Test leads to needless c-sections

In an article about electronic fetal monitoring for the Philadelphia Inquirer, Test leads to needless C-sections, maternal-fetal medicine specialist Alex Friedman tells the story of an eclamptic patient:

My patient needed to be delivered. She had just developed eclampsia, a potentially fatal disease that afflicts women in the second half of pregnancy. She had suffered a seizure and dangerously high blood pressure, and was at risk for far worse, including a stroke. No one knows why this condition arises, but delivery sure clears it up in a hurry.

So we gave medication to start labor, and the nurses placed a fetal heart monitor....

For three or four hours that night, I struggled with my patient's bad fetal heart strip. I wanted her to avoid a cesarean section. She had type 1 diabetes, and I expected her sugars to swing wildly after surgery, and her recovery to be slow.

To improve the strip, the nurses and I tried giving her oxygen, changing her position in the bed, even rubbing the baby's head through the cervix to wake it up.

Finally, at 3 a.m., I felt compelled to recommend cesarean. The strip continued to look bad, and my patient's labor progressed slowly.

We went to the operating room, and delivered the baby by cesarean. My patient's child greeted the world pink and well-oxygenated.

The test was wrong again.

Between those opening and closing paragraphs, Dr. Friedman discusses the strange history of electronic fetal monitoring. As a resident, he had strong faith in fetal monitoring's ability to detect a compromised baby.

I have performed hundreds of cesarean sections during residency, and many were the result of bad heart-rate strips....For the worst readings, we believed every second counted and rushed the surgery: If the baby wasn't delivered one minute from the first incision into the skin, we had moved too slowly.... But almost every time we whisked a mother back to the operating room, and I cut through skin, fat, fascia, and finally the muscle of the uterus, expecting a blue, floppy baby, the child I delivered emerged pink, healthy, and a little bit angry.

Were we saving lives and averting disaster? Or were we performing unnecessary surgery?

The rest of his article discusses the ins (few indeed) and outs (many, and increasingly well-documented) of electronic fetal monitoring, which Dr. Friedman calls "an appallingly poor test." Towards the end, he discusses why obstetricians still use EFM when the evidence is strongly weighted against it [emphasis mine]:

Why do doctors cling to continuous fetal heart monitoring? An obstetrician will most likely point to the fear of being sued, but the complete answer is more complex. Our medical culture prizes technology and tests, even if they don't work and can cause harm. "It's our bias that anything that can be quantified is an improvement," said H. Gilbert Welch, a professor at Dartmouth Medical School whose research focuses on harm caused by screening and over-diagnosis. "I think we get in trouble when we start promising things to . . . well [patients]," Welch said in an interview. "It is not that hard to make them worse."

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More reviews of Babies

Another review of Babies from Psychology Today...

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Your baby the tyrant

A blog reader alerted me to a bestselling book from French philosopher and feminist Elisabeth Badinter, Le Conflit, La Femme et La Mère (The Conflict, The Woman and The Mother).I haven't yet read the book, but I did read an article about Badinter's new book in The Times. Among other things, Badinter claims that babies have become women's new tyrants, and that cloth diapers, homemade baby food, and breastfeeding are major culprits in the oppression--even modern-day slavery--of women. "It may seem derisory but powdered milk, jars of baby food and disposable nappies were all stages in the liberation of women," she comments. 

I then took an amusing romp through the comments. Is it just me, or does Badinter's argument, and many of the ensuing comments, just seem so old and worn out? Is there a way to talk about these issues without lobbing personal attacks against Badinter or simply rejecting everything she says outright ("if you're too selfish to lay off cigarettes and alcohol for a few months, then frankly you're too selfish to be a mother")?

My take on this whole weary debate:

• "Choosing" not to breastfeed (and in lesser part, choosing disposables and processed baby food) and thus being obligated to purchase expensive, commercially manufactured products for a number of months and/or years does not feel very liberating to me. 
• For me, breastfeeding isn't just about getting food into the baby's body, but about relationship. How can you quantify something so complex as love or attachment or comfort?
• The women I've met who cloth diaper, me included, do it because they really enjoy using cloth, not out of a sense of grudging obligation to some unspoken ideal of motherhood.
• Speaking of washing diapers, is it really that much work to put diapers in a washing machine and hit a button? If we're talking about a new form of slavery, turning on a machine and spending...what?...30 seconds at a time doesn't seem all that terribly demanding to me. Now, cloth diapering would be a whole different story if I had to wash everything by hand... 
• I've never used either homemade or purchased baby food, and this particular example seems especially trivial. Children have to eat one way or the other. I don't see how buying small jars of prepared foods will somehow liberate women from an otherwise bleak life of slavery. 
• Badinter is coming from a position of wealth and privilege. She has the means to outsource many aspects of mothering, from feeding to childcare. What irks me are her grand, sweeping generalizations that all women ought to abandon the day-to-day tasks of mothering because she found them oppressive--as if economics and personal value systems played no role whatsoever in the various ways women choose to mother their children.
• I'm trying hard not to reject everything she says outright, but it's proving difficult. Especially her devaluation of children--they ruin your lives, just ship them off so you can do "important" things with "real" people, etc. Children are human beings, albeit small and often quite helpless, and they deserve an extra measure of compassion and care, not abandonment (however you might personally define it) to surrogates so their parents can "get on with their lives."
• I'm not buying her argument that French women are happier than German women because they are more successful at separating their motherhood from their womanhood. No room for nuance or personal preference. 
• Overall, Badinter speaks of breastfeeding, cloth diapering and stay-at-home parenting as if they were predominant practices that very few women dare break from. In reality, most women formula feed and buy disposables and send their children to day care. So I guess I am left wondering why she's getting herself so wound up over a non-existent "problem," as it were.
• I acknowledge that I am responding to someone else's summary of her ideas, since I haven't yet read the actual book. Great big caveat.
• I do think that modern-day, industrialized, nuclear family life can be isolating. I don't think humans were really meant to live in isolated, nuclear families where the father leaves to go to "work" and the mother "stays at home." I think it's a tragedy that most of us in the developed world have lost our extended kin networks. We no longer have sisters who can breastfeed our babies if we are away, or cousins next door to tend to our little ones, or grandparents who can be a daily part of their grandchildren's lives. We live in a culture in which work and family life occur in strictly separated spheres. Can we imagine new ways of combining the need to earn a living and raise a family, outside of todays' either/or options (working mom or SAHM? Paid out-of-the-home employment or unpaid stay-at-home parent?)

