after suturing, and taped to your abdomen under the dressing. You’ll be taught to use the monitor in order to control the amount of electrical stimulation you receive. The monitor can be detached so that you can shower normally. TENS is usually used just for the first two post-cesarean days. (237)
A quick search about TENS and cesarean recovery led me to this small but promising study done last year in Iran: The Analgesic Effect of Transcutaneous Electrical Nerve Stimulation (TENS) on Caesarean Under Spinal Anaesthesia. The authors concluded that "TENS may be used as an effective, non invasive and non pharmacological approach for reducing post caesarian section pain with reduced use of analgesics. This might lead to better outcomes in pain control and facilitating development of bonding between mother and baby."

If you are planning to give birth in a hospital (or even if you aren't, in the event that you end up transferring), you might want to inquire beforehand about the availability of a TENS unit for either laboring or post-cesarean recovery. Ask the staff if they have ever used TENS for post-cesarean pain relief and if they would be willing to try it if you have a surgical birth.
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Saturday, February 07, 2009

Public breastfeeding: why more is better

So often in discussions about nursing in public, breastfeeding advocates tend to frame their replies in one of the following ways:
  • breasts aren't inherently sexual; they're for feeding a baby
  • nursing in public is actually fairly discreet most of the time; often you can't even tell the baby is nursing unless you look closely
Both of those types of responses imply that nursing in public shouldn't really be noticed, either because it is just a baby eating or because it's really not that obvious anyway. But on the other hand, perhaps nursing in public needs to be noticed more. One of the biggest challenges of modern-day breastfeeding is that women usually have to reinvent the wheel by themselves, in isolation, only with some books or websites to help out. Public nursing can play a vital educational role, but only if women actually have the opportunity to see it in action.

Last month, TopHat related her experience with someone wanting to look over her shoulder to figure out how to nurse correctly:
A lady at church yesterday came up to me and apologized for watching me breastfeed...she was afraid that her watching made me uncomfortable. I don't even remember this, so that'll tell you how uncomfortable I was. :) She had been struggling with breastfeeding and was at the end of her ropes and going to switch to formula that day or the next. She wanted to see a good latch and watch someone who has done it. She did go to a lactation consultant the next day (or soon after that) and her baby is now 100% breastfed. Yay for her!

I think this exemplifies a lot of the problems we have in our culture with breasts and breastfeeding. We just never see breastfeeding--we don't know what it looks like and we don't know how to do it. We really have to go out of our way to see it. I went to 5 months of LLL meetings while pregnant to learn what a good latch is--and I'll even admit to trying to see a latch over someone's shoulder. I remember even contemplating, "Should I just ask her if I can watch her latch the baby on?" about a woman in our playgroup.
It doesn't help that, with our overly sexualized culture, videos of women latching babies on--such as one that I posted on Youtube when Zari was a few weeks old--are removed for their supposed "pornography or sexually explicit content." This particular video showed a real-life attempt at getting a newborn to latch on: it included a demostration of a cross-cradle hold while my other hand supported my breast, little hands that kept waving around and poking in her mouth and getting in the way, and multiple attempts at getting her mouth to open and her hands out of the way before the magic opportunity presented itself. These are things you can't see or understand from reading a book. You need to see them in action.

Jack Newman, a leading expert in breastfeeding, is fond of saying "Babies learn to breastfeed by breastfeeding. Mothers learn to breastfeed by breastfeeding." I suggest that we add: "Mothers learn to breastfeed by watching other mothers breastfeeding."
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Friday, February 06, 2009

Dr. Wonderful is "out" and needs your help!

Remember Dr. Wonderful that Navelgazing Midwife has written about? If you don't, visit these posts:
Well, his "secret identity" is now made public! So who is this mystery man, this fabulous OB that we all wish we had in our community? He is Dr. Robert M. Biter of San Diego! Read NGM's post about how he's out of the closet and see some lovely photos taken of him and babies he's caught recently.

