Better Birth

Andrea's Birth....

2010-03-05T17:28:00.000-08:00

I recently had the opportunity to attend a lovely home birth. It truly was beautiful and peaceful and wonderful in every way!

The birthing mother had a friend of mine, Rebecca Block, who specializes in maternity, baby and birth photography, there to capture every moment as a digital image. Rebecca put together the following slide show which is absolutely beautiful! I hope you enjoy watching the story unfold as much as I have!

The Ten Pound Baby - Too Big!

2009-10-26T13:52:00.001-07:00

I've heard it a hundred times and I should be used to it. But I'm not.
It happened again last week.

My friend was having her third baby. She's already pushed out two babies without problems - an 8 pound and a 9 pound baby.

She's into natural birth, even considered a home birth... but then got nervous thinking about it and went on with the obstetrician. He is a nice man. I like him a lot. If I had to pick a doctor, he'd be in the top dozen that I know. But he works in the hospital and thinks the way he was trained.

Two months ago my friend came home from a prenatal with the shocking, horrifying news, "Mary, they did an ultrasound and my baby already weighs over five pounds! He's gonna be HUGE by my due date!"

I talked her through it: She'd already pushed out a 9 pound baby. This one probably wouldn't be that much bigger, if even that big. She has a great body for having babies. If she was worried about her baby getting big, she could stay away from refined carbs and sugars.
She looked skeptical. I wondered if she really was scared of doing labor again and was hoping for a c-section. I hoped not, but I had to think that perhaps that was going through her head... I loaned her some books and told her that she'd already done it twice, and I was sure she could do it again.

About two weeks ago, they did another ultrasound. This time she was told that her baby already weighed a whopping TEN pounds! Her doctor didn't like the idea of her birthing a 10+ pound baby, and she really didn't like the idea. They mutually agreed that she'd have an elective cesarean section on the following Monday. She'd be 37 weeks. Everything would be fine.

So last Monday, her belly was sliced open and this "giant baby" was extracted. He weighed 6 pounds, 7 ounces. She sighed and laid there waiting for everyone to put her insides back together while he cried and squirmed in the warmer.

The doctor smiled - another successful c-section! No respiratory problems for the baby, no issues with the mother. The ultrasound estimate of size was a little off... but no harm was done, so that really didn't matter, right?

The nurses smiled, too. All was well as the new daddy stood near his baby and held his hand and the mommy was stitched neatly closed.

This is birth... the American way.

Morning Sickness Remedies

2009-10-26T13:15:00.000-07:00

Is there anything worse than to be excited about being pregnant, but to feel so nauseous that you can't enjoy it for months?!

I share these suggestions with my homebirth clients frequently, and thought that others might benefit from the knowledge as well. So here goes....

The cause of morning sickness is not really known, although there are many theories, including hormonal changes in pregnancy (elevated levels of estrogen and human chorionic gonadotropin [hCG]), low blood sugar (perhaps caused by not eating, thereby creating a vicious cycle), gastric overloading, slowed peristalsis (intestinal action), a body overloaded with toxins, and any number of other possibilities.
Nausea occurs in half to three-quarters of pregnant women. Most women experience the worst nausea and vomiting at about 11 weeks gestation. It typically begins around 5-6 weeks. About half of pregnant women with nausea and vomiting find it completely gone by 14 weeks and 90 percent by 22 weeks. Women with a multiple gestation (twins, triplets, etc.) often have longer-lasting and more severe nausea and vomiting. The theory is that the extra hCG produced during a multiple pregnancy may be the cause.

Persistent and severe nausea and vomiting beyond the first trimester may indicate hyper emesis gravid arum or hydatidiform mole and should be taken seriously.

There are so many different things that can help morning sickness, but there certainly isn't a "one size fits all" remedy! One or all or any combination or none may be effective for a particular individual. For many women, just knowing that something might help is comforting!

The following suggestions are well-known and fairly common remedies that often help alleviate or eliminate nausea and vomiting during pregnancy.

Please do not take these suggestions as medical advice! Always consult your care provider before trying something new!

1. Eat small, frequent meals, including a protein food each time, as often as every 2 hours, or just “graze” continuously, not allowing more than an hour or so to pass without putting something in your mouth. The food is more apt to be retained than 3 large meals a day and prevents the blood sugar from dropping enough to cause nausea. If this seems to work for you, keep snacks by your bed (almonds, cheese sticks, yogurt, peanut butter and apples, etc) and eat several times during the night when you wake to go to the bathroom. This will keep your blood sugar from falling by morning, leaving you feeling nauseous upon awaking.

2. Eat dry crackers or toast or plain yogurt before getting up in the morning.

3. Sip on ginger or raspberry leaf tea. The best ginger tea is made by pouring one cup boiling water over 3-5 slices of fresh ginger root. Let steep 5 minutes and sip slowly.

4. Take Ginger capsules with your meals.

5. Avoid foods with strong or offensive odors.

6. Many women claim that homeopathics are effective in easing morning sickness. The remedies are specific to symptoms. Research Pulsitilla, Sepia, Nux Vomica, and Ipecacuanha. Additional remedies to consider include: Antimonium Tartrate, Argentum Nitricum, Petroleum, Sulfur, and Tabacum. Good references are: “Homepathic Medicine for Women” by Trevor Smith, MD, and “Homeopathic Medicines for Pregnancy and Childbirth” by Richard Moskowitz, MD.

7. Drink carbonated beverages - especially ginger ale. (I wouldn't recommend doing this on a
regular basis, but it does help some women with severe nausea!)

8. Rest.

9. Vitamin B6 (pyridoxine) either 25 mg four times a day or 50mg twice daily can be very effective.

10. Use medication. Some women find 50mg Vitamin B6 and 1 Unisom tablet at bedtime in addition to 25mg B6 twice daily to be very helpful. (Or, 25mg B6 and ½ Unisom tablet three times a day). Unisom can cause drowsiness, and of course, consult your healthcare provider before trying any medication!

Feel free to comment, adding your own suggestions or what did or did not work for you.
I welcome the collective wisdom of pregnant women and their care providers everywhere!

The Best Care for Healthy Pregnant Women

2009-10-26T13:08:00.000-07:00

As technical advances become more complex, care has come to be increasingly controlled by, if not carried out by, specialist obstetricians. The benefits of this trend can be seriously challenged. It is inherently unwise, and perhaps unsafe, for women with normal pregnancies to be cared for by obstetric specialists, even if the required personnel were available. Specialists caring for women with both normal and abnormal pregnancies, because of time constraints, have to make an impossible choice: to neglect the normal pregnancies in order to concentrate their care on those with pathology, or to spend most of their time supervising biologically normal processes, in which case they would rapidly loose their specialist expertise.

Midwives and general practitioners, on the other hand, are primarily oriented to the care of women with normal pregnancies, and are likely to have more detailed knowledge of the particular circumstances of individual women. The care that they can give to the majority of women whose pregnancies are not affected by any major illness or serious complication will often be more responsive their needs than that given by specialist obstetricians.

-A Guide to Effective Care in Pregnancy and Childbirth,
Enkin, Keirse, and Chambers, Oxford University Press

People Tell You...

2009-10-13T22:29:00.000-07:00

People tell you how tired you'll be,
but they don't tell you...
that you'll be able to survive without much sleep
because the simple act of looking at your baby
is stirring, gratifying, energizing.

- Carol Weston

New Study: Home Birth as Safe as Hospital Birth

2009-08-04T21:41:00.000-07:00

Ahem!
Is anyone in the medical community paying attention?
This wasn't exactly a "small" study.
Will ACOG revise their radical stand opposing homebirth?
I'm just wonderin'. . .

Look at these rates:
Intrapartum death:
Home: 0.03% vs. Hospital: 0.04%

Intrapartum and neonatal death within 24 hours of birth:
Home: 0.05% vs. Hospital: 0.05%

Intrapartum and neonatal death within 7 days:
Home: 0.06% vs. Hospital: 0.07%

Neonatal admission to an intensive care unit:
Home: 0.17% vs. Hospital: 0.20%

It looks like people were just ever so slightly more likely to be "safer" at home. Hmm....
And as a side benefit, more happy and comfortable in their own beds and bathrooms and living rooms. Oh, and it cost less.

No matter where you have your baby, there is no guarantee that it will all turn out well or that you will like the outcome or that whatever happened couldn't have possibly been prevented in the opposite setting. BUT, to say that home is more risky than the hospital for healthy women...
Show me!!

NEW YORK (Reuters Health) Jul 28 -
In terms of perinatal morbidity and mortality, a planned home birth is as safe as a planned hospital birth, provided that a well-trained midwife is available, a good transportation and referral system is in place, and the mother has a low risk of developing any complications, new research shows.

"Low-risk women should be encouraged to plan their birth at the place of their preference, provided the maternity care system is well equipped to underpin women's choice," Dr. A. de Jonge, from TNO Quality of Life, Leiden, the Netherlands, and co-researchers emphasize in the August issue of BJOG: An International Journal of Obstetrics and Gynaecology.

Data regarding the safety of home births in low-risk women are lacking, due in part to the fact that studies with very large sample sizes are needed to assess relatively rare adverse outcomes. Moreover, randomized trials comparing home and hospital births have not been done because women usually want to choose their place of birth, the authors explain.

The present study, an analysis of 529,688 low-risk planned births, was conducted in the Netherlands, the only country in the west with a large enough data set. The group included 321,307 women who wanted to give birth at home, 163,261 who planned to give birth in the hospital, and 45,120 with an unknown intended place of birth.

All of the outcomes studied occurred with comparable frequency in the planned home and hospital birth groups. These included intrapartum death (0.03% vs. 0.04%), intrapartum and neonatal death within 24 hours of birth (0.05% vs. 0.05%), intrapartum and neonatal death within 7 days (0.06% vs. 0.07%), and neonatal admission to an intensive care unit (0.17% vs. 0.20%).

"As far as we know, this is the largest study into the safety of home births," the authors note. The findings, they conclude, indicate that with proper services in place, home births are just as safe as hospital births for low-risk women.

BJOG 2009;116:1177-1184.

"Pit Her til Distress..."

2009-07-10T08:51:00.000-07:00

Pit til distress... A scenario that happens all too often in the hospital.
The thought in the back of everyone's mind seems to be, "Well, we can always turn the Pitocin down, and if that doesn't work, we can always do an emergency c-section."

Here, the labor and delivery nurse tells it from behind the scenes:
Pit to Distress: A Disturbing Reality

Natural Birth Blogs

2009-06-18T07:26:00.000-07:00

Looking for more interesting natural birth blogs to follow?

Check out this list of 100 best natural birth blogs....
Top 100 Natural Birthing Blogs

The Classic Old-School Doc Re-Appears

2009-06-04T16:02:00.000-07:00

I am at one of the local hospitals pretty frequently, supporting doula clients in labor - often enough that I now have some favorite nurses and some of the L&D staff people remember me. That's usually a good thing.