I had to laugh at this comment: "I don't understand why washable nappies and breastfeeding should ruin your sex life? It sounds all in the mind to me, oh no darling not tonight I've got to wash some nappies!!??"

Please read the article and the comments (and be warned, some of them get really off-topic), and then come back and discuss!

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Breastfeeding with Comfort and Joy giveaway

I received this message from Laura Keegan, author of Breastfeeding with Comfort and Joy. I reviewed her book last year and have only glowing things to say about it. More details about the giveaway from Laura:

Breastfeeding with Comfort and Joy is now on Facebook! We have a fan page set up (one of the fans of the book kindly offered to setup the fan page and is actually the administrator, since I'm not on Facebook...yet) Click here or search "Breastfeeding with Comfort and Joy" on Facebook.

I am giving out 5 free books once the fan page reaches 500. The 5 winners will be randomly chosen from all the fans so that every fan has 5 chances to win.

I wanted to let you know about it, so that if you're on Facebook you can become a fan and have a chance to receive a free book, if you are interested; and let others know about it.

Those who might be interested in receiving a free copy could be:

• anyone who plans to start a family
• a pregnant woman
• a breastfeeding mom and her friends and family members
• anyone who works with pregnant and breastfeeding moms
• and anyone wanting to support the circulation of real, unabashed and beautiful breastfeeding images.

The purpose of the fan page is to present Breastfeeding with Comfort and Joy to a wider audience so moms who could benefit from it will know about it. Women benefit from many different types of information and support, and Breastfeeding with Comfort and Joy has a unique approach.

It is my hope, as the following review suggests, that while Breastfeeding with Comfort and Joy is an extremely practical guide for mom and her community, it also can help to change our culture as readers immerse themselves in images of beautiful breastfeeding families.

Even if you are not on Faacebook, please help me spread the word to those who are, if you think they’d like to become a fan and have a chance to receive a free copy of Breastfeeding with Comfort and Joy.

Laura Keegan
Author, Breastfeeding with Comfort and Joy
www.BreastfeedingwithComfortandJoy.com

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Huge doula giveaway

Nicole at Bellies and Babies is hosting a huge giveaway. See below for more details:

The month of May is International Doula Month - a time to raise awareness about these wonderful women and the role they play, a time to show your appreciation for those doulas who have attended you, and a time to show appreciation for those doulas whom you work with on a regular basis.

For this reason, Bellies and Babies is hosting an amazing, 2 week long, giveaway extravaganza. This giveaway is open to:

• Doulas
• Women who have had/have a doula whom they want to show appreciation for, by winning a gift for them
• Professionals who work with doulas whom they want to show appreciation for, by winning a gift for them

If you fall into one of these categories, then, in the first two weeks of May, be sure to check out Bellies and Babies blog for numerous chances to win. We will have 15 different businesses/organizations giving away everything from magazine subscriptions and training packages, to doula business tools, to jewelry and books!

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Self portrait with a pouch sling

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I no longer have a placenta in my freezer

I planted a weeping tree rose in this V-shaped garden area (which was all grass a few weeks ago)

It should look like this:

 

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New York City's midwives in jeopardy

With the closing today of St. Vincent's Hospital, New York City's home birth midwives have found their livelihoods cut from under them. Their pregnant clients, some only weeks or days away from giving birth, suddenly are without care providers. New York State law mandates that home birth midwives have signed practice agreements with either a physician or an institution. St. Vincent's Hospital provided this agreement to most, if not all, of New York City's licensed home birth providers. With the hospital's closing, more than half of the city's home birth providers have been unable to find a new institution or physician willing to sign the agreement and are thus unable to legally practice midwifery.

To learn more about the situation, read these articles and blog posts:

• St. Vincent's Hospital Shutdown Leaves Expectant Moms Without Home-Birth Option
• With the Closing of a Hospital, Women’s Childbirth Options Diminish
• St. Vincent's Hospital Closes its Doors After 160 Years
• Radical Doula: Access to Homebirth in NYC Put at Risk by Closing of St. Vincent's Hospital
• RH Reality Check: Solidarity Now! The Eleventh Hour for NYC Midwives
• Marvelous Kiddo: Help Save Home Birth Midwifery
• Choices in Childbirth blog has updates on the NYS situation and tells you how to get involved

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Review of "Lady's Hands, Lion's Heart" by Carol Leonard

"A midwife should have a lady's hands, a hawk's eyes, and a lion's heart."

Aristotle

This phrase on the cover of Lady's Hands, Lion's Heart: A Midwife's Saga captures the essence of Carol Leonard's memoir. An apprentice-trained home birth midwife at the beginning of the American midwifery renaissance needed courage, skill, and highly attuned powers of observation.

Several blog readers highly recommended Lady's Hands, Lion's Heart when I compiled a list of midwife memoirs. Readers said that her book was "a terrific read. Unputdownable" ... "an emotional, powerful book. The stories of the women and of the midwife are vivid, passionate and moving." This book, surprisingly, had not yet made it onto my reading list. Clearly, that needed to change.

