Friday, January 30, 2009


A recent editorial in the LA Times, Octuplets--why?, explores the issues of high-order multiple births and extreme prematurity. The author is himself familiar with multiples, prematurity, disability, and death: one of his 24-week twins died shortly after birth, and the other has mild cerebral palsy. I thought this editorial was interesting in light of last month's discussion about extreme prematurity.
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Thursday, January 29, 2009

A sacred circle

You must read Jill's recent post, which was spurred by her seeing an image of a heavily draped woman, legs splayed apart in stirrups, about to give birth. She concludes her narrative with a drawing of her recent birth, a HBAC (home birth after cesarean). She writes:

I'm not just catching the baby, I'm also protecting my vagina. I'm in a sacred circle, just me, no one else. The midwives are there, but I didn't draw them, because they weren't inside my circle. My hand is there guarding the gate to this world. Nobody else interferes. In fact the only time anyone other than me touched my vagina during labor was right after I started pushing, to make sure I was fully dilated. Just one time, and permission was asked, and granted. And I knew all along that my vagina wasn't broken, but I proved it right then. I didn't need anybody's help. I didn't need drugs or monitors or scalpels to get my baby out. Just my vagina. Yup, mine.

I love this drawing. I've been searching for inspiration for a new silk painting to create during this pregnancy, and I think I've found it! (If that's okay with you Jill.)
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Wednesday, January 28, 2009

Packages, big and small

This past week was a happy mail week for me: I got two packages in the mail. One was quite small: a Sansa Clip mp3 player. I've never had a mp3 player before (or a walkman or any other portable music device) so this is quite fun for me. I chose this one because it was tiny, inexpensive ($35 with free shipping), and had a view screen to select songs. I bought it primarily to listen to my Hypnobabies scripts, but it also picks up FM radio. I love listening to NPR when I go on walks now.
The other package was large and soft: a wine red Mamaponcho. I received some unexpected (but very much appreciated) graduation money from my parents and grandparents, just enough to buy a Mamaponcho, which I have wanted for years and years. It's made of pure wool and can be worn with the baby on the front or back. I am soooo excited to use it!

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Belly shot: 26 weeks pregnant

26.4 weeks from LMP. I really need to get some sunshine (which is easier said than done in this climate--it's either so cold you can't let any skin be exposed, or it's overcast, or both).

And now my freakout moment: this was me at 27 weeks (25 weeks gestation ) with Zari:
This was me at 35 weeks (33 weeks gestation) with Zari.
I gave birth to her just 3 weeks later:

I am SO much bigger this time!
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Tuesday, January 27, 2009

Dirt is good, corn syrup is bad...

I just had to share these two news articles that just came out. In Babies Know: A Little Dirt Is Good for You, Jane E. Brody discusses recent research finding a positive connection between a "dirty" environment--dirt, intestinal worms, and bacteria--and lower autoimmune and gastrointestinal disorders. Improved sanitation comes with a price:
In studies of what is called the hygiene hypothesis, researchers are concluding that organisms like the millions of bacteria, viruses and especially worms that enter the body along with “dirt” spur the development of a healthy immune system. Several continuing studies suggest that worms may help to redirect an immune system that has gone awry and resulted in autoimmune disorders, allergies and asthma.
These studies, along with epidemiological observations, seem to explain why immune system disorders like multiple sclerosis, Type 1 diabetes, inflammatory bowel disease, asthma and allergies have risen significantly in the United States and other developed countries.
Some suggestions for those of us fortunate to live in developed countries with access to safe drinking water: avoid using antibacterial soaps or cleaning products, wash hands in plain soap & water, let kids go barefoot and play in the dirt, and have a mixture of household pets.

So now that we've learned why worms, dirt, and bacteria are good for you, let's talk about high-fructose corn syrup. We already know it's not exactly good for us, but two new studies have found mercury to be present in HFCS. From an article in the Washington Post, Study Finds High-Fructose Corn Syrup Contains Mercury:
Almost half of tested samples of commercial high-fructose corn syrup (HFCS) contained mercury, which was also found in nearly a third of 55 popular brand-name food and beverage products where HFCS is the first- or second-highest labeled ingredient, according to two new U.S. studies.

HFCS has replaced sugar as the sweetener in many beverages and foods such as breads, cereals, breakfast bars, lunch meats, yogurts, soups and condiments. On average, Americans consume about 12 teaspoons per day of HFCS, but teens and other high consumers can take in 80 percent more HFCS than average.

"Mercury is toxic in all its forms. Given how much high-fructose corn syrup is consumed by children, it could be a significant additional source of mercury never before considered. We are calling for immediate changes by industry and the [U.S. Food and Drug Administration] to help stop this avoidable mercury contamination of the food supply," said the Institute for Agriculture and Trade Policy's Dr. David Wallinga, a co-author of both studies.
Yikes! Now there are very few foods in our house that would contain HFCS. We make almost everything from scratch, so the only culprits in the fridge would be condiments like ketchup or mustard. This makes me thankful for parents who taught me good eating and cooking habits. If taste, nutrition, or price aren't enough to convince people to make more of their own food themselves, perhaps mercury-contaminated HFCS will.

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Breastfeeding news & humor

Marin County, CA, introduced a new breastfeeding ad campaign last week featuring lifesize cardboard cutouts of women nursing their babies. The women hold cards that say: "When breastfeeding is accepted, it won’t be noticed." Here are two photos of the nursing mothers (and the looks they've been getting from passers-by).

And now for some breastfeeding humor:

Nurse Lochia shares a breastfeeding ditty, sung to the tune of "Be Our Guest" from Beauty and the Beast.
See our breasts, see our breasts--
Everywhere, half-naked chests.
While we nurse,
The prudish curse
And wish we'd button up our vests.
Sorry, folks, look away
If we're too decollete,
but this is what boobs are made for,
Not those Wonderbras you've paid for.
We refuse to go feed
Hunched in bathroom stalls--indeed,
We're appalled that you would make such rude requests.
Would you agree to eat
Upon a toilet seat?
See our breasts, see our breasts, free our breasts!
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Monday, January 26, 2009

Biodynamism: body and soil

I came across my comprehensive exams for my PhD this morning and had a fun time reading through the essays I wrote. One of the questions for my U.S. Environmentalism exam asked me to connect my interest in midwifery with my environmental interests. I've reposted my response below. Keep in mind that this was part of an 8-hour long sit-down exam (and another 8 hours the day before for my other field of study), so the grammar and organization won't be as polished as they would be in a research paper.

