Showing posts with label Canada. Show all posts
Showing posts with label Canada. Show all posts

Thursday, December 16, 2010

Birth Around the World: A Tale of Two Births in Canada

Joanne is a software engineer in Ontario, Canada. Her first child was born in 2007 at Kitchener Ontario's Grand River Hospital, which sees about 4,000 births per year. She chose a midwife-attended homebirth in 2010. This post is lengthy, but it’s really two birth stories in one! It shows two contrasting styles of maternity care available in present-day Canada.

When I became pregnant with my first child in 2007, I had no reasons to distrust the latest technology and knowledge of the Western medical establishment. My family doctor referred me to an obstetrician, who are in short supply in my area, so I “got who I got.” My pregnancy was highly normal and my care was fine (sparse but sufficient) up until the time my due date came and passed, and I waited... waited... waited to go into labour. My OB scheduled me for an induction at +10 days (a Friday--coincidence?) without discussion. I was worried about how I’d be able to handle an induced labour and thus mentally felt increasingly desperate as the fateful day approached.

The night before, I awoke with increasingly strong and regular contractions which I was pretty sure was finally it. When I arrived at hospital the next morning on schedule, the nurses confirmed I was 4 cm dilated and cleared me for continuing since I was in labour already. At noon my OB showed up and was quite annoyed with the nurses (and me) for not following his induction orders.

"We've got to get this baby out now."

"Why?"

"Because it's been long enough."

"I'm concerned about the pain with Pitocin contractions."

"It's called LABOUR for a reason; it's going to be painful. Look, you don't have to do it but I highly recommend it."

Seeing as I was contracting strongly, in pain, I wasn't expecting this, and I didn't have experience going against my primary care provider, I reluctantly agreed to let him break my water and start the Pitocin drip. Of course then I required continuous fetal monitoring, which made every little movement quite an event. The contractions quickly grew stronger, stronger, and more painful. I lasted another 4 hours and with such pain, the tension in my body hadn't actually let me progress past 4 cm. Discouraged, I agreed to an epidural. Admittedly it was a tremendous relief and I wanted to hug the anesthesiologist. Now that I could relax some, I actually progressed to 10 cm in a couple of hours. I also found out something I didn't know about epidurals--i.e. they don't provide total pain relief, at least not for me. Much of the time I could feel most of one side of my body, and the nurse would regularly have to call for permission to top it up.

Naturally I was confined to the bed, so I couldn't move around to deal with the pain. So pushing HURT. I was a good pusher and the baby descended steadily. At some point, the head nurse came in to say "she's got to stop pushing." It turns out (since it was now Friday evening) there was only one OB on the floor and she was busy performing an emergency C-section. And of course, my baby couldn't be born without a doc present. So they turned the Pitocin and lights off and rolled me on my side. What utter agony--I thought my body was going to push out the baby whether we were ready or not!!

There was some meconium in the fluid by this point (likely from the stress) although we could "hear" on the fetal monitor that baby's heartbeat was still reacting well. I was whimpering and at this point my partner secretly believed I was headed for a C-section too. He whispered to me "think of the other family" and I tried to. But eventually the OB and staff appeared, and another 2 pushes, and Alice was out. What relief--I simply cried tears of joy and relief.

The pediatrics team pumped the meconium out of baby’s stomach and luckily she was fine to stay in the room with me. So, in the end, despite all the "help" from the medical establishment, my body did what it was supposed to and I pushed my baby out. Looking back now, I realize I was probably lucky: this combination of Pitocin, epidural, and baby-stress can doom many a woman to an unwanted C-section.

I learned a few more things. I bled heavily after this birth and became anemic.... I learned later this can be a side effect of all the interventions. My tear/episiotomy site became infected, and I can’t rule out the possibility that the cause was from being in a hospital. But: my birth went well, didn't it? I had a healthy 8 lb. 10 oz. baby, delivered vaginally, no NICU visit, and all the nurses were really nice and helpful with breastfeeding. So, I should be satisfied, right? Right?? I had myself convinced for a while.