I contacted Carol Leonard about reviewing her book, and she graciously sent me a copy. Since then, we have corresponded on and off. She sends me updates of writing pieces she's working on, elaborates on the stories from her memoir, or tells me about her newest book project The Beauty Girls.

Lady's Hands, Lion's Heart is a memoir with two intertwined stories.* The first is--not surprisingly--the tale of Carol's midwifery career in New Hampshire from 1975-1987. After the not-so-great hospital birth of her son Milan in 1975, she was so fed up with the care she received that she left AMA in the middle of the night, yelling after her doctor "I am outta here!" Yes, Carol is one feisty character, and it only gets better.

Carol began her midwifery career in an unexpected venue--supporting women having abortions in a women's health clinic. (Today, such women are called "abortion doulas.") Around the same time, she started assisting an old-time family practice physician who attended home births, the only one left in the state. Before she knew it, she was catapulted into a career as a home birth midwife. It was the right time and place; the natural childbirth, counter-cultural, and back-to-the-land movements were going strong. Home birth fit easily into all three.

The other main narrative of the book is a love story. As her first marriage is falling apart, Carol falls in love with Dr. Ken McKinney, a handsome, sensitive, dedicated obstetrician whom she works with. Although they sometimes clash over certain obstetrical practices, he proves remarkably open to changing his practice style. This is a good thing, as they eventually marry and work in tandem. Unlike most American home birth midwives, Carol has access to a sympathetic backup OB who is willing to meet her clients at the hospital, no questions asked, night or day.

As Carol and Ken's relationship deepens in the book, they face increasing challenges. Carol learns how to work as an independent midwife--sometimes learning the hard way to be more patient or more humble. She also withstands considerable opposition from local physicians and hospitals and creates landmark direct-entry midwifery legislation. Ken's physician colleagues dislike his support of home birth (and his popularity with  patients) and eventually give him an ultimatum: stop providing backup to Carol, or lose your job. He leaves his group practice and forms a solo OB/GYN practice that becomes the most successful in town.

Lady's Hands, Lion's Heart is a gripping, fast-paced read. Filled with Carol's earthy humor and raw narrative style, you become immersed in the moment-to-moment life of a home birth midwife. Women birth in urban government-subsidized apartments and in quirky off-grid cabins. Carol climbs into tiny lofts, underneath a woman suspended midair, and through a storm of feathers unleashed by a laboring woman ripping apart her pillows. All in a day's work for a baby catcher.

This passage, which makes me laugh every time I read it, conveys how home birth midwives adapt themselves to laboring women's preferences:

Because Thea is so short, she braces herself, straight armed, in the space between the washer and dryer. This leaves her feet dangling about six inches off the floor. This is how she wants to do it--suspended in midair.


I on the other hand, am lying on my side, wedged in between both appliances. I am trying my best in these cramped quarters to guide the baby out. The amniotic fluid is dripping on my head. Dryer lint is sticking in my wet hair. I am covered, head to toe, with fuzz galls. When I finally stand up, I look like a gray Yeti.

The book is told entirely in first-person present tense, which lends an immediacy to the story. (Short aside: present tense is quite difficult to sustain over a long narrative. At times it was hard to remember the correct sequence of events, as everything was told as if it were all happening right now.)

As American midwifery evolves and professionalizes, today's student midwives will likely have different formative experiences than the midwives of the 1970s. Carol Leonard's memoir preserves and documents the soul of American midwifery, including the founding of MANA. For those wishing to learn more about this rich heritage, Lady's Hands, Lion's Heart should be read in combination with Sisters on a Journey: Portraits of American Midwives.

Ladys' Hands, Lion's Heart is available through Amazon or directly from Bad Beaver Publishing. 

*Or three main story lines--after I wrote this review, I read on Carol Leonard's website Bad Beaver Publishing: 
"The story spans thirteen years--1975 to 1987-- and is told with three threads. The first thread is the home births and my apprenticeship with the wonderful old country doctor, Dr. Francis Brown, the only physician in the state who still attended births at home. He took me on as his sidekick, and we trooped around the New Hampshire countryside for years while my own practice was blossoming. The second thread is the renaissance of the profession of midwifery in the United States, despite formidable opposition from a jealous medical profession. The third thread is my love story with the impossibly handsome and brilliant obstetrician, Dr. Ken McKinney."

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Interview with "Babies" filmmaker Thomas Balmès

I recently spoke with Thomas Balmès, filmmaker of the documentary Babies. Let me recap the highlights of our conversation.

In a time when movies and television inundate us with messages--from subtle to blaring--Thomas Balmès' documentary Babies returns to the basics: the joys, adventures, and discoveries of babyhood. Following four babies in their first year of life, Balmès lived with families in Tokyo, Namibia, San Francisco and Mongolia. His film is a cross-cultural voyage through infancy and babyhood from a baby's point-of-view.

Balmès did not create Babies with a social or political agenda in mind. "I don't deliver messages," he said. "I am not a postman. I am a filmmaker."

With little narration, the film speaks for itself via its stunning imagery and cinematography. Balmès favors long, unedited shots, like the opening and closing scenes in the trailer.

Selecting the families was a challenge. At many of the casting locations, he would have more than 100 families to choose from. Both Balmès and the families had to be a good match for each other, as he would live with them for almost a year, capturing their babies' every move on film.

Balmès filmed the four babies mostly serially, one after another. Occasionally, the parents shot additional footage themselves.

Balmès related that it was especially difficult finding American and Japanese families who were comfortable allowing a filmmaker into their intimate space for an extended period of time. He learned to integrate himself into the everyday life of the families. At times, this meant knowing when to step outside to give the families some time alone.

Thanks to the generosity of these four families, Balmès has created a spellbinding documentary. As the camera moves within the baby's point of reference, the quotidian becomes profound. When we see the film, we relive our own childhood. We remember the excitement our own baby's first steps and first smiles.

