On the heels of the 3rd International Breech Conference is this article about the resurgence of vaginal breech birth in some Australian hospitals.
Read the rest here.
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Read more ...
Read the rest here.
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Showing posts with label hospital birth. Show all posts
Showing posts with label hospital birth. Show all posts
Saturday, November 24, 2012
Monday, March 28, 2011
Money makes the babies come out
Our local hospital closed its maternity department in March, leaving a gap in OB coverage in our region. This came as a surprise to our community, since the hospital had recently renovated the maternity department and created new LDRP suites.
Newspaper articles cited financial issues as the main reason for the closure. I was talking with someone a few weeks back whose friend a hospital administrator. Here's the inside scoop:
55% of our hospital's maternity patients were on Medicaid. Medicaid reimbursements were so low that the hospitals' maternity department lost $500,000 last year. The administrators feared that the entire hospital would have to close if this trend continued. So they decided to close the maternity department, rather than risk shutting down the hospital.
Now, I'm not sad that this particular hospital closed. It had one of the higher c-section rates in the state (33.4% as of 2008). It also banned VBACs, another thumbs-down in my book. In contrast, a small community hospital 30 minutes away had a cesarean rate of 23.7% the same year. Both hospitals served nearly identical patient populations--only low-risk pregnancies and near/full-term babies--and did the same number of births per year.
But I am disappointed that I no longer have a hospital 5 minutes away. Granted, I'd only go there in an extreme situation where it would be impossible to travel to the other hospital (which does VBACs and is working on its Baby-Friendly certification).
Low Medicaid reimbursement doesn't just affect hospitals. Currently 60% of my midwife's clients are on Medicaid, 20% have private insurance, and 20% pay out-of-pocket. Although her global fee is $3,600, Medicaid only pays 15% of that amount per birth (a bit under $700). She cannot require her Medicaid patients to cover the rest of her global fee, which means that she actually has to pay to take Medicaid clients. Her birth supplies and birth assistant cost her more than she gets paid. She is currently deliberating whether to stop accepting Medicaid, since it is causing her practice to lose money.
A flip side of low Medicaid reimbursement is exorbitantly high billing for those with private insurance. A friend had her baby at our hospital a few months ago, before it closed. She had a spontaneous vaginal birth with no maternal or infant complications and no nursery stay. The total fees for her prenatal care and birth came to $25,000. The bill was negotiated down a few thousand dollars, coming to a total of around $22,000. Between her deductibles and co-pays, she had to pay close to $5,000 out-of-pocket to have her baby.
Other reading on the topic:
Read more ...
Newspaper articles cited financial issues as the main reason for the closure. I was talking with someone a few weeks back whose friend a hospital administrator. Here's the inside scoop:
55% of our hospital's maternity patients were on Medicaid. Medicaid reimbursements were so low that the hospitals' maternity department lost $500,000 last year. The administrators feared that the entire hospital would have to close if this trend continued. So they decided to close the maternity department, rather than risk shutting down the hospital.
Now, I'm not sad that this particular hospital closed. It had one of the higher c-section rates in the state (33.4% as of 2008). It also banned VBACs, another thumbs-down in my book. In contrast, a small community hospital 30 minutes away had a cesarean rate of 23.7% the same year. Both hospitals served nearly identical patient populations--only low-risk pregnancies and near/full-term babies--and did the same number of births per year.
But I am disappointed that I no longer have a hospital 5 minutes away. Granted, I'd only go there in an extreme situation where it would be impossible to travel to the other hospital (which does VBACs and is working on its Baby-Friendly certification).
Low Medicaid reimbursement doesn't just affect hospitals. Currently 60% of my midwife's clients are on Medicaid, 20% have private insurance, and 20% pay out-of-pocket. Although her global fee is $3,600, Medicaid only pays 15% of that amount per birth (a bit under $700). She cannot require her Medicaid patients to cover the rest of her global fee, which means that she actually has to pay to take Medicaid clients. Her birth supplies and birth assistant cost her more than she gets paid. She is currently deliberating whether to stop accepting Medicaid, since it is causing her practice to lose money.
A flip side of low Medicaid reimbursement is exorbitantly high billing for those with private insurance. A friend had her baby at our hospital a few months ago, before it closed. She had a spontaneous vaginal birth with no maternal or infant complications and no nursery stay. The total fees for her prenatal care and birth came to $25,000. The bill was negotiated down a few thousand dollars, coming to a total of around $22,000. Between her deductibles and co-pays, she had to pay close to $5,000 out-of-pocket to have her baby.
Other reading on the topic:
- Will Your Hospital’s Maternity Ward Close? By Dr. Linda Burke-Galloway
- Lower TennCare rates for C-sections upset obstetricians (thanks to The Unnecesarean)
- Bye-bye babies: South Seminole closing its birthing unit today
- 2 VA hospitals closing maternity wards
- Hospital Maternity Wards Are Closing Across U.S.
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Thursday, December 16, 2010
Birth Around the World: A Tale of Two Births in 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!
Tuesday, July 28, 2009
The business of being born
Childbirth is a big business. A recent article in the Minneapolis Star Tribune, Definitely, Not Your Mother's Maternity Ward, explores the multimillion dollar maternity wing renovations in the Twin Cities area done in the hopes of luring in potential customers. Rain showers, iridescent tile, whirlpool tubs, massages, wi-fi, and spa services are some of the amenities available in the updated birthing rooms. Click here for a list of the featured hospitals and amenities mentioned in the article.
What I want in a maternity service isn't the outward signifiers of a home or hotel--spa services or flat screen TVs or beautifully decorated rooms. I want policies that encourage physiological labor and birth, that follow evidence-based practice, and that, most of all, uphold women's autonomy and respect their need for dignity and privacy. The room's decor is largely irrelevant to me. The changes I want to see in maternity rooms cost little or no money, but are probably harder to introduce than the most expensive spa services. Things like rooms that promote movement and non-supine positions, policies that follow the best evidence, or nurses and doctors and midwives who are used to seeing women laboring unattached--free from monitors, IVs, and catheters.
In the Star Tribune article, Jeanette Schwartz, clinical director of Woodwinds, remarked that the new maternity renovations are "about customer service. It's all about giving moms choices in their care."
Really? In a country where almost 50% of hospitals ban women from having VBACs, where it's unusual to be allowed to labor without constant fetal monitoring or IV access, and where the majority of women receiving episiotomies were not consulted before they were cut, the rhetoric of "choice" rings hollow. Until I can freely choose those things and more, I will happily forego the "massages, manicures and nicer linens" and stay put in my own house where the real choices are mine to make.
At Ridgeview Medical Center in Waconia, women can now give birth in rooms with whirlpool tubs and wi-fi. At Fairview Southdale, new moms can hire a massage therapist or a portrait photographer. Even Hennepin County Medical Center has upgraded its maternity ward, with pastel decor and a deep tub for water births. All three are part of a major marketing offensive by hospitals to win a coveted demographic: mothers....When I was a graduate student, I took the tour of the new maternity wing and NICU at our large university hospital. Much of the PR material emphasized the maternity wing's hotel-like amenities, such as room service, internet access, and "custom beds" (which are the same kind used in just about every other hospital, the Stryker Adel). I was quite happy to see large whirlpool tubs in every labor room. Waterbirths were allowed, although when I was there none of the midwives or doctors were really doing them. I hope that has since changed. Overall, I was definitely underwhelmed with the multi-million dollar renovation.
Many women have taken childbirth preparation to a new level. Bombarded by marketing from retailers such as Babies "R" Us and websites such as babycenter.com, and inspired by reality shows such as "Maternity Ward" and home birth videos on YouTube, this generation has grand ideas about labor and delivery.
Some tour multiple hospitals before deciding where to deliver. Insurance policies mostly let women go where they want, though they might be constrained by where their doctor can practice. "[Childbirth is] a business that's very competitive," said Ted Blank, director of marketing at HCMC. "It's a planned thing and they have the luxury of shopping around."...
Obstetrics doesn't enjoy the fat profit margins of specialties such as orthopedics or heart care. But it makes up the difference in customer loyalty. For many women, it's their first time in a hospital. "If that's not a positive experience, they're not likely to come back," said Meri Beth Kennedy, birthplace director at Fairview Southdale, which redid its maternity wing a year ago....
The marketplace is so competitive that Fairview Southdale has an advisory board made up of women who have given birth there. To read the rest of the article, click here. The article is 4 pages long, so be sure to read the whole thing.
What I want in a maternity service isn't the outward signifiers of a home or hotel--spa services or flat screen TVs or beautifully decorated rooms. I want policies that encourage physiological labor and birth, that follow evidence-based practice, and that, most of all, uphold women's autonomy and respect their need for dignity and privacy. The room's decor is largely irrelevant to me. The changes I want to see in maternity rooms cost little or no money, but are probably harder to introduce than the most expensive spa services. Things like rooms that promote movement and non-supine positions, policies that follow the best evidence, or nurses and doctors and midwives who are used to seeing women laboring unattached--free from monitors, IVs, and catheters.
In the Star Tribune article, Jeanette Schwartz, clinical director of Woodwinds, remarked that the new maternity renovations are "about customer service. It's all about giving moms choices in their care."
Really? In a country where almost 50% of hospitals ban women from having VBACs, where it's unusual to be allowed to labor without constant fetal monitoring or IV access, and where the majority of women receiving episiotomies were not consulted before they were cut, the rhetoric of "choice" rings hollow. Until I can freely choose those things and more, I will happily forego the "massages, manicures and nicer linens" and stay put in my own house where the real choices are mine to make.
Wednesday, July 22, 2009
Beds and birth rooms
Henci Goer recently wrote about a pilot study examining the effect of birth room design & furniture on the progress of labor. In her Science & Sensibility post, The Labor Environment: “Many things that count cannot be counted”, Goer discussed the study's design:
In hospital birthing rooms I have visited personally, the bed is the central focus of the room. Even the flooring and ceiling materials emphasize the bed's central role in the drama to unfold: inlaid patterns around the bed circumscribe the area where birth is allowed to occur, and the spotlights on the ceiling further dictate the location of birth. These photos are from the new UIHC maternity wing in Iowa City, where I did my PhD. Notice the inlaid pattern in the flooring around the bed and the spotlights in the ceiling:
And these photos of my local hospital's LDRP rooms. Again, notice the inlaid pattern in the flooring that outlines and emphasizes the centrality of the bed. The room revolves around the bed: the couch and rocking chair face it, the monitoring equipment surrounds it, and the lights focus on it:
Read more ...
