Brown matter

No, this post is not about poop.

It's about creating a brown matter reservoir for composting. I just started composting last year, even though I've been married for 11+ years and we have owned houses for the past 9 years. It just seemed too scary and overwhelming, with all the talk about the proper balance of brown and green matter and turning and aerating and sifting...so I just didn't do it. And then I decided that my lack of familiarity with composting was a pretty lame excuse and it was just time to start.

I'm a pretty laid-back composter. I simply toss any appropriate kitchen or yard waste into a pile, throw on the occasional shovel of dirt if I'm digging something up, and let it sit until it turns into compost. I don't worry about all of the fancy technical stuff. My method is often called cold composting. If you're more into composting, you can do hot composting, worm composting, and probably a lot of other kids that I don't even know about yet.

Our next-door neighbors gave us a tumbling composter last year, and that's been wonderful to have. It speeds up the process immensely, especially if you have the proper ratio of brown to green matter. 

So back to brown matter: it's nice to have a mixture of green matter (kitchen scraps, green lawn cuttings, etc) and brown matter (fall leaves, paper, etc) on your compost heap. But we've always had trouble finding enough brown matter except for the fall months when leaves were falling. So this year, we took apart an old chain-link fence that we're getting rid of and made part of it into a huge leaf/compost pile.

Eric cut the four posts out of the top rail (we have a metal cutting chop saw, so it's quick and easy to cut anything metal) and pounded them into the ground with a fence pounder (which we bought years ago for installing metal fence posts). That way they're pretty solid, but not cemented in. Which is nice because I don't want to have to dig them out if we want to move the pile! He made the enclosure about 10'x5'. He cannibalized other parts from the old fence to make an enclosure with a makeshift gate. Not fancy or pretty, but definitely functional. The leaves in our back yard went into the leaf container. The front yard leaves went into the street for leaf collection; we had plenty just from the back yard anyway. The leaf container is even fuller. After I took this photo, I did another round of raking.

And from a slightly different angle, here are our raised beds, which are on a sunny, graveled area in the back of our yard.

After my first year of vegetable gardening (we've always worked in France during the summers until this year), I have a better feel for how much of each vegetable to plant. Mostly I want more of just about everything. More beets, more kale, more peas, more carrots, more onions. more green beans, more tomatoes, more melons, more squash... One of the few things I might not grow next year is broccoli. Now I adore broccoli and I can't eat enough of it. But it takes up a lot of space and has a very small yield for all of the time and work involved. Anyway, I hope to double my garden space next year by adding a few more raised beds, tilling up some of the back yard that doesn't have gravel on it, and planting raspberries along the back (south) side of our garage. I also want to add fruit trees and fruit bushes next year: apple, pear, cherry, gooseberry, & red currant at a bare minimum.

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The world, as seen by Zari

Zari has learned how to take pictures and she is addicted. Lots of blurry ones of random objects, of course, but she's also taken some nice ones of us recently.

Zari loves to organize, sort, and line things up. Anything is fair game: rocks from my flower vases, sling rings, blocks, stuffed animals. Today it was plastic dinosaurs (her birthday present from my mom).

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FuzziBunz giveaway!

I am exited to be able to sponsor a FuzziBunz giveaway! One reader will win their choice of a Perfect Size or One Size Fuzzibunz diaper.

How to enter:

Leave a comment with your favorite cloth diapering tip. Or, if you're new to cloth diapering, a question for the rest of us to answer! 

For additional entries (new comment for each entry, please):

• If you're new to cloth diapers
• If you've never used FuzziBunz before
• Follow FuzziBunz on Twitter 
• Become a FuzziBunz fan on Facebook 
• Subscribe to FuzziBunz at YouTube
• Link to this giveaway on Twitter/Facebook/blog, etc

 Giveaway ends Wednesday, November 11, 2009 at 5 pm EST.

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FuzziBunz cloth diaper review

A few weeks ago, a fluffy package arrived in the mail: two FuzziBunz diapers to review! FuzziBunz sent me a yellow One Size Diaper and an apple green Perfect Size Diaper in size medium. Now that I've used, washed, and dried both diapers several times, here is my detailed review of these cloth diapers.