Balmès' next project? Spending time with his wife and three children, the youngest of whom is just 3 years old. For the past few years, he has spent long periods away from home filming other peoples' babies, and now he wants to be with his own family.

When & Where to Watch Babies
Babies premieres on May 7th in North America. Click here to find when your local theater is showing Babies. And if it isn't, put in your vote on the Babies widget on the sidebar! The DVD release date has not yet been announced, but Balmès hopes it will be in time for the Christmas holiday season.

In the meantime, you can watch this featurette, which includes interviews with Balmès, producer Alain Chabat, and Focus Features CEO James Schamus. 


Your Turn:

What questions do you have for Thomas Balmès?

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One year old!

Dio turned one year old yesterday! It's going to be very hard to avoid cliche statements like the time goes by so fast and it feels like just yesterday that he was a tiny newborn because...well... they're entirely true!

And I know this next phrase will also sound overdone, but I have been really busy lately. So busy that I didn't even have time to write about Dio's first birthday on the day it happened. (I didn't get back from painting one of our rental apartments last night until 10:15 pm. By time I changed out of my painting clothes, checked my email, folded some laundry, wrote in my journal, and attended to other mundane tasks, I was totally exhausted.) And then tonight I made a really elaborate chocolate cake--one of those complicated recipes involving lots of sour cream and brown sugar and dark chocolate and sifting the dry ingredients together--and it tasted just like a cake mix. So disappointing. In fact, I nixed having a birthday cake/candles/song tonight because I want a dessert worthy of the occasion.

So here are some milestones Dio has reached over the past month or two:

• Standing independently
• Walking!
• Saying his first words ("uh oh" and last week, "dog")
• Clapping his hands
• Doing "so big!" with his arms up in the air
• Climbing up our outdoor slide all by himself
• Sleeping longer stretches at night and putting himself back to sleep when he wakes up
• Throwing and chasing a ball
• First haircut
• Climbing all the way up the staircase when I wasn't watching him. Now that's all he wants to do!

Some of the words/phrases/concepts he understands:

• Zari
• Papa
• nurse/allaiter
• potty/psssss
• uh-oh
• uh-uh (the phrase I use instead of "no")
• dog & cat
• ball
• chasing & being chased (usually with the phrases "Dio's going to get me" or "I'm going to get you")
• clap your hands/tapes les mains
• feeding and being fed, cued by an "ahhhh" sound (he loves to feed us now, so cute!)
• soft (as in, stroking a cat or dog's back, rather than pulling its fur out)

His body is lengthening out, and he looks more boyish and less babyish to me. He is becoming more and more confident with walking. Just a few days ago he was taking his first hesitant steps and needed lots of coaxing. Tonight, though, he walked across the room several times at a decent clip.

Despite all the reasons for celebration, Dio has been fairly miserable the last few days. He has two new teeth just popping through, a bad cough and congestion, and an on-and-off again low fever. He's been super whiny and cranky and clingy. Today was especially hard for him. He's tired and in pain and I can't magically make it all go away.

Maybe if tomorrow isn't as crazy, I will read through Dio's birth story, look at his birth pictures, and watch videos of him as a newborn.

Happy birthday Dio!

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Totally freakin' amazing birth stories

I've come across a few great birth stories that make me want to have a baby again. Which is looking a lot more possible since my period just started, right after my 32nd birthday. It's a birthday present that I have mixed feelings about. I like being period-free. Since January 2006 I have had 4 periods, total. But I am also happy to know my fertility is returning, to know that another baby is now possible.

So first off, Amy of Life in Slow Motion just had her second baby, another girl. I first started reading her blog when Zari was a tiny baby. I wish I lived closer to her, because she takes amazing photographs and I'd love to have our portraits and family pictures done by her. Her first baby was a fairly traumatic hospital birth, so she chose to give birth at home the next time. First, read Baby Ada's Birthday (and watch the video, too--it's amazing to see her literally deliver her own baby so calmly and naturally). Then you can read more about the birth at Welcoming Baby Ada.

The other stories are all on Birthing Beautiful Ideas--a blog I just discovered and wish I'd found much earlier!

Story #1: Birth and the Big Baby: An Unnecesarean Avoided. BBI was the doula for this woman, who was under considerable pressure to schedule a cesarean and/or induction for "suspected fetal macrosomia." Her client had already given birth vaginally to a 9-lb baby and didn't want surgery unless it was really necessary. She finally decided to consent to an induction, but her baby had other plans....

Story #2 part I: the written account of Beautiful Birthing Ideas' own VBAC waterbirth in a hospital-that-does-not-do-waterbirths. Notice the transformation in the nurse. Before: nurse keeps trying to get BBI out of the tub and onto the bed, and the sneaky doctor keeps thwarting her plans. After: nurse raves about how amazing the waterbirth was. Here's the doctor re-educating the nurse as BBI is pushing:

After a couple of pushes, Dr. N and Chris helped me to get into a hands-and-knees position so that I could gain the assistance of gravity in my pushing. And then Dr. N turned to my nurse to tell her the following: “Look at how beautifully she’s doing. Look at how natural and normal this is. She’s pushing on her own, and no one is yelling ‘PUSH’ in her face, no one is counting for her.” And you know what? My nurse started to get excited about this birth. In fact, about twenty minutes into my active pushing, she came into the room to remind me of my birth plan and of my initial intention to push in a side-lying position. Although I told her that I felt much more comfortable pushing on my hands and knees, I was so grateful that she had taken my birth plan seriously enough to remind me when I wasn’t following it!

And then the nurse almost cannot restrain herself with excitement:

A and I snuggled in the water for another ten minutes, and then we moved out to the main room. And my nurse—the one who wanted me the heck out of the tub—was nearly jumping up and down saying, “That was the most amazing thing I’ve ever seen! You are awesome!” ... Later, I learned that about five other nurses rushed into the room to see the woman who had the hospital’s first water birth.