The June 2009 issue of Birth contains the results of a pilot study gauging the effects of modifying the labor room to encourage mobility, reduce stress and anxiety, and discourage routine medical intervention. Investigators randomly allocated 62 healthy women in spontaneous labor to either a modified room or the standard labor room. Women attended by midwives or doulas were excluded from participating, effectively creating a study population not predisposed to be mobile in labor.As Goer noted, the results were promising, although the sample size was quite small (it was just a pilot study):
Changes to the labor environment were relatively modest. The most radical innovation was to remove the labor bed, replacing it with a portable double-sized mattress and pillows in the corner of the room on the floor....Rooms were also equipped with a birth ball, a chair that promoted sitting upright or leaning forward, an LCD projector with a selection of movies of calming nature images, an mp3 player with a selection of music, and a chart illustrating upright labor and birth positions. All labor rooms had a private bathroom and lacked windows. No nursing alterations were made other than mandating intermittent auscultation, leaving the overhead light off, keeping the door closed, and putting a sign on it asking people to knock before entering.
The trial was too small to draw firm conclusions, but the results certainly support conducting a larger one. Sixty-six percent of the women in the modified room reported spending less than half of their time in labor in bed versus 13% of women in the standard room, and only 35% spent three-quarters or more of their time in bed versus 87% of women in the standard room. (The bed was brought back at the woman’s - mostly for epidural analgesia - or caregiver’s request.) Women in the modified room were significantly less likely to have oxytocin augmentation (40% vs. 68%), and those who had it got it later in labor. Women also had somewhat shorter labors on average and longer times to initiation of analgesia/anesthesia.I found another article discussing this research at VOA News: Re-Thinking Delivery Room Design Eases Labor. The lead researcher, University of Toronto nursing professor Ellen Hodnett, conceived of the study after noting women's behavior when they were giving birth at home. They moved around a lot and used household furniture to aid their labors. She commented:
They used a dining room table to lean over. They used the bathtub. They walked around the garden. They were moving, or on all fours, or side-lying on a mat on the floor… a variety of things…And that struck me, even then, that there were more opportunities, more ways for a woman to help herself to be more comfortable and perhaps her labor to be more effective if she were not confined to a bed.Particularly interesting were Hodnett's comments on how the presence of a bed in a central location predisposes women to staying in bed, rather than moving around:
Doctors and midwives agree it's better for a woman to move around while she's in labor. Walking and changing position makes her more comfortable and helps the labor progress. But in many countries, women giving birth in hospitals are often instructed to lie in bed while their labor progresses.Goer also noted how the presence of a delivery bed influences women's mobility in labor:
University of Toronto nursing professor Ellen Hodnett observed that in many modern - and even some not-so-modern hospitals - a bed was at the center of the labor room.
"That bed is a problem," Hodnett says. "Because it's a central focus of the room, and it sends messages that that's where you're supposed to be in labor. And yet, we have pretty good evidence that spending long periods of time in bed, particularly confined in the way that a hospital labor bed confines you, is not conducive to normal, healthy labor progress."
The investigators noted that the bed is a major reason for lack of mobility. Its prominence conveys that it is the appropriate place for laboring women, and a woman in bed offers ready access for interventions, an observation backed up by research. (Both Listening to Mothers surveys reported that few women were mobile after hospital admittance. In the first survey, two-thirds of the women gave as a reason that they were “connected to things” and more than one-quarter said they were “told not to walk around.”)Switching from a delivery bed in the center of the room to a large, low mattress with several pillows in the corner of the room was something that French obstetrician Michel Odent did when he became the head of the maternity department at Pithiviers, France in the 1970s:
Before: Typical French delivery room
After: birth room & pool room
In hospital birthing rooms I have visited personally, the bed is the central focus of the room. Even the flooring and ceiling materials emphasize the bed's central role in the drama to unfold: inlaid patterns around the bed circumscribe the area where birth is allowed to occur, and the spotlights on the ceiling further dictate the location of birth. These photos are from the new UIHC maternity wing in Iowa City, where I did my PhD. Notice the inlaid pattern in the flooring around the bed and the spotlights in the ceiling:
And these photos of my local hospital's LDRP rooms. Again, notice the inlaid pattern in the flooring that outlines and emphasizes the centrality of the bed. The room revolves around the bed: the couch and rocking chair face it, the monitoring equipment surrounds it, and the lights focus on it:
I would love to see pictures of the modified birth rooms from Hodnett's study. Sometimes simple and inexpensive changes are better than the newest high-tech bed.
Tuesday, June 02, 2009
I'm allowed to do that?
A hospital's birth policies and routines can vary dramatically from one to another, as Rebirth, a nurse-midwife blogger, illustrated in My Last Shift. She is a L&D nurse who recently became a CNM and just found a new job working as a midwife rather than as a nurse.
On her last day at her old job, she took care of a laboring L&D nurse who worked at another hospital with a more old-style approach. This laboring mother was constantly surprised that she was "allowed" to do things like drink juice, avoid frequent vaginal exams, "labor down" (when you have an epidural and wait for the baby's head to descend to the perineum, rather than begin pushing as soon as the cervix is 10 cms dilated), sit or squat to push, or keep her baby with her after the birth. Her post illustrates the importance of doing your research and asking lots of questions before you choose a provider or a location for your birth. There is no generic or universal hospital experience. Or, for that matter, birth center or home birth experience.
For example, contrast some of the policies and intervention rates at two of my local hospitals, C. Hospital and L. Hospital. Both are small, rural community hospitals with similar populations, doing about the same number of births per year, and serving mostly lower-risk women with full-term (35 + weeks) babies. Here's a brief overview of some of the differences between the two hospitals:
C. Hospital:
Read more ...
On her last day at her old job, she took care of a laboring L&D nurse who worked at another hospital with a more old-style approach. This laboring mother was constantly surprised that she was "allowed" to do things like drink juice, avoid frequent vaginal exams, "labor down" (when you have an epidural and wait for the baby's head to descend to the perineum, rather than begin pushing as soon as the cervix is 10 cms dilated), sit or squat to push, or keep her baby with her after the birth. Her post illustrates the importance of doing your research and asking lots of questions before you choose a provider or a location for your birth. There is no generic or universal hospital experience. Or, for that matter, birth center or home birth experience.
For example, contrast some of the policies and intervention rates at two of my local hospitals, C. Hospital and L. Hospital. Both are small, rural community hospitals with similar populations, doing about the same number of births per year, and serving mostly lower-risk women with full-term (35 + weeks) babies. Here's a brief overview of some of the differences between the two hospitals:
C. Hospital:
- C-section rate is "above the national average" of 31.8%--so perhaps 35% or higher?
- VBACs not allowed
- the 3 doctors and midwives rotate call, so you have no guarantee of continuity of care
- mothers and babies are routinely separated: right after birth for weighing and measuring, and then again a few hours after birth for a 3-4 hour stay in the nursery
- 2008 C-section rate was 21%
- VBACs allowed (although I learned from someone who used to work there that very few actually happen there--not sure if that's patient-led or physician-led)
- during office hours, your doctor will attend your birth. After hours, they rotate call.
- the hospital is working toward its Baby-Friendly certification, so there is no routine separation of mother & baby and in fact, no nursery at all!
Thursday, May 14, 2009
What if you never saw a birth like this?
One of my readers, doctorjen, submitted this birth story for the book giveaway. I am reposting it here with her permission. She is a family practice physician who works in a small rural hospital. I always enjoy reading stories of the births she attends.
Sometimes I attend a birth that reminds me how different my experience is than many hospital providers. This birth was very powerful and beautiful, and reminds me again how awesomely powerful women's bodies are. It was not an easy birth, but the hard parts were still handled by the mama and her baby with amazing power and just a little help. I know that most hospital practitioners have never seen a birth like this - and I wonder how my view of birth would be different if I never had either.
B. is another one of my teenage clients. Unlike many of my teen moms that come of difficult backgrounds, B. was an excellent student, with loving, supportive parents. B.'s pregnancy was a huge shock to her family, and to her large circle of loving family friends. The circle of friends includes the family that are executive directors of the maternity home I often do prenatal care for. This family had known B. since birth, and despite their career being focused on caring for women with unintended pregnancies, B.'s was still a big shock. Family and friends both recovered well from the initial shock, and B.'s mom especially was very supportive and wonderful throughout the pregnancy, attending all her visits and being happy about the baby, even though she was disappointed about the timing.
B. was sort of a high maintenance pregnant client. She'd obviously been the petted baby of her family, and reacted strongly to all the discomforts of pregnancy. She had quite a number of unscheduled visits for belly pain, back pain, nasal congestion, pelvic pressure - you name it. She had multiple visits to labor and delivery for pre-term contractions (never true pre-term labor.) Her family, and even her boyfriend, always responded to her with loving concern, and attempts to make her feel better. I have to admit to getting a little frustrated with her - but did my best to keep it to myself.
During the third trimester, B. "studied" childbirth with a couple of family friends. Both of them had taken a Bradley class, and they went over their work book and notes with her. She also borrowed several books from me, and wrote a term paper in her junior English class on the risks of epidurals. She wrote a birth plan that looked very Bradleyish, and included not wanting to be induced and not wanting any pain medicines. Having at this point seen her in tears so often due to back pain, or Braxton Hicks contractions, I privately wondered about this birth plan - was it hers, or the friends? The one friend had a lovely unmedicated VBAC with me 3 years ago and she and her mother (who is the executive director of the maternity home) planned to be at the birth as support people.
As B. approached her due date, she stopped complaining about contractions. She joked about how ironic it was that she'd had them for months and now they were gone when she wanted them. Her due date passed, with no interest on her part in induction - she never even mentioned it, despite mentioning often how much she wanted to see her baby. At 41 weeks, she was scheduled for a biophysical profile. B. called on the way to the ultrasound to say she was having a little bit of pink tinged mucus when she wiped. By the time the ultrasound was done and she went up to labor and delivery for the NST portion, she was still having a little bloody show, and now having some irregular contractions as well. She asked a labor nurse to check her. The nurse called (my favorite nurse again) and said she thought B. was trying to start laboring. She was 1 cm dilated and 60% effaced, with irregular contractions (about 10 o'clock in the morning.) The ultrasound, however, showed a decent sized straight posterior baby. The nurse told me she'd suggested that B. go home and spend as much time on hands and knees as she could stand, and try to get this baby to turn around. She had appointment with me later in the afternoon, and planned to keep it.
Around 3 pm, B. came for her appointment. She told me the contractions had slowly been getting stronger and a little closer together all day long. She also told me she'd been crawling around as much as she could, and had her mom rubbing her back and was feeling contractions mostly in her back. She asked me if I'd check her again. During the visit, she had 3 strong contractions, and during the 3rd one, she started to cry, and when her mom asked her what was wrong she said "This just hurts so much!" I checked her a few minutes later, and she was now 3 cms and 80% effaced. B. was cheered up that she was actually making change. To my surprise, she said she wasn't ready to go to the hospital yet. I suggested she go home, eat supper, take a soak in the tub, a nap if she could manage it, and that I guessed she'd be back to the hospital later this evening. Her boyfriend was due to give a speech in a college class that evening, and decided to try to still get there to give it, while her mom planned to stay with her.
