Tuesday, December 30, 2008

More car trouble

On our way to Pittsburgh this morning, we got a flat tire. We had a spare tire but, as luck would have it, no car jack. So we had to wait for 2 hours before help arrived. There were four adults plus Zari in our little VW Golf, so we were quite cramped in there.

I think our car is cursed. In the past 7 months, we have had the following problems or repairs:
  • Mysterious problem with the car stalling and refusing to start, brought it to a VW dealership and spent almost $900 (and had to rent a car for 5 days). The same problem reoccurred the day after we brought it home. Then, once we got the car started on our own, it mysteriously went away.
  • New tires (old ones were totally bald): a couple hundred dollars
  • Replace rear brake rotors and pads (rotors were rusted and pretty much toast, causing the car to wobble and shake): a couple hundred dollars
  • Battery kept losing a charge, so we bought a battery charger so we wouldn't have to get the car jumped every time we needed to go somewhere. (Adding to the mystery, every time we had the battery tested, it came out fine!): $60
  • New glow plugs: $200
  • New timing belt: $600
  • New battery (after our car died last week in subzero weather and wouldn't restart): $160
  • Flat tire
Our car isn't even that old--it's a 2003 Golf with 70,000 miles. I just don't get it.
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Monday, December 29, 2008

Birth pool update

What's better than buying or renting a birth pool? Getting one for free!

My sister-in-law had her fifth baby almost two weeks ago. Her local hospital provides La Bassine pools for laboring in (and accidental water births, which is what happened to my SIL--she got in the pool and her baby was born 4 minutes later!). When they were getting ready to leave, the midwife said something about "taking your birth pool home." It turns out they give you the birth tub and all of the accessories after your birth! So she is lending it all to me: the pool and the Deluxe accessory kit (hose, electric air pump, faucet adapter, "Y" adapter, thermometer, plastic floor cover, debris net, mirror, & instructions). How awesome is that?
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Belly shots: 21 & 22 weeks

I realized I had miscalculated how far along I was; when I made my spreadsheets for keeping track of everything, I must have skipped ahead a week somewhere. So here are belly shots at 21.2 and 22.2 weeks from LMP. (And I'm not entirely sure about my LMP, since I have luteal phase bleeding/spotting that confuses everything...but I'll just stick with that for ease of calculation. Who's counting anyway, right?) I went back and corrected the dates on the older pictures.

21.2 weeks

22.2 weeks
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Saturday, December 27, 2008

Graduation pictures

The reception for doctoral students...I'm looking a bit pale and wasted after my night of food poisoning. My parents drove down for all of the ceremonies and celebrations.

Before the commencement ceremony
The funny robes...
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Wednesday, December 24, 2008

The weekend of doom

We've been traveling since last Friday and just this afternoon arrived at our final destination for the Christmas holidays. The weekend neither started nor ended on an auspicious note. Let me start my story a week ago.

On Tuesday, we took our car in for a routine oil change and service. I had noticed a funny rhythmic swishing noise, and the check engine light came on about two weeks ago. I asked our mechanic to take a look at those, too, since we were leaving on a long road trip. It turns out our glow plugs, timing belt, and water pump needed to be replaced for a grand total of $900. Okay, sounds good, at least we caught those problems before we went on the road, we thought.

On Friday, we drove out for my PhD graduation. We stayed with some good friends and went out to eat at a Thai restaurant. Soon after we came back home, I started feeling unwell. At first it was just a general bloated feeling, then it progressed into an angry, hot stomach. I laid down with Zari after I got her to bed, hoping it would go away. Well, it didn't. It turned into full-blown food poisoning. I was puking and running to the bathroom until 3 am, when it finally subsided a bit. I started sipping water and orange juice to replenish all the fluids I had lost and slept fitfully until morning.

I had a full day of graduation-related activities on Saturday. I almost didn't go to them, but I finally peeled myself off the couch. My parents had traveled down and I figured this only happens once in a lifetime. So I made it through a formal reception for doctoral students. I stayed sitting down and managed to eat two crackers and three strawberries. Graduation itself wasn't too bad, since we were sitting down except for the hooding ceremony. By the evening I was feeling well enough to go to a restaurant with my parents, although I was still only able to eat a few bites.

Side note: I find the academic robes & paraphernalia quite hilarious--in any other context you'd look like an utter fool, but because everyone else is wearing the same silly robes and funny hats, it's distinguished and solemn and oh so serious. The seamstress in me was analyzing how to make the doctoral robes and hood, in case I ever go into academia and need to wear them again. There's no way I would ever pay the $700 for the costume when I could certainly make it myself!

On Sunday morning, the temperatures had dropped to below 0 (Fahrenheit) with a biting wind. And our car wouldn't start. We plugged in the engine block heater, but our battery--which had been having a problem holding a charge--just couldn't turn the engine over. Finally my parents jumped us, and we were on our way to my sister in Dayton, Ohio. It's normally an 8-hour drive. The first two hours of driving were terrible: icy roads, whiteout conditions, close to 100 cars in the ditch. Probably 1/3 of them were upside down.

Just as the blowing snow and ice cleared up, our car stopped working. Just stopped, totally. In the middle of the freeway, with temperatures below zero and the windchill around -30 F. We couldn't get the car to start, and in fact the battery wouldn't even turn over. It was completely dead.

I pulled out my cell phone (a Virgin Mobile pre-paid phone that costs only $5/month--love it!) and discovered that the battery was almost out. I tried calling our emergency roadside assistance company and got a message that due to heavy call volume we would be on hold for a while. So I called my sister-in-law and relaid what had happened, and she was kind enough to go on hold for me. Forty minutes later, she called back with bad news: the company was so busy that a tow truck wouldn't be able to come for at least 3 hours and that I should just try to find someone on my own to help us and apply for reimbursement later.

Great. So I dialed 911 and explained my situation to the operator. She relayed my information on to the local police and towing companies and said someone would be coming by to help. It was at least another 45 minutes before the police car showed up. By then we were all getting quite cold. We had our coats on and were wrapped up in quilts and blankets, but there's only so much you can do when it's below zero. The officer was a very nice man. We sat in his warm car and chatted while we waited for the tow truck to arrive. Another 45 minutes later, we were finally on our way.