And Dr. Wonderful needs your help! NGM wrote:
For reasons I cannot disclose at the moment, I am looking for other Dr. Wonderfuls around the United States....If you know of progressive OBs (they have to be obstetricians or family practice docs, the higher on the rung the better), please email me asap. NavelgazingMidwife@gmail.com
If you know, have worked with, or are another "Dr. Wonderful" please get in touch with her ASAP.
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Thursday, February 05, 2009

Breastfeeding (sabotage) kit

Enfamil is generously offering, out of the goodness of their hearts, a Breastfeeding Kit. It's everything a new breastfeeding mom needs to get off to a successful start (at formula feeding, that is).
  • A sample of Expecta® LIPIL® DHA Supplement for pregnant and nursing moms. Because the first step to supplementing with formula is to undermine the mom's confidence that her breastmilk alone is sufficient for the baby. If you can't persuade her to supplement her baby, then start by getting her to take your magical supplements!
  • An excerpt from The Nursing Mother's Companion, a useful guide with tips and suggestions. Because the entire book would be too expensive and would probably give the mother enough information and confidence that she wouldn't need your magical formulas or supplements. I am guessing the excerpts are all the parts that would undermine breastfeeding: probably stuff about how to supplement with formula, etc.
  • A sample of Enfamil LIPIL®, our closest formula to breast milk, should you choose to supplement. Because, you know, it's all about choice. Never mind that the "choice" to supplement is often a one-way road to formula feeding, or that once a mom "chooses" formula, she cannot simply choose to go back to breastfeeding.
Does anyone else find this creepy and condescending? Well, at least one other person does: Mama-Is (formerly known as Hathor the Cowgoddess). She made a comic about it.

What would be in your ideal breastfeeding kit? Mine would have:
  • At least two breastfeeding books: one solid, informational, problem-solving one like Jack Newman's Ultimate Breastfeeding Book of Answers, and one funny/inspiring one.
  • A sling for hands-free nursing. I'm partial to Second Womb Slings...
  • A stainless steel water bottle: no worries about chemicals leaching out of plastic bottles, good for the environment, helps mama stay hydrated.
  • A DVD of helpful breastfeeding videos, such as the ones found on Jack Newman's site.
  • A collection of fun music and DVDs so mama can relax and enjoy herself while the baby is nursing.
  • A basketful of fruit, nuts, and other delicious snacks for those "holy cow! I need to eat something NOW I am so hungry" breastfeeding moments.
  • Breast comfort aids: Lanolin cream, ice packs for engorgement, gel pads for sore nipples, etc
  • Breastfeeding pillow & cover
  • Phone numbers to the local La Leche League and IBCLCs
  • Samples of Mother's Milk Tea
  • Nursing necklace for mom (for baby to play with when it gets older)
Any other things you'd suggest for Rixa's Ultimate Breastfeeding Kit?
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Wednesday, February 04, 2009

Cesarean section and uterine rupture

Two recent studies--one still in press--that I find quite fascinating relating to uterine rupture. I have the full text of the first one, and hope to access the second one* as soon as it is officially published. As always, email me if you'd like to take a look at the full text.

A few comments/questions/observations:
  • I hope that the evidence from the first study won't be used to risk out women who never went into labor before their cesarean section. Instead, I hope it will simply be used to give extra confidence and reassurance to women who did experience labor before they had a cesarean.
  • In the second study, note the correlation between oxytocics (i.e., Pitocin) and uterine rupture in both scarred and unscarred uteri. 21 of the 41 uterine true ruptures occurred in connection with oxytocics--9 among women with previous cesarean sections and 12 among women with unscarred uteri. This, of course, doesn't mean that using Pitocin = uterine rupture, but certainly it suggests the need for prudence and caution when administering Pitocin during labor--not just among women having a VBAC, but also among women with no previous cesarean section.

1) Laboring before a primary C/S reduces the risk of uterine rupture in a subsequent intended VBAC
C.S. Algert et al. "Labor before a primary cesarean delivery: reduced risk of uterine rupture in a subsequent trial of labor for vaginal birth after cesarean." Obstet Gynecol. 2008 Nov;112(5):1061-6.