When I became pregnant with my second child I knew I wanted to try something different for care, so I called a local office of registered midwives. At first, I assumed I would go to the hospital again for delivery because that was just what people did. After processing some of the materials in the lending library, to our surprise, my partner and I independently came to the conclusion that we wanted to try a homebirth. Some of the stories about actively-managed labour with OBs in a hospital setting were simply eye-opening--this is exactly what had happened to us!! I don't know if we would have believed them had we not gone through the experience, but we had. So all of a sudden we were committed to a different kind of birth.

homebirth by reading what natural childbirth subjectively feels like. All these stories, including Rixa’s own birth stories, helped me overcome the knowledge deficit and gain confidence in my body's own ability to give birth naturally. I drank these up in my quest to "reverse" society's notion that childbirth is necessarily a medical event to be managed medically.

So, my second due date came and went with no baby in sight. Even with a midwife supportive of natural birth at home, her guidelines dictate repeated non-stress tests and ultrasounds to check on an overdue baby, as well as a "plan" for what would happen should two weeks past due date come and go. I was starting to feel increasingly desperate again as I saw my dream for a simple homebirth, at risk.

But, eventually at +10 days (again) those pesky prodromal labour contractions finally (finally!) became strong and regular enough to push out my baby. I laboured quietly at night in my bed from 2:00-6:00 a.m. which was nice actually--I could relax sleepily between contractions, which I knew was important for dilation. It was just so great knowing I didn't have to deal with going anywhere. By 6:00 am contractions were too difficult to lay through so I woke up my partner and told him it was time to call our midwife. She took her time getting ready and arrived at 8:30 am to find me 6-7 cm dilated ("and your body did it all on its own," she encouraged me). I was anxiously awaiting her arrival so I could get in the bath tub, post cervix check, for a change of pace.

I laboured alone as the others got the bed ready and brought in all the midwife's equipment. I got on all fours for each contraction (couldn't have done that in the hospital!) and actually found a semi-sitting position that was comfortable for relaxing in between. (I found that was key for me in both labours--I felt a lot of pain in between contractions if I couldn't find a good resting position, and those were elusive.)

I was off in labourland when Nicole came rushing in with "do you feel like you need to push?" Apparently my vocalizations had changed to what they often sound like when the baby is descending during second stage. It was all involuntary, which was awesome--my body was doing it all and I was just along for the ride!! My water spontaneously broke with thankfully only a bit of vernix to see. After 2-3 pushes on my hands and knees (still in the tub--not my midwife's idea of a convenient position but I wasn't willing to move anywhere!), Claire was born, nuchal hand and all. Finally I understood what I had read about it being a relief to push--on my hands and knees, it did feel better to push, almost like applying counterpressure to the contraction. (This was a definite contrast from being confined on my back in the hospital.) I didn't feel a ring of fire or any tearing, although I did receive a second-degree tear again. In fact, comparing the two births, I would say the pain levels were similar, although the first one was with an epidural and the second was obviously much shorter in duration.

It was 9:30 a.m. by this point--all the birthing and emergency equipment was barely in from the car and the backup midwives hadn't even had time to arrive yet. The tub had had to be drained (since it wasn't deep enough for a water birth, unplanned anyway) so I knelt on the floor of the empty wet tub, clutching my slippery newborn. I couldn't believe it had really happened!! A birth at home, just the way we had planned. I cut the cord myself.

Out of the tub and back to the bed for the delivery of the placenta, stitches, and initiating breastfeeding. Another healthy girl, 8 lbs 11 oz. So THAT is what birth is supposed to be like! What a privilege to have been able to experience a safe, natural childbirth at home. This is an experience I would wish for more women. It was so perfect and meaningful and to this day it’s still hard to believe it actually happened all the way we planned!! It was an empowering achievement in the way that my first birth, amazing in its own way since it was my first, just wasn't.

So yes, I join the ranks of moms who had one undesirable hospital birth experience and, as a result, experienced a beautiful homebirth subsequently. 2-5+ years ago, I would have never believed I’d be one of these women!! I try to not be judgmental of other people's birth choices, but now I encourage others to at least call a midwife early in their pregnancy to give themselves some birth choices. I remember my grad school supervisor telling me that if you knew at the beginning what you had learned by the end, it wouldn’t have been a learning and growing journey.... It’s not an end by any means, but the beginning to parenting my two girls!
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Wednesday, September 02, 2009

New Canadian home birth study

A study comparing the outcomes of all planned home births with registered midwives in BC is just out in the Canadian Medical Association Journal: Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Other bloggers have already written up detailed explanations of the study's design and analysis, so I will suggest you read more on Lamaze's Science & Sensibility.

