Additional thoughts on birth plans

I've never written a birth plan. My first baby was a planned unassisted birth, so there wasn't any need to write a list of what I did or did not want to happen. I would just do it! With my second baby, I saw a nurse-midwife in a solo homebirth practice. Several times during my pregnancy, we discussed what I wanted her role to be at the birth. I'm seeing the same midwife this time; the only difference is she has added another CNM to her practice. They almost always attend births together, so my original midwife will likely be there. I've talked through my wishes with the other midwife, so she also knows what I expect her to do (basically, not much at all unless I ask for something or an urgent situation arises).

Some women planning out-of-hospital births write up a birth plan in case of a hospital transfer. Because my midwife is legally recognized, she can accompany me to a hospital with no fear of arrest or imprisonment. She knows what I want, and I figure between the two of us, we will be able to make my wishes known.

If we didn't have such a fragmented maternity care system, written birth plans would be largely unnecessary. When a woman knows her care provider well and has continuity of care through prenatal visits, labor, and birth, a birth plan is redundant. But this scenario exists mostly in out-of-hospital births, where the people attending the woman already know her and her desires. Most women give birth in hospitals, where nursing staff they have never met before provide most of the labor care. Hence the rise of the birth plan. Birth plans also exist because hospital routines vary so widely from one institution to another. If, for example, all hospitals were Baby-Friendly, then there would be no need to have a birth plan mentioning skin-to-skin contact or not giving pacifiers or sugar water to breastfed babies.

One of the best tools you can take with you to the hospital is getting BRAINS/BRAINED*. Go through these simple steps whenever you're facing a decision about a procedure, medication, or intervention. This is definitely something to print out for your birth partner!

BRAINED
Trying to make a decision? Get BRAINED!
Ask yourself, and your caregivers, these questions:

Benefits - How could the recommended course of action help me or my baby?
Risks - How could the recommended course of action harm me or my baby?
Alternatives - Are there any other courses of action I could consider?
Intuition - What are my gut feelings about this?
Nothing - What happens if I do nothing?
Evaluate - Can you give me some time to consider my choices? Then...
Decide - Now that I have the information I need, I'm ready to make a decision.

BRAINS

Benefits- How will this procedure benefit me and my baby?
Risks - What are the risks to me and my baby?
Alternatives - What are some other things we might try instead?
Instinct/Intuition - What is your gut telling you?
Now/Never/Nothing - What if we don't do the procedure right now? What if we never do it? What if we do nothing?
Safety/Satisfaction - Will this procedure increase the safety and satisfaction of the birth for me and my baby?

Additional reading on birth plans:
A physician speaks about doulas and birth plans
Kingsdale Gynecologic Associates: doula ban and birth plan
Ghouls and doulahs
Midwifery model of care

*The BRAINED acronym comes from a handout that someone gave me from "Lucina Birth Services." The BRAINS acronym was passed around on a doula list serve.

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Delayed Cord Clamping with Dr. Nicholas Fogelson

I'm snatching breaks of time between cooking for our dinner co-op to watch Dr. Nicholas Fogelson speaking about Delayed Cord Clamping. It's definitely worth watching!

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Thoughts on birth plans

Desiree of Hitting My Stride recently asked about birth plans--should she write one? If so, what to put in it? Is it too presumptuous to plan for an event that includes a lot of unknowns and uncontrollable factors? (She has two rare blood clotting factors that make hospital birth a necessity and induction fairly likely if the baby doesn't come by 38-40 weeks.)

I was thinking about what I'd say in response, and my first thought was: let's back up a bit first. Before even thinking of writing a birth plan, or list of birth preferences, or whatever else you want to call it, you need to know what is routine practice at your specific hospital. The last thing you want to do is write up a birth plan full of things that are totally irrelevant at your hospital. That will make the staff laugh or roll their eyes or label you as a control freak.

So first off, before you even think of writing up a birth plan, head to your hospital and talk specifics with the L&D nurses. For example, if you really want immediate, uninterrupted skin-to-skin contact after the birth, ask the nurses how likely it is to happen. What about skin-to-skin after a cesarean? If the mom or baby needs additional attention after the birth? If something is not routine practice, ask them what you need to say or do to make it happen. Go through all of the things that really matter to you. Ask the nurses which things won't be an issue and which you'll need to clearly communicate ahead of time.

Some things will need advance planning, such as wireless and/or waterproof telemetry. Some hospitals have telemetry, while others do not. If you know you'll be having constant monitoring (for example, for an induction) but want to have more freedom of movement, ask about wireless monitoring now, while you're still pregnant. If they don't have it, insist they order it! Ask to speak to the person who is in charge of ordering equipment and see what you can do to ensure they have the proper equipment in time for your birth. Or let's say you want to have access to nitrous oxide (aka gas & air or laughing gas) or TENS units for pain relief. These are both rare in the United States, although quite common in other countries such as Great Britain. You'd definitely need to inquire about them in advance.

My next advice--which Desiree seems to have down already--is don't worry about including any of the little things that you shouldn't even be asking permission for. The don't ask, just do kind of things. Eating and drinking if you're hungry, moving and changing positions, music, lighting, unhooking yourself from the monitors to move/go to the bathroom/etc (especially if, like most women, you have no specific reason to be on constant monitoring). Just do these things and don't take any flak from the nursing staff. Make sure your birth partner knows about these things and can buffer you from the nursing staff if you deviate from their policies or routines.

A third suggestion would be having two separate plans: one for the hospital staff with your most important preferences, and a longer, more detailed one for your partner, husband, or support person. Write down all of the things you want your support person to remember for you, so you don't have to remind them when you're in the middle of labor. Things like keeping the room lighting low, keeping you hydrated, helping you into different positions, asking you if you've had enough time to make X or Y decision, reminding both you and the staff of your preferences.

Now let's get back to the birth plan for hospital staff. Once you've eliminated all of the things that are irrelevant to your specific hospital and/or provider, write down the most important things in the briefest possible way. Keep it short and easy to read. Use lots of bulleted points, rather than long, wordy sentences. Don't go into any long-winded preambles. When I say short, I mean short. If you can make it fit onto an index card, all the better. Here's an example of how to communicate your pain relief preferences:

Pain relief:
~ Do not offer or suggest pain medications. If I want something, I will ask.
~ Do not ask me to rate my level of pain; please make up a number if required for your charting.
~ Please offer or assist with non-pharmaceutical comfort measures (showers, warm baths, birth balls, movement, changing positions, etc).

Instead of going into detail over every separate procedure, think of writing a general directive to ensure you are giving full informed consent. Something like this:

Please ask for my permission before every procedure, examination, medication, or intervention (including vaginal exams, AROM, episiotomy, routine infant procedures, etc).  If it is not an emergency situation, ask if I have had enough time to consider my options and review the alternatives before consenting to the procedure. 

When you arrive at the hospital, you can request a nurse who has experience with unmedicated labors (if, like Desiree, this is important to you). Have your birth partner talk to the admitting nurse and say something like "She really wants to labor without pain medications and labor and push in upright positions. Could you assign us a nurse who would be excited to help make this happen?" They might be too overstaffed to meet your request, but they might also be able to arrange nursing assignments to give you a nurse who loves working with unmedicated moms. This doesn't mean you are locked into having a "natural birth," just that you'll have more support for your initial desire to labor without pain medications.