I've also done exactly one birth each with quite a few different doctors. Fortunately, some I never see again. Other times, I wish we could trade back for the doc that attended the last birth.

As a side note, I have only ONCE in the last 4 years of attending hospital births, ended up at a birth where the attending physician was actually the laboring woman's own doctor. I used to kind of hope/assume that my client's doctor who had signed off on their birth plan and all would be there. I've stopped planning on that. It's always somebody else. Usually, somebody from that practice, but I find that doctors came come from the North and South Pole and still be in the same practice together! So, we're always in for a surprise when the doctor walks in the door (unless I've worked with him/her before... in that case, I may have an idea about what's coming!).

Not long ago, "Belinda" was due and planning a natural birth in the hospital. She had 2 little ones already, so part of our doula visits prenatally focused on who would take care of the kids and arranging transportation and all kinds of practical details. Besides her husband was in Iraq for most of the pregnancy, and arrived back just a few days before she went into labor.

As for the birth plan, her doctor had said that she was fine with everything on it.
She said that she doesn't do an episiotomy "unless it's necessary."
She said that she avoids C-sections whenever possible.
That she encourages natural birth for any of her patients who want to try it.
That she would allow her patient to move and walk and do whatever she wanted to during labor.
That she would allow her to shower during labor (since a birthing tub wasn't available).
The only thing the doc wasn't very agreeable with was delayed cord clamping. But my client decided to give on that one if she had to.

Then labor happened.

The couple had just been moved from triage into their room. Labor was progressing quickly. The nurse checked Belinda's cervix and cheerily announced, "You're a good, stretchy 7 centimeters! I better tell the doctor to come right in!" With that, she chucked her glove in the trash and hurried out. Belinda was concentrating hard on the next contraction. It looked like all she could do to keep from screwing up her face and crying out in pain.

Meanwhile, the nursing student was having trouble getting the I.V. inserted. So the phlebotomy tech came in to help. Eventually, the I.V. was in and running after the fifth try. Belinda grimaced as she gripped my hand and said, "This is the last stick, right?"

And then Mr. Old School Doctor walked in. He looked like a classic, right out of a book about an eccentric old man... And it began.

"How are you, Ms. Smith?" he asked, touching her shoulder briefly.

"I'm, uh, ok." She sighed, exhausted. "What do you need to do right now?"

"Well, we need to assess how quickly you're progressing. So, I'm going to check your cervix, and we can break your water..."

"No, I - uh, don't want my water broken. Not right now, anyway."

"Oh." he stopped and shrugged. "Well, then that's fine for now." He turned back to adjusting his glove.

Belinda spoke up quickly before the next contraction. "Then can I get up and walk around after you check me?"

"No, oh NO! No, dear. You're going to stay right in that bed. Catastrophic things can happen if you get up and move around in labor."

Belinda looked a bit shocked, but another contraction hit, and she sank back against her pillow and closed her eyes. A couple of minutes later, as she opened her eyes, and looked back at the doctor, she brought it up again. "But I've been planning to walk and be up in labor all along. My doctor said it would be just fine. We talked about it a lot. She said as long as the baby was fine, I could get into whatever position feels good while I'm having contractions."

I chimed in to try to help her. "Maybe," I appealed to the doctor, "She could stand by the side of the bed and lean over it, but not walk around...?"

He looked at me as though I was suggesting that we bring a real, live tiger into the room to help things along. I backed off and he repeated, "No, no, no.... "
Then turning to Belinda again, "Honey, I don't let people do that. The best place for you and your baby is right in that bed."

He sounded patronizing, kind of grandfatherly, and yet... I wasn't sure what to do next. The nurse had a sympathetic look on her face, but she was nodding with the doctor. I knew she knew there was no good reason for this. I had just done a birth with her several weeks earlier and that doctor had let the woman move anywhere she wanted during labor.

Belinda's husband looked uncomfortable. Clearly, he didn't like the conflict. "Uh, honey, maybe..." he trailed off as Belinda rode another contraction out.

Then she snapped her head around and said very calmly but firmly, "I want to be upright. I've read that it can help with labor. Can't I do something that will aid gravity to make the baby come down and out easier?"

"Ah... " he rubbed the white stubble on his chin. "We have ways to get babies out if you're worried about that. Have you ever heard of the McRoberts position?"

Another contraction hit, but he kept talking. Belinda stared, glazed over at Dr. Old School as he rattled on about the McRoberts position while she breathed and nodded and winced. I pressed on her back and wondered to myself what would come next.
He repeated, "Do you know what the McRoberts position is?"

Belinda gripped her husband's hand a little tighter. "No," she gulped, catching her breath.

"The McRoberts position opens up your pelvis as wide as possible for your baby to come through. Its when we lay you on your back and pull your knees back to your ears. So, let's do that. Okay? When it's time to push, we'll lay you on your back and your pelvis will open wider so this baby won't get stuck."

Belinda nodded and was swallowed up by the next contraction. Afterward, she tried one more time, "But can I get up now? Can I stand by the bed or something? These contractions are KILLING me! They are hurting so bad in my back here in bed."

The old doctor straightened up and adjusted his glasses. "No, dear, did you already forget what I just explained? We need you IN BED till you have this baby, okay? Terrible, terrible things can happen to babies sometimes when you get up. You wouldn't even want to know what. But they are catastrophic. Sometimes babies die. I'm just trying to keep your baby safe. And didn't you understand, the best position for this baby to come out in is when you lay back? Do you understand?"

Belinda meekly nodded her head and then looked away as she felt another contraction coming.

And so went the labor... the whole thing. I tried asking the doctor lots of questions about the how's and why's of what he was decreeing, but nothing made a difference. Every time he didn't want something done a certain way, he'd say in his most grandfatherly voice: "Catastrophic things can happen if you do ____ . Do you understand, honey?"

Belinda pushed her baby out in the McRoberts position, which the doctor insisted upon.
And really, everything went fine. Nothing catastrophic or even close to it happened. She didn't have a tear or skid mark or anything.

It wasn't that terrible of a birth. But, Belinda was frustrated at her helplessness to have any say in simple matters of labor. Frankly, I was, too. I thought the whole "not getting out of bed" thing was ridiculous.

I was honestly a little surprised to find a doctor around still practicing so "old school"... He suctioned really vigorously on the perineum for over a minute before he let the shoulders deliver... and the amniotic fluid was completely clear. And then he spent a full two minutes holding a pink, kicking, screaming baby upside down, wiping it's face again and again and again before he handed him off to his mother. I don't know what he was thinking.
I guess it was just protocol.

That's the kind of hospital births I see a lot. They're usually kind of okay, but some of the stuff you put up with is just... dumb and frustrating at times, and for some mothers, infuriating!

People like Belinda will probably have a homebirth the next time. But the hospital might get to keep her as a patient if all their doctors would just be a little more open minded to a very few things that can make a big difference in a mother's experience.

As for the catastrophic things that were likely to happen, I'm still a little confused. Beyond the possibility of a cord prolapse (which can happen at any time, in about any position), what did he think was going to happen if the mother stood beside her bed?!

Oh well. I just hope that I never run into him again at a birth. And should I ever need to have a baby of my own born at that hospital, I hope Dr. Old School won't be the one walking into my room.

But, then, again, it really wouldn't be the end of the world. If I really, really needed hospital care for me or my baby, I would put up with most of it. And I'd try to be grateful. But it would be hard to be impressed. I'm just sayin'...

The Trouble With Repeat Cesareans (Time Magazine)

2009-03-14T12:00:00.000-07:00

Time Magazine is starting to get it... the mainstream media is publishing articles that are telling the truth about what has gone wrong in our modern maternity care system.

"Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them. More than 9 out of 10 births following a C-section are now surgical deliveries, proving that 'once a cesarean, always a cesarean'--an axiom thought to be outmoded in the 1990s--is alive and kicking..."

Read the full article here at Time.

Waiting Till 40 Weeks of Pregnancy... So Much Better

2009-03-14T11:38:00.000-07:00

The Wall Street Journal published an excellent article back in December, stating the benefits of carrying a pregnancy to term and the risks of inductions that are "just a few weeks early."

"Conventional wisdom has long held that inducing labor or having a Caesarean section a bit early posed little risk, since after 34 weeks gestation, all the baby has to do was grow.

But new research shows that those last weeks of pregnancy are more important than once thought for brain, lung and liver development. And there may be lasting consequences for babies born at 34 to 36 weeks, now called 'late preterm.' "

Check out the rest of the article here at the Wall Street Journal

Allison's Birth: Braver than you believe, and stronger than you seem

2008-11-28T15:11:00.000-08:00

As a doula and a Certified Professional Midwife’s apprentice I see all kinds of births and they are all special. But some of them are just extra special… Births that I know I’ll never forget.

Such was the case with Allison. Her birth happened recently, but I think I’ll remember it for the rest of my life.

When I met Allison at the midwife’s house for her first prenatal, her happy, easy-going ways immediately made me think that she would be a fun client to work with. Her bleached blonde hair, perfect tan, and French manicure made me wonder for just a second if she would find it difficult to just “let go” when labor happened. Would she be able to listen to her body, make the sounds that she needed to make, and assume the positions that she needed to when it came time to birth a baby? Would she be worrying about her makeup or simply focus inward and do what needed to be done? How would she do without any kind of pain medication at home?

She and her husband were totally confident that they could and would do this birth naturally just fine, and had no concerns. They didn't know anyone who had ever had a homebirth, but they were so excited about planning their birth. Her husband was a respiratory therapist and had worked in the medical field for years. Their midwife asked, “So why do you want to do a homebirth? After all, your insurance would even cover your birth in hospital, right?”

Rick and Allison looked at each other and smiled. “We’ve known for years that we would never have our baby in the hospital unless we had to! Rick has seen too much stuff there, and my mom is a labor and delivery nurse there and she’s always telling us stories. We would just rather stay home and have one on one care with someone who knows us as more than a patient number for their shift. We want somebody that knows US and what we want and what my health has been like….”

* * * *

When Allison was about a week overdue, I got a call: "Allison's in labor. Her water just broke, but she’s not really having any contractions right now.”

As I was driving to Allison’s house, her midwife called me to update me on the latest.

Allison had come to see her over the weekend because she wasn’t sure if she was in early labor or not with mild contractions.

”I learned some things about her pelvis that I wasn’t aware of before…” Joanne said, a hint of worry creeping into her voice. And then she said it: “I just don’t think her pelvis is big enough for any baby to fit through!”

I was a little shocked, because it had never come up as an issue at any of the prenatals with Joanne that I had been present for.

Joanne explained that she had not done any kind of vaginal exams early in pregnancy at Allison’s request. She had done Allison’s first vaginal exam when Allison and Rick had come over, wondering if she was dilating. And Allison had never seemed like the kind of person who would have a pelvic issue. She wasn’t petite and seemed to have a very average frame.