In short, this study compared all BC planned midwife-attended home births with midwife-attended hospital births (the same midwives, since Canadian midwives practice both in home and hospital) and physician-attended hospital births. Both hospital groups met the same eligibility requirements for home births, meaning they were equivalent in health factors, risk status, etc. In other words, all of these women having hospital births could have chosen home births if they had so desired, under the BC midwifery regulations. From the abstract's conclusion:
Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
Like the Dutch home birth study that came out earlier this year (abstract available here), this Canadian study has a strong comparison group--something lacking in the CPM 2000 study in the BMJ.

I found the comment section in this news article about the study quite interesting. I really don't think most of the commenters actually read, or understood, what the study was saying. Rather, the comments were a series of emotional reactions for and against home birth. You know, "my baby would have DIED if I had been at home!" and "I will NEVER go to a hospital for childbirth again because it was so AWFUL!" Sometimes evidence from really good studies simply doesn't matter. It's more about emotion, perceptions of risk, and the need for a compelling narrative that makes sense of and gives finality to their birth experience.

I'm sure there is lots of discussion going on out there. For example, Woman to Woman Childbirth Education includes a comment by Gloria Lemay, in which she argues that the registration of BC midwives has not been a good thing overall. Any other good links/commentary about this study?
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Sunday, July 05, 2009

10 weeks old

For the two weeks that we've been visiting family in Alberta, we've already noticed changes in Dio. He looks bigger, he has more control over his head and limbs, and he loves to watch people. He's become less fussy, too, now that he can look around and see what's happening. And with 26 people in one house, there is a lot of action and noise. So he spends much of his day chilling in the middle of a crowd of people, either in our arms, on our laps, or propped up in the corner of the couch like this:
Canada Day was quite fun. There was a very large parade in our small town. We were decked out in Canadian paraphernalia, from temporary tattoos to t-shirts to Dio's Canadian diapers. (For a tutorial on how to make the diapers or diaper covers, click here.) We celebrated the 4th of July as well, with a multilayered red, white, and blue jello. We sang lots of songs and discussed whether one can be patriotic without being nationalistic or falling into an us vs. them or an I'm better than you mentality.

We spent Thursday through Saturday at a family reunion with Eric's extended family. We all camped at a ranch in the foothills of the Canadian Rockies. There were about 100 people, kids running all over the place. None of us got much sleep, but that's temporary. We went up into the mountains on Friday and hiked up a narrow canyon that has a very fast and very cold stream running through it. Most of the time you have to hike and climb in the stream itself, the canyon walls are so narrow I took Dio with me in the Fauxhawk I made last year. He slept almost the whole time and was a real trooper. Eric's youngest brother hiked with some friends quite a bit farther than the rest of us, until they saw a black bear in the canyon, upstream. They turned around stat! Next we went to a secluded place on a big river. The kids played in a small inlet where the water was tolerable. They made sand castles and mud castles and threw rocks into the water. Some of the adults (me included) were insane enough to swim in the river itself, which was just above freezing. I knew that if I didn't go in, I'd wish I had. And when will I be back here next? Eric swam, too, but he had a wetsuit so he was able to go in more than once. He brought his snorkeling gear and saw lots of big fish.

We had a terrible scare yesterday morning. I was sitting on a couch nursing Dio and Zari was running around with her cousins, getting ready for the kid's races and games. About 10-15 minutes later, Eric came in and asked where Zari was. He couldn't find her anywhere inside the building or on the grounds. We started gathering people to search for her father afield: down the roads, around the horse pond. Finally we got almost everyone looking for her. If you've ever lost your child, you know that feeling of sheer terror when you realize you don't know where they are and, worse, if they are still alive.