Among the graduate students with whom I’ve dealt at Iowa since 1992, you are rare in that you come with another profession--midwifery--already in place. I’m aware as well that another part of your written comprehensive examination will deal with medical issues within American culture, and having read your position paper, I see how your repositioning of American Studies as a field depends to some extent on your own professional background and experience. My questions here are, not surprisingly, more specifically related to the connection between your two fields: how do you link your environmental interests with your practice of midwifery? How would you construct a justification, at once intellectual and personal, for the practice of midwifery in this age seemingly dedicated to increasingly scientific intervention of all kinds? What are the implications--for our concept of the environment or for “environmental studies” in general--of your “non-traditional” medical background? How, in your preparation for this exam, did your environmental reading and your medical reading--or your actual practice of midwifery--reinforce one another? You are not obligated to answer all four of these sub-questions in order to answer this overall question successfully; rather, the sub-questions are intended only as guides to your meditation as you illustrate the link between your interest in midwifery and your interest in, and concern for, the biotic environment.

The Case for Biodynamic Birth

When I first chose my two exam fields, I must admit that I didn’t see very many connections between the two at all. They were just two areas I was interested in. After all, the history of medicine and especially the history of childbirth and midwifery are fairly “internal” fields, often focused on the body and on the lived experience of birth. On the other hand, most of my environmental history courses had concentrated on “external” problems: pollution, resource depletion, overgrazing, erosion, or wilderness preservation. Some of the first connections I started seeing between the two fields were in areas of disease and public health. Historical susceptibility to certain diseases was contingent upon one’s environment (in the sense of one’s physical surroundings). For example, I learned that polio became a real threat only when sanitation improved. Some diseases affected poor urban dwellers disproportionately, such as cholera, while others were more dependent on the immediate geography and climate, such as yellow fever. Hence cholera was initially understood as a moral problem, while yellow fever never acquired the same moral valence.

One of the first books I read that explicitly made a connection between environmental issues and childbirth was The Farmer and the Obstetrician (2002), by Michel Odent. (It’s not on my reading list but it should be!) Odent is a French obstetrician who was in charge of a maternity hospital in Pithiviers in the 1970s and 80s. With the help of midwives, he transformed the hospital rooms into homelike birthing spaces and eliminated most of the drugs and procedures common to Western childbirth. His focus was to discover the basic physiological needs of laboring women and to design rooms than enhanced, rather than slowed down, labor. The rooms had no delivery bed, but low comfortable mattresses and chairs. He was the first to introduce large pools of warm water into a hospital for women to labor and birth in. Women received no pain medications and rarely needed surgical or pharmacological assistance to give birth. He argues that the basic needs of women in labor are privacy, freedom from feeling observed or fearful, feeling secure, and not having their neo-cortex or “thinking” part of the brain overly stimulated. Odent has been extremely influential in childbirth reform and now heads a Primal Health Research Center in London that explores the connections between what happens at the period surrounding birth and human health and behavior decades after birth.

In The Farmer and the Obstetrician, Odent points out the connections between industrialized farming and industrialized childbirth, and between the organic farming and natural childbirth movements. He argues that industrialized farming and industrialized childbirth are two aspects of the same phenomenon: both are “typical ways to deviate from the laws of nature” (19). One is about non-human life, while the other concerns humans. Let me first explain what Odent means by industrialized farming and childbirth. The main features of industrialized farming, which arose in the early 1900s, are feeding cattle animal protein, heavy mechanization, synthetic chemicals, monoculture, hormone/antibiotic treatment, and scientific feeding. He defines industrialized childbirth as a phenomenon largely beginning in the 20th century with the transition from home to hospital births, from midwives to obstetricians, routine forceps and episiotomy deliveries, manual extraction of the placenta, heavy use of pharmacologic agents for pain relief and for controlling labor, machinery to monitor labor, routine IVs, and a recent explosion in cesarean section rates.

So what makes these two phenomena similar? How might the problems facing the environment inform my midwifery studies? Odent explains that industrialized farming and childbirth are both manifestations of a human desire to dominate nature. Both of these methods involve intense technological and material investment, were adopted quickly with little knowledge of their long-term effects, require large amounts of energy and intervention to maintain a functioning system, and rely on controlled manipulation of various factors.

Let me explain more in depth these similarities by providing some examples. In industrialized childbirth—which characterizes most births that take place in modern hospitals—very few women give birth physiologically, without large amounts of external manipulation and intervention. For example, a woman in labor entering a hospital will usually be required to change her clothes, receive an IV, have a vaginal examination to determine cervical dilation, and wear monitoring belts that record the contractions and baby’s heart beat on a computer printout. Wearing these monitors requires women to stay still, preferably in bed, as to not disturb the monitors. This has the effect of slowing labor and making it more painful. Industrial solutions to these problems include narcotics and anesthesia (which often renders women even more immobile and slows labor further) and artificial hormones to speed up labor. Because adrenaline directly inhibits the release of oxytocin, the hormone that causes the uterus to contract and labor to progress, women who are fearful, insecure, cold, or surrounded by strangers and bright lights will often experience a delay in labor. In addition, lying down often contributes to slowed or stopped labor, in part because the baby must work against gravity and the woman cannot move her body to help the baby into a more favorable position. Because normal physiology is often interrupted in the industrialized process, surgical interventions are frequent. Today over one quarter [now close to 1/3 as of 2006] of all American women undergo abdominal surgery to give birth. Most receive one or more types of pain medication, and a majority receive the synthetic form of oxytocin some time during labor or immediately postpartum.

Similarly, industrialized farming replaces normal biological “physiology” with artificially controlled environments. Monoculture of crops often leads to soil depletion and insect damage. Chemical fertilizers and pesticides are a temporary solution, but often heavily fertilized soils lose their fertility and must rely on further doses of chemicals in order to produce crops. Mechanization compacts the soil, while heavy plowing can lead to soil erosion. As with industrialized childbirth, certain actions have a “cascade” effect, with unintended consequences requiring even more intervention and energy. These systems are not infinitely self-sustaining, but require heavy amounts of energy investment in the form of mechanical labor and petroleum-based chemicals. In her essay on “Farming and the Landscape,” Jane Smiley critiques modern industrial farming because it has little biodiversity (animal, plant, or human) and must be cared for 24/7. The basic assumption of “new agriculture” that she finds problematic is that humans can and should manipulate nature at its very foundations for the sake of feeding as many people as possible. Instead she advocates a complex system of agriculture—biologically complex—that takes care of itself (Placing Nature, 1997).