Joanne had NEVER worried about anyone else's pelvis during any of the births I had ever assisted her with. Sure, some women had to push longer and harder to get their babies out, but they usually always succeeded in birthing their babies vaginally. CPD had seemed basically non-existent in Joanne’s practice. Until today.

She thought that the inlet and mid-pelvis was adequate. With Allison, it was the outlet (nearest the perineum) that felt so tight during the vaginal exam.

We pulled up at Rick and Allison’s home and there she was - happy and walking around excitedly in early labor. Joanne did a check for dilation (2 cm.) and then said, "Can Mary check you, too? She needs some more practice."

Allison didn't mind, except that every time anyone inserted two fingers (ever so gently and slowly when she was comfortable) to check, she would totally screw up her face and clench her pillow and say, "Owwwww! My tailbone hurts SOOO bad!" That seemed kind of odd. Her midwife commented that her tailbone had been that sore the day before, too when she had done the first exam.

Then Joanne told Rick and Allison that we were going out to breakfast to give them a bit of quiet resting time to themselves in early labor. They liked that idea, and we left.

As soon as we drove away, Joanne turned to me and said, "Did you feel what I'm talking about with her pelvis?! I wanted you to feel that. That’s why I asked if you could check, too."

I exclaimed, "Did I ever! I'm thinking the exact same thing you are. HOW is a baby going to fit through THERE?!"

When I had checked Allison, it seemed as though the very outlet of her pelvis where the base of my fingers rested barely had room for more than three of my fingers. Joanne said that she estimated at the widest part, her pelvic outlet seemed to be not more than 6 cm (that's bone, plus think flesh, then try to get a space 10 cm wide and get a head through there!).

Joanne told me that Allison's horribly sore pelvis seemed to confirm to her that her pelvis was, even though tiny, doing it's best to expand for labor.

As we drove on, Joanne sighed. "I don't think she's going to get this baby out no matter how long she pushes, but if she DOES, I think she's going to break her tailbone. This is probably one of those cases of true CPD, and I feel so bad for her because the reality of a C-section hasn't even crossed her mind."

I asked her what she had told Allison about her pelvis. She told me that she had only told her half the truth when she checked her the day before, saying, "You seem to have a marginal pelvis, and I think you are going to have to work harder than most people to get a baby out. But I think you can do it."

Joanne added, "I’m really not very sure about the thinking she can do it part, but we can only wait and see what happens when she starts pushing."

We went back to the house after breakfast, and Allison was munching on a granola bar and doing hula stuff with her hips and walking and swaying constantly. It looked like she had been to a belly dance class.

She did that all day long. She never stopped moving. She constantly paced, and swayed, and swiveled her hips and sat rocking on the birth ball. A couple of times, her midwife and I begged her to rest for five minutes, knowing she had a long, exhausting journey ahead once she started pushing.

Every time she got into a new position for a contraction, if it was more uncomfortable that way, she'd say, "Ooooh! This really hurts!"

We'd look at her and say, "Well, you can try something else... You don’t have to hurt yourself more!"

But throughout her entire labor her response every single time was, "No, this feels like it's opening me up and I want to bring it on! The more intense, the better! More, baby! Ooooh! Owie! This is powerful stuff!" She put herself in the most uncomfortable positions because she thought it would help her move things along. What could we say? We were impressed with her strength and determination. We just hoped that somehow she could and would birth this baby. She would be crushed if a c-section became necessary. But we kept our thoughts to ourselves.

As labor progressed through the afternoon, she became deeply focused between contractions (instead of watching a movie, talking, eating). Allison started to do all sorts of things that had her midwife and I exchanging some strange glances.
She looked like she was doing an instructional video for the The Labor Progress Handbook! We knew that she had never read any doula or labor progress books or seen these positions anywhere, so our mouths dropped open as she proceeded to do things like the double hip squeeze (pressing in on the top of the pelvis with a contraction, widening the outlet), the lunge and then she went into doing the lunge with one foot up on a chair and a huge, low, wide, squat with every contraction for hours. She'd hang on her husband and go lower and lower and wider and wider, saying, "Owwiee! This is wooorking!"

It would have been fun to try to keep up with charting her postions - she must have done at least twenty different ones, with no guidance from us! She would do something, and then say, "Is this okay? Should I do something else?"

We kept telling her that she looked like she was doing every position for opening the pelvis that we'd ever seen in a book and it looked like her body was telling her exactly what to do.

She'd smile and say, "Well, it hurts, but I want to do it. It just feels right." She was amazingly in touch with her body and so instinctual about everything she did!

By 5 pm that night, she was almost 10 cm, but because of the tight fit of baby's head and the pelvis, the anterior part of the cervix was getting "dragged down" with the head as the baby descended. The lip of the cervix that was in front of the head and under the pubic bone was starting to swell. The baby was descending, but stretching the anterior cervix along with it. It was such a tight fit in there that her midwife wasn’t even sure how to move the cervix back above the head. Finally, around 6 pm Joanne started trying to hold it back, from being shoved down any farther. She let Allison start pushing; trying to get the head past the cervix, hoping it would soon stay behind the head. But, because it was so tight in there, Joanne had an extremely difficult time holding it back. (Her fingers would get compressed between head and pubic bone, and baby started to mold around her fingers!)

Allison pushed and pushed and pushed (mostly on a birthing stool with her husband sitting behind her, encircling her with his arms and her gripping his knees.). At 8 pm, she finally got the head past the cervix.

The baby's heart rate sounded wonderful throughout pushing, so she just kept going and going and going.

We weren't "directing" her pushing, just telling her what a great job she was doing, but she voluntarily did the "purple pushing" like people are often coached to do in the hospital for four and a half hours! I've never seen anyone do that at home without being "forced" to. I guess she knew what she needed! Joanne and I watched in amazement as she pushed and pushed and pushed. Her face was red and purple and the sweat poured off her. This beautiful lady was working harder than we had ever seen anyone work! In spite of dissolving into sobs between contractions at the sheer frustration and hardness of what she was doing, she never said, “I can’t do this!” She seemed to have an iron will to get her baby through her pelvis.

And her baby’s heart rate never showed any sign of stress. Who were we to say that she couldn’t do it?

At 10:00 pm, we started to see head. And at 10:30 pm, we had a little 6 ½ pound baby boy with a very tiny, very coned head and a woman who had just become a mother, absolutely beside herself that SHE DID IT!

So much for a woman with a literal 6 cm diameter pelvic opening!

She did it anyway!

So much for a woman who seemed impossibly tiny to birth a baby!

She did it anyway!

Less then three minutes after she finished those four and half grueling hours of pushing, she caught her breath, looked at her little boy and said, "You're so worth every bit of work I just did to get you here!"

I glanced over at Joanne and saw tears glistening in her eyes. I knew that she had to be just as proud as I was of this woman who had showed us that women are braver than they believe and stronger than they seem!

Unassisted Childbirth... coming soon

2008-11-28T14:20:00.000-08:00

I'm still working on my article on Unassisted Childbirth.

If you have any articles, links, blogs, etc that you'd like to forward my way, I'm looking for some real life examples of why women have chosen to birth this way and what motivates them to avoid using anyone who has any kind of formal childbirth training. Send them to me at: betterbirth4you {at} gmail {dot} com. Thank you!

In the mean time though, here's a birth story for you...

Are We Causing Our Incredibly High Preterm Rate?

2008-11-18T09:30:00.000-08:00

The San Francisco Chronicle on the national trend towards C-section:

The Centers for Disease Control and Prevention have tracked an increase in preterm births for decades, with the percentage of births delivered before 37 weeks of gestation rising 21 percent between 1990 and 2006. That increase is the main reason the nation's infant mortality rate has stubbornly refused to decline, remaining higher than most other developed nations.

Some preterm births were linked to mothers' smoking, and others to the mothers' lacking insurance. But more than 90 percent of the increase in preterm, nonmultiple births is attributable to an increase in babies being delivered by C-section at 34 to 36 weeks gestation, according to the March of Dimes.

"It comes from a general change in obstetric practice in our society," said Dr. Alan Fleischman, medical director of the March of Dimes Foundation. "The doctors and the women are intervening in a much more aggressive style toward the end of pregnancy."

Fleischman and other medical experts say there are a number of reasons doctors and mothers are choosing C-section delivery - and not all of them stem from medical necessity, the health of the mother or infant.

Read the rest of the article here.

Unassisted Birth... A Good Thing?

2008-11-02T15:10:00.000-08:00

Unassisted Childbirth (sometimes called UC for short) seems to be growing by leaps and bounds in popularity. Is it a trend that we want to encourage and "sell" people on?

Did any of you watch the Discovery Health Feature about it a couple of weeks ago?

I've been thinking about commenting on the trend, but have 'til this point, decided to leave that controversial topic alone. I know that both sides of the debate have equally strong feelings... and to even venture to state my opinion on the whole matter is risky.

What shapes my opinion on the matter?
A lot of things.

~I was born unassisted, with only my dad and grandma there, in the early '80's.

~The first birth I ever witnessed was my little sister's unassisted birth.

~I'm now a hospital doula and a homebirth midwifery student.

~I'm friends with mothers who choose completely unassisted birth, non-professional (i.e. a crowd of friends and family) attended births, midwife attended home birth, midwife attended birth center births, midwife attended hospital birth, physician attended homebirth, physician attended birth center births, and physician attended hospital birth.

~I've spent more than my share of time dealing with birth-related policy issues through my work on midwifery and birth-related legislation.

Yes, I have a lot to say about unassisted birthing. Maybe I'm right, maybe I'm not.
I'll tell you what I think in a future post, as soon as I get my thoughts formatted.

In the mean time, though, why don't you tell me what YOU think about unassisted childbirth?

Check out the poll I just put up!

Study: Vaginal Delivery May Increase Maternal Responsiveness to Newborns

2008-09-30T19:27:00.000-07:00

Yet another study telling us another good reason why cesarean birth should be avoided when possible.

"We found a significant difference in activity in certain cortical and subcortical areas of the brain in this group of mothers who delivered vaginally compared with those who delivered by cesarean section. Broadly speaking, the cortical brain regions are believed to be important for regulating emotions and empathy," principal investigator James Swain, MD, PhD, FRCPS, told Medscape Psychiatry.

....While the mechanism is not entirely clear, researchers believe vaginal stimulation caused by vaginal delivery results in the release of oxytocin, a neuropeptide that is a key mediator of maternal behavior in animals.

Cesarean section, said Dr. Swain, may alter the neurohormonal experience of childbirth and therefore may decrease the responsiveness of the human maternal brain in the early postpartum.

The investigators are currently looking at 3- to 4-month postpartum data to determine whether these effects of vaginal delivery on the maternal brain endure. Although the final analyses are not complete, Dr. Swain said preliminary analysis in this healthy group indicates the contrast between the 2 groups may not persist, suggesting that mothers who deliver via cesarean section may eventually "catch up" to those who deliver vaginally.

-- Medscape Medical News

Some time I'm gonna compile a list of all the reasons why one should try to avoid a c-section.