First off, let me explain more about how FuzziBunz diapers are made and how they work. They are pocket diapers, which means there's an insert that you stuff inside the diaper and take out when you do laundry. The main diaper is made of two layers:

• outer layer: PUL (polyurethane laminate): a common breathable, waterproof outer layer used in many cloth diaper systems)
• inner layer: polyester microfleece, which wicks moisture away from the baby and onto the insert

The absorbent inserts are made of several layers of polyester microfiber serged together into a rectangle. I received one short and two long inserts. After the diaper is wet or soiled, you shake the insert out and toss both pieces into the diaper pail. The diapers are turned and topstitched with elastic along each leg opening and along the back waistband.

One nice thing about pocket diapers is that they dry more quickly than all-in-ones (AIOs). The FuzziBunz inserts are thick, probably at least four layers of microfiber terry serged together. If you used a folded insert instead of a layered, serged one, you could line dry these diapers in no time at all. 

Most cloth diaper systems use either hook & loop (velcro) or snaps for closure. FuzziBunz diapers fasten with snaps. Both the one-size and the perfect fit diapers have multiple snap settings so you can adjust the diaper to fit as your baby grows. Hook & loop is hands-down the easiest to fasten, especially at night when you don't want to turn the lights out, but it also wears out, snags in the wash, and attracts lint. (I know this from experience, because my own diapers have hook & loop. So far, the H&L has stood up well, but eventually I'll have to replace it.) The snaps take a little more manual dexterity, but you soon get the feel of which snap goes where.

 

FuzziBunz diapers come in a rainbow of colors and prints. I especially love the green daisy diaper. Mmmmmm....

Whenever a diaper claims to be "one size", I am curious to see how it's made. How can one diaper adjust to fit a tiny 7-pound newborn, then a chunky 20-lb baby (Dio's current size), then a 30+ pound toddler (Zari's size)?

FuzziBunz one-size diapers do it with 1) adjustable buttonhole elastic and 2) multiple snap settings. The back waistband and each leg hole have narrow buttonhole elastic that fastens onto hidden buttons. Each diaper has 6 buttons for the adjustable elastic: 2 on each leg and 2 on the waist. You can create 8+ different size settings on the legs and 4 on the waist. This picture shows the yellow One Size diaper with the elastics pulled tight (but not all the way to the smallest settings) and snapped up all the way, and then with the elastics let out and the snaps at the largest setting.

In the picture below, I have pulled the buttonhole elastic out from its "hide away hole" on the right side.

The elastics have numbers next to each hole, so you know that you have pulled the elastic the same distance on each side. There's a chart on the FuzziBunz website that gives suggestions for where to set the elastics, depending on your baby's size.

If your adjustable elastic wears out, you can get replacement pieces for a minimal fee. I called FuzziBunz to find out how this works. You can obtain replacement elastics if you bought the diapers new and can show proof of purchased from an authorized FuzziBunz retailer. If you bought them used, you're out of luck. (I tried searching the net for 3/8" wide buttonhole elastic and had no luck; it seems to only come in 3/4" and 1" widths). The elastic is easy to replace: simply hook the new piece to one end of the old piece with a safety pin and pull the new piece through.

Changing the snap configuration further adjusts the diaper's fit to your growing baby. Now, any one-size diaper will be quite bulky on your tiny newborn. But if you're willing to put up with extra fluff at first, the diaper will soon fit normally.

I tried both diapers on both of my kids. The yellow one size FuzziBunz actually have a trimmer fit at this point than the apple green Medium Perfect Fit diaper. The Perfect Fit diapers are about the same shape and size as the One Size, but they have sewn-in permanent elastic and slightly different snap configurations.

Zari has been wearing underwear for the past 6 months, but she was more than happy to model these for me. She especially loves stuffing the inserts in the diapers. (And how crazy is it that Dio's torso., bum, and thighs are as big as Zari's?!?)

I first tested the FuzziBunz diapers on Dio during the day, and I was pleasantly surprised at how I couldn't tell when he had peed or not. The microfleece wicking layer really kept him feeling dry, even when the insert was wet. But I was really curious to see how the FuzziBunz performed at night. Dio goes to bed around 8 pm and wakes up several times to nurse, usually every 2-3 hours. He wakes up between 7 or 8 am. When I am using my home-made AIOs (all-in-one cloth diapers made of hemp or bamboo fabric with PUL on the outside), I have to change diapers and/or potty him every time he wakes up. He doesn't like having a wet diaper, and at night this translates into extra night waking or restless sleep. So I put the FuzziBunz to the test. I stuffed each diaper with 2 inserts and tried several nights of no diaper changes.