The most interesting idea to arise from my environmental readings in regards to midwifery and childbirth is that of biodynamism. Odent himself uses the term in his book. He proposes “radically new attitudes” (105) towards childbirth based on biodynamics. He defines the term as “understanding the laws of nature and working with them” and as understanding the true physiological process, not just the culturally or medically controlled one (133). How does this compare to definitions of biodynamics as it relates to the environment?

During his career, Aldo Leopold gradually evolved towards a biodynamic ethic that respected the interactive, complex processes of nature. During the first part of his career, he would routinely shoot wolves and prevent forest fires—in other words, micro-manage the land—because the prevailing wisdom taught him that predators and fires were undesirable. He gradually learned that controlling these elements led to a cascade effect of unwanted consequences, such as exploding deer populations and terribly destructive fires. He advocated “the recognition of invisible interdependencies in the biotic community....Wildlife management...has already admitted its inability to replace natural equilibria with artificial ones, and its unwillingness to do so even if it could” (237). By 1936-37, he had come to a mature understanding of the complex processes of a biotic community (See his essays “Threatened Species,” “Means and Ends in Wild Life Management,” and “Conservationist in Mexico” in River of the Mother of God.) A more recent definition of “ecological health” by Jim Karr and quoted in Grumbine’s Ghost Bears further explains a biodynamic approach:
A biological system—whether it is a human system or a stream system—can be considered healthy when its inherent potential is realized, its condition is (relatively) stable, its capacity for self-repair when perturbed is preserved, and minimal external support for management is needed.
Grumbine comments that these standards are “serviceable at all scales, local, regional, global, because they embrace an ecosystem perspective” (184).

Several of my environmental readings illustrated how biodynamics plays out in specific situations. Rick Bass, writing about the reintroduction of wolves into Montana (outside of the national parks), noticed that the resurgence of wolf populations had a positive and unanticipated cascade effect on both plant and animal communities. The presence of wolves changed grazing patterns in their prey, which had a positive impact on areas that used to be overgrazed. In addition, once certain areas such as stream banks could recover from overgrazing, important native plant species re-established a foothold (The Ninemile Wolves, 1992). When rancher Dan O’Brien converted his South Dakota cattle ranch back into bison habitat, he learned that reintroducing one part of an entire ecosystem had a positive multiplicative effect. The soil became healthier because of the grazing patterns of the bison, which helped promote native prairie grasses and more plant biodiversity. Bison were more self-sustaining than cattle; they required far fewer external expenditures such as feed, water, vaccinations, or shelter in extreme weather. In addition, he noted that bison meat is much healthier for human consumption than beef (Buffalo For the Broken Heart, 2001). With the addition of wolves and bison, the biotic community became more stable and self-sustaining.

The principle of biodynamics can be a powerful framework for understanding and advocating changes in childbirth as well as in the environment. In fact, midwives and childbirth reformers have been following biodynamic principles even before Michel Odent applied the term to childbirth in 2002. A key principle of midwives, especially homebirth midwives who work outside of an institutional setting, is to promote and facilitate the natural process whenever possible. For example, instead of requiring laboring women to forego food and drink and accept an IV line (in case they have an emergency surgery under general anesthesia and aspirate their vomit), homebirth providers will encourage a woman to eat and drink freely as she desires. This keeps a woman from becoming dehydrated, hungry, or exhausted and prevents possible complications such as fluid overload or electrolyte imbalance. It also preserves the body’s normal physiology of digestion, thirst, and elimination.

Another example of biodynamics at birth is how homebirth midwives often approach slow or prolonged labor. The industrial/technological solution is to artificially stimulate labor with hormones, break the amniotic sac in the hopes of speeding things up, or to resort to an operative delivery. These approaches all have a cascade of consequences and frequently require additional drugs, interventions, or monitoring. A biodynamic approach, on the other hand, would determine first whether or not the “slow” labor is a problem. Most often, a midwife will encourage her client to rest if she is tired and labor slows down. A biodynamic caregiver might also seek to eliminate anything that causes the release of adrenaline, which has an antagonistic effect on the hormone oxytocin, which I described earlier. This could include asking certain people to leave the room, raising the room temperature, dimming the lights, giving the woman some privacy, or ensuring that she is not hungry or thirsty. They might also encourage the woman to move or change positions, based upon what feels good to the woman. These solutions all rely on the woman’s normal physiology to help labor progress, rather than substituting an artificial solution that often requires further management or intervention.

There is a measurable difference in outcomes between biodynamic and industrial approaches to childbirth. For example, the midwifery practice at The Farm, Tennessee, had a 1.4% cesarean rate between 1971-2000, compared to a national rate of over 27% [now 31.1%]. Infant mortality rates are comparable. (The Farm’s statistics include situations labeled “high-risk”—such as breeches, twins, or premature babies). Both systems have the same end “product”: living mothers and babies. However, the biodynamic system relies on the woman’s own complex physiology whenever possible to accomplish the birth, rather than on external hormonal, pharmacological, or surgical procedures. A biodynamic system is simply managed (if at all), inexpensive, and diverse, while an industrial system of childbirth is complex in its management, expensive, and fairly uniform in terms of interventions and procedures (see Davis-Floyd’s Birth as an American Rite of Passage and parts of my position paper).

A critic of homebirth midwifery might ask, “What’s the fuss all about? After all, most women and babies are healthy and the current hospital/obstetrical system works just fine.” This is the same thing one might comment about industrialized farming: yes, it’s expensive and requires vast amounts of chemicals and monitoring, but it has produced a marvelous amount of cheap, abundant food. And why bother preserving wilderness places? Most people never even visit a wilderness and survive quite well in human-mediated environments. Aldo Leopold and John Muir have provided me with answers to those questions in their wilderness philosophies. Wilderness advocate John Muir advanced a utilitarian case for wilderness common to 20th century ecology—that wilderness should be preserved as a place where natural processes continue to function unimpaired. Several decades later, Leopold argued for “Wilderness as a Land Laboratory” (River 1941). He acknowledges the recreational value of wilderness, but argues that it has even greater scientific value as a control for ecological health. In order to determine what is truly natural or healthy for a biotic system—a “base-datum of normality” (288)—he proposes studying wilderness as controls in comparative studies of used and unused land. Wilderness areas are perfect examples of healthy organisms that have a “capacity for internal self-renewal known as health” (287).