My final thought is that planning for birth is like preparing proactively for breastfeeding. There are the individual choices you make and have control over during pregnancy, such as provider or place of birth. There are the institutional protocols and provider preferences that will influence what happens to you during labor and birth. And then there are the unpredictable, uncontrollable events that may throw you a curveball during labor. Birth plans are primarily for the second category of events--navigating institutional routines and employee protocols that may or may not be what you want, and may or not be beneficial for your or your baby.

Birth plans also help ensure that you remain more in control over your individual, personal choices. Because if you really want an unmedicated birth, but the hospital staff and routines all push you towards having an epidural, you're going to have a hard time accomplishing your goal. Or if you want lots of uninterrupted skin-to-skin contact, but the hospital routinely takes babies to the warmer and only returns them after examining, weighing, bathing and swaddling, you'll probably find your arms empty after the birth. The birth plan itself does not ensure that your wishes will be followed. But it is a starting point for communicating what is most important to you. 

Labor and birth have unpredictable, uncontrollable elements. We cannot make these magically disappear simply by waving a birth plan around. But a lot of what happens to women during labor doesn't occur because of Mother Nature, but rather because of hospital routines, employee protocols, liability protection, and providers' preferences and training. This is where planning and preparation can make a difference.

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Extended skin-to-skin contact

The benefits of skin-to-skin contact immediately after birth are well-known (see, for example, the Cochrane review, the Lamaze Healthy Birth Practice #6, and the WHO summary of research). But what about extended skin-to-skin contact in the weeks or months after birth? Does it make any difference in outcomes such as breastfeeding rates or mother-baby relationships?

Thanks to a post by the Breastfeeding Coalition of Boone, Clinton, and Montgomery County blog, I learned of multi-disciplinary research conducted in Nova Scotia, Canada on the outcomes of extended skin-to-skin contact. The researchers have produced two DVDs, viewable for free, explaining their findings:

• Enhancing Baby’s First Relationship: A Parents’ Guide for Skin-to-Skin Contact with Their Infants gives a general overview of the findings (length 20 minutes). If you have difficulty opening the video from the link above try this link. 
• Enhancing Baby’s First Relationship: Results from a Study on Mother-Infant Skin-to-Skin Contact presents the findings in more detail (length 28 minutes). If you have difficulty opening the video from the link above try this link.

There is also a discussion guide (PDF) for the DVDs.

still shot from "Enhancing Baby's First Relationship"

So what did the study examine, and what were the findings? 
The study examined the effects of skin-to-skin contact over the first 3 months of life. Researchers from psychology, nursing, medicine, nutrition, and anthropology helped with the study. Over 100 mothers and their full-term babies participated. One group was given no special instructions; the other was instructed to do skin-to-skin with their babies during the first month after birth. Both groups of mothers kept records of how much skin-to-skin contact they had with their babies.

Research assistants visited each mother-baby pair at 1 week, 1 month, 2 months, and 3 months after the birth. They took records of how much skin-to-skin contact the baby had on a daily basis, noted whether the mother was breastfeeding or formula feeding, had the mother complete a postpartum depression scale, observed the mother feeding her baby, and recorded a session while the mother was playing with her baby.

During the first week, the skin-to-skin group provided on average 5 hours of skin to skin [not sure if it was 5 hours per day or per week]. After the first week, the average dropped to 3 hours through the first month of life. The control group had little or no skin-to-skin contact with their babies.

The researchers' key findings were that skin-to-skin contact through the first month of life

• Helped mothers maintain their choice to breastfeed
• Increased mother's sensitivity to her baby
• Reduced postpartum depression
• Increased baby's alertness
• Enhanced baby's responsiveness to their mother

The DVD features interviews with the researchers, mothers and fathers who participated in the study, and health care professionals commenting on the significance of skin-to-skin contact. It also shows video footage of mother-baby pairs interacting, nursing, and playing. It's remarkable how profoundly extended skin-to-skin influences outcomes for mothers, babies, and their developing relationships.

For more information, please contact:
Dr. Ann Bigelow
St. Francis Xavier University
P.O. Box 5000
Antigonish, NS
B2G 2W5
Canada

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Prenatal exam, 4-year-old style

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Pregnancy update: 36 weeks

36 weeks! That's almost done! Now I am officially freaking out over how much I need to do and how little time I have. Like deep clean the entire house, including dusting. Yes, I really do need to dust. Between cutting marble tile and sanding drywall and trimming cement board with an angle grinder, there is dust everywhere.

I am super anxious to get all of the renovation materials out of my bedroom. The bathroom is really coming together. I finished painting yesterday, and we hooked up the water lines this evening. Everything works! We filled up the jacuzzi and the kids and I had a nice hot bath together before bedtime. They were splashing everywhere. It's pretty exciting to have a real tub after using rubbermaid bins in the shower for 2 1/2 years. We didn't see any leaks in the tub, so the leak seal and Plast-Aid must have done the trick. Things left to do in the bathroom:

• hook up all of the switches in the outlet boxes
• install framless glass shower door
• cut holes in antique marble-topped washstand for the sink & faucet, and then install it. (Later on this spring, once the baby is born and it's warm enough outside, I'm going to strip and refinish the whole thing.)
• install pencil-edge marble pieces around the tub tiling
• install & repaint all baseboards & door trim
• put up towel bars and toilet paper holder

I even have a big stack of super soft, fluffy Egyptian cotton towels. Rich, deep red. I haven't had new towels since I got married twelve and a half years ago. The old ones will go upstairs and be "new" towels for that bathroom. The old upstairs towels will become birth towels. And the old birth towels have already become renovation towels. That's how we recycle at the Freezes.

My pelvis is starting to come unhinged. It's especially bad when I get up after sitting for a while. I hobble around like an octogenarian and laugh at myself when I'm not wincing. Yay for relaxin.

I sewed together most of the birth quilt. I'm missing one square and am holding out for my friend to get hers done. But I can't wait forever, because it has to be put together with the batting and backing in time for my blessingway on February 5th. Speaking of blessingways, I'm hoping to hold a virtual blessingway for all of you who'd like to take part but can't be here in person. Gina (aka The Feminist Breeder) mentioned a virtual blessingway last week and I thought it was a great idea. More later once I figure out the details.

I've been sleeping well thanks to the neti pot and nasal strips and canceled the sleep study. The baby's been switching back and forth between ROT and LOT. I've had some practice contractions this week that were definitely crampy, just enough to remind me what's coming...

...which makes me a bit nervous. Nervous and excited. I've done it twice before and know I can again. But still, I have to do it. No one else can for me. I'm not sure if I feel any more or less confident about labor even though I've done it before. Every labor is different. You never know how long or short it will be, or if it will be mega intense or slow and putzy, or if you'll have something funky like a malpresentation or nuchal hand. I don't want to get too cocky. But still, I also know that I can do it.

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Birth Around the World: A VBAC in Tajikistan

Rhiannon Laurie, a doula and student at Western Washington University, sent me the story of a birth she attended last year in Tajikistan. Rhiannon recently returned from a 10-month stay in Tajikistan studying childbirth and culture, funded by Fairhaven College's Adventure Learning Grant. She writes: "In Tajikistan I worked with an Intergovernmental Organization on AIDS prevention in Birth Hospitals, studied traditional medicine at a University, attended/observed one and a half births (read about them here), and (perhaps more importantly) sought to form deep and genuine friendships with the people I met."

Rhiannon runs the website Childbirth for Transformation.