The next challenge was to find a mechanic who was open on a Sunday night. The first place we tried, Wal-Mart, didn't do anything but oil changes. Fortunately, Sears' auto center was not only open, but the mechanic on duty was also certified to work on diesels (we have a diesel VW Golf). We wandered around the mall, waiting for the mechanics to take a look at our car. We suspected it was a case of frozen fuel lines combined with a bad battery and/or alternator. A few hours later, they called and said they'd replaced the battery but were still unable to get the car started. We plugged in the engine block heater and waited another 45 minutes. Finally, it started! Woohoo! As we had guessed, the car had died because of frozen fuel lines and wouldn't restart because the battery was toast.

We were on our way by 8:30 pm. We fueled up and added a diesel anti-gel supplement to prevent any more fuel lines from freezing. At this point there was no way we would be able to make it to Dayton, which was still 6 hours away. Instead, we drove to our house and arrived right around midnight. We had a good nights' sleep and were on our way the next morning.

Thankfully we have had no problems with our car (or with food poisoning) since then.
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Thursday, December 18, 2008

Conference downloads on sale

All downloads from AAMI's 2008 Trust Birth Conference and the Helping Hands Conference are on sale through the end of December. This is a fantastic way to listen to speakers you've always wanted to hear. Some of the ones I'd really like to get:
If I had to choose only one, it would be, hands down, Rachel Correa's talk about the stillbirth of her first baby. I can't even try to describe it so I will just say listen to it yourself. While she was speaking--about the stillbirth of her daughter Stella, about other parents of stillborn children, about her three other children's births--she showed photographs of these births and babies, of her family, of her grieving and healing process. If you buy this download, I'd recommend contacting Rachel about obtaining a copy of her Powerpoint to go along with her talk. I have no idea if she'd be willing to share the pictures, but I think the presentation is not complete without the images. She used my laptop during the presentation, so I am lucky to still have the slideshow on my computer.
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And the winner is...

"James and Andrea"! I'm emailing you so expect to hear from me soon. Thanks to everyone for entering the ring sling giveaway.
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Recent reading list

We're leaving tomorrow to head west for my PhD graduation, then back east to visit several different sisters over the Christmas break. I have a pile of books to return, so here's what I've been reading recently:

Breastfeeding-related books:
Pregnancy & Birth:
Food & Culture:
Top recommendations: Sisters on a Journey, Having Faith, and The Omnivore's Dilemma.

History of the Breast
was a fun read: it looked at the breast in Western culture from seven different perspectives: the sacred, erotic, domestic, political, psychological, commericalized, and medical breast. You don't have to read it in order or all at once--each chapter is mostly self-contained. Milk, Money & Madness was a great overview of the politics and culture of breastfeeding. I was very impressed with Our Bodies, Ourselves: Pregnancy and Birth for a comprehensive yet concise guide to pregnancy and birth choices. In Defense of Food should have been a long article, not a book--but its main advice was right on: Eat Food. Not Too Much. Mostly Plants.
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Last chance to enter

Reminding everyone to enter the Second Womb ring sling giveaway. I am closing the giveaway at 5 pm Eastern Time tonight!
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Tuesday, December 16, 2008

Help with birth pools

When I had Zari, we had an oversized Jacuzzi tub in our master bathroom, so I didn't have to worry about buying or renting a birth pool. This time, though, we don't have a single bathtub in our whole house! So now I am faced with a huge array of choices, from a cheap fishy pool to a rented birth pool with a heater and jets. I want something big and deep enough that I can move about freely, stretch out, and be fully immersed up to my chest. But if I get one that is too big, it might take too long to fill, since our water heater is only 30 gallons.

We've been wanting to install a tankless water heater, probably a Rinnai. If we do that, then we'll have limitless hot water so the tub size will be less of an issue. I'd also love a tankless heater so that I can stay in the shower for hours and hours if I feel like it.

Here are my possible choices from cheapest to most expensive:

1) $22 fishy pool (60 x 22" exterior, 106 gallons)
2) $35 Sevylor round I-beam pool (60 x 22" exterior, 72 gallons)
3) $67 Sevylor oval I-beam pool (100 x 68 x 21" exterior, 186 gallons)
I actually think this oval one would be too big--it's bigger even than the large Birth Pool in a Box (see below). It's more like a swimming pool than a tub. See how big it is with adults inside:
4) $110 La Bassine birthing pool: I-beam construction, oval rather than round, has inside handles (65 x 53 x 25" exterior, 53" x 41" x 22" interior, 100 gallons)
5) $190 Birth Pool In A Box: this is a really large inflatable pool, with a built-in seat. It's large enough to comfortably fit two adults, unlike the other pools. (76 x 65" x 28" exterior, 56 x 45 x 26" interior, 172 gallons). There's also a mini version that's roughly the same size as La Bassine--a bit shorter and deeper. (65 x 57 x 28" exterior, 45 x 37 x 26" interior, 127 gallons).
Then, of course, you can get into the rental birth pools such as the AquaDoula ($250 to rent). I've attended lots of AquaDoula births and while I like that it has a heater, I don't like the narrow rim. Often women want to drape themselves over the edge or rest their head, and an inflatable pool is much more comfortable than the AquaDoula for that.

Although I love the price of the round Sevylor, I am leaning more towards La Bassine because it is a bit bigger and longer. I still wonder if even La Bassine would be big enough for me. I am 5'8"--not extraordinarily tall but not petite either. I like I-beam construction far more than stacked rings. On an aesthetic note, I love the deep transparent blue of the Sevylor and La Bassine.

So, your advice is very much needed, especially if you've actually used one of these many options (or something else I haven't thought of yet!).
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Monday, December 15, 2008

Extreme prematurity

I've been musing about what I would do if I were to go into preterm labor. The answer is obvious if the baby were 30 weeks: go to a hospital with a good NICU. My own cutoff for an out-of-hospital birth would be around 36-37 weeks, depending on the particular situation, access to oxygen and a midwife skilled at recognizing signs of respiratory distress or other prematurity-related complications.