This control argument could be a powerful rationale for preserving homebirth and midwifery. One could argue that very few institutional care providers know what undisturbed birth looks like. When the vast majority of women birth in an unfamiliar location, receive some form of pain medications, are tied to IV lines and monitors, and receive artificial hormones during labor, very few caregivers have ever seen a truly physiological or biodynamic birth. (This has been called “natural” or “normal” birth, but those terms are quite problematic, as natural birth has become associated with the lack of pain medications, and recently has come to mean anything but a cesarean section.) It would seem logical to argue that in order to understand pathology, one must first understand physiology. This is not to say that homebirths are automatically free of any external influences. As Brigitte Jordan shows in her anthropological investigation of birth cultures, Birth in Four Cultures, birth can never be culture-free. However, some birth cultures do promote more physiological experiences than others. The key to determining which practices disturb physiology or upset biodynamism is to compare the birth (or a biotic community) against Karr’s criteria: ability to realize its inherent potential, stability, capacity for self-repair when disturbed, and minimal external support. This is a question Cronon addresses in Changes in the Land. He argues that Native Americans used and changed the land, but that there was a qualitative difference between Native American and European American land use. Native American land use was infinitely sustainable and preserved biodiversity, while European land use patterns quickly deteriorated biotic diversity and soil health.

Michel Odent points out that our ultimate priority shouldn’t be to transform certain farming techniques or birth practices, but to ensure the future of our civilization. He notes that industrialized farming and childbirth both show a “weakened ecological instinct” that impairs our capacity to love. How does this occur in childbirth specifically? He explains that until recently, a woman couldn’t become a mother without releasing a complex cocktail of “love hormones” (including oxytocin and prolactin) at the time of birth. However, industrialized childbirth has disrupted the normal flow of birth hormones. When anesthesia, narcotics, artificial hormones, cesarean surgery, or immediate separation of the mother and baby are present, the mother’s hormonal system is altered and usually the level of hormones released diminishes significantly. Odent is concerned with the long-term implications of any practice that disturbs these vital love hormones, because certain birth practices have been linked to higher rates of autism (induction of labor), suicide (surgical birth, asphyxiation at birth), and anorexia nervosa (presence of a cephalohematoma at birth). (A collection of studies documenting these associations are available through the Primal Health database.) All of these disorders are what Odent terms an “impaired capacity to love”—oneself, others, or nature. Aggressiveness towards non-human life, including the land, is a symptom of that impaired capacity. He concludes that “the current industrialization of childbirth should become the main preoccupation of those interested in the future of humanity” (137-38). Odent is not the only person I have read who insists that our relationship to our bodies and to the earth is connected. In chapter 7 of Unsettling America, “The Body and the Earth,” Wendell Berry argues that there should be a profound resemblance between our treatment of our bodies and of the earth; you can’t simultaneously devalue the body and value the soil.

A final useful concept I have gained from my environmental studies is that of humility and restraint in the face of the unknown. In his book You Can’t Eat GNP: Economics as if Ecology Mattered (2000), Eric Davidson argues that it’s silly to replace something that already works well with something that’s technologically complex and enormously expensive. He comments:
Technology is unlikely to find substitutes for these essential services provided by forests....Simply keep the climate from changing rapidly and keep the forests in good health, and we will have a proven natural ‘technology’ that we know will provide what we need. Start tinkering by replacing forests with new, unproven technologies, and we take a giant risk that is unnecessary and imprudent.
He provides several examples of already available technologies and the proposed “improved” solutions: forest watersheds that purify water, versus pumped and purified groundwater; forests’ beneficial effects on climate to regulate temperature and rainfall, versus giant space shields orbiting over the earth (92). Aldo Leopold likewise recommends caution in the face of the unknown: “If the biota, in the course of aeons, has built something we like but do not understand, then who but a fool would discard seemingly useless parts? To keep every cog and wheel is the first precaution of intelligent tinkering” (Quoted in Davidson 167). I wish to conclude with a quote from the famous Dutch obstetrician G. J. Kloosterman, who was an ardent supporter of midwifery and homebirth:
Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character. The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine--nil nocere [do no harm].

Works Cited:
  • Bass, Rick. The Ninemile Wolves. Mariner Books, 2003.
  • Berry, Wendell. The unsettling of America: Culture & agriculture. San Francisco: Sierra Club Books, 1977.
  • Cohen, Michael P. The pathless way: John Muir and American wilderness. Madison, Wis.: University of Wisconsin Press, 1984.
  • Cronon, William. Changes in the land: Indians, colonists, and the ecology of New England. New York: Hill and Wang, 1983.
  • Davidson, Eric A. You can't eat GNP: Economics as if ecology mattered. Cambridge, MA: Perseus, 2000.
  • Davis-Floyd, Robbie. Birth as an American Rite of Passage. Berkeley: University of California Press, 1992.
  • Grumbine, R. Edward. Ghost bears: Exploring the biodiversity crisis. Washington, D.C.: Island Press, 1992.
  • Joan Iverson Nassauer, ed. Placing Nature: Culture and Landscape Ecology. Island Press, 1997.
  • Jordan, Brigitte. Birth in Four Cultures: A Crosscultural Investigation of Childbirth in Yucatan, Holland, Sweden, and the United States. Montreal, Canada: Eden Press Women’s Publications, 1978.
  • Kloosterman, G. J., “Universal Aspects of Birth: Human Birth as a Socio-psychosomatic Paradigm,” Journal of Psychosomatic Obstetrics and Gynecology 1, no. 1 (1982): 35-41.
  • Leopold, Aldo, The river of the mother of God and other essays. Madison, Wis.: University of Wisconsin Press, 1991.
  • Leopold, Aldo. A Sand County almanac; and, Sketches here and there. New York: Oxford University Press, 1968.
  • O’Brien, Dan. Buffalo for the Broken Heart: Restoring Life to a Black Hills Ranch. Random House, 2001.
  • Odent, Michel. The Farmer and the Obstetrician. London: Free Association Books, 2002.
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Sunday, January 25, 2009

Just birth

This is a lovely birth video. I call it the "anti-Hollywood" birth scene. It shows a laboring woman and occasionally her husband. She labors and grunts and moans a bit and then she has a baby. Wow! Who knew it could be so simple? I like seeing birth videos that show the essence of giving birth--not the machinery, not the procedures, not the attendants, but just the woman working with her body to bring forth a baby.