Nighttime verdict: You *can* go 11-12 hours with a double-stuffed FuzziBunz, but by the end of the night it's really, really saturated and even the wicking layer can't keep a baby feeling dry with that much pee. Dio started getting rashes from having so much moisture against his skin all night. So I adjusted my routine and now change diapers and/or potty him when I go to bed (around 11 pm, which is when he wakes up for the first time) and maybe the next time he wakes up to nurse around 1 or 2 am. Then, with a fresh FuzziBunz on, Dio gets to spend the rest of the night without having to be disturbed by diaper changes. And me too!

Conventional cloth diapers have absorbent fabric right against the baby's skin, which feels wet as soon as the baby pees. (I don't mind this during the day, but it does pose a problem at night when you want your baby to sleep!) FuzziBunz , however, feel dry even when they're wet. You probably should change your FuzziBunz diapers once during the night if your baby is nursing as often as Dio is. By his age, though, many babies are sleeping longer stretches and nursing less, and you could probably get away with just one double-stuffed FuzziBunz at night.

Cloth diapers are a big financial investment up front, but they save a lot of money over the long-run. One Size diapers are a great solution to the initial cost of cloth diapers, since they will fit from the newborn stage until your child has potty trained. I suggest a minimum of 24 diapers and up to 36 if you have some generous family members who want to help out with baby expenses. I have 24 of each size of my home-made AIOs, and I wash every other day. You might be able to get away with fewer than 24, since FuzziBunz feel dry even when your baby has peed. FuzziBunz are available both online and in select stores. You can also find used FuzziBunz at Diaper Swappers.

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Correction

I requested a copy of my medical records from the first vein clinic. They arrived yesterday and I was a bit embarrassed, after I read them right side up, to find that they actually said "in no acute distress." That's what I get for reading things upside-down...Too bad, since the "acute distress" part made for such a good story! 

I had a followup visit today with Dr. W at the second vein clinic. He and the ultrasound tech did a lengthy exam of the veins on both legs, especially the area behind my left knee that developed a blood clot during my last pregnancy. The verdict: he recommended endovenous laser treatment (EVLT) of the greater saphenous vein. He does this right in his office with only local anesthesia along the vein. The varicosities behind my left knee are next to some nerve bundles, so instead of removing those veins via tiny incisions, he would do sclerotherapy injections in that area. He reiterated that while these procedures will permanently fix the affected veins, it's possible that, down the road and especially after more pregnancies, other veins may develop varicosities. He said that if my right leg isn't bothering me that much, it's not worth treating.

At the end of the visit, I asked him if he charged any "cosmetic fees." He looked a bit perplexed. I explained that the first vein specialist I saw charged a "cosmetic fee" of $400 per leg, even for procedures that were medically indicated and that would be reimbursed by insurance. Dr. W asked why he charged this. I said that Dr. F had explained that it was because "we are very meticulous with our work." Dr. W replied, "Well, I guess I'll be very un-meticulous and not charge you an extra $400!" I joked that he should start charging this fee so he could buy fancy office furniture.

I think I'm going to do it, since my leg is really bothering me. Dr. W's office is working on getting a pre-approval letter from my insurance company, and then I can schedule the procedure. I want to get it done before the end of the year, since both Eric and I have had a lot of medical expenses this year (minor knee surgery for him, pregnancy & birth for me) and have hit our deductibles for the year.

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Food for thought

Another quick post...I was going to head straight to bed but just had to link to this one:

At Feminist Childbirth Studies, she discusses breastfeeding, feminism, cost, and value, a post inspired by a comment to an earlier post breastfeeding, sexism, and feminism.

Also read her Slow Food Parenting Series. I especially love her thoughts on breastfeeding as Slow Food, which she talks about in parts III and IV.
Part I
Part II
Part III
Part IV

Okay, it's time for bed, really. I look forward to reading your comments over on her site!

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A few links and a giveaway

The kids are playing with blocks, so here's a quick post with a few links to read and think about. And a book giveaway!

