Monday, October 29, 2012

2 million

My stat counter hit 2 million today! Thanks to all of you for reading and keeping this blog alive. I've had the occasional existential blogging crisis, wondering if I was actually making any difference. But your stories and your emails have kept me going.
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Saturday, October 27, 2012

Selective vaginal breech delivery at term--still an option

Breech is on my mind, as I'm preparing to speak at the 3rd International Breech Conference in 2 weeks. I just came across this cohort study from a hospital in Finland: Selective Vaginal Breech Delivery At Term--Still An Option.

Here's a flowchart of the comparison groups and their planned vs. actual modes of delivery. Email me if you'd like to read the full text!


TOIVONEN, E., PALOMÄKI, O., HUHTALA, H. and UOTILA, J. (2012), Selective vaginal breech delivery at term – still an option. Acta Obstetricia et Gynecologica Scandinavica, 91: 1177–1183.


Objective. To compare the neonatal outcome between planned vaginal or planned cesarean section (CS) breech delivery and planned vaginal vertex delivery at term with singleton fetuses.  

Design. A cohort study.  

Setting. Delivery Unit, Tampere University Hospital, Finland, with 5200 annual deliveries.  

Population. The term breech deliveries over a period of five years (January 2004 to January 2009), a total of 751 breech deliveries, and 257 vertex controls.

Methods. The data were collected from the mother's medical records, including a summary of the newborn. In the case of neonatal health problems, the pediatric records were also examined.  

Main outcome measures. Maternal and neonatal mortality and morbidity as defined in the Term Breech Trial. Low Apgar scores or umbilical cord pH as secondary end-points.  

Results. There was no neonatal mortality. Severe morbidity was rare in all groups, with no differences between groups. The Apgar scores at one minute were lower in the planned vaginal delivery group compared with the other groups, but there was no difference at the age of five minutes. Significantly more infants in the vaginal delivery group had a cord pH < 7.05. There was one maternal death due to a complicated CS in the planned CS group and none in the other groups. Mothers in the planned CS group suffered significantly more often from massive bleeding and needed transfusions.  

Conclusions. Vaginal delivery remains an acceptable option for breech delivery in selected cases.
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Friday, October 26, 2012

How to get to school in style

I still haven't made any headway on getting a crossing guard near Zari's elementary school. I've talked multiple times to the school transportation department, the state highway department, the police chief, and more. Since no one was willing to DO anything, I took matters into my own hands:

With the police chief's blessing, I should add. He said he couldn't technically give me crossing guard equipment for liability reasons, but...

"But," I asked him, "there's nothing stopping me from buying my own equipment?"


The crossing guard equipment makes a huge difference. Cars actually stop for us (they're legally required to at the crosswalk, but that doesn't mean anything in our town). I get a kick out of holding the stop sign and blasting my whistle at drivers who aren't paying attention.

I'd like a more permanent solution to access to this school building, but it does the job for us.
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Sunday, October 21, 2012

Birth activism: let's get involved

There is lots of exciting birth activism going on right now. Please take a minute and join in one or more of these causes!

1. Human Rights Violations in the European Maternity Care

If you're a member of the EU, sign this petition addressed to the European Parliament about human rights violations in maternity care. Sponsored by the Human Rights in Childbirth conference, the petition notes:
In 2010, the European Court of Human Rights in Strasbourg stated, in the case of Ternovszky versus Hungary, that “the right to respect for private life includes the right to choose the circumstances of birth”. However, many European States have systems of birth care in which women's physical autonomy is routinely violated and their options are rigidly circumscribed.

2.  Your Voice Counts Day

Join women around the world in notifying hospital administrators and care providers about their experiences of giving birth. This movement asks women and their families to mail letters on or around Thanksgiving Day (Thursday, November 22). More about Your Voice Counts Day here. If we want to make changes in maternity care, we need to let care providers and institutions know how we feel about the care we've received!
Did you have a wonderful, empowering birth experience? Did you have a traumatic birth experience that made you feel hurt and confused? Stand up and tell somebody! On Thursday, November 22nd (Thanksgiving) join us in mailing letters to hospital administrators, birth center directors, and other birth workers to tell our stories. How will hospitals and birth workers know how they're doing if we don't tell them? Whether your birth happened sixty minutes ago, sixty days ago, or sixty years ago, your experience matters. We cannot be ignored if we unite and flood these establishments with letters at the same time. Stand up and be counted on Your Voice Counts Day. 
3.  Freedom For Birth

The documentary Freedom For Birth examines childbirth as a human rights issue. It had a global premiere on September 20th. I was tied up that day and unable to attend a screening, but the movement to spread awareness is just beginning. I ordered the DVD last week and can't wait to watch it.