But what about 28 weeks? 26? 24? 22? At what point would I allow the baby to pass on peacefully, rather than attempting heroic efforts at resuscitation with a small chance of survival and high likelihood of major disabilities if the baby were to live? My own gray area is between 24-28 weeks. By time a baby hits 26 weeks gestation, survival rates are between 80-90%, and about 15% of those surviving babies will have major disabilities as a result of prematurity. I think this would be the earliest point at which I would consider intervening.

General estimates of survival for live born infants who receive neonatal intensive care in the USA in the late 1990's are:

Completed Weeks of Gestation at Birth
(Using last menstrual period)
21 weeks and less
22 weeks 0-10%*
23 weeks 10-40%
24 weeks 40-70%
25 weeks 50-80%
26 weeks 80-90%
27 weeks >90%
30 weeks >95%
34 weeks >98%
*Most babies at 22 weeks are not resuscitated because survival without major disability is so rare.

A more accurate way of predicting survival is by birth weight, rather than gestation.

Birth Weight Survival (percent)
Pounds are approximate
Vermont Oxford Network NICHD
501-750g (1lb 2 oz - 1 lb 11 oz)
58% 49%
751-1000g (1 lb 11 oz - 2 lb 3 oz)
85% 85%
1001-1250g (2 lb 3 oz - 2 lb 12 oz)
93% 93%
1251-1500g (2 lb 12 oz - 3 lb 5 oz)
96% 96%

Still, survival rates and even major disability rates are not the only practical or moral considerations that I would have to account for. Having a very premature baby, in my own family setting, would mean I would have to commute to a hospital with an advanced enough NICU: probably 40 minutes away and most likely an hour or more. The stresses on our family, the realities of trying to spend my time in a NICU while caring for a nursing toddler, and the emotional and financial drains that an extremely premature baby would entail are all things I'd have to carefully think about.

In addition, my own moral/religious understanding of our life on earth would influence my decisions as well. I strongly believe that life is sacred, but that it is not always appropriate to take heroic measures to prolong life. Death is something to embrace when it is the right time, since we understand it as a passage(and at times a welcome release) from one sphere of existence to another, just as our coming to earth was. It is a temporary separation, although still painful and difficult for those left behind missing their loved one. (For another LDS woman's perspective on this, read Descent's post.)

I hope I will never have to make this kind of decision. Have any of you ever been faced with such a dilemma? If not, have you thought about your own personal criteria for intervening versus letting the baby go?
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Saturday, December 13, 2008

Belly shot: 20 weeks

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Friday, December 12, 2008

Tomato soup recipe

A reader requested the recipe for the tomato soup that Zari had so happily smeared all over her face and belly. It's on this post; scroll down to "country tomato bisque." It makes a big batch of soup, which I like because it freezes very well.
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Cotton Mother Dolls

A blog reader sent me a link to handmade mother & baby dolls that she makes: Cotton Mother Dolls. I WANT ONE!!!

The mother doll is around 20" long and has an expandable belly that holds her "unborn" baby. She can become pregnant and give birth to a baby, which comes complete with a detachable umbilical cord, placenta, and amniotic sac. The baby nurses via snaps on its mouth and on the mother's breasts. You can also order father and sibling dolls (infant, nursing toddlers, or older children) to make up your complete family. The dolls come in several different skin tones, hair colors and styles, and eye colors.

A mother and her nursing toddler, in a nursing dress.

Sooo, if anyone has some extra cash they need to find a use for, buy yourself (or me!!! pretty please?) one of these beautiful handmade doll sets. The woman uses the funds from the doll sales to finance her midwifery education.

Here is one mother/baby pair having a waterbirth:

Baby's head beginning to crown
Baby's head is out (notice the head is facing upwards,
which is typical if you're birthing on hands & knees)
Baby's body has just emerged
Picking the baby up out of the water
Bringing the baby to her chest

Another mother/baby set:
A prenatal visit with a midwife
Nursing after the birth.
Mother/baby sets come with a sling for the baby
A closeup of a baby, umbilical cord, and placenta:
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Wednesday, December 10, 2008

A not-so-quiet hospital birth

Another birth story from the family physician who wrote A quiet hospital birth. I gave the woman a pseudonym. Besides showing how a woman can be wonderfully supported through a challenging birth in a hospital setting, it also illustrates how a care provider's individual practice style can determine whether or not a birth concludes with surgery. This particular woman was "stuck" for 6 hours at 8 centimeters--something that many providers would have concluded several hours earlier with a cesarean section for Failure to Progress. But, as this story illustrates, there was no reason to suggest surgery just because a certain amount of time had elapsed.

This story also illustrates the importance of one-on-one nursing care as well as the continuous presence of the birth attendant. Some women are fine doing labor and birth mostly on their own, but others require a lot of physical and emotional support to see them through. Unfortunately, many hospitals do not have enough nurses to care for each laboring woman individually. Often one nurse will be in charge of several laboring women simultaneously, leaving her little time to provide this kind of labor support.

The recent discussion of the Dux article "Homework is the mother of prevention" made me think about where the "blame" for the state of U.S. hospital birth lies. Is it the fault of women for not preparing enough, or the fault of providers and a system that promotes unnecessary intervention? The recent birth story I wrote ("A quiet hospital birth") illustrates a very un-intervened hospital birth with a mother who had done her homework and knew what she wanted out of her birth. I thought it would be interesting to share another story, a story of someone who hadn't "done their homework" but had a vague idea of how they wanted things to go, to illustrate how a birth attendant and birthplace can still support someone who isn't as easy as my quietly birthing client to take care of! This story is nearly as long as this labor seemed, at the bedside providing support for someone working hard.

One of my younger clients Laura had a long and difficult pregnancy. From the very start, she seemed more sensitive to the normal discomforts of pregnancy, and frequently had a list of complaints at every visit. Nausea, breast soreness, and abdominal bloating were just the start and were followed by low back pain, cramping, pelvic pain, pubic bone soreness, vaginal discomfort, and more. She usually seemed satisfied with all the self-help tips I could think of to tell her, but she usually brought a written list of complaints to each visit. In the third trimester, she added frequent Braxton-Hicks contractions, some enough to keep her awake all night, and on several trips to labor and delivery she was indeed having regular contractions, but no significant cervical dilation. By 37 weeks, she was fairly miserable with contracting for weeks and ready to meet her baby.