Story #2 part II: Not Too Posh to Push (Upright and Spontaneously): A’s Birth Video. BBI shares videos from her VBAC as part of the Lamaze Healthy Birth Practices Carnival on upright and spontaneous pushing.

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Sleep update

A few weeks ago I posted about Dio's nightcrawling that was keeping all of us from sleeping well. A few days later, I wrote a quick update called Thanks. So what has happened between then and now?

The night after that update, I got 2 hours of sleep. Some of it directly because of Dio's wakings, and the rest indirectly because I was so stressed/exhausted/desperate that I literally could not sleep after 1:30 am. I decided that I could not go on like this. Something had to change.

So here's what we did the following night:

• Moved Zari into her own room so she wouldn't wake him up, and vice-versa
• Moved Dio's crib into his room and removed the twin mattress. We'd recently started keeping Dio in his room all night, and we resolved to keep that up.
• Closed both doors connecting our bedrooms, rather than just one, so I wouldn't wake up every time Dio made noise. 
• Ran a fan for white noise in our own bedroom, as well as Dio's, again to help mask all but the loudest crying.
• I decided that I was not getting out of bed until 3 am or later (with the exception of going to the bathroom). And I was only nursing Dio once. If Eric wanted to tend to Dio at other times, fine. But I was not going to.

I still wasn't sure what the plan was if Dio woke up and would not settle down for hours on end--something he'd been doing a lot lately. Would I actually be able to let him cry and cry if it came to that? Would he survive this sudden change in nursing schedules (from twice to once)? Things were at such a crisis point for me that I asked Eric to give Dio a blessing before bedtime.

So we put Dio to bed in his crib, in his own room, and waited to see what would happen. (Remember, the only change for Dio was that he was in a crib, rather than on his twin mattress. Otherwise same environment and routine.)

He slept until 4:30 am. I nursed him, put him back down, and he slept the rest of the night.

The next night he woke up once at 3 am to nurse, then slept the rest of the night.

I felt like a human being again. It was amazing. 

For the next two weeks, Dio would alternate between waking once between 3-5 am, or waking an additional time around midnight. Still not bad. More and more often at that earlier waking, we'd let Dio fuss for a few minutes to see what would happen. And, amazingly, he'd stop crying, lay himself back down, and go back to sleep. And we're not talking hours of crying here--usually just a few minutes.

At this point, Dio usually wakes up just once to nurse, around 3-4 am. And if he does wake up at other times, he gets himself back to sleep fairly quickly. And I've found that I no longer need the white noise in my room.

So what accounts for this radical shift in sleeping behavior? I think it's a combination of:

• Being in a crib where he can't fall off or wander around
• Being in a room so dark that there's nothing to see. Our room, where his crib used to be, is a lot lighter at night. He always wanted to be standing and partying when his crib was in our room (or screaming because he could see me, and it simply would not do to be 3 feet away from me). 
• Not being woken up by Zari, who thrashes around a lot at night
  
• Switching from 2 to 1 night nursings, which helped reset his nocturnal clock

I am so thankful.

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First steps!

Dio's been standing independently for the last week or two, including getting to standing without pulling on anything. And he did this today:

He seemed quite pleased with himself.

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A tale of 3 hospitals

Last month, The New York Times featured an article about a rural Indian Health Service hospital that has achieved very low cesarean rates even with a higher-risk population. Tuba City Hospital's most current cesarean rate was 13.5%--the national average is over twice that number. Some of the policies at Tuba City Hospital influencing the low cesarean rate include:

• Encouragement of VBAC
• Midwives attend most vaginal births, with obstetricians available if the need arise
• Midwives are on-site around the clock and tend to do fewer inductions
• Midwives and doctors at Tuba City are more comfortable with slow labors and less likely to call a cesarean section for "failure to progress"
• Doctors and midwives are salaried, so there's no financial incentive to perform certain procedures
• Practitioners and Tuba City have federal malpractice insurance, so they are able to offer VBAC without fear of their malpractice carrier forbidding it

The Navajo culture also plays a role in keeping cesarean rates low:

Some of Tuba City’s success probably arises from Navajo culture and customs. Couples often want more than two children, but repeated Cesareans increase the risk of each pregnancy, so doctors and patients are motivated to avoid the surgery. Also, Navajos regard incisions as a threat to the spirit, something to be avoided unless necessary.

Birth is a joyous affair here, and the entire family — from children to great-grandparents — often go to the delivery room.

“I’ve had 12 family members in the room,” said Michelle Cullison, a nurse-midwife. “I’ve frankly never seen a place like this. Whoever that woman wants to be there is there. It’s something I would take out to the community.”

Linda Higgins, the head of midwifery at Tuba City, said: “All of a sudden Mom is surrounded by women, and they’re all helping her and touching her.”

As a result, many young women have already seen children born by the time they become pregnant, and birth seems natural to them, not frightening. 

And just yesterday, the NYT ran another article about two Staten Island hospitals with drastically different cesarean rates. Richmond University Medical Center has a 48.3% rate, while only a few miles away, Staten Island University Hospital has a 23% cesarean rate. What accounts for that huge difference? Chairman of OB/GYN Dr. Mitchell A. Maiman at SIUH has created--and enforces--policies that keep the cesarean rate at a more modest level. These include:

• No non-medical inductions before 41 weeks of pregnancy
• No maternal-request elective cesareans
• Active encouragement of VBAC
• Physician peer review and accountability; residents report if they see other physicians about to perform unnecessary cesareans

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A Breech in the System

A recent documentary about an Australian woman who has a breech baby vaginally "in the system."


From the documentary's website:

A BREECH IN THE SYSTEM. A woman wants to give birth to her breech baby in a hospital. They say she has to have a caesarean section. This is an inspiring documentary about her to attempt to birth naturally against all odds.