I think that was the most valuable part of The Business of Being Born: seeing so many women simply give birth. (Now there was more busy-ness with some of the births than I would have liked; Cara is too hands-on and chatty for my own preferences, but I digress.) I think my favorite birth in that movie was the hospital birth center birth, where the woman in the minidress has her baby standing up.

At its core, birth is so simple and yet such a mystery.
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Friday, January 23, 2009

Lunch & lecture with Joel Salatin

Today Zari and I met Eric on campus to attend a lecture by Joel Salatin, owner of Polyface Farm. He is the "grass farmer" featured in The Omnivore's Dilemma by Michael Pollan. If you haven't yet read Pollan's book, he wrote an excellent article in Mother Jones about Salatin's farm, called No Bar Code.

The lecture was accompanied by a free lunch consisting of locally-grown foods. We feasted on:
  • locally grown organic hybrid beefsteak tomato salad with herb vinaigrette
  • baguettes & whole grain house made brioche made from local stone ground whole wheat flour
  • local barbecued pulled pork shoulder
  • free range chicken salad
  • local house cut sweet potato chips
  • local berries in the snow (delicious crumbly crust topped with creamy sweet goat cheese filling & berries)
Joel Salatin's speaking style was fiery with lots of rhetorical flourishes, waxing evangelical at times. It was enjoyable if a bit surprising; I had imagined him as more of a soft-spoken man. I didn't end up going to his evening lecture, but I imagine it was likewise well-attended. Many thanks to the campus organization Students for Sustainability that sponsored this event!
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Thursday, January 22, 2009

2-3T Sleeveless Dress Pattern & Tutorial

I bought this green linen dress from a thrift store and liked it so much that I wanted to make another one. I made a pattern by laying the dress out flat and tracing the seam lines. The tag was so faded that I couldn't make out the size, but I am guessing it's a 2T or 3T. Zari wore it last summer and it was a bit on the big side.

Here's the new dress I made from the pattern:

If you'd like to make this dress yourself, I turned the pattern into a PDF file: 2-3T Sleeveless Dress Pattern. Follow the tutorial below for sewing instructions.

Sleeveless Dress Tutorial

* Please note that all pattern pieces show actual stitching lines, NOT seam allowances. Be sure to add seam allowances before cutting out fabric. (I like 3/8" or 1/2" for small children's clothing.)
  • Cut out fabric as indicated on pattern, remembering to add seam allowances (except on center fold lines, bottom facing [blue line], and ruffle pieces).
  • With right sides together, join shoulder seams on front & back body pieces. Do the same for front & back facing.
  • Serge, pink, or zig-zag long the bottom of the facing (blue line on pattern).
  • With right sides together, join body and facing at neck and arm holes, leaving side seams open. Clip the inner curves, turn right side out, and press.
  • With right sides together, join side seams. Serge/pink raw edges and press to one side.
  • On the side seams, stitch in the ditch to anchor the facing pieces down.
  • Serge center back edges on each back body piece.
  • Sew back seam on the bottom, leaving the zipper area unstitched. Serge/pink raw edges and press to one side.
  • Join ruffle pieces into one long loop, fold in half and press. Gather and stitch onto bottom edge of dress. Serge or zigzag.
  • Apply zipper.
  • You're done!
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Wednesday, January 21, 2009

Snow day

We're warming up from last week's cold snap. It's finally nice enough to enjoy being outside. We showed Zari how to throw snowballs a few days ago. Today I taught her to eat snow. She gave me this really skeptical look when I handed her a piece and told her to eat it. Her first bite was hesitant. But then a big smile spread across her face and for the next several minutes that's all she wanted to do. "Eating snow, mama!" she would tell me. We also made big drawings of shapes and animals in the snow with our feet. I'd stomp out a shape, and she'd announce what it was and then trace my footsteps around and around.

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I think the template is done

So, any final comments? I am really liking the results. I wish I could find a way to have the sky be continuous across the top, but the only way I can get things to work properly is have a little bit of white on either side of the title. I resized the font on the left side bar, so hopefully those with lower screen resolutions will be able to see the whole poem. Is it small enough? Is it too hard to read with a smaller font size & typeface? Any other suggestions on nit-picky details such as font color, placement, etc?

My next task is to update & add to all of my links. I haven't done that in well over a year.
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Midwifery model of care

I enjoyed Jill's recent post about her thoughts on the midwifery model of care. She contrasts her two very different birth experiences and the types of care she received. I especially agree with her take on birth plans:
I'll never sit back and put 100% of my trust in any physician ever again. Even with my home midwives, the majority of the learning, research, and general work I did was fueled by my own desire, not by what they told me to do. It is so incredibly important for women to educate themselves on what's going on with their bodies, especially if they are using a model of care that doesn't take a personalized approach.

It's been said that if you need a birth plan to tell your provider what you want, then you've got the wrong provider. I think this is very true. I didn't even need to think about writing a birth plan with my home midwives, because not only had we already discussed in depth what I wanted and expected during labor, but it was assumed that, barring any medical necessity or danger, I would be getting what I wanted anyway.
She saw midwives for both of her pregnancies, so it's not simply the provider's initials or location that determines the quality of care a woman will receive.

I also wanted to urge any of you living in Virginia to contact your local representatives about some restrictive midwifery legislation recently introduced to the House of Representatives. Jill has more about it on her blog.
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Tuesday, January 20, 2009

Getting closer

I still need to resize the background image a bit, since the middle isn't wide enough and the top keeps getting cropped off...but I'm getting closer to a template that I really like! Stay tuned for more changes in the next few days.
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My zen wall

I finally hung up these silk paintings that I made last spring. They are based on the artwork of Australian artists Chrissy Butler; the originals were commissioned for the Trust Birth Conference. I hung them on the side wall of our bedroom, so they're the first thing I see when I wake up in the morning. The pictures make me feel happy and zen and peaceful. I should have taken pictures of them hanging against a window first, since they are even more colorful with light coming through them. I also made one other silk painting that I gave to Carla Hartley at the end of the conference.