Around 8 pm, B. arrived back to the hospital. At this point, her contractions were every 3 minutes, and she was breathing hard with them and having a lot of pain and pressure in her back. Her whole support team arrived with her - boyfriend (who'd gotten an A on the speech), mom, dad, family friends (the mom and daughter who were to be her designated labor support) The nurse called me and said B. was now 4 cms dilated and 90% effaced, and contracting regularly. I came in to see her at this point. B. was bouncing on the birth ball when I got there, and one of the friends was kneeling on the floor pushing on her back. B. was obviously working hard now, but excited that she might soon see her baby. Although she mentioned that she was hurting, she also seemed calm and determined, and although she asked for the support she needed ("Rub my back!" "Where's my drink?" "I'm hot!") she didn't talk about pain medicine.
For the next few hours, B. got in and out of the tub (we were having issues getting it hot enough, so she'd stay in until she was cool, then get out while we drained and refilled it) walked in the halls, bounced on the ball, drank juice, and leaned on her support team. For a long while, the contractions seemed to stay about the same, and then, they started to become less frequent instead of more frequent. B. started to be tired, and crabby, and struggled to stay on top of contractions. She'd not wanted a lot of cervical exams, so we kept trying to help her be comfortable. Finally, around 2 am, when B.'s contractions were only about every 7-8 minutes now, and she was falling asleep between them and waking up struggling to cope with them, I asked her if she wanted a cervical exam, and she said she did. I checked, and she was still 4 cms dilated, and 90% effaced. B. was really discouraged at this point. She'd now been laboring since about 7 in the morning, and had had absolutely no change since arriving to the hospital 6 hours ago.
We discussed options at this point. First of all, I told B. that her baby was fine, she was fine, she was coping beautifully and keeping up her hydration, peeing well, and overall doing great - so there was no medical need to do anything at this point. We could just wait and see what happened. I suggested if she wanted to wait, that we try dimming the lights, and tucking her up on her side in bed with all kinds of pillows for support, and she see if she could rest. She was exhausted at this point, and sometimes dozing off between contractions. Second, if she didn't feel like resting was an option, and she didn't want to just continue waiting, we could try something to augment her labor - either AROM or Pitocin. She asked a lot about what either intervention would mean. (Pitocin would mean continuous monitoring, and being stuck to the IV pole - AROM would commit her to delivery, might make contractions more painful, and might encourage the baby to stay in a poor position - but would leave her with the freedom to still move and be off the monitor,) She cried a little at this point, and said she was just so tired, and scared, and not wanting to hurt anymore. Her mom, who is very emotional, cried too, and said she felt so helpless to help her daughter feel better. Her dad, the boyfriend, and the family friends were all for AROM, wanting to get this show on the road. Seeing her distress, I suggested that she try just resting for a while, that there was no need to make a decision right now, and she calmed down and said she'd try that.
A few minutes later, at about 2:15 am, we had her tucked as comfortably as we could on her side, with pillows under her leg and arm, and mom rubbing her lower back still. We turned off the lights, and the nurse and I told her we'd be right outside the door if she wanted us. For 30 minutes or so, she was quiet, and we hoped she was able to sleep a little. Then, we started to hear her moaning through contractions and breathing hard again, although the contractions were still 7-8 minutes apart. Finally, around 3:15 am, her dad came out of the room and said B. would like to talk to me.
B. said again that she was so tired, and just so worried that doing anything would make her hurt more. I told her honestly that it may well make her hurt more - but I was also a little worried that she was so tired now, that if we waited a few more hours and she was still unable to rest that she would just be that much more tired and still in the same position. I assured her again that she didn't have to make any decision urgently, because she and the baby were fine. She thought for a moment and said she thought she'd like to try having her water broken. I checked her again - still 4 cms, 90% effaced, 0 station - and hooked her membranes with an amnihook, and clear fluid spilled out. B. had been lying in bed at this point, but the very next contraction, she sat straight upright, called for her friend to rub her back, and rocked back and forth. "That was much stronger!" she said, "I can't do this lying down!" We encouraged her to get up, and the next few contractions, which came faster and faster, she walked in the room, and leaned over her mother during a contraction. Soon, she was breathing harder, moaning through contractions, and saying this laboring stuff was not much fun. She wondered if getting in the tub would still help, and we decided to find out.
Once B. was soaking in the tub again, she was smiling some more. Contractions continued to come every 3 minutes or so, but she felt less pressure and less and less discomfort in her back. Since she was more comfortable, and anyway had such good support, I decided to lie down for a bit. By 4:15, I was snuggled in a recliner with some blankets from the blanket warmer and was able to doze. I slept fitfully off and on until the nurse woke me at 5:45. "B. is pushing a little with contractions, and she wants you" she said.
Back in B.'s room, the scene had taken on a much more intense feel. Somewhere along the line B. had shed all her clothes. She had the external fetal monitor strap on, and not one other thing. She was standing up, and during a contraction leaned forward holding up hanging from her mom's shoulders, and the friend was rubbing hard on her back (the friend later told me she was sure she'd left bruises since B. wanted such hard rubbing!) B. was sweating, and breathing hard. "Please, can't I just push?" she wanted to know, and I asked her if she felt like pushing. She said not really, but she just wanted it to be over. I suggested she just wait until her body started pushing. She reached out and grabbed my arm and said "Then please, won't you give me some pain medicine?" This was the first I'd heard her mention it since she walked in the door. I tried to talk to her about it - saying I thought she was close to having her baby, but she just kept saying "oh please, please do something!" Her support people (who've attended many births) both suggested that she was in transition, and tried to remind her what that is like. Her mom started to cry again, and said it was just so hard for her to see B. in pain. I had to agree it was hard to see her hurting and wished there was something to do for her. I told her we'd have to do an exam if she truly wanted pain medicine, and she willingly flopped down on the bed and said "Just check me then!" I did - but she was 8 cms or so dilated, with the cervix just stretching away during the exam, and the baby's head descending through it. Too late for IV pain meds, and even an epidural might not make it in time. Hearing this news, B. said again she did not want an epidural, so just forget it!
B. hopped back out of bed immediately, and went back to leaning on her mom. She was still working hard, but looked determined again. She'd snap at whoever was rubbing her back "Harder! Don't stop!" and snap at the boyfriend to bring her drink right now. After 10 minutes or so, she suddenly plopped down on the floor - completely naked, leaking amniotic fluid all over, sweating, breathing hard - flat on her rear end on the floor. Her mom sat down behind her, and soon she flopped backwards into her mom's lap. Mom sat cross legged, and B. laid with her upper body in mom's lap, curled her arms around mom's arms, and rolled back and forth with contractions. We could easily see each contraction build across her belly, and almost the outline of the baby since she was thin to begin with. After just a few contractions, she said she was having more pressure in her butt, but still no real urge to push, but couldn't I just check her again and couldn't she try to push the baby out anyway. And furthermore, she was not getting off this floor, couldn't I just get down here on the floor and check her anyway?
I can get on the floor of course, and after convincing her to at least slide a clean bed pad between her rear end and the (possibly yucky) hospital floor, I did a quick exam. Tiny anterior lip, with the baby pretty much through the cervix. B. said she just wanted to try to push, and I encourage her to wait for a true urge, but didn't think she'd hurt anything by pushing. Lying in her mom's lap with her arms curled under and gripping mom's arms, B. pushed with the next contraction. For the first couple contractions, she pushed in short bursts, or just grunted a little. Even so, we could soon see the outline of the baby's head bulging the perineum. B.'s mom's leg fell asleep, and she asked B. if she could move, and B. snapped "Don't you dare move!" The mom took a deep breath and held as still as she could. After a couple more contractions, B. said her tailbone hurt, and I asked her if she wanted to move. "I am NOT getting in that bed!" she said with a serious glare. I meekly replied that I just meant maybe she could try squatting or kneeling and get off her tailbone. She thought for a moment and said she'd try that.
B. slowly turned over - it taking quite a bit of effort to get off the ground at this point. She made it over to her knees, and I suggested she hold on to the bed. Her boyfriend lay down across the bed with his head at the side of the bed, and she knelt at the bedside, holding his forearms for support, and resting her head on his shoulder. He whispered encouragement to her - and told her he was sorry for doing this to her - and she held on to him for dear life. The poor mom finally made it to her feet with her asleep leg, and the support people moved to supporting the mom, who was just overwhelmed at the intensity of it all at this point. B.'s dad had been in and out of the room, and now was back in, but in the corner of the room. He could see B.'s head over the bed, but not the rest of her. The mom and the 2 friends stayed behind B., wanting to see the baby. Shift change happened just then, and the 3 new nurses joined the 2 I already had in the room. I knelt on the floor next to B. Although it sounds like a huge crowd, it was very quiet and intense in the room. The only sounds were B. working hard, and her boyfriend encouraging her, and the nurse or I telling her how wonderful she was doing. Within just a couple pushes, baby's head was staying visible even between pushes.
With the next contraction, B. slowly pushed her baby's head out, and mom started to cry, dad across the room started to cry, the friends cheered, the boyfriend started to cry. Even though B. was kneeling on the floor, I could see the baby's head emerge, and then almost look sucked back against the perineum - a turtle sign that immediately made me think of a shoulder dystocia. Baby was LOA, having turned I think somewhere late in labor. I waited for B. to take a few breaths, and asked her if she could push again, and she started to push. The baby didn't move at all and her face suffused with purple while B. pushed. I reached for the head and pushed up gently to see if the anterior shoulder would be freed - but it didn't budge. While B. pushed, I switched directions and tried to free the posterior shoulder - but it didn't budge. B. took a few more breaths, and when she started to push again, I lifted the head up again, and with a slight popping sensation, the baby's anterior shoulder came free, and almost immediately the whole baby slid out into my hands. There were 2 tight wraps of cord around the neck, but baby splashed right out. B. heaved a huge sob of relief and dropped her head and shoulders down on the bed. One of the nurses squatted on the floor with me and unwound the cord, and dried the baby's face as she coughed a couple times, and then started to cry. With the first cry the whole room erupted into laughter and tears and whoops of joy.