OBJECTIVE: To estimate the effect of the onset of labor before a primary cesarean delivery on the risk of uterine rupture if vaginal birth after cesarean (VBAC) is attempted in the next pregnancy.
METHODS: Longitudinally linked birth records were used to follow women from a primary cesarean delivery to a trial of labor at term for their next birth. The effects of characteristics of both the trial of labor and primary cesarean deliveries on the risk of uterine rupture were examined.
RESULTS: Of 10,160 women who had a trial of labor, 39 (0.38%) had a uterine rupture. Women who were induced or augmented for their trial of labor had a greater relative risk (RR) of uterine rupture (crude RR 4.24, 95% confidence interval [CI] 2.23-8.07). Women whose primary cesarean delivery was planned or followed induction of labor also had an increased risk of uterine rupture (crude RR 2.61, 95% CI 1.24-5.49), and this risk remained after adjustment for other factors. Women with a history of either spontaneous labor or vaginal birth had one uterine rupture for every 460 deliveries; women without this history who required induction or augmentation to proceed with a VBAC attempt had one uterine rupture for every 95 deliveries.
CONCLUSION: Labor before the primary cesarean delivery can decrease the risk of uterine rupture in a subsequent trial of labor. A history of primary cesarean delivery preceded by spontaneous labor is favorable for VBAC.
LEVEL OF EVIDENCE: II.

2) Half of all true uterine ruptures are not associated with prior cesarean section
Porreco RP, Clark SL, Belfort MA, Dildy GA, Meyers JA. The changing specter of uterine rupture. Am J Obstet Gynecol. 2009 Jan 9. [Epub ahead of print] Presbyterian/St. Luke's Medical Center, Denver, CO.

OBJECTIVE: The objective of the study was to review all patient records discharged with codes for uterine rupture in 2006 in Hospital Corporation of America hospitals. STUDY DESIGN: All patient charts were distributed to a committee of perinatologists and general obstetricians. Case report forms were analyzed for variables of interest to determine validity of coding and quality of care.
RESULTS: Of 69 cases identified, only 41 were true ruptures. Twenty patients had previous cesareans, and in 9 of these patients, concurrent use of oxytocics was documented. Among the 21 patients without previous cesareans, 7 had previous uterine surgery, and oxytocics were documented in 12 of the remaining 14 patients. Standard of care violations were identified in 10 of 41 true rupture cases.
CONCLUSION: Epidemiological data on uterine rupture based on hospital discharge codes without concurrent chart review may be invalid. Patients with previous cesareans represent only half of true uterine ruptures in contemporary practice.

* thanks to Jill for this one!
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Tuesday, February 03, 2009

Midwife-turned-med student blog

I recently started reading Mom's Tinfoil Hat, a blog by a self-described "hippiefreak idealist mom" who is currently training to become an OB/GYN. Here's a brief bio she wrote several months ago:
I trained as a midwife for two years, and had both of my children with a midwife. One in a hospital, on in a freestanding birth center. I have attended births in hospitals, including cesareans, in birth centers and at homes. I am training to be an Ob/Gyn, however, so you can take anything I say with whatever flavor grain of salt you like.
And here's a bit about her views on birth-related issues:
I support home birth in the full spectrum of reproductive choice and informed consent. I am afraid that obstetrics, the field I love and plan to practice, is in a very confused state in the United States. Interventionist practices are not based on evidence of improved outcomes. I just spoke to an attending at the closest Ob/Gyn residency who was appalled by the practices she saw when she started at that well renowned research and teaching hospital. What was the most appalling to her, and to me, is not simply that these are medical interventions. We are all in support of life saving technology. But, when these interventions have been shown in easily accessible peer reviewed research to lead to negative perinatal outcomes, why have they become standard of care in normal pregnancy instead of in the rare cases that they are indicated?
She recently commented on Jennifer Block's piece Can We Please Stop Blaming Women for C-Sections? This inspired a longer post on VBAC, in which she explores her experiences with VBACs and doctor-persuaded cesareans.
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Monday, February 02, 2009

Belly shot: 27 weeks pregnant

27.2 weeks from LMP and feeling good. I'm starting to get aching hips at night, even with a thick, deep memory foam mattress topper. That was probably the least fun thing about pregnancy last time around. I felt like an eternal pancake at night, always flipping from one side to the other.