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Monday, January 19, 2009

The root of my worries

I've been corresponding with my friend Jenne from Descent into Motherhood about my desires for this upcoming birth. We are both seeing a midwife and trying to decide what role we wish them to play in our upcoming births. She wrote to me yesterday something that perfectly sums up the root of my concerns:
Have you thought of it as a control issue? You have had an experience where you were totally in control, autonomous, and making your own decisions. And now it sounds with this particular midwife, you are going to have to give some of that decision making power to her because there will be things that she may not budge on. It's important to you that you are alone in the room, and she may not allow that to happen. Not only does that feel like your power is being taken from you, you may fear that her presence will alter your ability to birth in some way. I think I'm projecting my feelings on to you but I know that it's that reason that I would be uncomfortable with having a midwife. Maybe it's just what you've described to me about this particular midwife. Tell me if I'm wrong on that and I'll be quiet. My fears with having a midwife present are two-fold: I don't trust her to not take control of a situation in a way that overrides my autonomy. That of course is at the root of what I didn't like about my birth experience with my son and led me to consider a UC. I hated having to fight for the responsibility to make my own choices when I could choose to not have to face that fight at all.
My core concerns center on autonomy and control--not control of the birth process itself, but control of my surroundings and those people around me. It's important that I can totally relax during labor and not worry about any externals. For me, I accomplish that through careful planning and control over my birth environment. In a way, I seek to control some things before labor so that I can give up control when labor begins.
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Belly shot: 25 weeks pregnant

25.2 weeks from LMP. I'm feeling less squished and out of breath recently, as my body has adapted to having several major organs pushed in new locations.

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Blog template #1

How's this for a possible template/look for "Stand and Deliver"? I'll leave this up for a few days and then try another one.

I can't get the archives to work properly with this template (when you click on the year, it should show a list of months, but nothing happens). Hmmmm...
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Sunday, January 18, 2009

New blog title?

I think it's time for a new blog title & facelift. The blog name I have now is a makeshift one I just typed in one day. And then inertia set in. I'd also love to have a more visually appealing blog layout & design.

So, here are my top two ideas:

#1) Stand & Deliver with the subheading Don't Take Birth Lying Down
This is the name of my doula business too, and I like the play on words. One downside of this title & slogan is that it narrows the focus of the blog a bit to just childbirth (not that I would change what I write about, but it makes the blog seem like it's only about birth--which is something you could say about the current title, too).

#2) I Am the Same, And Yet Different
This line comes from an inscription on this statue in Eze, France by Jean-Philippe Richard. The sculpture was titled "Justine ou Isis" and was accompanied with the following short poem:

Vous m’avez reconnue…
Je suis la même
Et pourtant autre

You recognized me...
I am the same
And yet different.

I took the picture this summer, and I would love to incorporate it into the blog template/design. I like this blog title because it conveys a thoughtful, introspective approach and can apply to all aspects of mothering, not just pregnancy.

So, which one has your vote? Any other suggestions? And, could I tempt one of you to help me design a visually stunning blog layout/template? (Possibility of a free Second Womb ring sling in exchange for your work!)
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Friday, January 16, 2009

(Anti) Public Breastfeeding Thesaurus

I haven't posted about recent breastfeeding news, such as the Facebook controversy over whether photos of nursing children should be allowed. But this op-ed piece from the Calgary Herald, "New Moms Should Travel the Mammary Lane Discreetly", takes the cake for the largest number of accusatory, denigratory remarks about public breastfeeding in the shortest space. In only 267 words, Naomi Lakritz asserts that breastfeeding in public (or defending one's right to do so) is:
  • indiscreet
  • immodest
  • undignified
  • not classy; crass; low-class (as in daytime talk show television)
  • lacking decorum
  • making public an intimate, private, personal experience
  • voyeuristic narcissism
  • indecent exposure
  • a sign of a woman's lack of self-respect
  • a waste of energy and time on a trivial issue
Whew! She just about covered every possible angle there.
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Thursday, January 15, 2009

Working through some conflicted feelings

This pregnancy has been marked by a series of conflicting feelings about what I want for the birth. Zari’s unassisted birth was fantastic and really could not have been improved upon. I also felt strongly drawn to having an unassisted pregnancy and birth with her. While I of course had some doubts, fears, and hesitations along the way—doesn’t every pregnant woman at some point?—I just knew that an unassisted birth was what was right, what I needed to go through.

When I was a graduate student in Iowa and trying to conceive my first child, I was working as a doula and apprenticing with a direct-entry midwife. After we moved to Illinois, I started assisting a home birth CNM at prenatal visits and births occurring in my area. This pregnancy, I am living in a new state and for the first time in several years, I am not a part of the local midwifery community. This is part of the reason that I felt the need to initiate care with a home birth midwife here; I no longer had access to midwifery care, advice, or skills except through a formal, paying midwife-client relationship. There are a few things that I want access to: during pregnancy, I like checking my hemoglobin levels early in pregnancy and again around 28 weeks to be sure that my blood volume has expanded adequately (hemoglobin levels should drop by the 28-week check; if they are stable or rising, that is cause for concern). I want someone to check me for tears after the birth, suture/Dermabond if necessary, and to do bloodwork in case I want a Rhogam shot. While I could in theory go to a hospital for those postpartum services, it would be extremely disruptive and kind of pointless to get in the car hours after having a home birth!

I also find myself wanting the option of having skilled assistance during labor for certain rare emergency situations: shoulder dystocia primarily, and to a lesser degree rapid postpartum hemorrhage or the baby needing resuscitation (the latter is the least worrisome to me, even though it is probably the most common of the three scenarios I listed, since I am trained in neonatal resuscitation). This wasn’t as much of a concern during my first pregnancy, but I find it weighing more heavily on my mind this time. I suspect it’s because, now that I have a child of my own, the idea of losing a baby is no longer an abstraction to me. I wouldn’t say at all that I was simply being callous or naïve the first time around, just that the possibility of losing a child is more palpable to me now.

I was happy to learn that a home birth midwife lived only 20 miles away from our new house—the closest I have ever lived to a home birth provider in many years. Although I could pay out-of-pocket for a midwife, I was quite happy to find that she was a CNM who could accept my insurance. This means that instead of paying $3,600 for her global fee, my out-of-pocket expenses are around $1,000 ($500 for the deductible and another $500 for the 20% co-pay). Labwork and birth pool rental are additional; she rents out heated, jetted Spa-In-A-Box pools, but I won’t need that now that I have a free La Bassine.