Within a minute or so, B. was looking around for her baby. A nurse threw a clean pad down on the bed, and B. stood up, lifted her leg up while I passed the baby under to her hands, crawled onto the bed holding the baby, and sat cross legged on the bed holding her baby to her chest. (Only teenagers are that athletic in the minute after birth!) Her boyfriend wrapped his arms around them both, and we put a couple warm blankets around them all, and everyone sort of stepped back and breathed some sighs of relief ourselves. Baby was born at 7:17 am, about 24 hours after labor started, 11 hours or so after she'd come to the hospital, but just 4 hours after she'd been 4 cms and had her water broken.
After a while of sitting and holding her baby, B. started to feel more cramping and more uncomfortable and wanted to get the placenta out. She lay back on a few pillows, still holding her baby to her bare chest. We clamped the cord, and the boyfriend cut it with shaking hands, while everyone else took pictures. B. pushed once, and the placenta was out. While B. was pushing the baby's head out, since she was kneeling and leaning forward, I could easily see her perineum. The head had slid out slowly and atraumatically and I didn't think she'd had any tears at that point. However, as the shoulders came, there'd been a sudden little gush of blood, and I worried that the popping sensation as the shoulder came was a perineal tear. Sure enough, I could see a midline tear. At first, I though it was just the skin, but as I tried to follow it downward, I couldn't quite see the base of it. Worried about the extent of this tear, I decided to take apart the bed and put B.'s legs in the foot pedals and get decent light to see what was what.
Unfortunately, the tear turned out to be a partial 3rd degree laceration. The sphincter capsule and muscle fibers hung loose in the middle. I explained to B. that she would need some local anesthesia and stitches. This sounded like a just terrible idea to her at this point, but I was able to inject the local pretty much without her feeling much (sometimes the vagina and perineum are numbish from the stretching of the baby and overload of the nerves.) While B. snuggled her baby, and drank a Sprite lying down, I repaired the sphincter, then the perineal muscle layer, then the skin. The tear didn't go quite all the way through the sphincter, and the rectal mucosa was all intact.
Soon, we were done, and B. wanted to have the baby weighed. This skinny 17 rd old had managed to push out an 8 lb 13 oz baby girl - in less than 30 minutes! I asked B. if she was upset about not getting pain medicine and she said "Heck, no!" and that she'd have been very disappointed if she'd gotten pain medicine that close to the baby's birth after getting through all that labor on her own. We helped B. put the baby to breast, and cleaned up the room. B.'s baby mostly did not leave her arms for the next 24 hours, but snuggled with her mama, and nursed, and was loved. The next morning, the nurse who came on in the morning did her assessment exam - and was shocked to find crepitus over the right clavicle, and the baby wincing whenever she touched it. An xray showed that her right clavicle was broken. Looking back, I'm sure that was actually the pop I felt as the shoulder came free. Fortunately, babies' clavicles heal easily, and she has no nerve damage or other problems and just needs to have no one pull on her arm while she's healing. B. felt great, despite the long labor, the extensive perineal repair, and the lack of sleep. She positively glowed while describing her birth - and was so in love with the baby.
See, the thing about this kind of birth is that this mama had it in her to do it. All she needed was the space to do it in. She just needed folks around her to believe she could. It was not an easy birth, or a short birth, or an uncomplicated birth. It was ordinary and yet sacred, moving and extraordinary. Mostly, we just encouraged this young mama to do what felt right to her, and she took the powerful, primal energy of birth and used every bit of it to make it hers. Watching her, who'd seemed so young and vulnerable and needy, turn instead into someone powerful, and strong, and even commanding was an amazing thing. When she was hurting, she didn't need me to rescue her or feel sympathetic, she just needed me to trust her and give her the space to keep going.
So: What if you attended births, but you never saw a birth like this? What if instead your system encouraged, or even coerced, needy, opinionated teenagers like this into lying in bed, strapped to a monitor, until they were overwhelmed? And then you talked them into an epidural to make them comfortable? What if their birth plan was treated as the hubris of an inexperienced child and laughed at? What if her request for limited exams was seen as childish and responded to with "You were able to open your legs to get this baby in there!" type comments? What if she'd pushed and pushed, but her baby had been wedged posterior by the epidural, and her sacrum couldn't move squashed against the bed and the baby never came out? Or she did come out, but the sticky shoulders in hands and knees was a full blown shoulder dystocia in semi-sitting and she'd had a huge episiotomy and a brachial nerve palsy, or worse brain damage from lack of oxygen? Then you'd say "Those damn teenagers think they know what they're doing. Can you believe she thought she could do this? Thank God we saved her baby!" And knowing you were right about it all, you'd treat the next client just the same. Occasionally, you'd see some quick birth happen before you could intervene much, but those would be chalked up to luck, and the rest would have the full gamut of technology you can provide.
I've seen that alternate birth story during my training. I've heard it told to me by friends and clients who birthed elsewhere. I'm always so grateful when I get to witness a birth like this, a birth that took a woman to the limits of her abilities, but she stretched herself and did it. These are the births that keep me going, that I remember in middle of night awakenings, that remind how strong women are, that I wish every birth attendant would be required to witness.
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Sometimes I attend a birth that reminds me how different my experience is than many hospital providers. This birth was very powerful and beautiful, and reminds me again how awesomely powerful women's bodies are. It was not an easy birth, but the hard parts were still handled by the mama and her baby with amazing power and just a little help. I know that most hospital practitioners have never seen a birth like this - and I wonder how my view of birth would be different if I never had either.
B. is another one of my teenage clients. Unlike many of my teen moms that come of difficult backgrounds, B. was an excellent student, with loving, supportive parents. B.'s pregnancy was a huge shock to her family, and to her large circle of loving family friends. The circle of friends includes the family that are executive directors of the maternity home I often do prenatal care for. This family had known B. since birth, and despite their career being focused on caring for women with unintended pregnancies, B.'s was still a big shock. Family and friends both recovered well from the initial shock, and B.'s mom especially was very supportive and wonderful throughout the pregnancy, attending all her visits and being happy about the baby, even though she was disappointed about the timing.
B. was sort of a high maintenance pregnant client. She'd obviously been the petted baby of her family, and reacted strongly to all the discomforts of pregnancy. She had quite a number of unscheduled visits for belly pain, back pain, nasal congestion, pelvic pressure - you name it. She had multiple visits to labor and delivery for pre-term contractions (never true pre-term labor.) Her family, and even her boyfriend, always responded to her with loving concern, and attempts to make her feel better. I have to admit to getting a little frustrated with her - but did my best to keep it to myself.
During the third trimester, B. "studied" childbirth with a couple of family friends. Both of them had taken a Bradley class, and they went over their work book and notes with her. She also borrowed several books from me, and wrote a term paper in her junior English class on the risks of epidurals. She wrote a birth plan that looked very Bradleyish, and included not wanting to be induced and not wanting any pain medicines. Having at this point seen her in tears so often due to back pain, or Braxton Hicks contractions, I privately wondered about this birth plan - was it hers, or the friends? The one friend had a lovely unmedicated VBAC with me 3 years ago and she and her mother (who is the executive director of the maternity home) planned to be at the birth as support people.
As B. approached her due date, she stopped complaining about contractions. She joked about how ironic it was that she'd had them for months and now they were gone when she wanted them. Her due date passed, with no interest on her part in induction - she never even mentioned it, despite mentioning often how much she wanted to see her baby. At 41 weeks, she was scheduled for a biophysical profile. B. called on the way to the ultrasound to say she was having a little bit of pink tinged mucus when she wiped. By the time the ultrasound was done and she went up to labor and delivery for the NST portion, she was still having a little bloody show, and now having some irregular contractions as well. She asked a labor nurse to check her. The nurse called (my favorite nurse again) and said she thought B. was trying to start laboring. She was 1 cm dilated and 60% effaced, with irregular contractions (about 10 o'clock in the morning.) The ultrasound, however, showed a decent sized straight posterior baby. The nurse told me she'd suggested that B. go home and spend as much time on hands and knees as she could stand, and try to get this baby to turn around. She had appointment with me later in the afternoon, and planned to keep it.
Around 3 pm, B. came for her appointment. She told me the contractions had slowly been getting stronger and a little closer together all day long. She also told me she'd been crawling around as much as she could, and had her mom rubbing her back and was feeling contractions mostly in her back. She asked me if I'd check her again. During the visit, she had 3 strong contractions, and during the 3rd one, she started to cry, and when her mom asked her what was wrong she said "This just hurts so much!" I checked her a few minutes later, and she was now 3 cms and 80% effaced. B. was cheered up that she was actually making change. To my surprise, she said she wasn't ready to go to the hospital yet. I suggested she go home, eat supper, take a soak in the tub, a nap if she could manage it, and that I guessed she'd be back to the hospital later this evening. Her boyfriend was due to give a speech in a college class that evening, and decided to try to still get there to give it, while her mom planned to stay with her.
Around 8 pm, B. arrived back to the hospital. At this point, her contractions were every 3 minutes, and she was breathing hard with them and having a lot of pain and pressure in her back. Her whole support team arrived with her - boyfriend (who'd gotten an A on the speech), mom, dad, family friends (the mom and daughter who were to be her designated labor support) The nurse called me and said B. was now 4 cms dilated and 90% effaced, and contracting regularly. I came in to see her at this point. B. was bouncing on the birth ball when I got there, and one of the friends was kneeling on the floor pushing on her back. B. was obviously working hard now, but excited that she might soon see her baby. Although she mentioned that she was hurting, she also seemed calm and determined, and although she asked for the support she needed ("Rub my back!" "Where's my drink?" "I'm hot!") she didn't talk about pain medicine.
For the next few hours, B. got in and out of the tub (we were having issues getting it hot enough, so she'd stay in until she was cool, then get out while we drained and refilled it) walked in the halls, bounced on the ball, drank juice, and leaned on her support team. For a long while, the contractions seemed to stay about the same, and then, they started to become less frequent instead of more frequent. B. started to be tired, and crabby, and struggled to stay on top of contractions. She'd not wanted a lot of cervical exams, so we kept trying to help her be comfortable. Finally, around 2 am, when B.'s contractions were only about every 7-8 minutes now, and she was falling asleep between them and waking up struggling to cope with them, I asked her if she wanted a cervical exam, and she said she did. I checked, and she was still 4 cms dilated, and 90% effaced. B. was really discouraged at this point. She'd now been laboring since about 7 in the morning, and had had absolutely no change since arriving to the hospital 6 hours ago.