As one of my doctor friends says, "We talk about the 'hard' outcomes - the deaths, the morbidity... When do we factor in the 'soft' outcomes - like breastfeeding and bonding and emotional health and on and on?" And then as she often states so simply and yet so meaningfully, "Birth matters. It really does. We better get it right."

Patients DON'T Know Best - A Dr.s Rant on Homebirthers

2008-09-26T08:08:00.000-07:00

I found this physician's blog post and the ensuing comments to raise a lot good topics for discussion! While I can see the frustration of an OB who sees a woman is refusing what he believes is the best medical care (whether or not s/he is right!), I certainly don't agree with him that most women choosing natural/home/vaginal/fill-in-the-blank birth are doing it for any reason other than that they believe it is the very BEST choice for them and their baby.

"Call me old fashioned, but I am not alone. I often believe that patients don't have the capabilities to make proper decisions about their clinical options. When the issue is childbirth, excuse me, patients are often nuts. Just witness the epidemic of homebirths!" - Dr. Diastolic

Check out the whole post here.

A close up look at your cervix

2008-08-23T17:10:00.000-07:00

I am continually amazed that many women talk about a cervix, but don't know what it is. Some think that the perineum is the cervix. They talk about their cervix dilating from 0 to 10, yet they are not sure exactly where that part is - just "somewhere down there."

I will admit, I read about the cervix all the time once I started studying midwifery as a teenager, but I really had no idea what it looked like. People described it looking "like a donut," feeling "like the end of your nose..."

I was intrigued, but really I didn't have a good idea of what a normal, non-pregnant/laboring cervix was like until I watched a PAP smear being done. The Certified Nurse Midwife who I was working with at the time was more than happy to let me see and do everything she was doing, and the woman was extremely happy to let a student examine her cervix (I'm so grateful that some people like her don't mind!).

I hope that these pictures won't gross you out.... (okay, they are no worse than this picture below, except that they are in color!)

If you don't know what your cervix looks like, check out this daily "diary" of a cervix

here

You'll see the changes with the menstrual cycle and how different a cervix looks during menstruation vs. ovulation time.

On Birth Plans

2008-08-23T16:43:00.000-07:00

Sometimes I don't have to be original and write my own posts. Someone else has already written a great one.
This time it's Rebecca from Becca's Baby Blog.

Check out her excellent post on birth plans

here

"Just don't think about it, Honey, and you'll be okay!"

2008-08-23T08:36:00.000-07:00

I recently attended one of my doula client's prenatal visits with her obstetrician.

She had been telling me about her obstetrician for several months. "I like her," she would say. "She seems open-minded and willing to work with me and respect my wishes... but I'm just not sure if she's just stringing me along or not...."

Over all, most of the reports about her doctor sounded pretty good. She did say a couple things about her that concerned me. For one, the doctor couldn't really remember exactly what her c-section rate was, but she assured the patient that it was "pretty low" and definitely not higher than the other obstetricians in the practice because she only does them "when necessary."

I agreed to come along to a routine prenatal visit and meet her doctor. My client wanted me to tell her what my impression of her doc was afterwards.

I was liking her doctor a lot.
She was saying lots of good things, answering questions openly and took plenty of time to discuss anything my client brought up.

And then my client again brought up c-sections. "You know, Dr. Smith," she said earnestly. "I just don't want a c-section with this baby. I'm counting on you to do everything you can to make sure that doesn't happen to me. Surgery just freaks me out and I don't want end up there... I'm trying to get myself educated so that I know about the risks and benefits of various things and can know what is most likely to make a c-section happen. Is there anything I can do to help prevent myself from becoming a c-section statistic?"

Dr. Smith smiled. "Oh, honey! Don't worry yourself about having a c-section! There's only one good way to deal with that fear of becoming a c-section statistic -- Just don't think about it!
You probably won't have one, and if you end up with a c-section, you can just know that it was necessary and you can be happy that you and your baby are healthy!"

Dr. Smith turned back to charting, but my mind was spinning.

Her best advice on avoiding a cesarean section? Just don't think about it!

I wonder how many other docs give this advice to nervous couples expecting their first baby?

Back.... after a long absence

2008-08-23T08:16:00.000-07:00

It's been a long, long time since I've posted here. I've felt bad about it for months, especially since I've had a lot of posts rolling around in my head, and even a few in half-finished draft form.

I could give you a whole list of reasons why my living my life has seemed more important than posting to my blog... but I won't bore you.

Suffice to say, I can't promise to post really frequently, but I'll try to keep it regular and a few times a month.

Oh, and one last thing. In my last post, I talked about how Certified Professional Midwives are felons in Missouri. You probably heard back in June when it was news, but I still have to say it again.... Certified Professional Midwives are now LEGAL and free to practice midwifery in the state of Missouri!! Its been a couple of months since the Missouri Supreme Court made that ruling, but I still can hardly believe it's true. One of these days, I realize that it really IS for real!

A Good Friday Birth!

2008-05-03T18:48:00.000-07:00

On the morning of March 21^st, 2008, I started having consistent contractions and woke up around 3:30am. Not wanting to disturb my husband (in case this was the "real deal") yet unable to go back to sleep, I took a bath.

My husband came to find me and asked what I was doing. I calmly said that I was having some good contractions and wanted to see if they were regular. I relaxed in the tub and was fairly sure that these contractions were not going to fade like the Braxton Hicks ones I had been having for weeks. Once I was done in the bath I got back in my PJ’s and asked him to help me with some chores to prepare for the hustle and bustle of the wave of helpers that were soon to come.

As the contractions grew in intensity and came closer together I decided to rest on the floor of our family room. But as soon as I got on the floor my hubby panicked: "I’m calling the midwife... you are all over the place!!!" I chuckled after the contraction was over and said, "No I’m not, the floor is comfortable." He called the midwife and she said that she was on her way. He then called my sister in laws and the doula that was coming to help support us through the labor.

I decided to take a shower and attempt to relax. When I got out of the shower it was 7:10 am. Right then the midwife entered my bedroom. She was soon joined by my sister-in-laws and the doula. We had our team in place. My sister-in-law asked what I wanted to do. I firmly stated that I wanted to go for a walk and got dressed in some comfy clothes. We got my two sons dressed and got the Power Wheel out (compliments of Santa Claus), secured their helmets and off we went.

It was me and my two sisters-in-laws, the doula and my precious sons off on a mission to get this thing going. We left daddy behind with the midwife to get everything prepared for the delivery. The air was cold and felt good as my body progressed through labor and began working harder. It was comical to see my new sister-in-law chase my sons on the power wheel since normally it’s me toting my super sized belly while ensuring that they don’t run into anything and both remain on the Power Wheel.

We had made a complete lap around the neighborhood when we decided to grab coats for my sister-in-law and the doula. As I passed by the house, my sweet midwife she asked if she could listen to the baby to see how he was tolerating the labor. She checked on his heartbeat and it was perfect so off we went for round two. The boys decide to stay behind this time and have some breakfast, so my sister-in-law, my doula and I went on to finish the mission we had started.

After several tough contractions (breathing all the way) the contractions got to the point where I had to stop and lean on my sister-in-law for support. I decided to stick closer to home by this point and we took a few smaller laps. We approached the house and I decided that it was time to go inside and check on our progress. I had a series of two contractions on the porch and my doula gently applied pressure to my lower back to ease the pain in my back (you are heaven sent, Genny). We walked into the house and proceeded up the stairs to my bedroom. We had to stop on the way for another contraction on the stairs... again my doula applied pressure to my back. My son Ethan saw what the doula was doing and asked if he could help. I replied, “sure” as I was getting off the stair that I was leaning on for support and he gently rubbed my back (sweet moment between a laboring mom and her oldest son).

I proceeded up the stairs to my bedroom... When I entered my room I was greeted by the smell of lavender and Sara McLachlan playing softly in the background. In that moment my fears were lifted and I felt a sense of peace come over me... this was the moment I had dreamt about and prepared for. This was a birth on my terms and I could see my dream unfolding around me. As I reached the foot of my bed I knelt to floor with a strong contraction. At the end of the contraction I stated that I was ready to get into the tub. I was amazed how everyone worked together to help me get my needs met. One person drew the bath as another helped me get into the wrap I wanted to wear through the delivery.

My midwife was making her final preparations. After a few more contractions in the tub, and a little screaming, I told the midwife that I was ready to know where we were at (I wanted to know how dilated I was). She checked me and stated that I was nearly complete (10 centimeters) and asked if I wanted to feel the baby’s head. I nearly shouted "no way... you are pulling my leg... you’re just being nice... how dilated am I, really?" She told me that the baby’s head was right there and asked if I wanted to feel it. I was in a state of shock when I actually felt my baby’s head and I began to sob tears of joy. I found a renewed sense of purpose and again focused on the task at hand.

A few contractions later my midwife checked the baby’s heartbeat: "whoosh, whoosh, whoosh, whoosh (Mason in utero)" My midwife stated, "130 perfect!!!"

Then a strange sound entered the room: "reear, reear, reear, reear." Once the contraction had passed I exclaimed, "that’s not my baby’s heartbeat… that’s a saw!?!?" We were having a new deck built and the project was being completed as I labored. Here was yet one more thing to serve as a reminder for myself and my family of the AMAZING experience of welcoming Mason into our home.

Throughout my pregnancy my midwife and I had discussed a plan to avoid tearing open along my previous episiotomy line. We had decided that the best course of action was to refrain from pushing and let my uterus push the baby out. I knew that this would be a hard thing for me to learn to do, but I was up for the challenge.

As the urge to push became greater and I struggled to breath through the intense contraction I heard the voice of my doula: "remember our pushing plan." This clued me in and helped me to remember what my wishes were and helped me refocus on the job at hand. (Thanks, Genny.) I could feel my uterus contracting and my body automatically pushing. I did my best to breathe through the contractions… and soon enough I heard my sister-in-law (now serving as the camera woman) exclaim, "he’s coming, he’s coming."

My midwife told me, "Slowly, slowly… we don’t want a large tear."

With one last contraction Mason joined us. It was 11:10am. He was welcomed into a room full of people that had worked together to make his entry into the world peaceful and full of love. I was in awe of him from the moment I saw him. He is BEAUTIFUL and has been a blessing from the moment he entered our home. Mason… I love you!!!

In the months proceeding his birth I had many doubts concerning my ability to deliver at home and when all was said and done, all I had to do was focus on the time that I had spent bonding with this little person growing in my womb and think of the sweet reward that was waiting for me at the end of the pain. It was through my own inner strength and through the love and support of a carefully selected team that I was able to make this dream a reality. To all of you that were a part of this journey I thank you for believing in me and providing me with the encouragement and support necessary to lay claim to my own personal victory!!! I will never forget this day…it certainly was a Good Friday!!!

- Linda D.
O’ Fallon, Missouri

Thank you, Linda, for sharing your birth story and photos. Your birth was beautiful, and I hope that it inspires other women that they, too can have a beautiful, peaceful birth like yours.