I met with the midwife early on in my pregnancy to talk about what I was looking for and figure out if she would work for me. I talked about my first birth and how I was looking for a hands-off midwife who would respect my need for privacy. I had a few specifics I quizzed her about: was she willing to not listen to heart tones at all? (No; she’d like to listen every 30 minutes. But otherwise she is fine staying out of the room while I am laboring.) Was she willing to stay in another room during the actual birth? (No, she’d prefer to be in the room as the baby is being born to keep an eye on possible problems). I am actually quite fine with having heart tones checked. I understand from a midwife’s perspective why it is important to listen. If I am inviting a midwife to the birth, she does need to have a way to know if the baby is responding well to labor.

The second point is more of a stickler for me, and it’s been on my mind a lot recently. I feel very strongly about keeping the “birth bubble” intact in the immediate postpartum period. Even many home birth midwives tend to do a lot of stuff right after the birth: putting a hat on the baby, rubbing it gently with towels, speaking with the mother, suctioning the baby’s nose and mouth, taking a full set of vitals every few minutes (baby’s heart rate & respiration rate, mom’s blood pressure, etc), feeling if the placenta has detached, etc. While these activities are not terribly interventive in the grand scheme of things—after all, baby is usually still in the mother’s arms—they do “wake the mother” and take her away from that critical time in which her primary task, physiologically speaking, is to produce high levels of oxytocin to help the uterus clamp down efficiently, the placenta to detach cleanly and completely, and thus prevent a postpartum hemorrhage. In Michel Odent’s article “The First Hour Following Birth: Don’t Wake the Mother!”, he explains how midwives ought to behave in the immediate postpartum period:
They first make sure the room is warm enough. During the third stage women never complain that it is too hot. If they are shivering, it means the place is not warm enough. In the case of a homebirth, the only important tool to prepare is a transportable heater that can be plugged in any place and at any time and can be used to warm blankets or towels. Their other goal is to make sure the mother is not distracted at all while looking at the baby’s eyes and feeling contact with the baby’s skin. There are countless avoidable ways of distracting mother and baby at that stage. The mother can be distracted because she feels observed or guided, because somebody is talking, because the birth attendant wants to cut the cord before the delivery of the placenta, because the telephone rings, or because a light is suddenly switched on, etc. At that stage, after a birth in physiological conditions, the mother is still in a particular state of consciousness, as if "on another planet." Her neocortex is still more or less at rest. The watchword should be, "Don’t wake up the mother!"
Pamela Hines-Powell has written about this as well (and I interviewed her more in depth about what she does/does not do at births for my dissertation). Immediately postpartum, her default routine—what she does unless the mother requests otherwise—is to stay silent, out of the mother’s line of vision, and quietly observe the mother and baby from several feet away. No one but the parents touches the baby for the first hour or so after the birth. The midwives only step in to assist or interact once the mother initiates contact (barring, of course, an emergency situation). For example, here are a few of her common birth & postpartum practices, taken from a longer post about her midwife identity crisis:
  • Routine vaginal exams - during labor or prenatally. It’s not uncommon for us to never touch a woman’s vagina - or even see her vulva - until the baby is crowning (if we can see it) or afterwards when looking for tears/lacerations.
  • I’m not going to do perineal massage or even support of the perineum (some women with land births like to have some rectal counterpressure) as baby is being born…but I’m not likely to do anything at all during second stage in water births…blame it on me trying to protect my back and not wanting my shirt wet, but really it’s because the mother does it all on her own - and she knows best.
  • I do not - nor does my wonderful assistant - usually touch the baby for a good hour or so after the birth. No routine checking the heart rate - we look and observe tone and respiratory effort. Only if that is in question will we come closer and do vitals or listen to heart rate.
  • I typically do not do much face to face labor support, breathing reminders or talk women through labor contractions other than a very occasional gentle reminder of why she is doing this or that her body is working so well with her baby. If a woman needs more than that, I’m there, but my default is to stay in the background and support women to find their own way of laboring (and they have a tendency to breathe pretty well without instruction, too!) .
I have found myself fretting unproductively (since I haven’t had the chance to actually talk these things over with the midwife yet) about whether or not I would be able to have an undisturbed labor, birth, and especially third stage with a midwife present in the room. It’s this fruitless feedback loop of worry and anxiety that has been weighing heavily on me. On the one hand, I have had an unassisted birth and can’t really see how it could be improved upon. On the other hand, I have felt a need this time around to have access to a midwife, and I need to respect that as much as I listened to my need to have an unassisted pregnancy and birth with Zari. How can I reconcile my desire for an undisturbed birth with the presence of outsiders at my labor, when even having my own husband in the room felt distracting to me, made me feel self-conscious, like I was being watched, like how it feels when someone reads over your shoulder?

I talked over these things at length yesterday with my good friend Jen, who has experience both giving birth and attending births. She had her first baby in a birth center, her second at home with a CNM, and her third unassisted, with a midwife hired as a photographer. She is also apprenticing with a home birth midwife, so has seen birth from the other end of things, so to speak, including several more complicated/complex births. At the end of our conversation, she suggested that I, or this new baby, might need something that this midwife can offer. Perhaps my task this time is to learn how to move past my fears about having a midwife and to embrace this pregnancy and this birth journey for what it needs to be, rather than always comparing it against Zari’s pregnancy and birth. I think she was very wise to say this. Maybe there’s something unexpected that will arise during this pregnancy or birth that is spurring me to seek midwifery care. Maybe I need to learn how to let people into my life and accept assistance. I am a very independent, self-reliant person, and I always want to do things by myself. I have already proven that I can give birth alone, that I can do it all without assistance. Perhaps I don’t need go through that particular rite of passage this time.

I am eager to talk through these issues with the midwife the next time we meet, since I need to move beyond the unproductive anxiety that I have been feeling. I don’t like that this pregnancy has been so dominated by these unsettled concerns. Now that my birth is drawing nearer, I need to turn my emotional and mental energy in a more positive, productive direction, towards creating the birth that I desire rather than worry that it might not work out the right way. I know that my concerns are minor in the grand scheme of things—you know, compared to people dying of AIDS or extreme poverty or domestic violence or whatever—but they are still real and important to me.
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Wednesday, January 14, 2009

Fascinating article on pumping breast milk

In this week's The New Yorker, Jill Lepore explores the phenomenon of breast pumping in her article "Baby Food: If breast is best, why are women bottling their milk?" It's definitely worth the time to read. I have already come across commentary to the article, including this post from the Motherwear Breastfeeding Blog. Read both and share your thoughts!