We discussed options at this point. First of all, I told B. that her baby was fine, she was fine, she was coping beautifully and keeping up her hydration, peeing well, and overall doing great - so there was no medical need to do anything at this point. We could just wait and see what happened. I suggested if she wanted to wait, that we try dimming the lights, and tucking her up on her side in bed with all kinds of pillows for support, and she see if she could rest. She was exhausted at this point, and sometimes dozing off between contractions. Second, if she didn't feel like resting was an option, and she didn't want to just continue waiting, we could try something to augment her labor - either AROM or Pitocin. She asked a lot about what either intervention would mean. (Pitocin would mean continuous monitoring, and being stuck to the IV pole - AROM would commit her to delivery, might make contractions more painful, and might encourage the baby to stay in a poor position - but would leave her with the freedom to still move and be off the monitor,) She cried a little at this point, and said she was just so tired, and scared, and not wanting to hurt anymore. Her mom, who is very emotional, cried too, and said she felt so helpless to help her daughter feel better. Her dad, the boyfriend, and the family friends were all for AROM, wanting to get this show on the road. Seeing her distress, I suggested that she try just resting for a while, that there was no need to make a decision right now, and she calmed down and said she'd try that.
A few minutes later, at about 2:15 am, we had her tucked as comfortably as we could on her side, with pillows under her leg and arm, and mom rubbing her lower back still. We turned off the lights, and the nurse and I told her we'd be right outside the door if she wanted us. For 30 minutes or so, she was quiet, and we hoped she was able to sleep a little. Then, we started to hear her moaning through contractions and breathing hard again, although the contractions were still 7-8 minutes apart. Finally, around 3:15 am, her dad came out of the room and said B. would like to talk to me.
B. said again that she was so tired, and just so worried that doing anything would make her hurt more. I told her honestly that it may well make her hurt more - but I was also a little worried that she was so tired now, that if we waited a few more hours and she was still unable to rest that she would just be that much more tired and still in the same position. I assured her again that she didn't have to make any decision urgently, because she and the baby were fine. She thought for a moment and said she thought she'd like to try having her water broken. I checked her again - still 4 cms, 90% effaced, 0 station - and hooked her membranes with an amnihook, and clear fluid spilled out. B. had been lying in bed at this point, but the very next contraction, she sat straight upright, called for her friend to rub her back, and rocked back and forth. "That was much stronger!" she said, "I can't do this lying down!" We encouraged her to get up, and the next few contractions, which came faster and faster, she walked in the room, and leaned over her mother during a contraction. Soon, she was breathing harder, moaning through contractions, and saying this laboring stuff was not much fun. She wondered if getting in the tub would still help, and we decided to find out.
Once B. was soaking in the tub again, she was smiling some more. Contractions continued to come every 3 minutes or so, but she felt less pressure and less and less discomfort in her back. Since she was more comfortable, and anyway had such good support, I decided to lie down for a bit. By 4:15, I was snuggled in a recliner with some blankets from the blanket warmer and was able to doze. I slept fitfully off and on until the nurse woke me at 5:45. "B. is pushing a little with contractions, and she wants you" she said.
Back in B.'s room, the scene had taken on a much more intense feel. Somewhere along the line B. had shed all her clothes. She had the external fetal monitor strap on, and not one other thing. She was standing up, and during a contraction leaned forward holding up hanging from her mom's shoulders, and the friend was rubbing hard on her back (the friend later told me she was sure she'd left bruises since B. wanted such hard rubbing!) B. was sweating, and breathing hard. "Please, can't I just push?" she wanted to know, and I asked her if she felt like pushing. She said not really, but she just wanted it to be over. I suggested she just wait until her body started pushing. She reached out and grabbed my arm and said "Then please, won't you give me some pain medicine?" This was the first I'd heard her mention it since she walked in the door. I tried to talk to her about it - saying I thought she was close to having her baby, but she just kept saying "oh please, please do something!" Her support people (who've attended many births) both suggested that she was in transition, and tried to remind her what that is like. Her mom started to cry again, and said it was just so hard for her to see B. in pain. I had to agree it was hard to see her hurting and wished there was something to do for her. I told her we'd have to do an exam if she truly wanted pain medicine, and she willingly flopped down on the bed and said "Just check me then!" I did - but she was 8 cms or so dilated, with the cervix just stretching away during the exam, and the baby's head descending through it. Too late for IV pain meds, and even an epidural might not make it in time. Hearing this news, B. said again she did not want an epidural, so just forget it!
B. hopped back out of bed immediately, and went back to leaning on her mom. She was still working hard, but looked determined again. She'd snap at whoever was rubbing her back "Harder! Don't stop!" and snap at the boyfriend to bring her drink right now. After 10 minutes or so, she suddenly plopped down on the floor - completely naked, leaking amniotic fluid all over, sweating, breathing hard - flat on her rear end on the floor. Her mom sat down behind her, and soon she flopped backwards into her mom's lap. Mom sat cross legged, and B. laid with her upper body in mom's lap, curled her arms around mom's arms, and rolled back and forth with contractions. We could easily see each contraction build across her belly, and almost the outline of the baby since she was thin to begin with. After just a few contractions, she said she was having more pressure in her butt, but still no real urge to push, but couldn't I just check her again and couldn't she try to push the baby out anyway. And furthermore, she was not getting off this floor, couldn't I just get down here on the floor and check her anyway?
I can get on the floor of course, and after convincing her to at least slide a clean bed pad between her rear end and the (possibly yucky) hospital floor, I did a quick exam. Tiny anterior lip, with the baby pretty much through the cervix. B. said she just wanted to try to push, and I encourage her to wait for a true urge, but didn't think she'd hurt anything by pushing. Lying in her mom's lap with her arms curled under and gripping mom's arms, B. pushed with the next contraction. For the first couple contractions, she pushed in short bursts, or just grunted a little. Even so, we could soon see the outline of the baby's head bulging the perineum. B.'s mom's leg fell asleep, and she asked B. if she could move, and B. snapped "Don't you dare move!" The mom took a deep breath and held as still as she could. After a couple more contractions, B. said her tailbone hurt, and I asked her if she wanted to move. "I am NOT getting in that bed!" she said with a serious glare. I meekly replied that I just meant maybe she could try squatting or kneeling and get off her tailbone. She thought for a moment and said she'd try that.
B. slowly turned over - it taking quite a bit of effort to get off the ground at this point. She made it over to her knees, and I suggested she hold on to the bed. Her boyfriend lay down across the bed with his head at the side of the bed, and she knelt at the bedside, holding his forearms for support, and resting her head on his shoulder. He whispered encouragement to her - and told her he was sorry for doing this to her - and she held on to him for dear life. The poor mom finally made it to her feet with her asleep leg, and the support people moved to supporting the mom, who was just overwhelmed at the intensity of it all at this point. B.'s dad had been in and out of the room, and now was back in, but in the corner of the room. He could see B.'s head over the bed, but not the rest of her. The mom and the 2 friends stayed behind B., wanting to see the baby. Shift change happened just then, and the 3 new nurses joined the 2 I already had in the room. I knelt on the floor next to B. Although it sounds like a huge crowd, it was very quiet and intense in the room. The only sounds were B. working hard, and her boyfriend encouraging her, and the nurse or I telling her how wonderful she was doing. Within just a couple pushes, baby's head was staying visible even between pushes.
With the next contraction, B. slowly pushed her baby's head out, and mom started to cry, dad across the room started to cry, the friends cheered, the boyfriend started to cry. Even though B. was kneeling on the floor, I could see the baby's head emerge, and then almost look sucked back against the perineum - a turtle sign that immediately made me think of a shoulder dystocia. Baby was LOA, having turned I think somewhere late in labor. I waited for B. to take a few breaths, and asked her if she could push again, and she started to push. The baby didn't move at all and her face suffused with purple while B. pushed. I reached for the head and pushed up gently to see if the anterior shoulder would be freed - but it didn't budge. While B. pushed, I switched directions and tried to free the posterior shoulder - but it didn't budge. B. took a few more breaths, and when she started to push again, I lifted the head up again, and with a slight popping sensation, the baby's anterior shoulder came free, and almost immediately the whole baby slid out into my hands. There were 2 tight wraps of cord around the neck, but baby splashed right out. B. heaved a huge sob of relief and dropped her head and shoulders down on the bed. One of the nurses squatted on the floor with me and unwound the cord, and dried the baby's face as she coughed a couple times, and then started to cry. With the first cry the whole room erupted into laughter and tears and whoops of joy.
Within a minute or so, B. was looking around for her baby. A nurse threw a clean pad down on the bed, and B. stood up, lifted her leg up while I passed the baby under to her hands, crawled onto the bed holding the baby, and sat cross legged on the bed holding her baby to her chest. (Only teenagers are that athletic in the minute after birth!) Her boyfriend wrapped his arms around them both, and we put a couple warm blankets around them all, and everyone sort of stepped back and breathed some sighs of relief ourselves. Baby was born at 7:17 am, about 24 hours after labor started, 11 hours or so after she'd come to the hospital, but just 4 hours after she'd been 4 cms and had her water broken.
After a while of sitting and holding her baby, B. started to feel more cramping and more uncomfortable and wanted to get the placenta out. She lay back on a few pillows, still holding her baby to her bare chest. We clamped the cord, and the boyfriend cut it with shaking hands, while everyone else took pictures. B. pushed once, and the placenta was out. While B. was pushing the baby's head out, since she was kneeling and leaning forward, I could easily see her perineum. The head had slid out slowly and atraumatically and I didn't think she'd had any tears at that point. However, as the shoulders came, there'd been a sudden little gush of blood, and I worried that the popping sensation as the shoulder came was a perineal tear. Sure enough, I could see a midline tear. At first, I though it was just the skin, but as I tried to follow it downward, I couldn't quite see the base of it. Worried about the extent of this tear, I decided to take apart the bed and put B.'s legs in the foot pedals and get decent light to see what was what.
Unfortunately, the tear turned out to be a partial 3rd degree laceration. The sphincter capsule and muscle fibers hung loose in the middle. I explained to B. that she would need some local anesthesia and stitches. This sounded like a just terrible idea to her at this point, but I was able to inject the local pretty much without her feeling much (sometimes the vagina and perineum are numbish from the stretching of the baby and overload of the nerves.) While B. snuggled her baby, and drank a Sprite lying down, I repaired the sphincter, then the perineal muscle layer, then the skin. The tear didn't go quite all the way through the sphincter, and the rectal mucosa was all intact.
Soon, we were done, and B. wanted to have the baby weighed. This skinny 17 rd old had managed to push out an 8 lb 13 oz baby girl - in less than 30 minutes! I asked B. if she was upset about not getting pain medicine and she said "Heck, no!" and that she'd have been very disappointed if she'd gotten pain medicine that close to the baby's birth after getting through all that labor on her own. We helped B. put the baby to breast, and cleaned up the room. B.'s baby mostly did not leave her arms for the next 24 hours, but snuggled with her mama, and nursed, and was loved. The next morning, the nurse who came on in the morning did her assessment exam - and was shocked to find crepitus over the right clavicle, and the baby wincing whenever she touched it. An xray showed that her right clavicle was broken. Looking back, I'm sure that was actually the pop I felt as the shoulder came free. Fortunately, babies' clavicles heal easily, and she has no nerve damage or other problems and just needs to have no one pull on her arm while she's healing. B. felt great, despite the long labor, the extensive perineal repair, and the lack of sleep. She positively glowed while describing her birth - and was so in love with the baby.