*****

A VBAC in Tajikistan

by Rhiannon Laurie

An examination room at the birth hospital

The room is dirty and cold. There is a bare electric light hanging from the ceiling, but the power is only one from 6a.m. to 8a.m. and 6p.m. to 9p.m. and right now it is midmorning. So our light comes in through the dirty glass of the window, and the little heat we have is from wood stove boiling some water in the middle of a room.

“We” are a young woman, her kurta dress up over her knees, her long smooth legs bent into stirrups, and me. I’m the American standing uncomfortably on the side of the room in a borrowed white lab coat. The one who keeps putting her notebook down on the table and then picking it up again.

For ten months in 2009-2010 I lived in Tajikistan on a grant to “study childbirth.” It took me the better part of the year to manage to sneak through the red tape to see one, but it was certainly worth it. Even when the KGB chased me out of town later that week.

We are in a mountain village named Jirgatol in the valley of Gharm. It is one of the poorest parts of Tajikistan. Villages here cling to tiny bits of flat land between looming mountains and the river far below.

It was poor even to start with. Then the Gharmis lost the recent civil war and things got worse.

I am visiting from the capital, and the people I’m staying with won’t let me out of compound without an escort. Actually, they won’t let me go or be anywhere without an escort. This is the type of life I came here for, but already the KGB are pestering me for more documents every day, and the squat toilet visible to all the nearby houses is giving me a run for my money.

All this for a chance to see a birth.

Let’s call her Nodira, though no one told me her name. She has one of those gorgeous Tajik faces – light brown eyes, freckled skin, and softly curling brown hair. She’s so thin that her belly looks like it should belong in early pregnancy – and yet here she is pushing her baby out.

She is accompanied at various times by me, the doctor, the nurse-midwife, a “sanitation worker,” and her friend. And yet she seems thoroughly alone to me.

I’ve preached endlessly about cultural relativism – that reminder that something abhorrent in our culture may be quite right and good in another. But I can’t help but flinch at the way these normally kind people treat her.

The doctor, a small and equally pretty woman with four daughters (she plans to try again for a boy when her youngest turns two), turns into a force of rage and brutality in the birth room. She and the midwife stand between Nodira’s bent legs, chatting about unrelated subjects between contractions, and repeatedly flipping her dress farther up her body whenever she tries to pull it down to cover herself.

A contraction comes up and the midwife leaves the room to get something, opening the door briefly onto a busy hallway with medical students rushing by – no money for curtains for privacy here. The doctor wedges herself between Nodira’s knees – one shoulder digging into one and both arms pushing the other. Her legs are braced against the bottom of the bed so as to force Nodira to open even farther.

I do yoga every day and there is no way I could get myself into that position at all, much less on a high steel bed as I tried to birth my baby. Nodira cries in pain. Her friend, standing at her left side, worriedly shushes her. I remember my host mother’s proud words: “The Russians and Americans might scream in birth, but we Tajik women keep quiet.”

When the contraction is over, the doctor flashes a frown. She picks and plucks at Nodira’s belly with her fingernails to start another contraction, and begins to lecture.

“You think we’re just going to cut this baby out too because you’re too lazy to push? That’s not an option. You either kill your baby by not trying or you push it out.”

Nodira is crying, “Oh Ochajon, please don’t do this to me.” The doctor just glares. “Try harder.”

I move over to her side, uncomfortable with the voyeurism of my situation. I pick up Nodira’s smooth hand and smile. I know that Tajiks feel affection differently than I do – that a stern word can be a sign of care and love. But I can’t leave this room without having given her some warmth and light, even if it’s culturally inappropriate to do so.

She rolls her tired eyes over towards me and smiles back through her surprise. I’d be surprised too – a stranger showing up in the birth room. It breaks all my rules of conduct for attending births in the U.S. but here I am.

Before the next contraction, Nodira slips into that late labor sleep I’ve seen in births I’ve attended at home. There we would see it as a good sign, provided labor was progressing normally. It means that the mother is staying relaxed, getting the rest she needs, and that she’s basking in all those late birth hormones.

The sanitation worker, a kindly old woman boiling water with which to scrub gloves and aprons, lets out a “oy!” and the rest of the team is called into action. The doctor flicks cold water in Nodira’s face.

“Didn’t you sleep last night? If you pushed better you’d be in the recovery room napping by now.”

When the next contraction comes the doctor is once more pushing legs every which way. I lean down close to the mother and whisper “good job, wonderful job, you’re doing so well,” though I can’t tell from her response if she even understands me. I learned Tajik in the south from southerners and the Gharmi accent is different.

A few more contractions pass and more lectures are given. I quietly demonstrate what effective pushing looks like and Nodira watches intently. This backfires when the doctor sees and exclaims “see, even this unmarried American knows how to push!” but with subsequent contractions she seems to be doing it better. Finally the baby begins to crown.

Now it looks like all the U.S. birth rooms I’ve seen, with everyone screaming “push, push, push,” though in the U.S. we ought to know better.

As the baby comes out, Nodira reaches down to feel its head, to guide it out with her hand. The doctor slaps her, “Don’t touch! What’s wrong with you!” and begins to wrestle Nodira’s right hand back up the bed towards me.

Her friend and the midwife are both working together to hold down her left arm but I am aghast at the brutality of it even as I’m once more in awe of birthing women’s power. The sanitation worker has to lay on her right arm by herself, without help from me.

Then suddenly, like it is always sudden, there is a big wet baby in the room. She’s a big healthy girl. I can’t believe she fit in such a small body. The set her on a blanket on her mother’s stomach to cut the cord, suddenly upset that she won’t touch her baby. “Are you going to let her fall off you?!”

That is only momentary. She’s whisked off to the other side of the room to be cleaned, dried, measured and wrapped – all with supplies Nodira had to bring herself. Then they turn her to one side (presumably so she won’t choke on anything) and leave her all alone on the high table.

As soon as they take her baby away, Nodira begins to shake. Through her tremors she asks if it’s a boy or girl, and lets out a small wail when she hears “girl.” In most of Tajikistan, people are excited by all children and most families want girls as much as they want boys.

But in Gharm boys are a much more important commodity and a young daughter-in-law’s status is precarious until she’s had a boy. With a second girl Nodira has deeply displeased her husband’s family. The doctor looks at her kindly and says “girls are gifts from God too, you know.” I want to hug her and strangle her at the same time, but I’m still holding Nodira’s hand.

The placenta is easily delivered but then there is a tear to be sewn up. A struggle ensues between the wildly panicking Nodira, who bucks and shakes as though she wants to crawl right out of the bed and into the sky, and the determined doctor, who is going to give her stitches. I can’t watch. I can’t listen. I walk back over to my notebook and pick it up. Put it down again. It’s all over soon.

Nodira’s friend asks if they can put a jacket on her. It’s almost as lovely as her kurta dress – I guess they are the finest things she owns, gifts from the birth of her first child. She is covered up and turns her head on the pillow, closing her eyes as if to sleep.

I realize that everyone is leaving the room. The midwife is already gone, monitoring some of the other women in labor. The sanitation worker has finished mopping the floor and left as well. The doctor looks at me, that familiar look telling me I’m doing something strange again, and says “let’s go have some tea.”
I glance at the baby, lying on the table a good ten feet from her mother, and back to the doctor. “Come on. It’s tea time.”

You don’t disagree with your elders. I go.