The saddest thing about Linda's birth is the fact that Linda's midwife could face up to seven years in prison for having attended her birth. Currently under Missouri law, midwives are committing a Class C felony every time that they attend a birth, which carries a penalty of up to seven years in prison.

We have spent several decades trying to change our law but year after year, the power and money of organized medicine has won in the State Legislature as groups like the Missouri State Medical Association have defeated the midwives bills every time.

Last year, one sentence was passed in a larger health insurance reform bill that would have made Certified Professional Midwives (CPMs) legal in the state of Missouri. However, organized physicians groups took the new provision of midwife law to court, alleging that it was unconstitutional and should not have been included in the larger bill. The physicians groups (with aid from the AMA and ACOG) have spent hundreds of thousands of dollars over the past year, trying to maintain Missouri's felony status for Certified Professional Midwives.

The physician's groups won a lower court ruling in August of 2007, saying that the Certified Professional Midwife provision was unconstitutional and unrelated to the health insurance bill that it was contained in. Consumer groups like Friends of Missouri Midwives
(www.friendsofMOmidwives.org) as well as individual pregnant couples appealed the ruling to the Missouri Supreme Court, where it was heard in early March 2008. We are waiting to hear the ruling of the Missouri Supreme Court, which will probably be issued by June of this year.

Linda's midwife was committing a felony under Missouri law
as she assisted with her home birth.
(Only her midwife's hands are pictured above to protect her identity.)

The groups and individuals in defense of midwives have also accumulated huge legal bills, as they have had to hire top lawyers to match the ones hired by the well funded Missouri State Medical Association, et al. So far, they have raised about one hundred thousand dollars for the court cost through bakes sales, fund raisers, and generous donations from all across the U.S. However, giving has recently stalled out and there is still about $40,000 more needed to finish paying off the court costs.

Would you consider contributing to this worthy cause? $5, $10, $50, or $200... Whatever you can give will go a long way towards paying off this debt to "Free the Midwives" of Missouri, so that more women can have a birth experience like Linda!

You can donate online or find information for donating by check at:

www.freethemidwives.org

Thank you!

Mary

They Know So Much That Ain't So

2008-05-01T16:59:00.000-07:00

The trouble with people is not that they don't know,
but that they know so much that ain't so.
Josh Billings

Dear "Sarah": There IS Hope for a Better Birth!

2008-04-14T11:48:00.000-07:00

Sarah,

When I read your email, my heart went out to you. I know of so many women who dread to think of having another baby... because of the trauma of labor and birth. Some of my friends, even though they've wanted another baby, have told me that they've cried to see the little pink line appear on their pregnancy test, as reality hit them and they knew that once again they would be subject to a overwhelmingly painful labor in a few short months.

I can't promise that this birth will be different for you, even if you do everything suggested. Some women have relatively easy births. And some women have agonizing births. I've learned over the years, it's not all about whether the woman is a wimp or not or whether she thinks positive thoughts, or whether she just hasn't yet discovered the pain coping technique that "works for her."

You are absolutely right. Some of the most painful and overwhelming labors are those that happen so fast. Women talk about 12 or 20 hours of painful labor, and then say, "What?! You got away with 2 hours of labor?!" In reality, what most of them don't realize is that many times a 2 hour labor is just like compressing the 12 or 20 hours that they experienced into a fraction of the time. So, yes, it is often even more overwhelming, relentless, and excruciatingly painful. There is not magic solution to slow your labor down and let it hit you with the normal intensity that most women experience, but there are certainly some things that you can do to make it a better memory.

Some women try everything and still, they have miserable labors and/or births.

For many women,

Getting prepared is good, but it doesn't fix everything.

Being well-supported is good, but it doesn't fix everything.

Being in the right environment is good, but it doesn't fix everything.

Neither does trusting your care team,

or being in water

or being upright

or being in bed

or planning to "just ask for pain meds"

or listening to music

or being at home

or being in the hospital

or eating handfuls of Vitamin C tablets

or overdosing on Calcium and Magnesium in labor

or eating more beans during pregnancy

or the hundred other things that friends, magazines,
websites and other helpful people will recommend!

Sometimes you do everything right (I'm not implying that all of the above are "right" or a good idea) and STILL your birth is a miserable experience.

But I can offer you hope. Rarely does a women come to birth well prepared, well supported, choosing the right environment and the right care provider for her situation and still hate the way it turned out.

A friend of mine who I'll call Susan has had 8 children. They've all been hospital births, mostly with epidurals. One was a forceps delivery that damaged her son's spinal column for life. One of the middle kids was a c-section for an emergency that arose in labor. She has polyhydramnios (too much amniotic fluid in pregnancy) and she has borderline gestational diabetes. Sometimes her doctors control her diabetes with insulin, sometimes she controls it with diet. She's been induced for part of her labors. Other times she's labored naturally for about 24 hours before making little progress and succumbing to an epidural.

Susan has talked about how horrible birth is for as long as I can remember. As a teenager, my mental picture of birth was partly painted by the things Susan would tell me about her births. I shuddered to think that birth had to be that hard and that for her, the only saving grace was an epidural.

When she became pregnant with her eighth and last child, I had recently taken some doula training, and offered to be at her birth. With very little experience and only a stack of books to loan her, she began unloading on me the full horrors of her past birth experiences. She explained how she never goes into a normal contraction pattern once she gets past about 5 centimeters dilation. She said, "The doctors always come in and look at my fetal monitor strip and say, 'Wow. You don't do contractions like most women. You just have one long contraction till you start to push.' "

She explained how her contractions all melt into one, and she only gets a short break of a minute or less every half hour or so. "So, you see why I can't do it without the epidural," she explained. I totally understood. If I had one long contraction for 48 hours, I'd be begging to get signed up for the epidural as well! I felt very powerless to change what her body does to her. After all, this had happened seven times now, right?

But I encouraged her to work towards what she wished her birth experience could be, even if it wasn't likely to happen that way. She began reading books on Natural Childbirth and for the first time in her life she was saying, "Oh, I wish my labors were normal so I could do them without the epidural...." She really did want a natural birth, but she felt that would be absolutely impossible in her situation. Nevertheless, she prayed desperately that somehow this baby would be born differently. My dear friend had endured 30-40 hours of torture with other earlier births before getting the epidural, and saw no point in doing that to herself again with this one. I didn't disagree with her decision, just tried to be supportive.

The day came when she wondered if she was in labor. We headed to the hospital to see. Contractions were regular, but not very painful or strong. Things were most likely just putsing around. The doctor gloved up and reached for the cervix, when his eyebrows shot up.

"Oh, my!" he exclaimed. "Have you been doing this labor for awhile?"

"Well," she said, "Kind of all day, but I pretty much ignored it and went on with my work because I had a lot going on."

"Well, you're going to be happy. You're a stretchy 7 centimeters!"

Now we looked shocked. She the most shocked as she stammered, "I've never experienced 7 centimeters without an epidural! Never! I've never been able to handle it by the time I get to 5 centimeters. Usually by then I'm climbing the walls with pain, and there is no break between contractions! And usually by the time I get to 5, I've been in labor for at least 24 hours!"

An hour later, Susan was sitting on the birth ball, still smiling and talking between contractions.

An hour later, after the doctor broke her water, she was declared completely dilated and ready to push with her next contraction. Things were getting intense at that point as she was in transition and crying, "I can't do this. It hurts so bad!"

Then for ten whole minutes, her husband, the doctor, the nurse, and I just stood and waited for a contraction that didn't happen. Susan kept looking around the room and saying, "This is so weird. It's surreal. Is something wrong? Why am I not contracting anymore?"

The doctor wisely smiled. "Oh," he said, "Sometimes this happens. It's usually just your body giving you a little break for what's ahead..."

Soon the contractions resumed and she set to work pushing, which she had never experienced without an epidural. Even though she could feel what she was doing, and was being more effective that her usual pushing, she hated the feeling. Fifteen minutes of pushing, a few screams, yelps, blowing and breathing, a few more,"I can't do it's" and "Yes, you can! You're moving your baby down" later, she had a chubby pink baby girl in her hands.

Sobbing, and panting she looked over at me and said, "I don't know how that happened like that! I can't believe I just had a baby like that! I wanted a natural birth. I never thought I'd get one, but I did! God is so good!"

Years later, she still talks about her birth to almost every woman she meets, telling them that birth isn't always bad, and there is always hope that you can have a "good" birth, no matter how many miserable experiences you've had.

She's asked me over and over again what it was that I did for her to miraculously change her birth experience. I have told her over and over that I honestly didn't do anything except answer her questions, breathe with her, get her extra pillows, and show her husband where counter-pressure felt good on her back during labor. I didn't do anything special, but her body obviously did a totally new labor pattern that she had never experienced with her seven previous babies.

I don't know what happened or why that birth was different. All I know is that her last birth radically changed her life. Instead of feeling helpless and at the mercy of a "dysfunctional body," she's never forgot how empowered she felt to push out her own baby and to see her body work perfectly fine.

I wish for you the same miracle.

In the meantime, though, I suggest that you do everything you can to prepare for the birth you've always wished to have.

I recommend an experienced doula as #1 on your list.

When you are experiencing overwhelming contractions, it makes all the difference in the world to have someone there to walk through each one with you, and keep you centered, helping you to stay on top of the pain. Of course, husbands are great and it sounds like your husband does a great job helping you through labor, but they can also be so emotionally pulled into your pain that they can't focus on your need in the same calm, reassuring way that a motherly doula can. It is optimal to have one person there to focus on whatever you want physically (back pressure, massage, cool washcloth for your forehead, etc) and one person there who is going to stay right at your face constantly during every contraction, watching your every facial expression, and listening to everything you do so that they can totally focus on where you are at "in your head" and walk you through the contraction one at a time. Find a doula who is experienced and has attended at least a few dozen births in that role. Someone who you feel comfortable with and can trust. Many doulas are certified through ALACE (http://alace.org/) or DONA (http://dona.org/), but other very good and qualified doulas have attended hundreds of hospital births, but have never been certified. Interview them thoroughly. Who do you like? Who seems to understand how you feel about birth and what you wish could be different? Who do you feel completely comfortable with?

My #2 recommendation would be to evaluate whether your birthing location and caregiver are appropriate and best for your situation.