Karin Ecker’s interest in social issues has brought her international credits for her filmmaking plus photographic art. From filming European children exploring environmental issues in the Bahamas to physically handicapped people scuba diving in the Egyptian Sea, she now brings her lens to the issue of childbirth choices in Australia. She intends to use this film as a tool to support the voice of ‘woman’.

Click here to learn more about the story behind the film.

I would love to review this documentary, if the filmmaker is interested.

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Thoughts about unassisted birth: part II

If you had the time to read back through the selected posts listed in part I, you might have noticed a gradual shift in tone. During Zari's pregnancy and immediately after her birth, I was on my "honeymoon" phase in my relationship with unassisted birth: a bit idealistic, breathlessly in love with the idea of undisturbed birth as the pinnacle of the birth experience, enraptured and fascinated with the practice. Now, it was still me writing, which means that my pragmatic and analytical selves were still present even when I was strongly advocating unassisted birth. But compared to how I feel now, after a second pregnancy and birth, I would say that my relationship with unassisted birth has settled into a more mature, complex, and nuanced pattern.

Towards the end of writing my dissertation about unassisted birth, I was already finding myself critical of certain trends I saw emerging in online UC communities--the trend toward dogmatism, the distrust or even demonization of midwifery, the embracing of slogans (trust birth! breech is just a variation of normal! etc.) that mask the complexity of reality. In particular, the abandonment of education and preparation--and of midwives--in favor of "trusting my body/following my intuition."

Here's an excerpt from my dissertation on this topic (from chapter 4):

After years of immersion in UC communities, I have started to notice a trend toward dismissing the necessity of knowledge and preparation, toward emphasizing intuition to the exclusion of almost anything else....I am not sure if this anti-education and risk-denying undercurrent has always existed and just I never noticed until now, or if it really is a new development. This tendency is not universal, but it is prevalent enough that others besides me have noticed it....

Over-reliance on any one type of knowledge can be dangerous. No one source of knowledge about birth is infallible or complete. Even if intuition is believed to be inherently accurate, it is not omniscient or omnipresent. UCers and midwives have separate sets of challenges regarding intuition. As Lucia Roncalli noted, midwives need to incorporate intuition into their clinical training and experience and give it adequate respect. For UCers, the challenges are to sufficiently refine one’s intuitive skills and to balance education and preparation with a trust in intuition. This is a difficult process—walking the knife’s edge of embracing intuition as a “knowledge that matters” without falling into the trap of intuition becoming “the only knowledge that matters.”

To be fair, I wonder if some of the things I'm perceiving is just that--a problem of perception. Since I finished my dissertation, I haven't followed online UC communities as closely as I used to. I'm more of a casual browser/eavesdropper now, rather than regular reader and participant. I know that just dropping in on certain messages might not give me the full context of the larger discussion--just as overhearing bits of a conversation is not the same as participating in it from start to finish. Knowing the full context really does make a difference.

What I am not doing in this post is disavowing unassisted birth. I am just trying to explain that I feel many different ways towards the idea all at the same time. I do feel less comfortable "promoting" UC than I used to. If a woman hires a midwife or a physician, she can shirk the responsibility of education and preparation, and things will probably be okay--in a "everyone comes out alive and relatively healthy" sense--because there is someone else there with extensive knowledge and training and skills to fill the gap (even if we might debate the usefulness of, say, surgical skills for a normal vaginal birth). But with UC, all of the weight is on you and you alone. There's no one else to catch you if you stumble.

I am reminded of one of my favorite professors: ethnobotanist Dr. Paul Cox. He served an LDS mission in Samoa, and his approach when teaching people interested in his church was to talk them out of joining. He wanted them to be 100% sure that they were joining because they had a personal testimony and unwavering belief. If he couldn't talk them out of it, he knew they were really serious. I feel the same way about UC. I think giving birth unassisted is wonderful--but I don't want to talk anyone into it. I don't want to over-romanticize it, or promise women a pain-free ecstatic birth if they just get rid of the midwife/their fears/their doctor/the hospital. I want women to have an undeniable inner knowing that an unassisted birth is right for this baby, this pregnancy. And to have the concomitant desire to do the necessary preparation for giving birth without a care provider present.

I absolutely stand by my decision to give birth to Zari unassisted, just as I do my midwife-attended birth with Dio. If anything, both experiences have taught me to trust that inner voice--call it intuition, divine/spiritual guidance, whatever you like--no matter where it takes me. It might sound airy-fairy for some readers, but nevertheless it was undeniably real for me in both pregnancies. I hope I never need to give birth in a hospital, but if I do feel drawn towards that for a future pregnancy, I hope I can embrace that guidance and move forward with confidence.

If I didn't feel strongly guided one way or another, I'd probably hire the same midwife if I became pregnant again. I really enjoyed our prenatal visits. Her presence at Dio's birth didn't disturb me or interfere with the birth in the least--of course it helps that she arrived only 30 minutes before he was born! And I do like having someone with extensive knowledge and skills that I can call upon. I would not have access to that where I live if I were planning an unassisted birth and doing my own prenatal care. But I also recognize that my unassisted birth with Zari played a huge role in knowing what I wanted from a midwife and in knowing how I labor and birth. If anything, that first unassisted birth gave me more confidence in myself to be able to labor successfully in many different settings.

Stay tuned for part III, in which I respond specifically to Barb Herrera's post The UC Oxymoron.

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Facebook

I have a Facebook account, but rarely use it because 1) I don't have the time and 2) my computer won't let me access Facebook except once every 3 months or so. In other words, if you've sent me a FB message or added me as a friend, don't hold your breath on hearing back from me. The best way to contact me is via the email address on the blog sidebar. And if you do add me as a FB friend, be sure to introduce yourself because I only add people I know. (Am I the only one who gets totally random friend requests--people I have absolutely no idea who they are?)