That was my Tajik birth. I was invited to another later that day, but the woman was Kyrgyz so I couldn’t communicate with her and she seemed uncomfortable with my presence. Still feeling conflicted about my role in the earlier birth, I bowed out. And then the KGB kicked me out of town and there was no way for me to see more.

I don’t want to give an unfair representation of this clinic. Most births in that region take place at home, though home birth is technically illegal. Births in the clinic are the worst cases – often women who’ve been brought in from hours away on donkey back and near to death.

Hemorrhaging and pregnancy induced hypertension were high. And yet the doctor and her team did the best they could for women every day with the skills and training they had. And they were kind enough to let me hang around observing and asking questions.

All the births I’ve attended sneak up on me sometimes. I’ll suddenly stray into a memory of a mother’s breathing, or relive the moment she truly accessed her inner force. But this birth is with me even more. It stalks me, calling me back. Calling me to midwifery training and then to organizations which improve birth practices in Central Asia.

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Who's afraid of a neti pot?

I was, until a few days ago.

I was so sleep deprived that I was desperate to try something. Anything. Towards the end of pregnancy, my nasal passages always feel engorged and swollen. With pregnancy-induced sleep apnea a possible culprit in my sleeplessness, what might help open my breathing passages?

I came up with two ideas: nasal strips and a neti pot. A short walk to my local pharmacy and $20 later, I was armed with my anti-insomnia devices.

I was a bit hesitant about trying the neti pot. I knew it involved pouring warm salty water up your nose and it somehow coming out the other side. Not really my idea of a party.

It wasn't too bad, though. I thought the water would go farther up my nose and throat before coming back out. But the neti pot was simple to use and did an amazing job at clearing my nose out completely. Not even a hint of congestion.

Next, I put on a nasal strip. Nasal strips are stiff bands of plastic that adhere over the bridge of your nose. The plastic lifts your nasal passages open wider as it attempts to flex back to its original position. I laid down to sleep, and wow! I could suddenly breathe about 10 times easier. I didn't notice any of the gasping for breath or startling awake I'd been experiencing recently.

I slept normally last night (for being 8 months pregnant) after 6 consecutive nights of hardly any sleep.

Sleep issue solved? I hope so.

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ACOG issues new opinion on home birth

ACOG position statement quoted in full; see additional reading below.

The American College of Obstetricians and Gynecologists Issues Opinion on Planned Home Births

Washington, DC -- The American College of Obstetricians and Gynecologists (The College) issued a Committee Opinion today that says although the absolute risk of planned home births is low, published medical evidence shows it does carry a two- to three-fold increase in the risk of newborn death compared with planned hospital births.* A review of the data also found that planned home births among low risk women are associated with fewer medical interventions than planned hospital births.

"As physicians, we have an obligation to provide families with information about the risks, benefits, limitations and advantages concerning the different maternity care providers and birth settings," said Richard N. Waldman, MD, president of The College. "It's important to remember that home births don't always go well, and the risk is higher if they are attended by inadequately trained attendants or in poorly selected patients with serious high-risk medical conditions such as hypertension, breech presentation, or prior cesarean deliveries." Based on the available data, The College believes that hospitals and birthing centers are the safest place for labor and delivery.

Although The College does not support planned home births given the published medical data, it emphasizes that women who decide to deliver at home should be offered standard components of prenatal care, including Group B Strep screening and treatment, genetic screening, and HIV screening. It also is important for women thinking about a planned home birth to consider whether they are healthy and considered low-risk and to work with a Certified Nurse Midwife, Certified Midwife, or physician that practices in an integrated and regulated health system; have ready access to consultation; and have a plan for safe and quick transportation to a nearby hospital in the event of an emergency.

The recommendations state that a prior cesarean delivery is an absolute contraindication to planning a home birth due to the risks, including uterine rupture. Women who want to try for a vaginal birth after cesarean are advised to do so only in a hospital where emergency care is immediately available. Attempting a home birth also is not advised for women who are postterm (greater than 42 weeks gestation), carrying twins, or have a breech presentation because all carry a greater risk of perinatal death.


Committee Opinion #476, "Planned Home Birth," is published in the February 2011 issue of Obstetrics & Gynecology.

*****

*Referring to the Wax meta-analysis, whose conclusions excluded the largest study of home birth and included flawed studies known to include unplanned home births.

For related reading on home birth position statements, please visit:
ACOG & AAP position statements on place of birth
Code mec! Code mec!
AMA on home birth
RCOG and RCM on home births
Responses to ACOG
10 responses to ACOG's position statement on home birth

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A loving farewell

My grandpa Clyde died last night, surrounded by his wife and most of his eight children. He had open heart surgery last Thursday to replace a failing valve. The days following were a roller coaster of hope and worry. We had several scares followed by improvements. When the physicians removed the heart pump yesterday morning, though, his liver and kidneys shut down and he took a turn for the worse.

The irony is that the operation is what killed him. Of course, all of the other heart operations he had since his first heart attack at age 39 kept him alive this long. Besides his genetics that gave him terrible cholesterol & heart problems, my grandpa was super healthy all his life. He never drank or smoked. He exercised daily with my grandma. He still fit into his World War II uniform 50+ years later. As with all of his operations, he knew there was a risk, but he felt good about going ahead with it.

I am sad that he is gone, of course, but not the sad of regret and grief. He lived a long, happy life. I hadn't seen my grandparents for several years until we took a trip back to Utah this summer. My grandpa Clyde was a civil engineering professor at Utah State University. They stayed in the same town and house after he retired. We spent a lovely day with them, walking around Third Dam in Logan Canyon, picking apricots in their backyard, and making Wienerschnitzel. My grandma Clyde is from Germany/Austria and she insisted on showing Zari how to prepare the meal from start to finish. I'm glad that Zari and Dio were able to meet their great-grandparents.

When my mom called last night with the news, she said that his death was a very sweet, happy event. She found the Intensive Care Unit intimidating at first. But she soon grew to see the wires and tubes as lifelines of love. She and her family were able to say their goodbyes as his condition worsened. He left this world encircled by those he cared most about.

That's not a bad way to go.

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Pregnancy update: 35 weeks

The theme of the week is exhaustion. I've either been unable to fall asleep, or unable to get back to sleep once I wake up to pee, or both. I've never had these problems before this pregnancy and it's killing me. I'm really worried how I'm going to function if this persists. How will I be up to the task of labor if I'm this exhausted? What about when the baby is born? The saving grace of having a newborn is being able to fall asleep as soon as you're done nursing in the middle of the night (and some lucky people can sleep while they're nursing--not me, though).

I can't think of any reasonable explanations for my inability to sleep. My mind isn't racing like crazy, I'm totally wiped out, I go to bed as soon as I feel tired, I don't drink anything with caffeine. I've taken Unisom on and off and sometimes it seems to help, sometimes not. Maybe it's that I've stopped going to the gym during the past few weeks of renovations? My midwife gave me some valerian tincture and has suggested doing a sleep study. To be honest, I've put it off primarily because of the cost. Plus if I can't sleep in my own comfortable bed, how on earth will I be able to sleep somewhere else, attached to monitors?!

I had my home visit today, which made the upcoming birth seem more of a reality. I probably only have 1-2 more midwife visits left before the baby arrives, unless I go 41 weeks or later (which, with my history, would really surprise me). The baby is now LOT, after a long time of hanging out ROT. We still haven't heard back from the OB who had expressed interest in attending a home birth.