4. Birth Action in Canada

If you live in Canada and have experienced any violation of informed consent or human rights during your birth, please get involved by taking this survey. Organizer Dr. Nancy Salgueiro explains what she hopes to accomplish with these surveys:
Canadian courts have repeatedly reaffirmed a patient’s right to informed consent as well as the right to refuse treatment. IN ONTARIO, the Health Care Consent Act of 1996, clearly outlines your legal right to informed consent....

We have a arranged a group of Ottawa lawyers willing to volunteer to commission legal affidavits of the violations in your birth experience.   Once we compile enough legal affidavits these will be brought forward to force a public inquiry of the systemic abuses to women in childbirth.
She has also provided examples of violations of informed consent:
  • Treatment occurred without YOUR PERMISSION.
  • Treatment occurred after REFUSAL of consent.  (You said, No”)
  • Treatment occurred without fully INFORMED consent.
  • You were not informed or misinformed as to the NATURE OF THE TREATMENT.
  • You were not informed or misinformed as to the expected BENEFITS of the treatment.
  • You were not informed or misinformed as to the material RISKS of the treatment.
  • You were not informed or misinformed as to the material SIDE EFFECTS of the treatment.
  • You were not informed or misinformed as to ALTERNATIVE COURSES OF ACTION.
  • You were not informed or misinformed as to the likely consequences of NOT HAVING THE TREATMENT.
  • Consent was given but obtained through MISREPRESENTATION, OMISSION, COERCION or FRAUD.
  • Consent was given but NOT GIVEN VOLUNTARILY. (Told you have no choice but to consent).
  • Consent was given but DID NOT RELATE TO THE TREATMENT that was provided.
  • You were DENIED RESPONSES TO YOUR REQUESTS for additional information about those matters.
  • You were denied the opportunity to have a DISCUSSION with the DOCTOR/MIDWIFE about the proposed treatment.
  • Consent only consisted of a form to sign when you walked in the door with NO DISCUSSION OR EXPLANATION BY THE DOCTOR/MIDWIFE.
I'm also interested in other recent activism, including the National Rally for Change on September 3 (Labor Day).

Did anyone participate in this or other recent birth activism? Please tell us all about it! 
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Tuesday, October 16, 2012

Vaginal breech, ECV, and NRP Workshops

I have another announcement to make...Not quite as exciting as my pregnancy, but pretty close!

We are organizing another workshop with Dr. J. Peter O'Neill, the Canadian OB who taught vaginal breech skills last summer in Indianapolis. This time, he will be leading two full-day workshops: Vaginal Breech Birth and External Cephalic Version with Ultrasound Guidance. Both sessions include hands-on simulation.

On top of that, we have a NRP course tailored for out-of-hospital attendants, taught by Penny Lane, CNM, MSN, IBCLC. This course will cover full resuscitation skills, including intubation, medication administration, and umbilical line placement.

The workshops will take place in Niceville, Florida on June 7-10, 2013. We also have some fun free sessions for conference participants, including evening conversation circles and film screenings.

You can mix & match any of the 3 workshop days. We are offering deep discounts for students and for early registration; sign up now to take advantage of these fantastic prices.

Please spread the word about the Vaginal Breech, ECV, and NRP workshops! More information can be found at

Ps--any of you coming to the Third International Breech Conference in D.C.? I'll be there!

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Monday, October 08, 2012

First prental visit

It's nice to finally be able to blog about being pregnant! I've known for a while, but I just didn't feel like sharing with the whole world. Now it's beginning to be obvious that I'm pregnant if I wear a tight enough shirt, so no more secrecy.

This pregnancy is funny--I really don't know when to expect this baby! I'm either 16 weeks along or 12 weeks along. After my very early miscarriage, I thought I had another cycle...but it was really light and really short. Nothing like I've ever had before. I strongly suspect it wasn't a cycle at all, but just some breakthrough spotting that happened to come right when I would have had a period. Other reasons for thinking I'm 16 weeks along:
  • I'm measuring spot-on for being 16 weeks pregnant: 2-3 finger widths below the umbilicus. 
  • I started feeling movement about 4 weeks ago. 
  • The timing of my icky/queasy/exhausted stage also points to being 16 weeks, not 12 weeks. 