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Transcript of CBC radio program on breech birth

Below is the transcript of the CBC radio program, All In A Day, about breech birth from April 13, 2010. Host Alan Neal interviews Dr. Glenn Posner and Robin Guy. Click here for the podcast and here to listen directly to the show. 

Transcript typed by yours truly. 

All In A Day: Breech Births

Alan Neal: A couple times on “All In A Day” we’ve checked in with a group called the Coalition for Breech Birth. This coalition advocates for the natural delivery of babies who are in the breech, or bottom-first, position. The Society of Obstetricians & Gynaecologists [of Canada] reversed it position on breech deliveries last year. They now say it’s safe to deliver breech births naturally in most cases. But a lot of obstetricians aren’t trained in delivering breeches because for years, doctors have been directed to do C-sections instead. Well, this is all slowly changing at Ottawa hospitals. The Montfort Hospital has been delivering natural breech births over the past year, and just recently, the general campus of the Ottawa Hospital started joining in as well.

Dr. Glenn Posner is an obstetrician/gynaecologist who’s been trying out his new skills in natural breech delivery. And Robin Guy is the co-founder of the Coalition for Breech Birth. Both join me on the phone. Hello there.

Dr. Glenn Posner: Hi.

Robin Guy: Hi. How are you?

Alan Neal: I’m fine. Dr. Posner, I’m going to start with you. Take me back to med school. What kind of training did you actually receive during your residency when it came to breech births?

Dr. Glenn Posner: Right. So I graduated from med school in 1999 and started my residency in Ottawa just as Mary Hannah’s trial was being stopped early because they found that there was more risk in the trial of labour group. So basically my welcome to residency in Ottawa was: no more breech deliveries vaginally. So my cohort of residents—we started training about 11 years ago—are, I’ve been saying, the worst-trained obstetricians in Canada!

Alan Neal: So no one knew how to do the breech births.

Dr. Glenn Posner: Right. We practiced our skills at cesarean section, we practiced on simulated models, but there’s nothing like real hands-on experience. We practiced with second twins that are still acceptable to be delivered breech. We never really got to see a planned trial of labour for breech.

Alan Neal: Can you just remind us why this was the policy?

Dr. Glenn Posner: We try, as much as we can, to practice evidence-based medicine. There was a trial that was published in the Lancet in 2000 that said that babies that were born by elective, planned cesarean section did better, had less problems, than babies that were born when a trial of labour was planned.

Alan Neal: So then the SOGC changes its recommendations, saying it’s okay to deliver breech babies naturally. What happened for you then?

Dr. Glenn Posner: [laughs] Right. So I did 5 years of residency. I had practiced at Montfort for 5 years. I started working at the General last year, and they tell us that now it’s okay. Well that’s all fine and dandy, but in my group of 12 obstetricians, there’s only 9 of us who actually are trained to do it. So what happens when somebody comes in in labor on my shift? I want to provide a safe experience to anybody who comes in when I’m working.

Alan Neal: So what did you decide to do at the Ottawa hospital?

Dr. Glenn Posner: My group has got together and decided that if somebody comes in when I’m on call, I’ll do my best to find one of the veterans to come in and supervise me. And if they’re on call, they’ll call me in to come and watch them. And that way, over the next few years, my experience will kind of get up to speed.

Alan Neal: But are the veterans you’re talking about—are they particularly familiar with breech birth?

Dr. Glenn Posner: Well you know, all you need to do is a few difficult cases and to be able to get yourself out of trouble a few times. There are certain techniques and maneuvers, certain forceps that we use. All you really have to do is to see that in action a couple of times. I’ve done a few breech deliveries now, and they both went really, really smoothly. That’s not actually educational for me! [laughs]

Alan Neal: Yeah. You kind of need the complications.

Dr. Glenn Posner: To be a real obstetrician, you really have to be able to get yourself out of a tight corner.

Alan Neal: When you’re doing the birth simulation, then…

Dr. Glenn Posner: Yeah, I actually teach residents how to do breech deliveries. I can teach somebody the theory. I can teach somebody the maneuvers. We have all these fancy names that we call when we try to make sure the arms come out okay, and what we should do, and how to put on these forceps. But it’s totally different when it’s a real person whose baby’s head is trapped, that you have to actually ask for that pair of forceps, and actually put them on a real person. Your adrenaline level is completely different than at the simulator.

Alan Neal: Of course. So you attended a birth last week.

Dr. Glenn Posner: Yeah.

Alan Neal: What was it like to deliver a breech baby?

Dr. Glenn Posner: That was the second one. What made this one really interesting was that we’re trying a new position, where mom is actually on all fours. And it was absolutely amazing. It went great, and I was very, very that my colleague, Dr. Geneviève Rousseau, came in from home on her day off to watch me do this delivery and to be there for me in case I ran into trouble. And that’s why I was calm during the delivery, because she was there next to me.

Alan Neal: Can you describe what this was like, what that process is? So the mother’s on all fours…

Dr. Glenn Posner: It was crazy. So mom’s on all fours. I could tell by watching her body language that it was imminent. We went to go prepare the operating room. I went and put on a pair of gloves in case we didn’t make it to the operating room. What makes the story even funnier is that Betty-Anne Daviss, the midwife who was helping with this, had just shown me a video from the German experience not 10 minutes earlier. There I am: everybody has left the room to set up the operating room. The next thing you know, the nurse is yelling for me that the baby’s coming out. I come back into the room, and it looks exactly like the video did 10 minutes earlier!

Alan Neal: So hopefully you were paying attention to those 10 minutes!