When we discussed her labor plans, she was certain she did not want an epidural, and planned to be unmedicated. I admit to being fairly surprised by this, given how uncomfortable she'd been throughout the pregnancy, but, since this was her plan, I laid out for her my usual description of what we could do in the hospital to help her. I always try to have this conversation beforehand, and to remind my clients that pain medicine is always available, but I will not be repeatedly offering it in labor as I find repeatedly offering pain meds influences people to accept, maybe when they weren't really wanting it. I also remind them that I will not be trying to argue with them in labor either – a request for pain medication will be honored. I always tell my clients, too, that most women who choose ahead of time to avoid pain medication do so successfully in labor, and that they are likely to be able to do so, if that's what they wish.

In addition, there are lots of non-drug things we can do for pain relief and comfort measures. Specifically, we encourage women to find their own comfortable positions; we monitor intermittently unless there is a need for closer monitoring, in which case we can monitor by telemetry or waterproof telemetry; we have tubs in every labor room; we have birth balls and rocking chairs and squat bars; and nurses willing to provide back counter pressure, or cool wash clothes, or hot packs. We encourage laboring women to drink throughout labor, and to eat as they feel up to it, and we encourage them to have the support people of their choice with them throughout. Laura heard all of this before she arrived in labor.

One early morning, when Laura was 38 ½ weeks pregnant, labor and delivery called me early in the morning to say she'd arrived having strong contractions. She'd been woken from sleep around 4:45 am, and arrived to the hospital around 7 am, and was contracting every 2-3 minutes. Her water hadn't broken, and the nurse checked her and found her to be 3-4 cms dilated, 80% effaced, and with a bulging bag of water. The nurse told me on the phone that Laura was working pretty hard with contractions already, breathing and moaning, and was pretty irritable. I hoped that all the prodromal labor she'd had would mean a shorter labor, and hoped the irritability was a good sign.

I arrived around 9 am, and Laura 's water had just broken. She asked for another exam, and was 4-5 cms now, and 85% effaced, with the head at -1 station. By the time I arrived, Laura was breathing hard and frequently yelling through contractions, and pounding on the bed railing. Her boyfriend looked pretty uncertain and was keeping his distance. Laura had eaten some toast and fruit just before I arrived, and that would end up being all she ate the whole day. The nurse encouraged Laura to get out of bed (she'd been trying to encourage her out of bed for some time by this point) and Laura agreed to try the tub. She sat on the toilet and rocked and yelled with contractions while we filled the tub. I really like water for labor and find it relieves a lot pressure. Frequently I'll see a laboring client sink into the water and smile for the first time in hours. This was not to be the case with Laura. Shortly after getting in the tub, she felt too hot and nauseated and weak, and wanted out. We helped her out, and she vomited once, cried for a while, and talked about how frustrated she was that she hurt so much and nothing was helping. At this point, the nurse just asked once if she wanted something for pain, and Laura yelled back that she'd already said no (and a few less printable words!)

After drying off, Laura crawled back into bed, lay on her side, and continued to have frequent, strong contractions. With each one, she'd start to breathe hard, then moan a bit, and then work up to yelling "Ow, Ow, Ow, OWWW! Tell me when it's going away!" and the nurse would tell her as soon as the monitor suggested the contraction had peaked. The nurse tried to encourage her to get out of bed, to sit on the ball, or walk, or at least sit up, but Laura didn't want to move. For a while, in between every contraction she told us over and over that nothing was working, that she just didn't think she could do this, and why couldn't we help her? My nurse did a wonderful job of providing support, without giving in to any "oh, you poor thing" thinking. She'd tell Laura: "You ARE doing this – every contraction gets you closer to baby." She calmly let her know when her contractions were peaking, fanned her with a laminated card, gave her sips of water, and encouraged her to at least roll and change sides every so often. During this time, Laura 's boyfriend started to find his groove as a labor support person too. He pulled his chair next to the bed, wrapped his arms around her, wiped her face with a cool cloth, whispered words of encouragement, and ducked when she'd occasionally pound on the bed railing.

Around 11 am, Laura asked for another exam, wanting so much to be close to done. At this point, she was 8 cms, but the head was still -1 station, and not well applied to the cervix. Still, 8 cms was very encouraging news to Laura, and she got a bit of a second wind. She decided to get out of bed at this point and walked for a few minutes in the room, but quickly decided the contractions were just too intense standing up. She sat down in the rocking chair, then, and rocked through contractions. Laura preferred to have the contraction monitor on, and at the start of each contraction she'd yell for the nurse to tell her as soon as the contraction peaked and was starting to go down. The nurse would hold one hand, while her boyfriend held the other, and Laura continued to yell through contractions, usually some variation of "OW!" until the nurse told her it was going down, and then she'd count out loud until the contraction was done. I took a break to eat lunch at this point, and during lunch I could still hear Laura yelling through her contractions, and the calm voice of her nurse telling her she was doing great, the contraction was almost over, just keep breathing and rocking.

After lunch, the nurse and I switched so she could have her lunch. At this point, the nurse had been in the room pretty steadily for several hours, and she needed a break. Laura continued to cope pretty well in the rocking chair. She would get up every so often to go to the bathroom to urinate and would spend a couple contractions rocking on the toilet. By now, Laura was getting pretty tired and discouraged. During and after every contraction she told me repeatedly that she just couldn't do this, she was too tired, it hurt too much, and the baby wasn't coming, and yet, somehow she made it through every contraction.

Around 2 pm (the nurse had long since returned and taken over primary support) Laura wanted to be checked again. Her contractions had spaced out to more like every 4 minutes, but were stronger and longer. She felt like she had a lot of pressure in her bottom, and in fact had taken to running back to the bathroom with almost every contraction, although usually she wasn't able to actually pee and she'd tried for some time to move her bowels without success and we'd told her we thought the pressure was just the baby. I checked her again, and she was still just the same, 8 cms, about 90% effaced, with the head not well applied to the cervix. This was one of those times I was sorry we'd done an exam, as Laura was pretty crushed by this news when she'd hoped she'd be about to have a baby.