See, the thing about this kind of birth is that this mama had it in her to do it. All she needed was the space to do it in. She just needed folks around her to believe she could. It was not an easy birth, or a short birth, or an uncomplicated birth. It was ordinary and yet sacred, moving and extraordinary. Mostly, we just encouraged this young mama to do what felt right to her, and she took the powerful, primal energy of birth and used every bit of it to make it hers. Watching her, who'd seemed so young and vulnerable and needy, turn instead into someone powerful, and strong, and even commanding was an amazing thing. When she was hurting, she didn't need me to rescue her or feel sympathetic, she just needed me to trust her and give her the space to keep going.
So: What if you attended births, but you never saw a birth like this? What if instead your system encouraged, or even coerced, needy, opinionated teenagers like this into lying in bed, strapped to a monitor, until they were overwhelmed? And then you talked them into an epidural to make them comfortable? What if their birth plan was treated as the hubris of an inexperienced child and laughed at? What if her request for limited exams was seen as childish and responded to with "You were able to open your legs to get this baby in there!" type comments? What if she'd pushed and pushed, but her baby had been wedged posterior by the epidural, and her sacrum couldn't move squashed against the bed and the baby never came out? Or she did come out, but the sticky shoulders in hands and knees was a full blown shoulder dystocia in semi-sitting and she'd had a huge episiotomy and a brachial nerve palsy, or worse brain damage from lack of oxygen? Then you'd say "Those damn teenagers think they know what they're doing. Can you believe she thought she could do this? Thank God we saved her baby!" And knowing you were right about it all, you'd treat the next client just the same. Occasionally, you'd see some quick birth happen before you could intervene much, but those would be chalked up to luck, and the rest would have the full gamut of technology you can provide.
I've seen that alternate birth story during my training. I've heard it told to me by friends and clients who birthed elsewhere. I'm always so grateful when I get to witness a birth like this, a birth that took a woman to the limits of her abilities, but she stretched herself and did it. These are the births that keep me going, that I remember in middle of night awakenings, that remind how strong women are, that I wish every birth attendant would be required to witness.
Monday, March 30, 2009
Cesarean section and VBAC, again
Here are a few recent articles that are worth reading given recent discussions about VBACs, cesarean sections (elective or otherwise), and the ever-climbing cesarean rate.
The first is an excellent, thorough article in The Poughkeepsie Journal covering the trend to perform cesareans more and more often: Birth by Surgery: The Skyrocketing Cesarean Rate. The author did quite well in covering the salient issues in depth. The article begins with the story of a woman who had an "elective" cesarean for a large baby that turned out to be 2 1/2 lbs lighter than the ultrasound estimate:
Read more ...
The first is an excellent, thorough article in The Poughkeepsie Journal covering the trend to perform cesareans more and more often: Birth by Surgery: The Skyrocketing Cesarean Rate. The author did quite well in covering the salient issues in depth. The article begins with the story of a woman who had an "elective" cesarean for a large baby that turned out to be 2 1/2 lbs lighter than the ultrasound estimate:
The next article by the same author, Modern medicine increasingly intervenes in the birth process, discusses many of the same issues, in addition to the increasing medicalization of childbirth.Two weeks before Kristi Ashley gave birth to a son in 2007, an ultrasound exam estimated the baby at a hefty 12 pounds, 10 ounces — too big, her doctor believed, for a safe vaginal delivery. After the child weighed in at 9 pounds, 4 ounces in the delivery room, Ashley came to believe that the planned cesarean section she had, with its attendant pain, long recovery and what she called "emotional damage," may have been a rush to judgment.
"It's very hard to go up against your physician, especially at the 12th hour," said Ashley, 38, of Hopewell Junction. "I think doctors are very quick these days to get scared. They would rather opt for the surgical solution."
Determined to avoid another surgical birth and aided by a supportive doctor, hospital and birthing coach, Ashley last month did something that has become increasingly rare for post-cesarean women today: She gave birth vaginally, to another son.
In an era of soaring malpractice premiums, technology that sometimes sets off false alarms, physicians pressed for time and mothers-to-be conflicted by fear, cesarean-section birth is soaring to its highest levels ever. Read the rest of the article here.
In the decade through 2002, something momentous happened to babies in the wombs of American women, especially white women. The average time fetuses spent there decreased from 40 weeks to 39.The decline, reported in a 2006 study in the medical journal Seminars in Perinatology, appears to have little to do with nature.
Instead, earlier births may be the outcome of “increased use of induction (of labor) and other obstetric interventions such as cesarean delivery,” said a January report by the U.S. Centers for Disease Control. Prematurity rose 20 percent since 1990, the report said, and the rate of low birth-weight babies hit a 40-year high.
“We are shortening the gestational age,” said Dr. Carol Sakala, program director for the research and advocacy group Childbirth Connection. “That is a big interference with mammalian evolution, human evolution.”
Researchers, midwives, birth coaches and mothers point to such data as symptoms of a flawed system of birthing in America, one they say over-manages, over-medicates and over-monitors labor and delivery, often leading to unnecessary cesarean-section births. Read the rest of the article here.
The last article is a glimmer of hope amidst the gloom of our contemporary obstetrical culture. In C-section births fall, one hospital has lowered its cesarean rate (18% last year, usually around 16%). Some of the key practices the hospital has adopted are taking a midwifery approach to childbearing with a focus on facilitating spontaneous, natural births, minimizing the routine use of technology and interventions, and offering and encouraging VBACs.
North Adams Regional Hospital performs significantly fewer c-sections than other hospitals around the state — an average of 18 percent of all births at the hospital compared to the state average of 34 percent, according to reports released by the state Department of Public Health. The hospital also has a better prenatal care record, according to the reports: 94 percent of women giving birth have had nine or more prenatal care visits versus the state average of 87 percent having that many visits. "I think what is being reflected in our numbers is that we are taking a more 'midwifery' approach with our practice then before," Robin Rivinus, a certified nurse midwife with Northern Berkshire Obstetrics & Gynecology at the hospital, said last week. "It means that we do fewer unnecessary interventions — inductions, Cesarean sections, episiotomies. We treat childbirth as the normal, natural thing that it is. We only step in when it's medically necessary, which is much better for both the mother and the baby." Read the rest of the article here. While more and more women choose to undergo Cesarean section births despite a national push by the federal government to decrease the number, the local rate has declined and is well below the state average.
Friday, March 20, 2009
Hospital tour #2
I just got home from touring another hospital in my area that is about 30 minutes away. Like my home town C., the town of L. is the county seat and has a population of around 15,000. The hospital is fairly new--perhaps 6 years old. The Maternity Center in L. has four LDRP rooms, two with jacuzzi tubs and two with large showers. It sees about 400 births per year. There are four OBs who attend births at this hospital. They usually attend their own patients' births, although they do rotate call after-hours so there is a small chance you might not get the OB you have been seeing during pregnancy.
The hospital has a lower than average cesarean rate; in was 21% in 2008 (compared to the 2007 national rate of 31.8%). The hospital has 24-hour anesthesia and offers VBAC (vaginal birth after cesarean). I forgot to ask the nurses how many VBACs they see per year, but they sounded quite supportive of them. They couldn't think of any special policies or requirements for VBAC labors, but instead said they would be treated like any other labor.
Standard admittance procedures are a 20 minute monitoring strip and, once they've made sure the woman is in active labor, a saline lock (done in conjunction with the standard blood draws). They say the physicians usually don't require actual IVs, so women just have saline locks unless there's a specific indication for an IV drip, such as antibiotics for GBS+, Pitocin, epidural, etc. I asked about how hard it would be to refuse the saline lock, and they said they'd advise you why they suggest a saline lock and then give you a form to sign saying you declined the procedure. So it seems that if you have a strong preference about not having a saline lock in place--I've had one before for a non-birth-related issue and it HURT constantly--you can assert your wishes and simply sign any necessary paperwork.
The official policy for eating and drinking in labor is ice chips or sips of water only, but the nurses all emphasized that it is your body and your choice. They would simply document that they explained why they suggest not eating or drinking. Then it's up to you if you want to eat or drink. One of the nurses, when we were chatting about this and other topics, said, "I remind people in my childbirth education classes that you don't check your rights as an individual when you walk in the hospital door." There is a small kitchenette stocked with food and drinks by the nurse's station: milk, juice, pop, yogurt, cereal bars, etc. The nurses said that if you wanted healthier choices, be sure to bring your own snacks and drinks with you.
I asked about how common inductions and epidurals were. The nurses replied that they do see a lot of both, but they are definitely not pushed on the women. Instead, a lot of women insist on being induced or on having anesthesia. It's not the physicians pushing induction or the nurses pushing medications. They didn't give me any hard numbers, but I got the sense that the epidural and induction rates were probably lower than in the hospital in C. The nurses talked for a while about how inductions and epidurals are so common everywhere now and how they're most often patient-led. I got the feeling that they liked working with women who want unmedicated births and spontaneous labors.
If a woman doesn't have an epidural or Pitocin running, they encourage her to walk around, to have intermittent monitoring, and to use the jacuzzi tubs. They usually do intermittent monitoring via a strip every hour (usually 15-20 minutes I think) but if you want intermittent auscultation rather than going on the monitors periodically, you can request that. They do not have wireless monitoring (telemetry); I encouraged them to get a wireless & waterproof unit so women could get closer monitoring if needed, but still be completely mobile and even in the shower or tub.
I wasn't able to take pictures of the rooms due to security reasons (which I've never heard of before), but they were fairly typical for a new hospital. The labor room has a delivery bed, rocking chair, couch, baby warmer, monitor table, wooden cupboards, and handwashing sink for the staff. The bathrooms are a good size with either a jacuzzi tub or a large shower. They have Hill-Rom beds, which are a lot more adaptable than the Sryker beds at C. Hospital in my town. The nurses mentioned using the squat bars, and I saw birth balls in some of the rooms. The jacuzzi tubs are large corner units, roomier than the ones in C. Hospital. There's also a showerhead in the tubs if you'd like to take a shower. The two rooms with showers only at least have large showers, probably 5x3 feet. There's a shower chair in there, so you can sit down and rest while you're showering. All rooms, of course, have private bathrooms--pretty much standard in modern maternity wings.