You may have always went to the hospital and used an obstetrician for your births, but perhaps your situation would be more appropriately handled at home with an experienced, well-trained midwife. That is a decision that you will have to make, based on lots of research and reading. Of course, you may be a person with certain risk factors that makes a hospital birth a necessity. If so, or if you just aren't comfortable with a homebirth, then make sure that you have the best doctor (or hospital based CNM) and hospital for your particular situation. Is your doctor committed to helping you have the best birth possible? Is s/he sensitive to your wishes and needs during labor and birth? Do they adhere rigidly to protocols and procedures that are typical, but not evidence-based? Will your doctor allow you to labor in whatever position/use whatever comfort techniques are helpful to you?
Many people think of homebirth as more "risky" than typical hospital birth. It can be when not done right or not properly attended. But when properly attended, it can actually be safer for healthy, low-risk women. I encourage you to do your research carefully. All of the quality homebirth studies show that planned homebirth (when attended by a well-trained midwife) is equal or safer in outcomes for mothers and babies, with far less interventions like c-sections and forceps/vacuum delivery. Of course, there are things that can occur at home that would be better handled in the hospital, because they have the technology/machines to deal with that particular situation. But, on the other hand, there are many situations that occur in the hospital (think: under staffing, more medical errors, infection rates) that would be more safely handled at home. The risk factors for home and hospital birth are different. But that does not mean that there are more risks at home for healthy low risk women attended by experienced, knowledgeable midwives. If, after much research, you decide that homebirth is for you, do some more research and talk with your midwife about the possibility of water birth. Obviously, it's not for everyone and benefits and risks should be carefully considered. But, for many women who have really intense, painful births, having a water birth makes all the difference in the world to them. Waterbirth International (Barbara Harper, author of Gentle Birth Choices) offers lots of resources in this area.

There are many, many ideas out there for reducing the pain of labor. Some of them have been suggested in the comments section of the previous post. Many of them have not been mentioned on this blog. As I find time, I will post more ideas for you.

Regardless of who you decide to have deliver your baby, and where you decide to give birth, I hope that you will think it through carefully and research your options. Birth is never something to be taken lightly. On one hand, it carries with it a life and death responsibility, and on the other hand, it can be the most joyous, beautiful day of your life!

Plan for your birth to be better this time, know that it can be, and then take steps towards making that happen!

And whatever happens, I applaud you for your bravery to experience natural, unmedicated childbirth to give your baby the best start possible. You are among the bravest 10% of American women who experience labor with no pain medication!

Sarah's Births - "Will I always Scream and Find the Pain Unbearable?"

2008-04-05T21:29:00.000-07:00

Since the last post, I have received a number of emails from women asking all sorts of questions... telling sad birth stories, asking if things could have been different for them.

I decided that rather than try to respond to each person individually, I would try to respond to some of these emails on my blog as I have been given permission.

So, here is the first email I will respond to.
First, though, while I am composing a reply, I thought I'd put it out there for the rest of you to comment on. Please do suggest anything that you think might be helpful for this mother. I look forward to hearing your ideas and even just your stories, validating what she has experienced. It is the worst feeling to feel like you are the only person in the world with a particular problem or experience.
I know from my years of experience as a doula that "Sarah" is not alone and there are many women who are like her.
If you would like to reply to her off-list, feel free to email me at: betterbirth4you {at} gmail {dot} com and I will gladly forward your messages to her as well.

Thank you!

Hi Mary,
I am wondering if there is a way I could have a less painful birth experience. I am pretty certain that we are pregnant right now with our fourth baby. Our three previous births have all been with midwives (but not at home)who never encouraged "purple pushing", but my births are horribly painful toward the end.

I have a very high tolerance for pain, but I still end up screaming every time. Our first birth was by far the worst. It was so traumatic for me that I literally cried for almost a year any time I actually thought about what I had been through. Just remembering the pain brought back tears. I screamed with every contraction for five or six hours before our little girl was born.

Then I had trouble with bleeding afterward, as I have with every one of our births. My uterus does not want to contract back into shape after the baby is out, so I lie there in a happy state of shock, bleeding away. It is always scary to everyone but me. I turn pale, and hardly feel a thing. I am totally happy to have a little baby in my arms and to be out of pain, but everyone else sees the blood and my paling face and gets worried. That's after the birth...

Before the baby is born, this is what it is like. My early contractions are usually tolerable until I get to about four centimeters. I wince and ache, but I can pace and breathe through them. Then at that point, my body usually kicks in high gear and I dilate the rest of the way very quickly. Once my body decides to get serious I can go from four to ten centimeters in half an hour. This period is so intensely painful that I choose to start pushing as soon as I am fully dilated because I can't stand the pain. The pain is especially intense in my lower back, so I usually birth in a hands and knees position while my husband pushes HARD on my lower back with his fist/knuckles, which helps a little, and which I really appreciate. I push the baby out as fast as I can because I am screaming and exhausted and I can't stand the thought of slowing down and allowing the pain to linger a moment longer than it has to.

I always wondered if I was wierd. I know that nurses don't seem to be used to the screaming. I never hear screaming when I know the woman down the hall is giving birth, too. It's a little embarassing for me. I am definitely not a dramatic type of person who would choose to put on a show like this. And I am definitely not just screaming because I think it's therapeutic or something. It just really is THAT bad. I can't stop it or help it.

When I have spoken about this, other women tend to doubt that it could have been this way for me. It seems like outright screaming is unusual. I never knew that it was until I started reading other people's birth stories. No screaming. I have even heard people say that they experienced almost no pain at the very end, that all their pain came during dilation, whereas my pain just kept going until the baby was born.

My births are done without pain medication. They never give me pitocin until after the baby is born, to deal with the bleeding problem.

Am I doing something wrong? Is there a way I could do this differently? Have you ever worked with someone like me? Do you have any thoughts on this?
Any ideas or words of wisdom you could share with me would be greatly appreciated! Thanks for taking the time to read this.

Sincerely,

"Sarah"

Ten Centimeters. Push!

2008-03-14T07:12:00.000-07:00

Last week I found myself in one of my favorite positions -- Leaning over a hospital bed, rubbing the back of a laboring mother.

Over all, the labor wasn't bad.

I went in with a positive attitude, hopeful of seeing a good birth. I liked the obstetrician - she was an extremely nice woman with a great personality, and seemed to genuinely be enjoying her job. She was very supportive of the mother's desire to have no epidural if possible. Although medical reasons made the obstetrician decide that induction of labor was appropriate, she respected the mother's wishes to keep the Pitocin drip at a minimum and not turn it up once she started contractions.

The mother had given birth in the same hospital twice previously and was well prepared for labor. Her husband was supportive and as helpful as possible.

As labor progressed and the Pitocin induced contractions became more and more unbearable and on top of each other, the nurses were awesome. They provided one-on-one care, basically having someone in the room with us constantly. They, along with the father and I, encouraged the mother to try all sorts of positions - standing, hands and knees, sitting on the birth ball, rocking, etc.

I was even more impressed when the nurses got into whatever positions they had to to continue to monitor the baby's heart rate. It seemed that whenever the mother was in an upright position, the electronic fetal monitor (EFM) just wasn't tracing the heartbeat very well. So, the nurse had to stand there for several hours continuously holding the doppler in place to maintain a tracing. There was absolutely no "I'm really busy. You'll just have to lay in bed so we can get a decent tracing" or any, "I'm sorry this isn't working. We're going to have to put in a fetal scalp electrode." (The obstetrician wanted constant monitoring because of an increased risk of fetal distress with the Pitocin induction.) Care was all focused around what the mother wanted and needed and what made her most comfortable.

I was also impressed with the information that they provided the parents with before taking any action. The mother got vaginal exams when she wanted them, not every two hours or according to any set protocol. The father and mother both didn't want her water broken early in labor. The hospital staff respected their decision and didn't do it till near the end, when the mother requested it.

As I massaged the mother's shoulders and gave the father suggestions for new ways he could support her and asked the nurses to better explain the progress to the couple, I found myself thinking, "This birth isn't bad. It's about as good as hospital birth gets."

Of course, the Pitocin made things miserable for the mother, and more than once she just burst into tears and cried, "I just can't do this anymore!" But every time she got to that point, we managed to re-focus her on dealing with this contraction and just getting through right now. Her obstetrician poked her head into the room at just such a moment, and very quietly, almost reverently watched her experiencing an intense contraction. "Wow," she whispered. "You just never see women willing to do this any more. I'm so impressed."

Ten centimeters came as the sun came up. The shift would be changing soon, but these nurses were excited that they would get to see the fruit of this labor before they left. The doctor was summoned. Mother got back into bed and was positioned in a semi-sitting position. The bed was broke down, and her legs were spread apart while the overhead lights were turned onto the site of action. The doctor gowned and gloved. Two nurses held one leg (since the stirrups were uncomfortable) and I held the other. Sterile drapes were placed everywhere, leaving only the vaginal opening exposed. The father, nervous and excited at the same time, held her hand, and reassured his exhausted, tearful wife that she was almost done. She was so tired, and kept saying, "I don't think I have the energy to push. I can't."

We all assured her over and over that she could and would get her baby out. The doctor leaned in close to her face and looked her in the eyes, "Just listen to me and do what I tell you. Just follow my instructions closely and you'll be just fine."

The mother nodded through her tears, and the father whispered, "Honey, you can do it. Just listen to the doctor."

"Okay, on the next contraction...." The doctor began to explain the process of letting the contraction build, then taking a deep breath and holding it while pushing as hard as possible while the nurses count to ten.

I sighed to myself. Purple pushing. Why do all doctors think that this is the only way to get a baby out? I knew they'd do this. Why do I even hope that this time will be different?

("Purple pushing" is the above described technique, termed such by many doulas and midwives because the mother has so little time to breathe and exerts herself so intensely that she often starts to turn purple and even burst the blood vessels in her eyes. It has been employed at nearly every hospital birth I've ever attended. It barrels a baby a baby out faster than any other method of pushing. A first time mother who might take an hour to push a baby out when allowed to do it at her own pace, will usually push a baby out in less the 20 minutes with this incredibly intense way of pushing. I personally think that purple pushing can be necessary and effective if a baby is in fetal distress and there is a good reason to get the baby out as quickly as possible. If there is not medically indicated reason, I think it just traumatizes the mother's body [tissues don't have much time to stretch and she's more likely to tear, etc.] more than necessary, not to mention that she thinks of pushing as one of the hardest, most exhausting things she's ever done.)

So, the pushing began. "Take a deep breath. Hold it! PUSH!! One.... two..... three..... four.... no, no, don't take a breath yet! Keep pushing down and out as hard as you can!... five.... six... that's a girl!... seven.... eight... nine... TEN! Good push! Now, quick, quick, another deep breath, and down and out! One.... two.... three.... "

(Mother falls back exhausted. "I can't! I have to catch my breath! I can't breathe! Just let me catch my breath!")

"No, honey. Not till this contraction is done." (Pulling her forward) "Take a deep breath right now, and hold it. Hold it while I count to ten... (more insistently) ONE! TWO! THREE! FOUR...."

Ten minutes have passed. We're seeing a baby's head. The doctor comments on all the hair. Mother is gasping for air between pushes and saying she needs to slow down. The Pitocin drip is still going, and the contractions are coming right on top of another.

"No, not till your baby's here. Keep going!"
The nurses get in her face to help her stay with the pushing a little longer. I want to tell her she can take a 10 second break, but that is obviously not the opinion of the doctor.