Finally we heard a shout that she'd been found. One of Eric's brothers had walked over the big hill (off to the right of this picture) and saw a tiny purple speck way down the road. He almost didn't keep going, thinking it was just a fence post or something, but thankfully he did. It was Zari, standing in a driveway, sobbing hysterically. She had snot running down her face and she had peed her pants. (This picture was taken before she got lost, when the adults were running a 3K race).

We've been talking a lot about how she got lost, how it made us scared and sad, and how she should tell us if she wants to go on a walk. I can't figure out why she left in the first place--it's not characteristic of her to go off alone. The only thing I can get out of her without any prompting is "I stopped walking." I'm glad she did.
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Wednesday, July 01, 2009

Gearing up

It's Canada Day tomorrow and this little town has been getting ready in full force. Flags are everywhere. I even saw one house with a huge red & white "Eh?" sign filling the picture window. We went to an annual town celebration complete with cowboy poetry, fiddling, and country music. It almost felt unreal because it was so...Western and folksy. But it was real.

In honor of Canada Day, I wanted to mention the article Debunking Canadian Health Care Myths. I've heard some people ranting and raving about how, if the US were to adopt national health care, "the country would become like the UK or even Canada!"
Myth: Canada’s government decides who gets health care and when they get it.
While HMOs and other private medical insurers in the U.S. do indeed make such decisions, the only people in Canada to do so are physicians. In Canada, the government has absolutely no say in who gets care or how they get it. Medical decisions are left entirely up to doctors, as they should be. There are no requirements for pre-authorization whatsoever. If your family doctor says you need an MRI, you get one. In the U.S., if an insurance administrator says you are not getting an MRI, you don’t get one no matter what your doctor thinks – unless, of course, you have the money to cover the cost.
Yes, such a terrible fate.

Thanks to Mom's Tinfoil Hat for the link.
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Sunday, June 28, 2009

Breech: what to do next?

From Robin Guy, co-founder of the Coalition for Breech Birth:
Dear friends of CBB,

Well, here we are. Women's voices are finally getting heard -- the Society of Obstetricians and Gynaecologists of Canada has issued new breech guidelines that above all, advise that women need to be offered the choice of vaginal breech birth. What is the most important about these guidelines is not the nitty-gritty of candidate selection and techniques of delivery, but rather that they have tackled the ethical issue of forced surgery and come down firmly on the side of not obliging women to have surgery they neither want nor need.

Here is a link to the new guidelines and commentaries (please especially read Andrew Kotaska's commentary).

For those of you not in Canada, this is a great opportunity to approach your own organizations and present this example of progressive movement towards recognizing women's autonomy over their own bodies and ownership of their birthing.

So one battle is won, but the next is beginning. The guideline change will offer those doctors and midwives who were willing to catch, but afraid of professional censure or litigation, the excuse they need to start catching openly and helping to train their colleagues. The SOGC is also launching training initiatives that will help the care providers currently in school to gain these skills and graduate competent to include vaginal breech in their practice.

However, as always, the real change must come from us. The real change must come from women and their families expecting better care. Expecting to be offered unbiased informed choice discussions and for our choices to be respected and supported. Expect referrals to competent attendants when our own midwife or doctor legitimately doesn't have enough experience to safely catch our breech babies.

Please. Tell your friends what has happened. Shout it to the rafters. Watch for the International Breech Conference registration announcement (it will be October 15-16, in Ottawa), and do whatever you can do to be here.

Let's make some noise.

Blessings, Robin
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Friday, June 19, 2009

More on breech & the SOGC

There's a lot of conversations about the new SOGC guidelines on vaginal breech birth. If you'd like to read the complete text of the new guidelines, an editorial by Dr. Lelonde, or commentary by Dr. Kotaska (one of the physicians featured in Pushed; he traveled to Europe to obtain training in vaginal breech birth), visit the SOGC's Media Advisory site on breech birth. Those documents, and more, are available as PDF downloads near the bottom of the page. Be sure to read the editorial and the commentary!

A few more links discussing the SOGC guidelines.
Any other blogs, articles, or links worth reading?
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Wednesday, June 17, 2009

Canada does a 180!