I recently re-tested my hemoglobin and although the level itself is good, it hasn't dropped from my 18 week level. If you've read Anne Frye's textbooks, you'll know that she is a stickler for wanting to see a falling Hg level between 12 and 28 weeks, since it indicates adequate blood volume expansion. I didn't have a chance to check my Hg earlier than 18 weeks, so it's possible it was a bit higher at 12 weeks. Anyway, I'm working on increasing my protein intake, as well as ensuring I'm getting enough colorful fruits and veggies and calories overall. I feel like I am already maxed out with how much I can eat--there's only so much room in my stomach!--but I am doing what I can. I'm still only 10 lbs above my pre-pregnancy weight, whereas last pregnancy I was close to +20 at this point. (I started out the same weight each time.) It's bizarre that I am so much bigger this time, yet have gained less weight. Where is it all (not) going???
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Recent research on cesarean sections

Pre-term elective cesareans:
Elective cesarean before 39 weeks worsens neonatal outcomes. Source: Alan T.N. Tita, et al. "Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes." NEJM 360.2 (Jan 8, 2009): 111-120. Email me for full text.

There have been several news reports about this recent study in the New England Journal of Medicine.
I think Jennifer Block's response, Can We Please Stop Blaming Women for C-Sections?, is spot on.
Elective implies freely chosen, life-enhancing. Laser eye surgery is elective. Tattoos are elective. But the vast majority of so-called "elective" cesarean sections are not, and it is inappropriate and disingenuous to call them so in the medical literature, as did the recent study in this month's New England Journal of Medicine, "Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes."...

[I]n spite of the true risk, VBACs are often vehemently discouraged. In fact, many obstetricians now refuse to attend them, and hundreds of hospitals have officially banned them. And malpractice liability fears are a strong motivation to schedule the surgery early, so as to avoid the possibility of labor—and vaginal birth. The fact is that VBAC is inaccessible to most women.

So, if a woman with a scar from a previous cesarean goes to her OB and is recommended to schedule a repeat cesarean—and is told that a vaginal birth would be risky, and that anyway it won't be done by this doctor, this practice, or this hospital—can the surgery possibly be called "elective?"
ICAN is currently compiling a database of all US hospitals' VBAC policies. So far, out of more than 1,600 hospitals, close to 1/3 have an outright ban on VBACs. Several hundred more restrict the practice with de-facto bans; even though the hospital might not have a written policy forbidding VBACS, in actual practice no physicians will attend them. I feel that access to VBAC is one of the most pressing issues in US maternity care today.

Cesareans and Serious Maternal Complications:

The increase in cesarean rates also seems to be tied to a rise in severe obstetric complications. Here are a few articles discussing the recent research article Severe Obstetric Morbidity in the United States: 1998-2005 in the Feb 2009 issue of Obstetrics & Gynecology. (Email me if you'd like to see the full text).
Benefits of Maternity Leave:
Maternity leave benefits moms and babies. Maternity leave before pregnancy is connected with much lower c-section rates. And taking more leave afterwards is beneficial for breastfeeding (big surprise, right?). Email for the full text of the following two articles:
Sources: Sylvia Guendelman et al. "Maternity Leave In The Ninth Month of Pregnancy and Birth Outcomes Among Working Women." Women's Health Issues 19.1 (January-February 2009): 30-37.
Sylvia Guendelman et al. "Juggling Work and Breastfeeding: Effects of Maternity Leave and Occupational Characteristics." Pediatrics 123.1 (January 2009): e38-e46.

Canada's C-Section rate at Record High:
From The Calgary Herald:
Canada’s pregnancy specialists are calling on doctors to curb the fast-growing use of caesarean sections to deliver babies, saying the worrisome trend is exposing mothers and infants to more risk, not less. With one in four births now occurring by C-section - 92,799 babies a year - it is time to get “back to the basics,” says Dr. Vyta Senikas, associate executive vice-president of the Society of Obstetricians and Gynaecologists of Canada.

The group is urging doctors and women to choose a C-section only when there is a medical reason to justify one. “Safety of a woman and a baby should be the driving decisions here,” Senikas said. “We have to come back to the basics, and the basics are that 90 per cent of women will have a nice vaginal delivery without any problems to produce a healthy mother and baby.”
Read more ...
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