Dr. Glenn Posner: I was. This baby is hanging there. Imagine—the bum is out, the legs are folded up, the feet are still inside mom, the head is still inside mom. The baby’s folded in half and just dangling there. And obstetricians really like doing things. We want to help out. But the video said: don’t do anything, just watch and be ready to help out. I’m just poised there between mom’s legs, waiting for this baby to fall out. Then Betty-Anne ran back, and Dr. Rousseau ran back. They’re all talking me through this thing. And there was actually nothing to do! It happened beautifully, exactly like the video. The feet popped out, and then we did this tiny little maneuver [likely the Louwen maneuver] to help out with the shulders, and then the hands came out, and then the head came out.

Alan Neal: What is it like waiting? What is that moment like?

Dr. Glenn Posner: You know what, this one wasn’t as bad as the first one I did. With the first one, the patient had an epidural, so it took even longer. It’s very hard for an obstetrician to wait. But this one went fairly quickly and afterwards, we’re all on this adrenaline high that this delivery took place and everything went well. I’m feeling bad for all the people that I’ve sectioned over the last 11 years! My own wife had a cesarean section for breech for our second baby, and our second baby would have come out, probably, no problem also.

Alan Neal: I’m going to get back to you in just a moment. But Robin, I was wondering what these new practices at the hospital mean for your group. You’ve got doctors who are now training and wanting to find out how to do this.

Robin Guy: Well, you know what’s really exciting about this is not just that we’re starting to see vaginal breech births happen more frequently, but that we’re seeing an openness to a change in practice. It has been traditional in North America for women to have been, like it or not, placed on their backs, which actually causes some problems. It increases the likelihood of cord compression during a breech birth. Putting the mom on all fours—we’ve got early data from a group in Germany who made these videos that this [all fours position] is actually a real significant increased safety for the mother and the baby. So to see this adopted and to see the collaboration with a midwife. We don’t like it, but there is professional snobbery. There are women everywhere who are cheering for Glenn Posner, who wasn’t afraid to take advice from a midwife. We’re cheering for you Glenn; we love you!

Alan Neal: And the fact that he paid attention to the video, too, that she showed him 10 minutes earlier.

Robin Guy: Yeah. We are actually seeing real collaboration obstetricians and midwives and other professionals, working towards real patient care. And that is extremely exciting for women who have been frustrated by a lack of collaboration.

Alan Neal: Dr. Posner, you mentioned that you were waiting for births that would have more complications to them in order to learn better. What are some of those complications?

Dr. Glenn Posner: Well, when it comes right down to it, the head can get stuck. The whole body is out and the head is still in. If the head is too big to come out that way, then you’re in trouble. We have maneuvers to try to prevent that from happening, and ways to hold the baby, and not to pull on the baby, and then we have a special set of forceps, and where your assistant is supposed to push on the abdomen. The other complications is, if you do pull on the baby, the baby’s arms can actually get stuck behind the neck and make it more difficult for everything to come out.

Alan Neal: What do you do in that situation?

Dr. Glenn Posner: Well, you shouldn’t have been pulling on the baby to begin with, is what they tell me. But we have maneuvers. Like everything in medicine, they all have names, named after somebody who has invented them. We go through our maneuvers. But the two that I’ve seen were so easy, I really feel like—I don’t know—I’ll have to see 5, 10 nice breech deliveries before I stop calling my partners in from home to help me out, or I stop coming in from home to watch my colleagues do it.

Robin Guy: If I can add for just a second, this group in Germany who has been pioneering the hands & knees position in the hospital, they’ve been doing this for 5 years and 400 births. And they have not had to use forceps to get a baby out. Not once.

Dr. Glenn Posner: That’s great to hear.

Robin Guy: So it’s a big change in practice, if we can convince—we’re trying to get a randomized controlled trial going internationally examining the difference between delivering a breech baby with a woman on her back and delivering a baby on all fours, so we can actually quantify the difference. Having some data there would make a real difference for a lot of people.

Dr. Glenn Posner: Yeah.

Alan Neal: That, Dr. Posner, what Robin’s just saying there, that need for data: is that what you’re hearing from a lot of your colleagues as well?

Dr. Glenn Posner: Yeah. I find that really reassuring. If they did that many deliveries and never had to pull out the Piper forceps, that makes me really happy. Because I do not want to put on a pair. If I had to put on a pair of Piper forceps tonight to save the baby, my coronary arteries would be squeezing a little too hard.

Alan Neal: Are there colleagues who are still saying, “well, we don’t want to do it”?

Dr. Glenn Posner: I think that if we do more of this, and it becomes the standard of care again, people just want to practice safely. We all want the same thing. We really do. Obstetricians sometimes get a bad rap for doing a lot of cesareans, but at the end of the day, we want healthy moms and healthy babies by whatever means necessary. Do I do more cesareans, personally, than some of my colleagues who are really good with forceps? I probably do, but I deliver safe babies. And if I do a couple extra cesareans a year than some of the others, I can live with that because I deliver healthy babies. So sure, there are going to be places in town that are more reluctant to do it. Some obstetricians would be more reluctant. And we’re still going to be doing a lot of cesareans. There are a lot of people who are not going to qualify for the perfect breech delivery that we’ve stipulated. We’re still going to be doing a lot of cesareans, but at least in ideal circumstances--especially when people have had babies before vaginally, with good-size babies, who are having good labours--if we can avoid a few more cesareans, that would be great.

Alan Neal: Dr. Glenn Posner, Robin Guy, thanks for being with us.

Robin Guy: Thank you, Alan. Thanks for the attention to the issue.

Dr. Glenn Posner: Thanks.

Alan Neal: Goodbye. Dr. Glenn Posner is an obstetrician/gynaecologist at the General campus of the Ottawa hospital. Robin Guy, the co-founder of the Coalition for Breech Birth.

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CBC radio program on breech births

I'm listening to a story on CBC Radio 1 (91.5 FM in Ottawa) about breech births. Dr. Posner and Robin Guy are talking with the program host. Click here to listen!

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