But...I can only say I'm about 95% sure. There is still the possibility of my baby coming in late April rather than late March! This uncertainty doesn't bother me at all. In fact, I like not really knowing and not really caring.

The icky stage was pretty awful. And I know I have it easy compared to so many other women. I never puke; I just feel queasy all day and all night. I feel dizzy and weak. I am extremely exhausted. Like my other pregnancies, these symptoms lasted about 6 weeks. But this time was brutal. I've never experienced such exhaustion before. And when you have three small children, you can't just lie on the couch all day! I'd basically collapse once Eric came home.

My best coping strategy was reading; I devoured my way through books 2-5 of Diana Gabaldon's Outlander series. I highly recommend her books: they're smart, entertaining, passionate, and incredibly well-researched.

But now I feel great. I have tons of energy, I have an appetite again, and I am not a useless blob who neglects her children in favor of reading a book. Take today, for example: I taught my 8 am freshman composition class (biking there and back), sewed 4 slings, fed the children lunch, worked on a vaginal breech workshop I'm organizing, walked the kids to pick up Zari from school, went to my first prenatal appointment, prepared 2 dinners for later this week while Eric cooked fried green tomatoes, and put Inga and Zari to bed. I couldn't fathom doing any of these things earlier this pregnancy--except I had to do some of them.
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Sunday, October 07, 2012

Freeze family math

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Friday, October 05, 2012

Optimal Care in Childbirth

I'm really excited to review Henci Goer and Amy Romano's new book Optimal Care in Childbirth: The Case For a Physiological Approach. In fact, I've put off writing about some other exciting developments in order to finish this review.

I've read through the whole book once and skimmed through many chapters a second time. That's no small feat, considering the book is a hefty 583 pages with small font.

Optimal Care in Childbirth is an outgrowth of Goer's two earlier books that made sense of maternity care research and obstetric practices: Obstetric Myths Versus Research Realities: A Guide to the Medical Literature (1995) and The Thinking Woman's Guide to a Better Birth (1999). Henci Goer has been a medical writer, speaker, and consumer educator for the past few decades. Amy Romano is a nurse-midwife with clinical experience in both home and hospital settings. She currently works as a consumer advocate with Childbirth Connection.

So what is Optimal Care in Childbirth about? What does it accomplish? And is it worth the investment? My answer is an unqualified yes. Here's why:

Optimal Care in Childbirth is not simply an updated version of Goer's earlier books. It delves deeper into factors driving maternity care, analyzes an expanded body of research studies, and critiques even more forcefully the abundance of poorly designed research and the gap between research and practice  In Goer and Romano's own words, the book examines:
  • why the research shows so little benefit for physiologic care and so little harm from medical-model management
  • what’s behind the cesarean epidemic
  • what the research establishes as optimal care for initiating labor, facilitating labor progress, guarding maternal and fetal safety, birthing the baby, and promoting safety for mother and baby after the birth
  • the true, quantified risks of primary cesarean surgery, planned VBAC versus elective repeat cesarean, instrumental vaginal delivery, and regional analgesia
  • how the organization of the maternity care system adversely impacts care outcomes

The book begins with three introductory chapters. The first explains the impetus for writing the book. Goer and Romano note that while careful use of technology and obstetric intervention can save mothers and babies, injudicious obstetric practices do "considerable physical and psychological harm to mothers and babies." Their book sets out what optimal maternity care--"the least use of medical intervention that will produce the best outcomes given the individual woman's case"--can and should look like.

The second chapter examines the weaknesses of medical research. Although the rise of evidence-based medicine (EBM) is an improvement over the older GOBSAT (Good Old Boys Sat At Table) model of obstetric decision-making,  EBM has several downfalls. The privileging of randomized controlled trials (RCTs) often means that other kinds of studies are dismissed, even though they contribute important information. RCTs themselves are subject to poor design and flawed interpretation, and systematic reviews are no less immune to bias. Finally, EBM has become an almost inescapable dogma that precludes other ways of knowing and discourages individualization of care. Despite these drawbacks, EBM still holds promise for pointing to maternity care strategies that work to promote minimal harm with maximum benefit. Goer and Romano comb through the research literature, summarizing and clarifying what we do and do know know, explaining what works and what does not.

The third chapter gives readers an orientation to the rest of the book. They present their methods upfront, arguing that transparency is the best antidote to bias.