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We have furniture!

We sold our living room furniture with our last house (the sellers fell in love with both the house & the furniture and we were happy to have a buyer so we said okay). Things have been feeling a bit bare until early this week, when our new furniture arrived. Now all the room needs are some pictures on the walls, something with lots of color to break up the green.

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Monday, January 12, 2009

Belly shot: 24 weeks

24.2 weeks from LMP. I'm measuring around 26-27 cms, which is a few centimeters larger than my last pregnancy. But my weight gain has been slower so far this time around, which I find curious. No major complaints, just feeling quite squished and out of breath at times.

And I think it's time to change to a maternity shirt soon! This one is so snug now that you can see where the waistline of my maternity jeans presses into my stomach.

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Sunday, January 11, 2009

Born Free: Unassisted Childbirth in North America

My dissertation is online and publicly available!

I've been waiting for ProQuest to put my dissertation online. In the meantime, here is a link to the manuscript, Born Free: Unassisted Childbirth in North America (PDF document). It's actually a more recent version than the one I submitted to ProQuest, since I have recently changed several typos and made a few minor corrections. I'll be periodically updateding the manuscript as I find more typos or small items that need clarification or correction. Like any published book, the dissertation is copyrighted so, obviously, no quoting passages or paraphrasing without an appropriate citation.

I would love to have detailed feedback, comments, and/or criticism on the manuscript. Feel free to email me about anything from typos to major conceptual or organizational issues. My next project is submitting a proposal to publishers, so I would especially appreciate input related to turning the academic dissertation into a book.

Happy reading!
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Sewing up a storm

I made Zari a ring sling yesterday to match mine. She loves it.

Zari in "mama's sling" when she was about four months old.

A sling I sewed yesterday for my sister-in-law, who had her fifth baby a few weeks ago.

A recent Second Womb order:

And a sling I made today, just for kicks. I like it so much I might need to make another one for myself! It's white embroidered linen with a black linen band at the end of the tail. It has black sling rings and black embroidery across the pleats.
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Quack quack

One of Zari's Christmas presents was duck towel, made by her aunt Brittany (& uncle Ben). The hood of the towel has two eyes and a duck bill. Her cousins got duck & frog towels.

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Saturday, January 10, 2009

UC Davis confirms sharp rise in autism rates

A recent study of autism rates in California, led by UC Davis researchers, found a "sharp rise" in autism rates even after accounting for higher rates of diagnosis and the inclusion of milder forms of autism. From an article in the Press-Enterprise, which covers Riverside and San Bernadino counties:

UC Davis researchers who analyzed 16 years of records concluded that California's dramatic rise in autism cases since 1990 cannot be blamed on population increases or the way the disability is classified or diagnosed.

The study's authors, from the university's MIND Institute, called for a switch in research emphasis from a genetic cause to possible environmental triggers including chemicals, medications, fertility treatments and childhood vaccines.

The incidence of autism in children 6 or younger increased from less than nine per 10,000 children born in California in 1990 to more than 44 in 10,000 children born in 2000.

Read the rest of the article here.

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Study on Hyperemesis Gravidarum (HG)

The University of Southern California is conducting a study on the genetics of HG (excessive vomiting during pregnancy). If you have suffered from HG, you may be eligible to participate:
HG Researchers need your help! This study is designed to identify individuals affected with HG, to study epidemiologic factors via an online survey, to collect DNA samples from saliva through the mail at no cost or travel for you, and to search for genes and risk factors that may be potentially associated with this condition. To be eligible, you must have suffered from HG and had treatment for your HG that includes i.v. hydration, TPN or other form of non-oral feeding (ie nasogastric feeding), OR both, and are able to recruit a friend with at least 2 pregnancies who has NOT suffered from HG to serve as a control. If you live in the United States and are interested, please contact Marlena Schoenberg Fejzo, PhD at or 310-210-0802. Download the USC Consent Form (108 Kb PDF) for more details about the study.
If anyone needs a "control friend," I would be happy to sign up with you! To learn more about the study and the Help HER foundation, click here.
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Friday, January 09, 2009

Back home

We arrived back home on Wednesday night after almost three weeks of traveling to Iowa City, Dayton, northern Ohio, and Pittsburgh. We had no car problems on the way home, for which I am very thankful. It's nice to be home again and to sleep in my own bed (with a new 4" thick memory foam topper...mmmmm). Zari was around hordes of cousins, aunts, and uncles the whole trip, and now I fear she may go through cousin withdrawal.
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Monday, January 05, 2009

Anyone with graphic design/web design skills?

I've been wanting to open a real, professional-looking website for my Second Womb Slings. I recently purchased a domain name ( and am ready to put a website together. Is there anyone out there with graphic design/web design skills who would be interested in helping me design a website template and/or logo in exchange for a beautiful handmade sling? Once I have a good template, logo, and overall "look," I can design the rest of the web pages with the web design software I have. I want something that's sophisticated, hip, and beautiful. Nothing too cheesy or cutesy.

If you're interested in trading skills, please email me!
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Belly shot: 23 weeks

23.2 weeks from LMP:

I'm feeling great, although quite stretched out all over. I already feel like I'm running out of room and, obviously, have a ways to go still! I have to sit up very straight otherwise I feel like I can't breathe. I'm feeling tons of movement all over the place, although it's more often in the lower uterus or cervix. I wonder if my placenta is quite high on my fundus, since I feel the least amount of movement there. Or it could be that this baby prefers to be head-up right now.

I've got varisocse veins for the first time. I first noticed them once I arrived at my sister's house after about five days of traveling in the car. They're all over both of my lower legs. Ugh. I don't care so much about the looks (although they are ugly) but they ache and throb at times. I ran out of fish oil a few weeks before we left for Christmas break. I bought more fish oil last week and the varicose veins have been bothering me much less ever since I started taking it again. Coincidence? causality? who knows...
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Friday, January 02, 2009

Journey into Motherhood

Sheri Menelli has recently made her book, Journey Into Motherhood: Inspirational Stories of Natural Birth, available for free as an e-book. Click here to download it as a PDF. Of course, if you can spare the money I'd still suggest buying a new copy so she receives royalties for her hard work. I haven't read this yet and am glad to have something new to read.
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