At this point, I offered 2 options. To begin with, Laura and the baby were doing just fine. Although she was tired, and frustrated, and fairly miserable, Laura was coping pretty well, and the baby was tolerating labor perfectly, and I explained there was no real need to do anything. One option was to just carry on with labor, as nobody was in trouble and there was no emergency. The other option was to try adding some Pitocin to see if that would encourage her cervix to dilate. Laura had been 8 cms for at least 3 hours at this point, past the medical definition of failure to progress, although it's been studied that merely waiting 4 hours instead of 2 can reduce the cesarean rate for failure to progress by 50%. Laura was tired, and hurting, and frustrated, and wanted anything that might speed things up. Her choice was to start Pitocin.

The nurse hooked up Pitocin, and we slowly titrated it up over the next hour, and Laura 's contractions got closer together again, coming every 2-3 minutes. For a while, she lay in bed on her side again, and yelled her way through some more contractions. After an hour or so, the nurse checked her again, and found her to still be 8 cms, with the baby's head still not descending well to the cervix. She talked Laura into sitting upright for a while, in a chair position in the bed, hoping that would help the baby descend. Then Laura decided she needed another trip to the bathroom, and since she was more comfortable there, we encouraged her to stay sitting on the toilet for a while. We put a pillow behind her head so she could lean back between contractions, and her boyfriend wiped her face with a cool cloth. During contractions she'd rock and sway and yell, and in between she'd flop back on her pillow and close her eyes. Around 4 pm, Laura informed me she was really done, she just couldn't take it anymore, and she knew she had to be ready to push. She flopped back down on the bed in tears, and demanded to be checked again. You guessed it: still 8 cms. Now, however, more of the cervix seemed to be in the front, the baby was lower, and the cervix was very soft and stretchy. Laura was really disappointed to hear this, but I tried to emphasize the positive changes (softer, stretchier, head lower) and within a few minutes she went from crying hard to asking if there was anything else that might move this along. I suggested she try hands and knees, thinking maybe that might help move the cervix that was mostly in the front.

Within a few minutes, the nurse had helped Laura turn around in bed, so she was kneeling on the bed with her arms draped over the back of the bed that we had cranked all the way up. During a contraction, she'd kneel even more upright and sway back and forth, and she went back to pounding her fists, this time on the back of the bed. At the start of each contraction, she'd sort of wail the nurse's name at the top of her lungs, and then yell "Tell me when it's going down!" In this upright position, we couldn't actually pick up her contractions on the monitor, so we had to go with educated guesses on when the contractions were peaking, leading to a few times the nurse saying "It's going down!" and Laura wailing "Oh no it's not!" In between, she'd sometimes rest, and sometimes repeat over and over "I just can't do this!" Close to 5 pm, Laura said "This is IT!" and flopped her self back over on her back. She grabbed my hand and said "I'm done. I just want a c-section. That's possible, isn't it?" I had noticed that she had grunted a bit with the peak of the last couple contractions, and I hoped that meant she was close to pushing at last. I talked her into an exam instead of an instant cesarean, and was disappointed to find that same 8 cm cervix, although still it was very stretchy and low. At this point, she'd been 8 cms for 6 hours, and the baby was still doing very well, but she was obviously emotionally at the end of her rope. On a gut feeling, I suggested she just try pushing a couple times and see what would happen. Worst case scenario, I figured nothing would change and we'd be right back where we'd been. With Laura 's permission, I did an exam during her next contraction, and encouraged her to push hard. To my surprise, I could feel the cervix just melt away as she pushed, and the baby surged lower. By the end of her second contraction, she was fully dilated. (And then I wondered what would have happened if I'd tried that 4 hours earlier – but it was only in the last few minutes that she'd started having some spontaneous pushing urge, so likely 4 hours earlier it wouldn't have done anything.)

At first, pushing gave Laura a big second wind. Briefly, she became much less irritable, and even talked about how glad she was not to have a c-section after all. She was quite tired, and at this point, she wanted only to try pushing in a semi-sitting position. Over the next half hour, though, she started to get discouraged again, and to tell us again and again that she was sure she just couldn't do it, that the baby wasn't coming, and that it was all just too much. We encouraged her to try a different position, and to see if she could get a little more strength behind her pushes. She agreed to try the squat bar, and she pushed in the full squat for a while. In between, her boyfriend continued to give her drinks, wipe her face, kiss her cheek, her arm, and her knee, and tell her she could do it – and she would tell him no way, she definitely couldn't do it! After a while, she was too tired to stay squatting, and she moved back to semi-sitting. By now, with each push we could see just a tiny sliver of the top of the baby's head. For a few pushes, hearing that we could see the baby's head encouraged Laura, and she pushed hard and merely rested in between, but when the baby still wasn't out, she started to be more discouraged again. The nurse encouraged her to keep going, and helped her up to squat again for a while, then gave her a sheet to tug-of-war with while she pushed. Finally, a little bit more of baby's head appeared with each push, and even Laura could feel that the baby was moving, although as the baby slid back out of sight in between each contraction, she yell and pound the bed "Don't go back IN!!!" and she kept asking us when the baby was ever going to come.

Like the rest of her active labor, crowning took quite a while. For the last 5 contractions, I was sure each time that this would be the one. But, although the baby didn't slide back any longer, he just moved a millimeter at a time and slowly, slowly, slowly a little bit more and then a little bit more, and then even a little bit more of the head stretched the perineum. Finally, when it seemed there was no way more head could be out and the baby not be born, the baby's forehead, and then eyebrows, and then one eye, then the other, the nose, and baby's mouth slowly slid out. Once the head came, the whole baby tumbled out quickly, wrapped tightly once in the cord around the neck, which I unwrapped as he tumbled out. Laura didn't want the baby immediately on her chest–she somehow managed to gasp out a reminder while the baby crowned that she wanted him dried and cleaned off first. I don't like to cut the cord immediately, so the second nurse brought a couple receiving blankets, and we held the baby level with mom's belly and dried him and wiped off all the blood. Baby was immediately pink and had wonderful tone, and let out a yell. The first nurse (the one who'd been there all day) encouraged Laura to look at her baby, and asked her if she thought he was clean enough to put on her belly, and Laura agreed. We laid the baby on his mother, and she wrapped her arms around him.