I've started getting things ready for the baby. I scored a free used crib, painted white, which at first will be used mainly when the baby is napping. I sewed a few sets of fitted crib sheets from unbleached linen and this cotton print. As soon as our bathroom is finished, my plan is to put Dio upstairs in Zari's room and set up the downstairs bedroom with the birth tub.

35 weeks with Dio

35 weeks pregnant with Zari

 In my Undercover Mama--I told you it was long and stretchy! And this is a size small...

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Undercover Mama Giveaway!

I'm thrilled to host a giveaway of an Undercover Mama! The winner receives her choice of size and color. Be sure to read my review if you're new to this blog.

How to enter:

• Follow Undercover Mama on Twitter and/or Facebook, then leave a comment here letting me know. 
• Giveaway ends Friday, January 21 at 5 pm EST.

ps--There's another Undercover Mama giveaway at Glimpse Reviews. They also offered a 10% off coupon with the code "MAMA" through February 15th.

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Undercover Mama

One of the things I hate about nursing in the wintertime is exposing my body to the cold when I lift my shirt up. I have a few winters tops with necklines low enough to pull down and "nurse from the top," so to speak. But most of my winter wardrobe is geared towards staying warm. That means a lot of high necklines and turtlenecks.

For that matter, I'm not a huge fan of lifting my shirt up even in the summertime. Especially right after I've had a baby, with all those postpartum folds and bulges!

So when I heard about Undercover Mama, my first thought was "brilliant! I've got to try one out." The Undercover Mama is a strapless tank that clips onto your nursing bra. It's a simple, yet genius, idea. After all, nursing tanks only fit the lucky few who have exactly the right bust size and shape. The rest of us have to stick with our nursing bras.

The Undercover Mama solves this problem, allowing you to wear your own bras and turn them into a nursing tank. This means that any shirt can become a nursing shirt, no matter the fit or style. Here's how it works: You put on your bra, then the Undercover Mama (which is like a tank top, minus the straps), and clip the hooks onto the part of your nursing bra that folds down.

Here's what it looks like partially unclipped:

I contacted Undercover Mama to see if they'd let me review their product. They were happy to send me one. They also let me know a bit more about the company's origins and founders. Elisa came up with the idea and partnered up with Elena, a childhood friend, to bring Undercover to the world in 2010. Here's Elisa's story:

Shortly after the birth of my fourth child, I became frustrated with the lack of options I had for nursing wear. I didn't want to buy a whole new wardrobe to feel comfortable while nursing. I was aching to get back into my regular, everyday clothes. The problem I faced was when I pulled my shirt up to nurse in public I was left with my back, side and belly partially exposed; not something I loved showing off, especially after having a baby. I wanted something to keep my skin "undercover", but I didn't want to deal with more clasps, flaps, etc. to dig through and do back up each time I nursed my baby. When I didn't find what I was hoping for, I designed it myself. I continued to make changes and improve it and realized how much I enjoyed wearing it. I thought just maybe other mamas out there were looking for a solution to the same issues I had faced. After many months of research and testing, Undercover Mama was born. I hope it helps you to be more comfortable so you can more fully enjoy the wonderful experience of nursing.

The Undercover Mama is soft, super stretchy (5% spandex and 95% cotton), and plenty long. It goes far down over the hips, giving ample coverage over the waist and hip areas. You generally order a size smaller than your regular shirt size. I usually wear size medium, so I ordered a small. It easily stretched (albeit snugly!) over my large pregnant belly. If you like a looser fit, you can go with your normal shirt size.

The Undercover Mama comes in 7 different colors, from size S to XXL. You can order it online or at any of these store locations.

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Birth Around the World: My Alien Baby

Inspired by Brieanne's story of giving birth at night to the sound of coyotes, Anna wrote a generational saga of two births – her own arrival in Azerbaijan, and her daughter's birth in the USA. Anna has been a blog reader for several years. She wrote to me:

Your blog was my gateway to the birthing blog world. Ten months ago, I gave birth to a baby girl in a homebirth-turned-unplanned c-section. I was so excited about birthing my baby at home. The c-section was incredibly traumatic. I have been working on recovery since the birth. As my daughter's first birthday approached, I felt a more urgent need to heal spiritually from her birth.

Writing the story has helped enormously – writing down my anger at God for letting this happen to me has allowing me to slowly let go and grow in my compassion.

Besides writing the story, I have been working on several writing projects, including my blog. In one way or another the majority of my writing is prayer for my daughter. Her soul was unable to enter this world peacefully, writing for her, addressing my writing to her in the final sentence is my way of sending her divine peace.

Writing is my prayer.

Anna blogs about faith, feminism, and spirituality at Sotah.

*****

My Alien Baby

I believe that is possible to birth yourself.

That I can get down on all fours, open my womb, and emerge from within – whole.

My mother birthed me in a small hospital in Baku, Azerbaijan, a hospital that by all accounts (and by all accounts I mean my mother’s account) was a third world shithole. She was there for three weeks before my birth in a high risk ward, because I was Rh+ and she was Rh-, a potentially fatal mix without a RhoGAM injection. Though it had been available in the west as a routine matter for women at risk since 1968, it was not available in the Soviet Union, even in 1984. Ten thousand babies a year are saved by a RhoGAM injection to the mother. This terrible combination of lacking the real cure, RhoGAM, and still attempting to be helpful overtook the medical establishment. And so, listening to the advice of her doctors, my mom checked herself into a hospital a week before she was due and spent the next three weeks living in a room with a dozen high risk women, whose babies, generally, did not make it. Three weeks of the dead baby parade – followed by labor, alone. Visitors wore not allowed in soviet maternity wards. My mother is laboring alone with her first (and only) baby, knowing little about birth. She has never been to a birth or seen a video of a birthing woman. There were no birthing classes for her to attend.

On the shores of the Black Sea, in the small town of Sudak, Ukraine, a radical apprentice trained midwife, Elena Tonetti-Vladimirova, is running birthing camps where hundreds of women are coming to birth in the sea’s shallow lagoons with the dolphins. There is available footage of eleven of these births in a documentary called Birth as We Know It. These images are alive. I am wet with the ocean water. Elena talks about the spiraling motion of galaxies and of our hips: they are the same.

I am born in the hospital, finally. We are drugged and I am sluggish in the birth canal. The doctors cut an episiotomy. It will be stitched up without drugs – female genital mutilation. I was born after six hours of labor, a short labor for a first birth. No one ever asked my mother to draw her birth energy with washable crayons on white poster-paper, such things did not exist for her in Azerbaijan, and yet there was Sudak and the dolphins.

Three days after my birth and after bribing a nurse, she was finally able to see me. Another woman was breastfeeding me for those three days. Was I lying there, mostly alone, for my first three days? I feel petty wondering how this birth affected me – how I might have been different if I was born into the sea. If my mother welcomed me on to this good earth and laid me on her chest and snuggled my gooey, vernix covered, unfurled newborn body? Would I then have peace?

My mother told me the story of my birth many times – I have always known this story. It is a sad story of the pathologizing of birth. It is a typical story of modernity gone wrong – characterized by an authoritarian imposition of power acting upon the most vulnerable, a laboring woman and her infant.