I tell myself that this is ridiculous, but determine to keep my mouth shut. I'm the doula, not the obstetrician. The doc keeps taking sideways glances at the monitor. The baby's heart rate shows no sign of compromise. It's plugging away with nice short and long term variability around 140, even during contractions with head compression. Wow! The doctor smiles, "Your baby is doing great! Let's hurry up and get him out!"

The contraction ends. Mom falls back on her pillow and sobs and gasps for air. "Just... just let me rest for a minute..." I'm happy to see that the contraction is over and baby is wonderful. Surely they will let her rest till the next contraction hits. The father looks slightly concerned, torn between wanting to help his wife get what she says she needs, and wanting to follow the doctor's orders for the safety of the baby.

But, no, rest is not an option. The doctor wants to get this kid OUT! "You're almost crowning! You can't stop pushing now till your baby's head is out," she says firmly. The mother wearily sits forward, clutches her thighs again and pushes.

"No, harder, longer. Take a deep breath. Hold it while we count...." And again.... and again.

Finally a head emerges.

I breathe a sigh of relief. Finally the mother will get to inhale once without holding her breath for the count to ten.

I wait for the doctor to feel for cord around the neck. Instead she graps the baby's head firmly, locking her fingers under it's jaw line on both sides, braces her feet against the base of the hospital bed, and leans back, pulling for all she's worth. "PUSH!" she shouts at the dazed mother.

I watch with horror. The baby hasn't even rotated! How does she expect to pull the little guy out without allowing his shoulders to properly spiral through the pelvis?

The baby doesn't pop loose. Her eyes register panic. I see "lawsuit!" flashing through her mind. She yanks a little harder on the head. Still no baby. "Stuck baby!" the doctor half whispers severely to the nurses. The father has realized that the doctor is frightened and something is dead wrong. Tears squeeze out of his eyes.

"Supra-pubic pressure!" the doctor shouts in the direction of the nurse at her right shoulder. There are four nurses and a respiratory therapist standing by. Three of the nurses dive for the mother's stomach. (Supra-pubic pressure is usually applied with the palm of the hand, pressing down hard on the top of the pubic bone, trying to help the baby's shoulder "pop" out from underneath. It's a maneuver used for shoulder dystocia.)

One nurse lays the bed back flat with one swift maneuver. The other three pile onto the mother, leaning all of their weight into her stomach. She screams. "PUSH!" everyone yells together. "HARDER! HARDER! You've got to get this kid out!" The mother again grips her thighs, now having her knees almost to her ears and pushes with every ounce of strength she has left.
The doctor leans back and with all of her 200 pounds, pulls on the baby as if her life depended on it.

The baby pops out. It's been less then 15 seconds since the head emerged. The doctor quickly grabs a hold of the pink, squirming body of a crying baby and suctions and cuts the cord while uttering a sigh of relief. All that scare and an APGAR of 10. The nurses straighten up, slightly shaky. The parents can't stop crying and shaking. Their little boy is here, but his arrival was the worst minute of their life.

I stand there, still holding the mother's trembling leg and rubbing it and thinking...
About how this birth happened. About how it could have happened differently, if only some common sense had been used and everybody hadn't been in such a rush.

I replay every move over and over. It wasn't a shoulder dystocia. It was a little 6 lb. baby, being pushed out by a woman with a more than ample pelvis. If the baby would have been given another 30 seconds to rotate and line up the rest of his body, he would have slid out with the next push.

I shake my head, feeling sorry for the obstetrician who created her own emergency and is still shaking about the "close call" she had.

I feel most sorry for the mother and father who just went through some of the scariest moments of their life as they welcomed their baby.

The obstetrician tugs on the still pulsing cord, pulling out the placenta and throws it into a basin for pathology to inspect. She asks the nurse to turn the Pitocin up (to keep the mother from bleeding), and then inspects for tearing.

Seeing none, she looks pleased. It's been almost 5 minutes since the baby was born. He is wailing in his little warmer next to the bed. The mother is too exhausted to want to hold him right now, so the nurses are playing with him. The doctor pats her patient on the leg and says, "You look great! You'll be a little sore. Just use ice packs for a couple days. Congratulations! You have a beautiful baby!" She breezes out the door, to deliver the next patient.

I like her. She's a nice, caring woman. She's sweet and friendly. The nurses were great.

But now I know why I don't want a hospital birth. Sometimes I forget.
I'll remember this one for awhile.

Daylight Section

2008-02-25T08:34:00.000-08:00

After receiving the email from our mutual friend about her new grand baby's delivery, my friend wrote the following poem, which she has given me permission to share with you...

Daylight section

Your baby is here!

What an awesome blessing!

Congratulations!

You hear

7 lbs, 3 oz baby girl

Healthy, full head of hair

Your baby is here!

You should be so happy!

Broken water

Ticking time-clock

Fetal monitor, pitocin drop

Doesn’t matter now, be happy!

Rejoice, rejoice, your baby is here!

Happy, healthy, full head of hair.

Tied down, trussed up, starved and drugged

Lied to, terrified, heart tones dropped?

But your baby is here, you should be happy,

Congratulations!

They did their best for you

Congratulations.

Your baby is here.

Prepped for surgery, shaved and scrubbed

Catheters, monitors, gaping wound

Daylight section

Beautiful baby extracted

A good outcome, no distress after all

Congratulations.

…and condolences.

This poem is dedicated to Sofia, Noelle and all the others
who have been cut from their mother’s womb for no good reason

Be Happy! It's a 7lb, 3oz. Baby Girl!

2008-02-25T07:09:00.001-08:00

I received this email from a new baby's grandma about week ago. It's the story of millions of American women who don't know whether they should grieve over their surgical birth, or just move on and "be happy" that they have a healthy baby.
After all, what more could they ask for? Their doctor all but promised them a healthy baby.
S/he didn't promise how that baby would arrive, except that it would be in the safest way possible, the best that 21rst century medicine can deliver.

"Noelle" was surgically delivered before noon today

7 lb 3oz.

They say she has a full head of long dark hair and that she is pink and alert when awake, nursing at least every 3 hours.

They sent a picture of her to my cell phone. The picture of Noelle is now my cell wallpaper.

The interventions and subsequent "fetal distress" were horrific. I cried all day long from anxiety over what they did to "Sarah" [daughter in law] and my granddaughter. They tied her, they trussed her, they starved her, they drugged her, they exhausted her and they terrified her.
After that torture, "fetal distress" was inevitable. (Eeek! fetal heart tones dropped to 127!!)
.... It was all conveniently resolved with major abdominal surgery.

In spite of the interventions, Noelle was vigorous upon extraction. Oops, no cord wraps or fetal depression after all, hmmm.... But they got the kid conveniently "delivered" during daylight hours and within the 24 hour deadline from spontaneous rupture of membranes (SROM). Another "good outcome" for their stats.

A good outcome on paper. But was it good for mother and baby?
Did the treatment they received increase their chances of safety, of life, of successful breastfeeding,
of bonding, of happy mothering?

They had a one in three chance of C-section just by choosing hospital birth in the United States.
But 1 to 3 is 100% if you happen to be the ones sectioned.
It's not like my daughter-in-law was only 33% sectioned.

I am grateful that Noelle seems to have weathered the storms of intervention fairly well. But who knows the long term effects? Mommy, on the other hand, is now not only a new mother, but a post operative patient.

There is a place for emergency C-sections. But in this case, the emergency was created by the very system my loved ones blindly trusted to provide "safety".

I was painfully aware of the peril they were entering with their choice of care and helpless to avert the impending tragedy.
I did what I could to provide accurate information and techniques for dealing with a system that is more about avoiding medical liability than supporting the normal process of birth. (And I had prayed that they would "luck out" and end up being blissfully ignorant of the dangers they had avoided.)

I am so angry at the successful "sale" of "services" with which my loved ones got a total "bait and switch".

The reality of grandmotherhood has not really set in. I SO want to be happy.
And I am grateful for the precious child.
But I am heartbroken by the inhumane way she and her mother were treated at such a crucial time in their lives.

Thankfully, Sarah planned to breastfeed which seems to be going fine.

It's tomorrow now. Maybe I have cried myself out and I can get some sleep now.

On Surgeons and Normal Birth

2008-02-15T19:22:00.001-08:00

"In [European] countries, obstetricians serve as specialists. They are essential members of the maternity care team, but they play a role only in the 10 to 15 percent of cases where there are serious complications. Most women have babies without ever setting eyes on a doctor.

In the United States, the numbers are reversed. Obstetricians "attend" 90% of births and have a great deal of control, essentially a monopoly, over the maternity care system. Obstetricians are taught to view birth in a medical framework rather than to understand it as a natural process. In a medical model, pregnancy and birth are an illness that requires diagnoses and treatment. It is an obstetrician's job to figure out what is wrong (diagnoses) and do something about it (treatment) - even though, with childbirth, the right thing in most cases is to do nothing.

To put it another way, having an obstetrical surgeon manage a normal birth is like having a pediatric surgeon babysit a normal two-year-old. Both will find medical solutions to normal situations -- drugs to stimulate normal labor and narcotics for a fussy toddler. Its a paradigm that doesn't work."

Marsden Wagner, M.D., M.S.

Born In the USA,
How a Broken Maternity Care System Must Be Fixed
to Put Women and Children First,
University of California Press, 2006

ACOG's lastest grenade tossed at homebirth

2008-02-10T19:57:00.000-08:00

It should come as no surprise... homebirth advocates are stirring the water and challenging groups like ACOG to justify their stances on homebirth and midwives with evidence. No new studies in the works, just another statement of their opposition to homebirth...

ACOG NEWS RELEASE

For Release:
February 6, 2008

Contact:
ACOG Office of Communications
(202) 484-3321
communications@acog.org

ACOG Statement on Home Births

Washington, DC -- The American College of Obstetricians and Gynecologists
(ACOG) reiterates its long-standing opposition to home births. While
childbirth is a normal physiologic process that most women experience
without problems, monitoring of both the woman and the fetus during labor
and delivery in a hospital or accredited birthing center is essential
because complications can arise with little or no warning even among women
with low-risk pregnancies.

ACOG acknowledges a woman's right to make informed decisions regarding her> delivery and to have a choice in choosing her health care provider, but
ACOG does not support programs that advocate for, or individuals who provide,
home births. Nor does ACOG support the provision of care by midwives who are
not certified by the American College of Nurse-Midwives (ACNM) or the
American Midwifery Certification Board (AMCB).

Childbirth decisions should not be dictated or influenced by what's
fashionable, trendy, or the latest cause célèbre. Despite the rosy picture
painted by home birth advocates, a seemingly normal labor and delivery can
quickly become life-threatening for both the mother and baby. Attempting a
vaginal birth after cesarean (VBAC) at home is especially dangerous
because if the uterus ruptures during labor, both the mother and baby face an
emergency situation with potentially catastrophic consequences, including
death. Unless a woman is in a hospital, an accredited freestanding
birthing center, or a birthing center within a hospital complex, with physicians
ready to intervene quickly if necessary, she puts herself and her baby's
health and life at unnecessary risk.