After 20 minutes or so, the placenta separated and Laura had more cramping and pushed it out. She had a small 1st degree skin tear, but it was on the outside of the perineum, where they often sting quite a lot without suturing, so I offered sutures and Laura agreed. Fortunately, after all her hard work, she barely felt even the local anesthesia going in, and the sutures were quickly done. This baby turned out to be very calm and alert, and he latched as soon as his mom shifted him near the breast. He was born at 6:43 pm, nearly 8 hours after the first time Laura had been 8 cms. He was 7 lbs and 2 oz, with dark hair, dark grey eyes, and long slender toes. Once the baby arrived, as I'd seen so many times, Laura perked up and all the frustration and discouragement disappeared into the joy of holding her new baby.

The nurse and I, however, were fairly exhausted. Watching someone work that hard and need so much constant encouragement for so long is really draining. The nurse commented that she didn't think she could hear "I can't" one more time and stay sane. But Laura intended to birth her baby without pain meds or an epidural, and with a lot of encouragement (and some questionably useful help of Pitocin augmentation) she did just that. Of course in a home setting, we may well have not known about the long pause at 8 cms, and she may well have started to push spontaneously, and the fact that she dilated from 8 to 10 with her first 2 pushes may well have never been known. But even in a hospital setting, with a more medical approach, a client who hasn't done any research or have any knowledge about how things are supposed to go (and some interventions which may or may not have been helpful) can be supported in her wishes to get through labor without an epidural – even if she herself is sure a lot of the time that she can't do it!
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Tuesday, December 09, 2008

Toot toot

Blowing my own horn a bit, but here's a recent review from a Second Womb customer.

I want to remind everyone to enter my ring sling giveaway & sale--deadline is December 18th. If you are thinking of buying a sling, don't forget to take advantage of the free shipping & extra giveaway entries, good through December 18th. Visit Second Womb Slings for a look at the current selection of fabrics.

And for those do-it-yourself types, I have created pleated ring sling and padded pouch sling tutorials.

Happy babywearing!
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Cloth toilet paper

Also called cloth wipes or family cloth, cloth toilet paper is simply replacing disposable paper products with reusable, washable cloth ones. I made the switch last month and I really like it! When I was sewing some teeny tiny diapers for Zari's new doll, I noticed that I had lots of smaller scraps left over from making diapers. They were mostly washcloth sized--perfect for cloth wipes. I rounded off all the irregular corners and had an instant stash of cloth toilet paper. It's no extra work to use cloth toilet paper since they go in the wash together with Zari's diapers.

I keep the clean wipes in the bottom drawer of my bathroom vanity, which I can reach when I'm sitting on the toilet. Used wipes go in the diaper pail, which is right outside the bathroom door.

I should note that I keep "regular" toilet paper on hand for poop and other really messy things that I don't fancy throwing in the wash. I am amazed at how little toilet paper we go through now. If I were really motivated, I suppose I could dispense with the disposable TP altogether, but for now I'm content using cloth for pee (and blowing noses, etc) and paper for poop. Now that I'm pregnant, I have to pee all the time and the cloth has really cut down on our TP bills.

Although there are places that sell cloth toilet paper, it's ridiculously easy to make your own for cheap or even free. Cut up old t-shirts, flannel diapers/pajamas, or other knit material--no need to hem or serge! Cut old towels into smaller pieces and serge or hem the edges. Use old socks that have holes in the heels or toes. My own wipes are made of hemp fleece, cotton terry, or bamboo velour with the occasional old sock thrown in.

For only $0.50, you can download a Guide to Family Bathroom Wipes at Fern and Faerie. This blog post at Walk Slowly Live Wildly also has a detailed explanation of how her family uses cloth toilet paper, as well as just about every other imaginable cloth product to replace disposables.

If you aren't already using cloth toilet paper, I challenge you to make the switch!
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Monday, December 08, 2008

Toy storage

We found this steamer trunk at an antique store for $40. It's in really good shape, except the leather straps are a bit old and brittle. It's perfect for storing Zari's toys. The living room is also her playroom, and it was getting really messy with all of her toys scattered around and nowhere to put them. We thought about using it as a coffee table, but it was a little bit too high. So now it's against the far wall in our living room.

I like finding new uses for old items that are inexpensive and aesthetically pleasing. Yes, it would have been cheaper to buy a plastic Rubbermaid bin--but I wanted something durable, nice to look at, recyclable (you could burn or compost almost every part of this except the metal hardware and leather straps) and, most importantly, something that didn't add to the amount of stuff in the world. This trunk has been around for 80-100 years and will likely see at least that many more years of use if it is taken care of.

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November pictures

A random sample of what Zari is up to these days:

This is what happens when Eric does her hair

Enjoying my homemade tomato soup
Soup as body art?

Counting to 10

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Sunday, December 07, 2008

Do your homework

In Homework is the mother of prevention, Monica Dux argues that careful research and preparation during pregnancy are important, and that adopting a "wait and see" attitude might leave you with undesired results.
Despite all the rhetoric about the importance of consent and respecting the patient's wishes, my experience of giving birth in a big hospital is that women are encouraged to take a passive role, to defer to both their doctor's opinion and to the institutional imperatives. If you argue, you are often told "that's just the way we do things."...

Many of the medical procedures that are routinely offered — such as episiotomies, epidurals, and forceps — are significant interventions that can have consequences for the health of the mother or the baby, and for the progress of the labour. Waiting until the maelstrom of labour engulfs you is not the time to investigate whether these procedures are right for you. If you do, the likely result is that you will simply agree to whatever is suggested.
Dux is a writer and co-author of The Great Feminist Denial. Read the rest of the article here.
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Saturday, December 06, 2008

A quiet hospital birth

Just today a family physician friend emailed me this birth story, and I am reposting it with her permission. I thought this story was pertinent given our current discussion about the book Homebirth in the Hospital. Notice how the nurses and physician pay close attention to the woman's personality and desires and adapt accordingly.