I need a radically different story to tell the un-born creature; to tell myself. In the Torah, the Hebrew Bible, characters are constantly rebirthing themselves in new stories. Each new story is a tikkun, a metaphysical and proverbial fixing of the story that came before, a rebirthing of itself. I want a tikkun for myself and for Eve, who was cursed to bear children in pain. In an inflatable kiddy pool, decorated with fish drawings, on the second floor of my DC apartment, I would undo Eve's curse with my very own birth. There would be no dolphins and no black sea, only my inflatable pool where I would know God in the moment of her birth – a creature emerging from between my legs. Z, welcome to the good earth.

*****

At five am, when I get out of bed to pee, my water breaks like it does in the movies. Many women labor the entire time with their amniotic sac intact, only to have it break at the very end. Some women's water never breaks - the baby is born in caul; this is auspicious. Babies born this way are believed to have shamanic powers in some cultures, including in medieval Europe. My water just burst open, gushing down my legs. It bursts clear and beautiful. I cannot feel any contractions. And as the amniotic fluid continued to leak out, the color changes from clear to yellow to green. Meconium

It is a sign of fetal distress – routine in late stages of labor, but abnormal at the start. My midwife arrives and I know what she is going to say – hospital. I did not pack a hospital bag. I bought home birth supplies instead; gloves, gauze, wash clothes, dozens of receiving blankets in a warmer, mesh underwear, chuck pads, plastic sheets and umbilical tape. I spent the previous week trying to make sure I had the right connector from the water hose to the sink, so the inflatable pool could be filled. I did not pack a hospital bag.

I mourn the birth I will not have – the peaceful, undisturbed birth in the dark, on my knees. The earth, the Universe, God, all of you, how can you let this happen to me? I am so sad. I cry for the next four days – I cry till I am finally home, and then I cry some more. I can barely walk around the block. I am scared to shower alone. I cannot lift my baby from her bassinet – it’s too deep. I go to a shrink and she tells me that I am turning birth into a contest, that it is not my fault. I never go to her again. I don’t blame myself – I blame God. Hospital-pitocin-epidural-csection-hospital-potocin-epidural-csection-hospital-pitocin-epidural-csection. I was going to be a mystic, a seer, a conduit for the energy of the earth, spiraling my hips like the galaxies: I wanted to be a birthing woman.

I read a story of a woman giving birth, squatting on the cold hard earth, howling with the coyotes. I wanted to howl with the coyotes and dance with the moon. I wanted Z's birth to be the exact opposite of my own – no fear, no pathology, no suffering. I dreamt of my birth, imagining the opening of my womb – until she and I emerged on the other end. I was thrilled that Z was female, perhaps, one day she might find herself dreaming like this – dreaming of her own birth.

This was not my way – not this time.

Z was born in the hospital operating room. The operating rooms are insanely cold (for the prevention of infection they told me). I was shivering on the operating table, warming blankets all over the body parts I could feel, mostly my arms and neck. There was no way Z could stay in that room for more than a moment, wet and new, simply because it was far too cold for her. She screamed when she was born – the TV scream, loud and distraught. I held her three hours later – after she was cleaned and the IV port was inserted. She was wrapped in the blue and pink stripped blankets – appropriate for both females and males. I saw the babies in the nursery wrapped in the special blankets their parents brought – we did not think of bringing any special blankets. When the nurses brought her, I read the number from my hospital bracelet, and then they give her to me. My baby.

Maybe Z is an alien. C-sections are really an alien invasion, where our human babies are being taken by the aliens, and they are sending instead little aliens, disguised as babies to study us. Z is sending back messages to her home planet, I hope she likes us and we will be spared when the invasion comes.

I am sad because I did not see her emerge from between my legs. It disconnects me from my body, leaving me wanting for prophecy and vernix; for words, for my placenta, which I did not make prints from. The prints I have seen look like trees. I never saw my placenta. Was it more like a maple or a spruce?

My first nurse after surgery was wearing a gorgeous cap – brightly colored, absolutely fantastic. I love nurses who accessorize their uniforms. She had three c-sections. She tried to birth her first two babies; with the third she scheduled the c-section from the start. Michelle Dugger, a mother of 19 children with a show on TLC, had twelve children vaginally after a c-section. Did she howl with the coyotes when she opened again during the birth of her eighteenth baby? Do her hips spiral with the energy of galaxies? Her nineteenth baby was a preemie and a c-section. She was due the same week as Z, but born over two month earlier. Z and Josie Brooklyn are the same real age – both aliens.

The c-section scar is surprisingly small, a thin line only three inches long. The doctors put their hands in this small wound took out my baby, feeling good about themselves. A textbook c-section and healthy baby. The doctors do not know what I am mourning for. I wanted to birth us both, on my knees on the dirt, howling at the moon with the coyotes, and swimming in the sea with the dolphins in my DC apartment. Would the doctors be sad if they knew?

Z, my c-section alien baby, happy birthday – welcome to this good earth.

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What's for dinner?

In November, I and two other families started a dinner co-op, which I wrote about here. We were all so happy when the holidays were over and we could start it up again! I'll be keeping an updated list of our weekly menus on this post, if anyone needs dinner inspiration.

America's Test Kitchen Family Cookbook = ATK
The Complete America's Test Kitchen TV Show Cookbook 2001-2012 = CTV
Comfort Food Fast = CFF
Cook's Illustrated = CI

This week's menu:
Me: Country tomato bisque, artisan bread with caramelized onions rolled up inside, dark chocolate brownies
O Family: raw veggie spring rolls with Thai peanut sauce; noodle stir fry with tofu, peanuts, carrots, and broccoli; gingersnaps

Previous weeks:
Me: Quinoa "mac & cheese", roasted garlic lemon broccoli, artisan bread
Me: hearty Tuscan bean soup (CTV), braised green beans (ATK), cranberry-orange bread, garlic-rubbed toast

Me: BBQ beef with caramelized onions, cranberry-orange bread (ATK)

Me: White bean & garlic soup, quinoa pilaf with apples & almonds, braised carrots with lemon, honey, & thyme (all recipes from ATK)


Me: Peruvian chicken with spicy mayonnaise, roasted crispy potatoes, raw vegetables (recipes from CI).

Me: French onion soup (CTV), artisan bread, salad with goat cheese & sweet peppers, lemon pound cake.

O Family: Thai noodles & vegetables in peanut sauce, fruit salad, banana bread.

Me: White chicken chili topped with a "salsa" made of red onions, raw apple cider vinegar, raw sugar, paprika, celery seed, lemon juice, and salt; saffron rice pilaf; broccoli, cabbage, & carrow slaw.
O Family: green peppers stuffed with brown rice, zucchini, and raisins and topped with sour cream, chives, and almonds; broccoli carrot soup; artisan bread.