Of the four OBs, Bob and Ted were recommended as being more used to women birthing in less conventional upright positions than the two newer physicians Sara and Joseph, who are more accustomed to the semi-sitting position for giving birth (aka the "stranded beetle" position). Bob and Ted did their OB training in a hospital that had a lot of midwives, so they are used to more flexible, less conventional care of laboring women. However, the nurses said to be clear about your preferences with your physician, and they will all work with you to honor your preferences.
The Maternity Center in L. is currently working on becoming Baby-Friendly certified. They don't have a well-baby nursery, so babies always stay with their mothers. I asked about what happens immediately after the birth. Unlike C. Hospital, where babies go immediately to the nursery for weighing and measuring and where they have a 3-4 hour stay in the nursery a few hours after the birth, the Maternity Center keeps the babies right with the moms the whole time. They ask the mother what she would prefer--baby skin-to-skin on her chest, baby on a towel on her chest, or baby cleaned off a bit in the warmer and then put on her chest--and they follow the mother's wishes. There is a small room with two warmers and one incubator for special cases where the baby is having medical issues and needs constant monitoring, but otherwise there is no mother-baby separation (except briefly towards the end of the stay for the newborn metabolic screening, etc). They said their breastfeeding rates have gone up quite a bit recently, probably due to the baby-friendly practices that they follow.
Like C. hospital, the Maternity Center in L. does not have a NICU. If the baby is severely ill, it would be transferred to a larger tertiary care center about 1/2 hour away. Both hospitals refer out high-risk cases to larger medical centers, so if you went into labor before 35 weeks, for example, you probably wouldn't be able to give birth at either C. hospital or L. Maternity Center.
Things I forgot to ask:
Read more ...
The hospital has a lower than average cesarean rate; in was 21% in 2008 (compared to the 2007 national rate of 31.8%). The hospital has 24-hour anesthesia and offers VBAC (vaginal birth after cesarean). I forgot to ask the nurses how many VBACs they see per year, but they sounded quite supportive of them. They couldn't think of any special policies or requirements for VBAC labors, but instead said they would be treated like any other labor.
Standard admittance procedures are a 20 minute monitoring strip and, once they've made sure the woman is in active labor, a saline lock (done in conjunction with the standard blood draws). They say the physicians usually don't require actual IVs, so women just have saline locks unless there's a specific indication for an IV drip, such as antibiotics for GBS+, Pitocin, epidural, etc. I asked about how hard it would be to refuse the saline lock, and they said they'd advise you why they suggest a saline lock and then give you a form to sign saying you declined the procedure. So it seems that if you have a strong preference about not having a saline lock in place--I've had one before for a non-birth-related issue and it HURT constantly--you can assert your wishes and simply sign any necessary paperwork.
The official policy for eating and drinking in labor is ice chips or sips of water only, but the nurses all emphasized that it is your body and your choice. They would simply document that they explained why they suggest not eating or drinking. Then it's up to you if you want to eat or drink. One of the nurses, when we were chatting about this and other topics, said, "I remind people in my childbirth education classes that you don't check your rights as an individual when you walk in the hospital door." There is a small kitchenette stocked with food and drinks by the nurse's station: milk, juice, pop, yogurt, cereal bars, etc. The nurses said that if you wanted healthier choices, be sure to bring your own snacks and drinks with you.
I asked about how common inductions and epidurals were. The nurses replied that they do see a lot of both, but they are definitely not pushed on the women. Instead, a lot of women insist on being induced or on having anesthesia. It's not the physicians pushing induction or the nurses pushing medications. They didn't give me any hard numbers, but I got the sense that the epidural and induction rates were probably lower than in the hospital in C. The nurses talked for a while about how inductions and epidurals are so common everywhere now and how they're most often patient-led. I got the feeling that they liked working with women who want unmedicated births and spontaneous labors.
If a woman doesn't have an epidural or Pitocin running, they encourage her to walk around, to have intermittent monitoring, and to use the jacuzzi tubs. They usually do intermittent monitoring via a strip every hour (usually 15-20 minutes I think) but if you want intermittent auscultation rather than going on the monitors periodically, you can request that. They do not have wireless monitoring (telemetry); I encouraged them to get a wireless & waterproof unit so women could get closer monitoring if needed, but still be completely mobile and even in the shower or tub.
I wasn't able to take pictures of the rooms due to security reasons (which I've never heard of before), but they were fairly typical for a new hospital. The labor room has a delivery bed, rocking chair, couch, baby warmer, monitor table, wooden cupboards, and handwashing sink for the staff. The bathrooms are a good size with either a jacuzzi tub or a large shower. They have Hill-Rom beds, which are a lot more adaptable than the Sryker beds at C. Hospital in my town. The nurses mentioned using the squat bars, and I saw birth balls in some of the rooms. The jacuzzi tubs are large corner units, roomier than the ones in C. Hospital. There's also a showerhead in the tubs if you'd like to take a shower. The two rooms with showers only at least have large showers, probably 5x3 feet. There's a shower chair in there, so you can sit down and rest while you're showering. All rooms, of course, have private bathrooms--pretty much standard in modern maternity wings.
Of the four OBs, Bob and Ted were recommended as being more used to women birthing in less conventional upright positions than the two newer physicians Sara and Joseph, who are more accustomed to the semi-sitting position for giving birth (aka the "stranded beetle" position). Bob and Ted did their OB training in a hospital that had a lot of midwives, so they are used to more flexible, less conventional care of laboring women. However, the nurses said to be clear about your preferences with your physician, and they will all work with you to honor your preferences.
The Maternity Center in L. is currently working on becoming Baby-Friendly certified. They don't have a well-baby nursery, so babies always stay with their mothers. I asked about what happens immediately after the birth. Unlike C. Hospital, where babies go immediately to the nursery for weighing and measuring and where they have a 3-4 hour stay in the nursery a few hours after the birth, the Maternity Center keeps the babies right with the moms the whole time. They ask the mother what she would prefer--baby skin-to-skin on her chest, baby on a towel on her chest, or baby cleaned off a bit in the warmer and then put on her chest--and they follow the mother's wishes. There is a small room with two warmers and one incubator for special cases where the baby is having medical issues and needs constant monitoring, but otherwise there is no mother-baby separation (except briefly towards the end of the stay for the newborn metabolic screening, etc). They said their breastfeeding rates have gone up quite a bit recently, probably due to the baby-friendly practices that they follow.
Like C. hospital, the Maternity Center in L. does not have a NICU. If the baby is severely ill, it would be transferred to a larger tertiary care center about 1/2 hour away. Both hospitals refer out high-risk cases to larger medical centers, so if you went into labor before 35 weeks, for example, you probably wouldn't be able to give birth at either C. hospital or L. Maternity Center.
Things I forgot to ask:
- if there's a limit on how many people can be with the woman during labor & birth
- can you photograph or videotape the birth
- what is their typical and their fastest decision-to-incision time for a truly emergency cesarean
- what happens to the baby after a c-section (since they don't have a nursery, I'd guess that they baby would be with the mom ASAP in most cases)
- when standard newborn procedures are usually done (such as weighing and measuring, bathing, etc)
Saturday, February 21, 2009
The back story to the Times article
Pamela Paul, author of the Times article The Trouble With Repeat Cesareans, wrote another article in The Huffington Post: Childbirth Without Choice. This piece gives the back story of the Times article, including her own fight to have a VBAC in a supposedly "pro-VBAC" hospital.
She writes:
Read more ...
She writes:
I wrote an article in this week's issue of Time magazine called "The Trouble With Repeat Cesareans" on the subject of women's diminishing patient's rights. I won't repeat the story here, since you can link to it here, but will give some of the back story for those who want more:Read the rest of the article here.This was a story I've been wanting to write for a long time. The short version is, doctors and hospitals are no longer allowing many women to have a vaginal birth after cesarean (or VBAC, pronounced "vee-back") because the "medicolegal" costs are too high. Or, as one ob-gyn put it when I asked why she and other doctors no longer allow VBACs, ""It's a numbers thing. It is financially unsustainable for doctors, hospitals and insurers to engage in a practice when the cost of doing business way exceeds the payback. You don't get sued for doing a C-section; you get sued for not doing a C-section."
Wednesday, February 18, 2009
Wednesday wrap-up
I might start doing a weekly wrap-up of miscellaneous news & articles that I find interesting. If I wait much longer than week, they start piling up rather quickly:
Speaking of upright/vertical birth...
For Expectant Moms, a Happy Medium Between Hospital and Home Births: profiles the struggles of one birth center to obtain permission to open
Breastfeeding
Pedialyte Alternative recipe (not necessary for breastfeeding babies, but great for older children & adults)
Gardening
25 plants you should consider growing
Read more ...
Speaking of upright/vertical birth...
- This midwife-designed stainless steel mirror is designed especially for women adopting upright birthing positions
- Mom's Tinfoil Hat had some thoughts about Standing up for birth
- The "Authorities" Resolve Against Home Birth: a recent editorial by Nancy K. Lowe, editor of the Journal of Obstetric, Gynecologic, & Neonatal Nursing ( Volume 38, Issue 1, Pages 1-3). Click on the article title for the full text. An excerpt from her editorial: "The point is that we have no system of maternity care in the United States that provides a healthy woman the choice of giving birth at home and if she needs to transfer to a different type of care during labor, the transfer is easy. We do not have a system in which this woman is treated with respect and kindness, and her provider either maintains responsibility for her care or professionally and respectfully is able to transfer responsibility to another provider. Interestingly, while ACOG and AMA have declared that hospital grounds are the only safe place to give birth in the United States, the National Perinatal Association (NPA) adopted a position paper in July 2008 titled, 'Choice of Birth Setting.' The paper supports a woman's right to home birth services....Further, in Canada following the model of British Columbia, the province of Alberta has recently expanded its health care system to include women's access to midwifery services 'in a variety of locations including hospitals, community birthing centers, or in their homes.' "
- Two Charleston Gazette articles: Midwife delivers babies in mothers' homes and Home delivery: After three hospital births, fourth-time mom was determined to deliver the old-fashioned way
- A Herald Tribune (FL) article narrates how a home birth unfolds in Home Delivery
- An article featuring Womancare Midwives of North Idaho
- Tribute to Maude Callen, a nurse-midwife serving rural South Carolina for over 70 years. Make sure you click on the Life photo archive for lots of fantastic pictures!