I attended an amazingly beautiful birth last week. This is the second birth for this couple and I attended their first as well. This couple does an amazing job of taking over and creating their own atmosphere in the hospital—to the point that the nurses and I feel almost bad intruding on them, yet they are so sweet and pleasant that you want to be with them. It's hard to describe, but basically there is like a bubble of personal space around them.

Mama was 2 days overdue, and had asked me on the Monday before Thanksgiving to strip her membranes as all her family was coming for Thanksgiving. She was a good 3 cms already, 70% effaced, and it was easy to sweep her membranes for her. She told me later that she started having contractions almost immediately. She was able to sleep off and on during the night for most of the night. She's a teacher, and she debated going to work in the morning, but finally decided to call in, as did her husband. They took their daughter to her day care provider anyway, and spent the day together doing errands and walking and getting a little nap. She called me around 2 pm and let me know her contractions were getting closer and stronger, but she wasn't ready to come in yet. I made sure she'd been eating and drinking, which she had.

Labor and delivery called me around 3:30, to say she'd arrived and was 5-6 cms, but smiling and looking comfortable. I was still seeing patients in the office, and so arrived around 4:45 pm. At that point, the nurse had just checked her again because she wanted to get in the tub, and she was 7 cms. I found her in the tub, wearing a gorgeous black tankini swim suit (top and bottoms!) leaning back with her legs crosses and the jets on, and sipping a drink with a straw. She smiled at me and informed me she was pretending she was on the beach. She stayed in the tub until close to 6 pm, and the nurse just checked heart tones every so often, and otherwise we left her and her husband alone, and they talked and held hands, and really didn't need us. Around 5:45 pm, she called the nurse and said she was getting out as the contractions were too intense for the small tub. The nurse asked if she wanted help, and she smiled and said that her husband would help her. We retreated from the bathroom again, and they shut the door.

A few minutes later, she emerged from the bathroom, fully dressed again—in a tank top and long work out pants, looking fresh and rested. She walked around the room a bit, then sat on the ball for a bit, and the nurse continued to take heart tones every 15 minutes. The last time the nurse was in the room, my client and her husband were playing cards! A few minutes after that, she called me in the room and said she just wasn't sure how much more she could take. She was still smiling and when I was in the room for a contraction, she just took several deep breaths and focused hard on her husband, and looked like someone in very early labor—but I knew she'd been 7 over an hour before and she was likely close to having the baby. I asked her if she wanted an exam, or if she felt like pushing, and she said she was starting to feel a lot of pressure like she was close to pushing, but not quite yet, and she didn't wanted to be examined. She said she didn't feel like she should push if her water hadn't broken, and I suggested she just wait for a few contractions, maybe push a little or grunt a little at the peak of contractions and see if she felt better. She agreed, and then sort of refocused on her husband, and I again felt like I was intruding, so the nurse and I stepped back in the hall.

A few minutes later, the husband opened the door and said calmly, "her water broke." Conscious of keeping the quiet mood, the nurse and I got up and walked in slowly, and the second nurse went to get warm blankets and snuck in a few minutes later. My client was kneeling on the bed, and she smiled at me and said "NOW, I want to push" They had pushed the cards to the side on the tray table, but she was still fully dressed. I asked her if I could help her with her pants, and she said "sure!" and we helped her get her pants and underwear off (I got a kick out of this as she was wearing thong underwear with a thong pantyliner which I've never seen anyone in labor do!), which were absolutely soaked.

The nurse asked her quietly if she wanted to push kneeling, and she said she'd try semi-sitting first. With the next contraction, she pushed hard, and we could already see some bulging of the perineum, although no baby hair yet. She then said maybe she'd rather kneel, and flipped over to her knees again, and pushed hard with the next contraction. She quickly decided the kneeling was too intense, and flipped back to her back. My nurse asked her if she'd like the squat bar, and she thought maybe she would, so we set it up, but as another contraction started very quickly, she ended up just resting her legs on the squat bar and decided she didn't want to get up. With the next contraction, a little patch of baby became visible. Her husband was holding one of her hands and whispering in her ear, and the rest of us were very quiet. With another contraction, the baby's head slowly emerged, turned to line up with his shoulders, and then fell into my hands. My client reached for him and pulled him up to her chest immediately. When the big sister had been born, she'd been just as quiet as her parents, and didn't cry at all, but this guy was having none of that—he let out a huge yell immediately and let us all know that he wasn't too happy with the cool air and brighter lights! Mama patted him and soothed him, and the placenta delivered spontaneously just a few minutes later, and we clamped the cord and the nurse took pictures of the dad cutting the cord. Mama pulled up her tank top and the baby shifted over an inch or so and immediately latched and nursed like he'd been doing it forever.

Unfortunately, mom started to bleed at this point. Fortunately, my nurses are used to calmly taking care of situations, while trying hard not to disturb the new couple. We gave her IM pitocin, then hooked up some IV pitocin, then some IM methergine, and massaged her belly—all while the baby nursed in his mother's arms. She had a small skin tear that seemed to be bleeding, which I put 2 stitches in, and finally after all that the bleeding slowed and stopped. As soon as we were able to step back from them for a few minutes, the dad wrapped his arms around his wife and son, leaned his forehead to hers, and prayed over them all softly.

After an hour or so, baby was finally weighed and given right back to his mom. 8 lbs 1 oz. Mom got dressed again (she is not like some of my clients who prefer to be naked throughout!) and they all walked up to a postpartum room together. When I talked to the nurse this morning, she said the whole family had spent the night snuggled in bed together.

I love a birth like that—where I am absolutely useless! (Well, at least until the postpartum hemorrhage, and then I'm glad it's me and not some birth attendant who panics and turns the whole thing into a circus as we just very calmly and quietly dealt with it while the new family had their chance to be together.) I wish I had pictures of this mom, 7 cms dilated, in the tub in her gorgeous swim suit, kicking back with a drink in hand! It's amazing to be invited in to something like this, and to be allowed a glimpse of such an intense and private event.