Me: Roasted butternut squash soup (the recipe is fairly complex, but it's really, really good), artisan no-knead bread, vegan chocolate cake (similar to the Moosewood recipe)


P Family: roast chicken, roasted root vegetables, green salad

Me: split green lentils with tomatoes; saffron rice pilaf with raisins and cashews (both recipes from Indian Home Cooking by Raghavan Iyer, which I highly recommend); artisan bread

Me: potato, bacon, & mushroom soup topped with cheddar cheese; artisan bread; baby spinach with feta cheese.
O Family: Thai peanut stirfy on basmati rice; pumpkin cake
P Family: spinach/ricotta/mushroom calzone; salami/olive/mozzarella calzone; homemade marinara sauce; oatmeal chocolate chip cookies

Me: country tomato bisque; artisan baguette, leftover Blessingway cake (they didn't mind!)
O Family: egg, sausage, onion, & green pepper bake; banana coconut cream pie
P Family: barley, lamb, & carrot stew; green salad; bread
Me: black beans, quinoa, zucchini, tomatoes, avocados & green onions with a lime/olive oil/Tabasco dressing; butternut squash spice cake (I halved the brown sugar & dusted the top with powdered sugar); corn bread with whole corn mixed in
O Family: bean & beef chili topped with cheddar & sour cream; cornbread; green salad with blue cheese & red onions

P Family: [can't remember...]; green salad with fresh mozzarella & sunflower seeds
Me: whole wheat Belgian waffles; raspberry and blueberry syrups; whipped cream; salmon quiche
O Family: broccoli soup; olive bread; glazed carrots
P Family: spinach & mushroom souffle with tomato-balsamic topping; green salad with fresh mozzarella & tomatoes

Me: split pea soup, artisan bread; green salad with sugar snap peas and fresh mozzarella; Lebkuchen (German spice cookie, recipe from my German grandmother)
O Family: barley & vegetable soup; bread; broccoli and cauliflower in a garlic & herb sauce
P Family: curry with mushrooms & butternut squash; rice; pumpkin bread

Me: Moroccan lentil soup; fresh pineapple; homemade artisan bread; green salad with red onions, cranberries, & Gorgonzola
O Family: Indian vegetable curry; basmati rice; peach strudel
P Family: chicken & vegetable pot pie with puff pastry crust; green salad with red onions, feta, sunflower seeds, & Greek olives

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Belly pictures: 34 weeks

34 weeks and change with baby #3

34 weeks with Dio

33 weeks with Zari:

I grouted the marble tile all day until dinnertime. I finished the shower and floor areas and have the small area surrounding the tub left. We can finally install our toilet tomorrow. If I get up the energy, I'll finish the grout tonight. Now that I'm sitting down, though, I am feeling a bit less motivated! Next renovation task: sanding the final coat of drywall mud, priming, and painting.

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Birth Around the World: Mother Health International in Haiti

On the anniversary of the terrible earthquake in Haiti that took so many lives, I want to highlight a non-profit organization dedicated to improving maternal and child health in Haiti. Mother Health International was founded a year ago today to "respond and provide relief to pregnant women and children in areas of disaster and extreme poverty." It is run by a volunteer medical advisory board of CNMs, CPMs, OBs, and NDs.

Mother and baby at MHI

From the MHI mission statement:

We are committed to reducing the maternal and infant mortality rates by creating healthy, sustainable holistic birth clinics using the midwifery model of care with culturally appropriate, education for the health and empowerment of women. With every healthy birth there is a positive benefit for the communities that we serve and the world as a whole. Our ultimate mission is to empower and educate the local clinic staff, with gender equality, to become the health care providers for their community.

I wrote to Heather L. Maurer, Co-Founder and Executive Director, for more information about her organization. Here is a brief history of MHI:

Located in the country’s southern coast, Jacmel suffered extensive causalities as well as was left littered with crumbled buildings and destruction after the January 12, 7.0 earth quake. MHI founding members were part of a first responder team of seven medics, midwives and support staff, originally affiliated with Bumi Sehat International Foundation, who traveled to Jacmel, Haiti on January 28, 2010 via Santa Domingo, DR to offer disaster relief to women and children. With the help from private donations, NGO’s, nonprofit organizations and government organizations, the team was able to provide emergency medical aid, water and food to the women and children who survived the earthquake.

Shortly after arriving in Jacmel, the founders of MHI recognized the greater need beyond disaster and emergency aid and began the process to build a holistic birth clinic in the heart of one of the most under served areas in Jacmel, St. Helen Parish. On March 10, MHI officially opened our doors to pregnant women and started prenatal evaluations. A few weeks after the opening of the birth clinic, the first baby boy was born into the hands of a volunteer midwife, peacefully and healthy. Today over 400 babies have been born at our birth center and thousands of women have received prenatal visits. Midwives and OB/GYN’s come from around the world volunteer their time in the birth clinic. Our birth attendants are skilled at gentle birthing techniques intended to offer women a place of dignity in which to give birth, reduce pain, decrease interventions and cesarean sections. Our model of care incorporates traditional holistic midwifery care while respecting and embracing Haitian culture and customs.

Our plans are to build permanent structures to serve as our birth clinic and we are searching for a sponsor/donor. We are in immediate need for this as the demands are growing.

Mother Health International's birth clinic in Jacmel has seen over 425 births since its opening in March 2010. It is housed in a 44-foot diameter (1,500 square feet) dome from Pacific Domes. The birth center has 9 beds.

Interior of dome

Dome at night

I love reading the employees' and volunteers' stories of their time at MHI. To keep this post from running too long, I won't repost them all here. Please take the time to visit these links--I think you'll find them as inspiring as I have:

• A reflection from volunteer Melinda
• Meet Marie Antoinette Helen Jeune, Assistant Midwife at MHI
• Meet Ninotte Lubin-Assistant Midwife, Administrator
• Judith Baptist-HIV Counselor
• Sheline Agella
• Clare Loprinzi: Haitian women move with strength and grace
• Tata's Story
• Meet Nadege Medee-Another MHI team member
• Meet Shela Barthelemy-Student Midwife

For a feel of what it's like to give birth at the MHI clinic, read Imaccula's birth story or the story of MHI's first set of twins. You can learn more about MHI at their website, blog, and Facebook page.

Eloufeine traveled 2 hours to birth at the MHI clinic.

If you like what MHI is doing, please consider donating to help keep the clinic operating. All money donated to MHI goes directly to maintain and sustain the birth clinic in Haiti; board members and directors work on a volunteer basis.

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Pregnancy update: 34 weeks

I have definitely rounded the corner from feeling like the birth is forever away in the distant future to ack! I'm going to have a baby in a matter of weeks and how on earth will I be ready in time?! I wondered if I'd ever be chomping at the bit to get the baby out toward the end, but I'm usually thinking more along the lines of "give me some more time; I have so much to get done still." Of course, my babies were born at 38 and 39 weeks, so their arrivals both felt like surprises.

I feel really good in my body right now: strong, capable, not too awkward or cumbersome (although I have delegated certain things to Eric, such as putting drywall mud on the hard-to-reach ceiling areas above the tub or carrying really heavy boxes of marble tile). I enjoy doing physical work while I'm pregnant. I have an almost perverse sense of wanting to show that I'm not helpless and incapable just because I'm growing a baby. I probably go overboard sometimes, like when we installed our privacy fence during a major heat wave this summer...that did both of us in.

Yesterday we tiled the shower, and today we tiled around the tub. Tomorrow we'll install the tile on the floor...which means only 2 more days (or as soon as we get the grout installed) to having a working toilet downstairs! No more having to use my friend's Luggable Loo for middle-of-the-night bathroom trips.

I apply the mortar and lay the tiles while Eric does all the cutting. We used marble tiles with lots of  decorative accents. The lighting was poor for this picture, but you can see the mosaics we installed. The narrow mosaic strips came from large mosaic tiles that we cut apart with scissors. Much cheaper than buying decorative mosaic borders. We interspersed larger brown glass tiles in the mosaic strip.

So back to pregnancy...I did a science experiment last week. I bought new test strips for my glucometer and tested my fasting levels for 4 days in a row. I also tested simultaneously with the old and new strips to see if the old strips were perhaps giving me inaccurate readings. Guess what....?