- Adventures in (Crunchy) Parenting wishes to move beyond binary views of safety
- Future Search Conference on Home Birth currently being planned. From the description:
- It will be a multi-disciplinary consensus conference of key stakeholders around the provision of home birth services in the United States, to be convened by the University of California San Francisco and various organizations, including the American College of Obstetrics and Gynecology the American Academy of Pediatrics, the Association of Certified Nurse Midwives, Mothers and Midwives Associated, Lamaze International, Association of Women Hospital Obstetric and Neonatal Nurses, and the International Center for Traditional Childbirth. Further, it is hoped that public health practitioners and students, insurers, government agencies, health economists, medical anthropologists, state and national legislators, and women who have given birth will be among the eventual participants. The purpose of the conference is to start to bridge the "divide" between the medical and midwife communities over out-of-hospital births in the United States. Safety of birth in any setting is of utmost priority. Rights to choice and self-determination and culturally appropriate healing are also core values in American discourse that influence this issue. The purpose of this multidisciplinary conference of key stakeholders will be to craft a consensus policy and strategy on provision of home birth services. The project may also inform regulatory discourse, alternative funding structures, and the required modifications of curricula to prepare physicians and midwives in urban, rural and remote settings to provide maternity services across birth settings.
- Evidence-based labor and delivery management. Berghella V, Baxter JK, and Chauhan SP. Am J Obstet Gynecol. 2008 Nov;199(5):441-2. From the abstract: "Evidence-based good quality data favor hospital births, delayed admission, support by doula, training birth assistants in developing countries, and upright position in the second stage. Home-like births, enema, shaving, routine vaginal irrigation, early amniotomy, "hands-on" method, fundal pressure, and episiotomy can be associated with complications without sufficient benefits and should probably be avoided." (Email me for full text).
- Born in the USA: Exceptionalism in Maternity Care Organisation Among High-Income Countries by Edwin van Teijlingen, Sirpa Wrede, Cecilia Benoit, Jane Sandall and Raymond DeVries. Sociological Research Online, Volume 14, Issue 1. From the abstract: "In lay terms, childbirth is regarded as a purely biological event: what is more natural than birth and death? On the other hand, social scientists have long understood that 'natural' events are socially structured. In the case of birth, sociologists have examined the social and cultural shaping of its timing, outcome, and the organization of care throughout the perinatal period. Continuing in this tradition, we examine the peculiar social design of birth in the United States of America, contrasting this design with the ways birth is organised in Europe."
- Postnatal quality of life in women after normal vaginal delivery and caesarean section. Behnaz Torkan, Sousan Parsay, Minoor Lamyian, Anoshirvan Kazemnejad, and Ali Montazeri. BMC Pregnancy Childbirth 2009; 9: 4. From the conclusion: "Although the study did not show a clear cut benefit in favor of either methods of delivery that are normal vaginal delivery or caesarean section, the findings suggest that normal vaginal delivery might lead to a better quality of life especially resulting in a superior physical health. Indeed in the absence of medical indications normal vaginal delivery might be better to be considered as the first priority in term pregnancy." (full text available by clicking on article title).
- Health Care Reform in the U.S. Organisation for Economic Co-operation and Development Working Paper #665, Feb. 6. 2009 by David Carey, Bradley Herring and Patrick Lenain. From the abstract: "In spite of improvements, on various measures of health outcomes the United States appears to rank relatively poorly among OECD countries. Health expenditures, in contrast, are significantly higher than in any other OECD country. While there are factors beyond the health-care system itself that contribute to this gap in performance, there is also likely to be scope to improve the health of Americans while reducing, or at least not increasing spending. This paper focuses on two factors that contribute to this discrepancy between health outcomes and health expenditures in the United States: inequitable access to medical services and subsidized private insurance policies; and inefficiencies in public health insurance." Full text PDF available by clicking on the article title.
- List of abstracts on VBACs with twin gestations
- Some NHS trusts will no longer offer primary elective cesareans because of cost and safety issues. Read more in Caesarean births rationed by hospitals in order to cut costs
- A midwife-led initiative in Southampton has lowered cesarean rates and boosted VBAC rates
For Expectant Moms, a Happy Medium Between Hospital and Home Births: profiles the struggles of one birth center to obtain permission to open
Breastfeeding
Pedialyte Alternative recipe (not necessary for breastfeeding babies, but great for older children & adults)
Gardening
25 plants you should consider growing
Sunday, February 15, 2009
Eduador's vertical maternity ward
In an effort to lower maternal and infant mortality rates, one Ecuadorian hospital has implemented a "vertical maternity ward" in which traditional practices--including upright or "vertical" birth, medicinal teas, bathing & massage during labor, and indigenous spiritual rites--are encouraged. Read more about it in the article 'Gravity Birth' Pulls Women to Ecuador Hospital. Some excerpts from the article:
Read more ...
Gravity is the invisible midwife in indigenous birthing rituals, says Rosa Colta, a traditional midwife and intercultural health promoter in Otavalo, a town in the Andean highlands of Ecuador.For that reason a maternity ward in the dimly lit hospital of San Luis de Otavalo calls to mind a small yoga or ballet studio.
Six horizontal bars covered in colorful rope hang on the back wall, forming a gradient, or "chakana," in Kichwa, the dialect of the Quechua language spoken here.
In a room right around the corner from the hospital's emergency room, laboring women move down the chakana's rungs during delivery, transitioning from almost standing before contractions, to kneeling with their palms on the lowest rung, back curled like a cat, posterior high and ready for birth.
The practitioners believe the downward abdominal pressure as a woman moves down the steps or switches from standing to squatting helps push the child out and speeds up dilation of her cervix.
Part of a model effort to lower maternal and infant mortality and attract more women to hospital deliveries, San Luis de Otavalo is the first public hospital in Ecuador to provide a so-called vertical maternity ward that connects indigenous birthing practices with access to modern medicine. The ward opened in April 2008.
"It was a hard fight for us to get into the hospital and care for women with our ancestral wisdom and practices, with our teas and waters, our sacred cleansing rites," says Colta. "Everyone has bad energy. But we shoo it out at birth."
I particularly enjoyed this gynecologist's commentary about vertical versus horizontal birth:
Pedro Luna, the chief gynecologist at the ward, attributes the speed of ... vertical deliveries to the use of a natural position. "Vertical birth-delivery, adapted by the Kichwa tradition, is a natural and instinctive process that makes physiological sense," says Luna. "Horizontal birth is an occidental practice brought by the conquistadors with zero medical logic."
First chosen mostly by indigenous women, vertical births are becoming more common among mestizas as well. Vertical births have also lowered the hospital's cesarean rate from 18% to 8%.
Monday, February 02, 2009
News, research, and more
It's time to clean out my files and bookmarks again.
Are antibiotics beneficial for preterm labor or PPROM?
Preterm Abx beneficial for PPROM, but not for preterm labor. A newly published meta-analysis has concluded that antibiotic use prolongs pregnancy and reduces neonatal morbidity in women with preterm premature rupture of membranes (PPROM) at a gestation of 34 weeks or less. The same analysis found little evidence, however, of a benefit from using antibiotics in preterm labor occurring at 34 weeks or less. Source: American Journal of Obstetrics & Gynecology 2008;199:620e1-e.
Is Acupuncture Effective at Inducing Labor?
Acupuncture to induce labor: a randomized controlled trial.
Obstet Gynecol. 2008 Nov;112(5):1067-74.
For women with a scheduled postterm induction, acupuncture sessions before the induction did not reduce the need for inductions or the length of labor. This trial used sham acupuncture, which is a great way to lessen the placebo effect of acupuncture. The conclusion from the abstract: "Two sessions of manual acupuncture, using local and distal acupuncture points, administered 2 days before a scheduled induction of labor did not reduce the need for induction methods or the duration of labor for women with a postterm pregnancy."
Precipitous births in the news:
Read more ...
Are antibiotics beneficial for preterm labor or PPROM?
Preterm Abx beneficial for PPROM, but not for preterm labor. A newly published meta-analysis has concluded that antibiotic use prolongs pregnancy and reduces neonatal morbidity in women with preterm premature rupture of membranes (PPROM) at a gestation of 34 weeks or less. The same analysis found little evidence, however, of a benefit from using antibiotics in preterm labor occurring at 34 weeks or less. Source: American Journal of Obstetrics & Gynecology 2008;199:620e1-e.
Is Acupuncture Effective at Inducing Labor?
Acupuncture to induce labor: a randomized controlled trial.
Obstet Gynecol. 2008 Nov;112(5):1067-74.
For women with a scheduled postterm induction, acupuncture sessions before the induction did not reduce the need for inductions or the length of labor. This trial used sham acupuncture, which is a great way to lessen the placebo effect of acupuncture. The conclusion from the abstract: "Two sessions of manual acupuncture, using local and distal acupuncture points, administered 2 days before a scheduled induction of labor did not reduce the need for induction methods or the duration of labor for women with a postterm pregnancy."
Precipitous births in the news:
- A UK mum gives birth in an ambulance outside restaurant. She had planned a home birth, but decided to transfer when the baby unexpectedly presented breech. On the way to the hospital, the baby flipped back to vertex and was born en route.
- Baby boy arrives on bathroom floor. The couple was planning a home birth anyway; the midwife dind't arrive on time. So dramatic! How amazing that the mother and father managed to deliver their own baby!
- A Denver woman riding a city bus goes into labor and has the baby in a public library.
- Erykah Badu gives birth at home to a girl
- Routine epidural turns deadly (this is an older article but I am trying to clear out all my extra bookmarks).
- Call for Abstracts for the Australian College of Midwives 16th Biennial Conference: "Midwives & Women: A Brilliant Blend" is being held at the Adelaide Convention Centre, from the 22 - 25 September 2009. I wish I could go!Any way I could get funding for this?
- Home Delivery: The Movie. From the website: "This film documents the lives of three women in New York, who for very different reasons have decided to go up against social trends and take the birth of their children into their own hands… and homes." I haven't seen this one yet. It's available for purchase here.
- BirthLove is back (don't know how long, though) on this website!
- Woman to Woman Childbirth Education shares her thoughts about the UK documentary on Freebirthing. She argues that "if doctors or midwives want to stop [unassisted births], they have two choices — scare women out of doing it, or make the alternatives more appealing."
- The Independent Childbirth blog examines Why American Women Can't Handle Labor (or why people think they can't).
- The Times (UK) discusses how pregnant women are "risk magnets."
Pregnant women are risk magnets, attracting every sort of scare about potential damage to their babies at a time of their lives when they are most fearful, for themselves and for the new life they carry. Not only are food scares (too much liver, too much fish, etc) aimed squarely at mums-to-be, but there are also horror stories about the maternity services. The irony is that the perception of risks may be more harmful than the actual risks.
- Babywearing Coat Instructions: this tutorial shows you how to alter a normal jacket or winter coat into a babywearing coat. A great project to try with a secondhand coat! I'll have to make one of these for next winter.
- CPSC grants one-year reprieve for certain products. This news has handcrafters relieved, as many were worried they'd have to shut down because of the prohibitive costs of lead & phalate testing. Forbes op-ed piece on the CPSC law (written before the reprieve was announced).
- How Women Can Bleed Green: an article about reusable menstrual products
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