The rest of Optimal Care in Childbirth tackles the evidence and customs behind the following maternity care practices:
  • cesarean sections (including cesarean rates, repeat cesareans, and VBAC)
  • facilitating labor progress (induction, progress of labor)
  • guarding maternal and fetal safety (fetal monitoring, oral intake in labor, epidurals)
  • birthing the baby (second stage practices, instrumental vaginal delivery, fundal pressure, episiotomy)
  • promoting safety for mother and baby after the birth (third-stage management, newborn practices)
  • optimal practices for a maternity care system (supportive care in labor, midwife-led care, birth centers, and home birth)

Each chapter begins with an analytical essay explaining the historical and cultural influences behind the obstetric practice in question. The essays then summarize the evidence and examine how far evidence strays from practice. These essays are lively, impassioned, and wonderfully humane in tone. One would expect a book summarizing and interpreting medical evidence to be dry reading, but these essays are refreshingly enjoyable. Biting wit and humor intermix with thoughtful analysis and provocative questions.

Following the essays, Goer and Romano provide a concise list of strategies for optimal care based on the evidence. Here's an example of optimal care strategies from the chapter on second stage (pushing) practices:
The following strategies facilitate a physiologic second stage, maximize the chance of spontaneous birth, and minimize the chance of genital, perineal, or pelvic floor injury:
  • Encourage non-supine positions. 
  • Avoid interventions that restrict movement and position-changes. 
  • Make physical props available and encourage position-changes, enlisting labor companions to assist with support, encouragement, and mobility as needed. 
  • Encourage women to follow their spontaneous pushing urges. Discourage prolonged breath-holding. 
  • If coaching seems prudent, suggest open-glottis techniques rather than prolonged breath-holding. 
  • In women laboring with epidural analgesia, await a spontaneous bearing down urge before beginning active pushing efforts. Encourage open-glottis pushing when the urge develops. 
  • Use a supportive and encouraging communication style to promote the woman's sense of safety and wellbeing and diminish her fears. 
  • Guide the laboring woman in birthing the baby's head gently between contractions.

Finally, each chapter ends with several mini-reviews of the available research. The reviews carefully note inclusion/exclusion criteria, study design and limitations. and clarifying information. The mini-reviews are where you can really dig deeply into the research evidence. Mini reviews are numbered and organized by topic.

I was struck by how difficult it is to design studies that capture the nuances of an intricate physiological process. Despite mountains of research, very few studies measure more than one small element at a time. That is the nature of medical research, but it works poorly for understanding the complex, interconnected nature of human labor and birth. Too often, a study's design guarantees that very little difference will be found between the "control" (usually an intervention) and the "intervention" (sometimes another intervention, other times a physiologic practice such as oral hydration or walking during labor). Isolating one small practice while keeping the overall package of care unchanged usually shows minimal results.

I was amazed at how much information Goer and Romano were able to glean, despite the limitations of obstetric research. Overwhelmingly, the evidence points to the value of doing less--or rather, the value of understanding and supporting the physiological process so that labor and birth can unfold without undue complication or interference. It's not that obstetric technology has no place; it's just that most of the time, that technology could be safely replaced with patience, respect, careful observation, and following the woman's lead. In order to shift to this style of maternity care, we need studies that examine not just one small change at a time, but that compare entire packages or systems of care. Ambulation during labor in a conservative hospital environment might make little difference in the course of a woman's labor. Ambulation in a care setting that encourages mobility, provides a full range of non-pharmaceutical pain relief options, upholds maternal preference and autonomy whenever possible, and discourages routine use of technology is another story.

Optimal Care in Childbirth is a book we cannot do without. Imagine if every maternity care facility--from the busiest tertiary hospital to the smallest home birth practice--adopted all of the strategies for optimal care set out in Goer's and Romano's book. We would have a maternity care system that supports the wants and needs of laboring women, no matter their location or their individual health profile. We would have a system that delivers optimal care--promoting the physiological processes whenever possible and providing obstetric interventions judiciously and appropriately. We would have a system that uses fewer resources, leads to fewer physical and psychological complications, and has healthier, more confident, more satisfied mothers.

Optimal Care in Childbirth is available at and retails for $50. The authors have offered Stand and Deliver readers a special 15% discount and free domestic shipping through October 31st. Use coupon code MOQLM3W8. Also available on Amazon.

Disclosure note: Goer and Romano provided me with a review copy and invited me to participate in a referral program.
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Monday, October 01, 2012

Girl power + breastfeeding = awesome

via Facebook
via Pinterest
via Kate Hansen Art
More images & discussion of breastfeeding & roller derby at Kate Hansen Art.
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