The Society of Obstetricians & Gynecologists of Canada (SOGC) has made a dramatic about-face this week. In a reversal of its earlier prohibition of vaginal breech birth, the SOGC just announced its new recommendations: to offer vaginal breech birth and to establish nationwide training programs so that physicians can learn the necessary skills. From The Globe and Mail: C-section not best option for breech birth:

Physicians should no longer automatically opt to perform a cesarean section in the case of a breech birth, according to new guidelines by the Society of Obstetricians and Gynecologists of Canada.

Released yesterday, the guidelines are a response to new evidence that shows many women are safely able to vaginally deliver babies who enter the birth canal with the buttocks or feet first. Normally, the infant descends head first.

“Our primary purpose is to offer choice to women,” said André Lalonde, executive vice-president of the SOGC.

“More women are feeling disappointed when there is no one who is trained to assist in breech vaginal delivery,” he adds....

The new approach was prompted by a reassessment of earlier trials. It now appears that there is no difference in complication rates between vaginal and cesarean section deliveries in the case of breech births....

This article also highlighted the SOGC's position on normal birth:

The new decision to offer vaginal breech birth aligns with the SOGC promotion of normal childbirth – spontaneous labour, followed by a delivery that is not assisted by forceps, vacuum or cesarean section. In December of 2008, the society release a policy statement that included its recommendation for a development of national practice guidelines on normal childbirth.

“The safest way to deliver has always been the natural way,” said Dr. Lalonde.

“Vaginal birth is the preferred method of having a baby because a C-section in itself has complications.”

Cesarean sections, in which incisions are made through a mother's abdomen and uterus to deliver the baby, can lead to increased chance of bleeding and infections and can cause further complications for pregnancies later on.

“There's the idea out there in the public sometimes that having a C-section today with modern anesthesia and modern hospitals is as safe as having a normal childbirth, but we don't think so,” said Dr. Lalonde.

“It is the general principle in medicine to not make having a cesarean section trivial.”

The SOGC believes that if a woman is well-prepared during pregnancy, she has the innate ability to deliver vaginally.

Another article in The Vancouver Sun, Canadian docs to stop automatic C-sections for breech babies, covers much of the same information about the change in breech policy:

In a major shift in medical practice and another assault on Canada's rising cesarean section rate, Canada's delivery doctors are being told to stop automatically scheduling C-sections for breech babies and attempt a normal delivery instead — something significant numbers of obstetricians aren't trained to do.

New guidelines issued Wednesday by the Society of Obstetricians and Gynaecologists of Canada say women carrying babies in the breech, or bottom-first, position should be given the right to choose to attempt a traditional delivery when possible.

The society says that women in Canada want the choice, and that some women with breech babies are delivering at home "because they knew if they went to hospital A, B or C it would not be offered," says Dr. Andre Lalonde, executive vice-president of the obstetricians' group and an adjunct professor of obstetrics and gynecology at McGill University and the University of Ottawa.

Lalonde says the group is working aggressively to ensure future specialists are trained in breech vaginal deliveries and is organizing courses across Canada for practising doctors to refresh their training.

I am somewhat stunned at this dramatic shift in policy. The ACOG could definitely take some hints in listening to women and looking closely at the evidence from their friendly northern neighbors...This makes me want to go outside and sing "O Canada" at the top of my lungs!

ps--I love Unnecesarean's illustration!

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Tuesday, March 31, 2009

New midwifery program in Canada

My mother-in-law just sent me a link to this article, Calgary college plans midwifery degree. There will finally be another four-year midwifery degree program in Canada by as early as 2010! This is much-needed, as there are currently only six midwifery education programs in the entire country. In addition, demand for midwives vastly outnumbers supply, so many Canadian women wanting midwifery care are unable to access it. The degree program will be offered through Mount Royal College in Calgary, Alberta.

Canadian midwives are required to obtain a university-level degree in midwifery. In provinces where they are legally recognized, they attend births at the location the woman chooses (home or hospital or, if available, freestanding birth centers). For more information on midwifery in Canada, visit the Canadian Association of Midwives.
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Sunday, August 19, 2007

The New Normal

Just out: an article about the medicalization of childbirth in Canada. It's called "The New Normal", written by Elizabeth Payne in The Ottawa Citizen.


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