Jill of Keyboard Revolutionary wrote about how birth impacts a mother, a lengthy response to my earlier post Thinking, no conclusions yet. A few excerpts:

I'm not sure on which side of the fence I fall. I guess like in most things in life where there's a fence, I straddle it. Birth, to me, is definitely important. But is it THE most important thing in your or your child's life? Not really. And to say otherwise would do women a disservice, because birth is by nature a wild beast that can go rogue with no warning, and it's cruel and petty to verbally beat up women who fall prey to the werewolf (but that's what my next post is going to be about, so I'll just leave it at that). However, to say that birth holds absolutely no meaning isn't necessarily true either, at least not in my opinion.

I think the problem with these two lines of thinking is that they both seem to believe that only a "good", i.e. natural/drug-free/vaginal/home/water/etc. birth is capable of being a life-changing event. The former cling to this gold standard, and the latter reject, nay, outright abhor it, but vilifying something is still giving it power.

I believe that EVERY birth has the potential to transform a woman and offer her many lessons she can apply throughout her life, instead of just being one day of empowerment and awesomeness (or trauma and suckitude). Take for instance the births of my two children. They could hardly be more different. One, a Cesarean after a long hospital labor with "the works." The other, a VBAC waterbirth at home. Both have taught me countless things that have shaped who I am, not only as a mother, but as a woman and a human being....

I also learned what it felt like to be IN THE MOMENT. I think I coped with a lot of what happened before, during, and after my Cesarean by going outside my body and watching passively from afar, a trick I honed to near-perfection from a traumatic childhood and adolescence. I detached myself far away from the moment. But when Jacob's head came out of me and into my hand in the water, never before had I felt more alive and RIGHT THERE. For the first time I did not need to detach myself to survive. No, the only way to get through was to throw my whole self into it, with every fiber of my being....

Both of my children's births were profoundly important in my life. But they are hardly the axis that my or their lives revolve around. Although I still cuddle Jacob and think of him as my VBAC baby, I don't look at Jameson and think of him as my Cesarean baby. I suppose the potency of Jacob's birth might fade eventually - the pain certainly has! - but the power I gained never will. And what I learned from Jameson's birth set me up to receive it, so those lessons will always be with me.

Next, a lovely birth story. A few paragraphs that resonated, since one of my sisters is awaiting her fourth baby any day now and, at close to 41 weeks, is trying hard to stay patient.

Waiting is hard. Waiting to look into those new eyes and see that sweet spirit. Waiting to confirm whether it was a boy or girl. Wondering if that painful contraction meant something was happening. Hoping my husband would be home when labor started. Praying I would find the challenge and meet it and be refined.

After a few false alarms I resigned myself to surrender to the unknown. Labor would start eventually. There was certainty in a birth and a baby. And there was probably no way I was making it through another week so the certainty was soon.

And finally, a giveaway of Making Babies: A Proven 3-Month Program for Maximum Fertility. I recently received this book to review, and I am really impressed with it. Hope to get the review written soon!

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Dio's first solids

A baby's first solid food is often an exciting milestone. You might snap photos of them tasting an apple slice or film them grimacing over mashed up carrots. Dio's first solid food was...well...a bit more exotic than mushy vegetables.

Today Dio was grunting and working hard to poop. I thought, "Hmmm, that's weird. It's not like breastmilk poop is solid." So when I changed his diaper, I found two small pieces of cardboard, still bright green on one side. They came from a thin box holding comic book candy sticks. I saw him chewing on it yesterday and fished a piece of mushy paperboard out of his mouth. Obviously I missed the other pieces.

I'll spare you the pictures.

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3 years old!

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

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

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

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

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

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

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

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

Happy birthday Zari!

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Ghouls and Doulahs

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

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

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

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

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

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Siblings

 

 

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Be scared...be very scared

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

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

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

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A tale of two doctors

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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6 months old!

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

He topples over every so often.

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

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

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

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Thinking, no conclusions yet

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

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

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

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

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

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

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

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

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Things that make me smile

I came across three things today that made me smile.

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

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

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

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Conference pictures

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

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Advice and information needed

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

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

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

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

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

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

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

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

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

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International Breech Conference: Day 2 continued

Friday, October 16, 2009

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

Some notable comments from women on the panel:

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

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

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

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

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

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

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

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International Breech Conference: Day 2 (The Germans)

Friday, October 16, 2009

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

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

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

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

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

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

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

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

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

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

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

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

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