The old strips were bad! With my new strips, my fasting levels were consistently around 84-86. With the old strips, they were around 105. These numbers were from the same finger prick.

Lesson learned from this whole saga of blood glucose testing: be sure the test strips are new and accurate before taking any actions from your readings. Now, the old strips hadn't yet reached the expiration date marked on the canister, but I don't know how long they had been opened. (You're supposed to use them within 6 months of opening.)

As with all my pregnancies, my fundal height is measuring dead-on. I've gained right around 20 lbs so far, almost identical with my other two pregnancies. This baby likes to hang out ROP/ROT, sticking its butt on the right of my ribcage and its feet on the left. Just like Dio.

Stuff to do in the next week or so:

• Plan a blessingway date and send out invites
• Buy a 25' drinking water quality hose for filling the birth tub. I can't find my old one...I think that it never got returned from one of the families I lent the tub to.
• Finish the bathroom and enjoy the new jacuzzi tub!!
• Get supplies ready for my midwife's home visit next week
• Sew together the quilt squares for the baby's birth quilt (still waiting on about 6 squares...if you're one of those people, hurry up and get them done!)

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Need your input ASAP!

I've been so busy with our bathroom renovations that the deadline for submitting proposals for the next Lamaze Conference sneaked up on me--they are due tonight! I would love to speak again next year and have several ideas floating around for presentations. But first, I want to hear from you--childbirth educators, doulas, and L&D nurses in particular--about what topic you'd like to hear me speak about at the Lamaze conference. Please submit your suggestions ASAP. I hope to still make the deadline!

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Favorite breastfeeding DVDs under $60

A new Bradley instructor recently emailed me for recommendations on breastfeeding videos to show her childbirth education students. Her budget is $60. I'd love to hear your suggestions.

This one, by the creator of the BabyBabyOhBaby infant massage DVD, looks fantastic but it hasn't been released yet.

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Review of DVD "Skin to Skin in the First Hour After Birth"

I am the professional outreach coordinator for my local breastfeeding coalition. At our last meeting, we discussed how to spend funds from a breastfeeding grant we're applying for. We came up with several ideas:

• Provide copies of Thomas Hale's Medications and Mothers' Milk: A Manual of Lactational Pharmacology to local pharmacies, obstetricians, pediatricians, and family practice groups
• Give copies of Linda Smith's Impact of Birthing Practices on Breastfeeding to local L&D units and obstetricians
• Donate consumer-oriented breastfeeding books and videos to local libraries

I suggested providing copies of the DVD "Skin to Skin in the First Hour After Birth: Practical Advice for Staff after Vaginal and Cesarean Birth" to our three local hospitals. I first learned about this DVD at this years' Lamaze Conference in Milwaukee. Linda Smith showed excerpts of it during her presentation on how birthing practices affect breastfeeding. I loved what I saw and asked the producers, Healthy Children, for a review copy. The DVD just came out in 2010 and teaches hospital staff how and why to provide immediate, uninterrupted skin-to-skin contact after birth.

The DVD has three main sections. Section 1, "Advantages of Skin to Skin in the First Hour and Examples of the Baby's Stages" (15 minutes) first reviews the short- and long-term benefits of skin-to-skin care for both mothers and babies. Next, this section explains the 9 observable stages of a newborn placed skin-to-skin in the first hour of life. These stages usually occur in the following order: Birth Cry, Relaxation, Awakening, Activity, Rest, Crawling, Familiarization, Suckling, and Sleeping. Each of these stages is illustrated with video footage and explained by the narrator. We see several different mother-baby pairs going through these stages with both cesarean and vaginally born babies, and we see how many minutes after birth each stage typically occurs.

Section 2, "Skin to Skin after a Vaginal Birth" (9 minutes), instructs staff how to prepare parents for skin-to-skin contact during prenatal visits and upon labor admission. Next, this section offers several practical instructions for how to facilitate skin-to-skin contact. The advice addresses topics ranging proper maternal clothing, routine infant care and admission procedures (which should be done while the baby is on the mother's chest, and with the goal of disturbing the baby as little as possible), keeping the mother-baby pair covered with warm blankets as necessary, and providing supports for the baby's head and mother's arms.

Section 3, "Skin to Skin after a Cesarean Birth" (11 minutes), offers instruction for facilitating immediate skin-to-skin contact after a cesarean section. Some of the advice is the same as for vaginal births (prenatal counseling, maternal clothing during the delivery, supports for the mother's arms, or keeping baby and mother skin-to-skin with warm, dry blankets on top as needed). Other advice is specific to cesarean surgeries, such as keeping surgical equipment away from the baby, positioning the baby properly in relation to the surgical drape and the mother's body, or transporting mother and baby together skin-to-skin from the OR to the recovery room. As with the section on vaginal birth, we see the different newborn stages illustrated in the video footage, along with how many minutes it took for that particular baby to reach the stage.

Both sections 2 and 3 have extensive video footage showing care providers how skin-to-skin care works in a "real life" hospital environment. These two sections also address providing skin-to-skin care if either the mother or baby needs special assistance. In many cases, the baby can be cared for directly on the mother's chest. If the mother needs medical attention and cannot hold the baby, the father or partner should provide skin-to-skin care until the mother is stable. We see fathers doing skin-to-skin after both vaginal and cesarean births  when the mother could not have the baby on her chest for medical reasons.

My thoughts and reactions
Even though I am used to seeing mothers and babies skin-to-skin after birth (most of the births I attended as a doula were at home, where the practice is routine), I was still impressed with how much the pace just...slowed...down in Skin to Skin in the First Hour After Birth. I've seen lots of immediate skin-to-skin care, but not necessarily baby-led breast crawls. I would like to try this with my next baby. I wonder if I'll have the patience to do so!

I highly recommend this DVD, especially for those wishing to implement skin-to-skin care in a hospital setting. The DVD is short, easy to understand, and affordable. I anticipate that this DVD would be a tremendous help in overcoming care provider & staff resistance to doing skin-to-skin care, especially after cesarean sections. Once you see it in practice, you realize how simple it really is. Baby goes on mom, mom and baby rest and relax together, and the staff easily perform any necessary procedures with the baby and mom right in the same place.

My only suggestion for improvement would be to make the DVD easier to find and purchase. It is sold through  Healthy Children's online bookstore and is easy to miss as you're scrolling down the page. You can't order it directly online; instead, you have to mail, fax, or phone in your order. I would recommend making the DVD easier to find on the bookstore page--perhaps with some pictures of the cover and embedded excerpts from the DVD--and adding a Paypal button so people can purchase it immediately online. I would also love to see this DVD sold on Amazon.

Healthy Children is just about to release another DVD about skin-to-skin care aimed at parents, called The Magical Hour: Holding Your Baby Skin to Skin for the First Hour After Birth. I hope to review this DVD as soon as it is available!

Other reviews of this DVD are located at Lamaze's Science & Sensibility.

Skin to Skin in the First Hour After Birth
Executive producer and videographer: Kajsa Brimdyr, PhD, CLC
Executive and content producers: Kristin Svensson, RN, PhD (cand.) and Ann-Marie Widström, PhD, RN, MTD.
DVD, 2010
39 minutes
$39.00
Click here to download an order form (PDF). You may also order by phone (508-888-8044) or fax (508-888-8050).

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