Comments about "quiet" birthers: As a birth attendant, I don't want to give the impression that in labor and birth quiet=good and loud=bad. I think it has a lot to do with the personality of the woman, and the situation of her birth—the support people, the location, the expectations she and her team have. Women who are vocal in regular life tend to be vocal birthers, and quiet women tend to be quiet. I've attended some really lovely births with mom bellowing at the top of her lungs—and I enjoy those just as much as the quiet ones.

I was most impressed with last night's birth by how well this couple created their own world and the environment that was most like them to birth their baby in, if that makes sense. This mama is really quiet in real life, and private, and modest. Instead of letting the hospital environment and staff overwhelm her, she somehow created her own space and did it her way. At her first birth, the nurse who cared for her remembers going into the room to first introduce herself at shift change and finding the mom walking in the room with her husband, wearing sweat pants, a t-shirt, and a sweatshirt zipped up to her chin. The nurse said to me "I took one look at her zipped up to here and thought, aha—it's going to be like that!" (That nurse is a master at assisting women to have the birth they want; she meant by that statement that she just knew that this was not a woman who would welcome a lot of touching or have a lot of need for hands-on support, and who would not want to be messed with much. That nurse, like last night's nurse, simply checked heart tones every so often and said, "let us know when you want to push!" and she eventually did.)

On the other hand, I've attended plenty of women who NEEDED to be very vocal, and needed a lot of touching, reassurance, even direction some times and that doesn't make their birth any less perfect. Sometimes, for me, it's nice to be needed! The big mistake many hospital providers make is thinking that a noisy client needs to somehow be shut up—medicated or belittled into keeping still usually. I always tell my own clients that being free to make whatever noise and move however you need to have a baby is what helps us humans have babies—we don't birth under a bush with predators lurking, so we can be free to be as loud as we want!
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Belly shot: 19 weeks

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Friday, December 05, 2008

Homebirth in the Hospital: Book Review

I just finished reading Homebirth in the Hospital: Integrating Natural Childbirth with Modern Medicine by Stacey Marie Kerr, a family practice physician. Kerr has an unusual background for a medical doctor; she lived for several years on The Farm, gave birth to her first baby in a birthing clinic and her second at home, and then entered medical school in her mid-30s. She strongly supports the midwifery model of care in a hospital setting. Her book explains more about her approach to birth, which she calls "integrative childbirth." She argues that by integrating the midwifery model of care with the best that modern medicine has to offer, a woman can have the "best of both worlds."

Dr. Kerr's book begins with a brief explanation of her childbirth philosophies. Next, chapter 2 explains what she means by "homebirth in the hospital." Written specifically for expectant parents, she outlines five essential elements for a successful integrative childbirth: choice, communication, continuity, confidence and trust, and control of protocols. Dr. Kerr supports natural childbirth and encourages women to birth at home or in birth centers if that is what they desire. However, she acknowledges that most women feel safer and more comfortable in a hospital setting and that the empowerment of a home birth can still be experienced in a hospital setting. She writes:
If we combine the two styles, basing our initial care plan on the midwifery model and using the medical technology only when necessary to save lives and to serve the needs of laboring women, we have a true integration: the best of both worlds.

The integrative childbirth model increases patient safety and decreases the physician's risk of liability be creating a strong focus on the individual and her family. Clear communication decreases the risk of litigation by improving patient satisfaction and involving patients in their own care. It is important to remember that technology should never replace experienced human attention during the birthing process.

When the midwifery model is applied, between eighty-five and ninety-five percent of healthy women will safely give birth without surgery or the use of instruments. Medical interventions come into play as part of sensible monitoring during pregnancy, labor, and delivery, but only if they're clearly necessary. In reality, intervention is often inappropriate and may actually be harmful when used purely for convenience or profit.
After these two introductory chapters, the bulk of the book contains fifteen different birth stories, including those of Kerr's two children. Each story is told through the words of the parents. Kerr also offers a brief introduction and commentary to each birth story. Some of these births were with Dr. Kerr, while others were with other integrative family physicians.

Kerr concludes with a chapter written specifically for physicians on how to practice integrative childbirth. This chapter largely repeats what was written in chapter 2. She stresses the same key elements--communication, continuity, confidence and trust, and control of protocols--from a health care provider's point of view. She reminds her physician readers that integrative childbirth is not only safer and more satisfying for the mother; it also can be more rewarding for the physician and, because of the enhanced communication and trust between physician and patient, leads to fewer malpractice suits.

I would recommend this book for pregnant women who are seeking mainstream medical care or who, due to certain circumstances, cannot choose an out-of-hospital birth. It explains how the judicious, rather than routine, use of medical technology is appropriate. For those women already immersed in natural childbirth/midwifery/home birth/unassisted ways of thinking, the book is less useful.

Now for some nit-picking: I do have issues with the phrase "homebirth in the hospital" and with the idea that a hospital birth with an integrative physician is "the best of both worlds." Kerr argues that the key elements of home birth are "satisfaction and empowerment." With that perspective, you can transpose the feeling of a home birth to any location. However, there are other elements of giving birth at home that cannot be transposed to an institutional setting. One could certainly argue that, however satisfying or empowering, a hospital birth can never be a home birth. Not to say that one is inherently superior--just that they are inherently different, and to respect that difference. Some of the best elements of a home birth cannot really exist in a hospital setting, and likewise some of the best parts of modern medicine--especially its strengths at responding to life-threatening emergencies--cannot exist at home. The idea that there is a "best of both worlds" implies that there is an ideal way to approach childbirth, rather than acknowledging that what is best for one woman might be terrible for another.

I also worry that women who read this book may become lulled into a false sense of security that they can "have it all" when, in fact, most physicians do not practice like Dr. Kerr. I know some fabulous family doctors who do, but they are usually rarities in their communities.

Despite these concerns, I am glad that Dr. Kerr has written Homebirth in the Hospital and hope that it will inspire more physicians to adopt integrative medicine. I also hope that it will spur women into thinking more critically and carefully about their maternity care choices.

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