Advocates cite the high US cesarean rate as one justification for
promoting home births. The cesarean delivery rate has concerned ACOG for the past
several decades and ACOG remains committed to reducing it, but there is no
scientific way to recommend an 'ideal' national cesarean rate as a target
goal. In 2000, ACOG issued its Task Force Report Evaluation of Cesarean
Delivery to assist physicians and institutions in assessing and reducing,
if necessary, their cesarean delivery rates. Multiple factors are responsible
for the current cesarean rate, but emerging contributors include maternal
choice and the rising tide of high-risk pregnancies due to maternal age,
overweight, obesity and diabetes.

The availability of an obstetrician-gynecologist to provide expertise and
intervention in an emergency during labor and/or delivery may be
life-saving for the mother or newborn and lower the likelihood of a bad outcome. ACOG
believes that the safest setting for labor, delivery, and the immediate
postpartum period is in the hospital, or a birthing center within a
hospital complex, that meets the standards jointly outlined by the American Academy
of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that
meets the standards of the Accreditation Association for Ambulatory Health
Care, The Joint Commission, or the American Association of Birth Centers.

It should be emphasized that studies comparing the safety and outcome of
births in hospitals with those occurring in other settings in the US are
limited and have not been scientifically rigorous. Moreover, lay or other
midwives attending to home births are unable to perform live-saving
emergency cesarean deliveries and other surgical and medical procedures
that would best safeguard the mother and child.

ACOG encourages all pregnant women to get prenatal care and to make a
birth plan. The main goal should be a healthy and safe outcome for both mother
and baby. Choosing to deliver a baby at home, however, is to place the process
of giving birth over the goal of having a healthy baby. For women who
choose a midwife to help deliver their baby, it is critical that they choose only
ACNM-certified or AMCB-certified midwives that collaborate with a
physician to deliver their baby in a hospital, hospital-based birthing center, or
properly accredited freestanding birth center.

The American College of Obstetricians and Gynecologists is the national
medical organization representing over 52,000 members who provide health
care for women

Response to ACOG's recent statement on Home birth

2008-02-10T19:42:00.000-08:00

PushNews from The Big Push for Midwives Campaign

CONTACT: Steff Hedenkamp, (816) 506-4630, RedQuill{at}kc.rr.com

FOR IMMEDIATE RELEASE: Thursday, February 7, 2008

ACOG: Out of Touch with Needs of Childbearing Families

Trade Union claims out-of-hospital birth is “trendy;”

tries to play the “bad mother” card

(February 7, 2008) — The American College of Obstetricians and Gynecologists (ACOG), a trade union representing the financial and professional interests of obstetricians, has issued the latest in a series of statements condemning families who choose home birth and calling on policy makers to deny them access to Certified Professional Midwives. CPMs are trained as experts in out-of-hospital delivery and as specialists in risk assessment and preventative care.

“It will certainly come as news to the Amish and other groups in this country who have long chosen home birth that they’re simply being ‘trendy’ or ‘fashionable,’” said Katie Prown, PhD, Campaign Manager of The Big Push for Midwives 2008. “The fact is, families deliver their babies at home for a variety of very valid reasons, either because they’re exercising their religious freedom, following their cultural traditions or because of financial need. These families deserve access to safe, quality and affordable maternity care, just like everyone else.”

Besides referring to home birth as a fashionable “trend” and a “cause célèbre” that families choose out of ignorance, ACOG’s latest statement adds insult to injury by claiming that women delivering outside of the hospital are bad mothers who value the childbirth “experience” over the safety of their babies.

Hundreds of Missouri home birth families in support of midwives fill a Senate Hearing room in 2005

“ACOG has it backwards,” said Steff Hedenkamp, Communications Coordinator of The Big Push and the mother of two children born at home. “I delivered my babies with a trained, skilled professional midwife because I wanted the safest out-of-hospital care possible. If every state were to follow ACOG’s recommendations and outlaw CPMs, families who choose home birth will be left with no care providers at all. I think we can all agree that this is an irresponsible policy that puts mothers and babies at risk.”

The Big Push for Midwives calls on ACOG to abandon these outdated policies and work with CPMs to reduce the cesarean rate and to take meaningful steps towards reducing racial and ethnic disparities in birth outcomes in all regions of the United States. CPMs play a critical role in both cesarean prevention and in the reduction of low-birth weight and pre-term births, the two most preventable causes of neonatal mortality.

Moreover, their training as specialists in out-of-hospital maternity care qualifies CPMs as essential first-responders during disasters in which hospitals become inaccessible or unsafe for laboring mothers. In addition, CPMs work to ensure that all babies born outside of the hospital undergo state-mandated newborn screenings and are provided with legal and secure birth certificates.

Currently, Certified Nurse-Midwives, who work predominantly in hospital settings, are licensed and regulated in all 50 states, while Certified Professional Midwives, who work in out-of-hospital settings, are licensed and regulated in 24 states, with legislation pending in an additional 20 states.

The Big Push for Midwives http://www.TheBigPushforMidwives.org is a nationally coordinated campaign to advocate for regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, the District of Columbia and Puerto Rico , and to push back against the attempts of the American Medical Association Scope of Practice Partnership to deny American families access to legal midwifery care.

Media inquiries should be directed to Steff Hedenkamp (816) 506-4630, RedQuill{at}kc.rr.com.

Is It Safer to Have Another Cesarean or Attempt a Vaginal Birth (VBAC)?

2008-02-04T17:21:00.000-08:00

And the evidence in favor of vaginal birth over repeated cesareans just keeps piling up!
Check out this most recent study, just published in the journal of
Obstetrics & Gynecology
(2008;111:285- 291).

The study's OBJECTIVE:
To estimate the success rates and risks of anattempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs.

METHODS:

From a prospective multicenter registry collected at 19 clinical
centers from 1999 to 2002, we selected women with one or more prior low
transverse cesarean deliveries who attempted a VBAC in the current
pregnancy. Outcomes were compared according to the number of prior VBAC
attempts subsequent to the last cesarean delivery.

RESULTS:

Among 13,532 women meeting eligibility criteria, VBAC success
increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%,
and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively
(P<.001).

The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52%(P=.03) .

The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.

CONCLUSION:

Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy. Contrast that study with another from Obstetrics & Gynecology (2006;107:1226- 1232) which found that there is maternal morbidity associated with multiple repeat cesareans.

OBJECTIVE:

To estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries.

METHODS:

Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay *significantly increased *with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively.

CONCLUSION:

Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery.

Miscarriage... Is There an Answer?

2008-01-23T08:43:00.000-08:00

I think so, and I want to write a book about it!

Several years ago, I was contacted by several women who were having repeated miscarriages. They desperately wanted to have a baby. These women found their hopes soaring several times a year when they would find themselves pregnant, only to be harshly crushed a couple of months later when they began spotting... bleeding... cramping.... staying in bed, calling their doctor or midwife.... and then miscarrying.

Some of them would call me sobbing, saying, "All I want is a live baby! Why can't anyone tell me what's wrong with me? Why doesn't my doctor know what to do? I've done every test that modern medicine has invented and they still don't know why this keeps happening!"

I didn't know any more than their doctors did.
All I could say was, "I'm sure there's an answer somewhere. Obviously, something's wrong, and usually when there is something wrong, there is almost always a way to fix it..."

Their agony of miscarriage after miscarriage compelled me to try to find answers. I read books.
I spent days and months online, researching. I waded through big, fat textbooks, and boring Swedish studies on reproductive health. I read fertility books. I talked to mothers and their doctors and midwives.

I began to find bits and pieces here and there... things that sounded reasonable and helpful. I began forwarding articles and information on to my friends who were struggling with miscarriage.

Before long I began receiving calls - I'm four months pregnant and I'm doing fine!"
Mothers would beam, "This baby is our miracle baby!" and then they'd tell me about taking vitamins, drugs, herbs, hormone supplements, additional testing - all kinds of things that I had found info on.

One of those success stories!

I began to see things that were working for some of these women. They were solving their own problems with lots of information in front of them. They started passing my number on to their friends. Soon I found myself besieged with calls from desperate women from across the country who would call me at all hours, apologizing for their call, but explaining that they were spotting or cramping and thought maybe I could help them because their friend had told them about me.

I really couldn't "prescribe" anything to them. I couldn't tell them what to do. I wasn't a medical professional, and I wasn't their caregiver. But I had several big folders, packed with studies, articles, recommendations from both the medical field and alternative healthcare practitioners.
And now, I had personal stories from women who had live, healthy babies, and credited it to what they had done with both modern medicine and things as simple as herbal teas and healthy foods.

I decided to find the best book to recommend to these women... And I began searching for a "miscarriage bible" - an all encompassing book, explaining miscarriage and it's many causes and a whole range of possible solutions. When I realized it didn't exist, I began looking for a book from the medical model, focused on miscarriage and how to prevent it and a book from the holistic perspective as well. I bought most of the books I could find, but none of them seemed to be what these mothers needed.

So, I decided that I would write the book, since no one else has. I have a lot of information. I need to find a lot more. I need to know more of the most puzzling questions about miscarriage and what women want to know about it. My work on this project has been on hold for nearly two years now, as I have had other things to focus on. But, I want to get back to work on it shortly, because I know that every day there are women looking for answers, and I want them to find them somewhere...

If you have any suggestions, or questions about miscarriage that you would like to see answered, or if you have ideas for studies that you wish somebody was doing, or... whatever you think would be most helpful in the arena of miscarriage, I'm looking for more material and questions.

If you know of anyone who is currently researching miscarriage, or who has a special "remedy" or unique information in their practice, I'm anxiously waiting to hear more!

I'm interested in anything and everything that can be done to prevent a miscarriage - drugs, herbs, surgery, vitamin and mineral supplements, hormones, nutrition, family relationships, essential fatty acids....

I'd like to know what testing is most helpful and practical, and what has not be helpful in determining the causes of miscarriage.

I'd also love to include stories of women who have struggled with miscarriage, and of course, some success stories!

Email me at: betterbirth4you {at} gmail {dot} com.

The Struggle to Be Skinny Enough

2008-01-14T21:43:00.000-08:00

It was a few weeks ago. I found myself sitting in a little restaurant, the walls covered with retro advertisements and old Coca Cola signs from the 50’s.

I sat there, sipping my drink and waiting on my food, when the thighs of a bright and smiling girl with bouncy curls on a poster on the wall caught my eye. She wore a yellow pleated mini skirt, and was leaning back, holding her Coke. Her thighs were prominent in the picture and they were so … uh, normal sized. She wasn’t fat, or chubby, but her rosy cheeks glowed. She looked healthy and hearty. I couldn’t stop staring at her. It just seemed so weird to see a model about my size, not rail thin, on the wall.

I spent more time starting at the rosy cheeked girl with a huge smile on the Coca Cola poster than I did eating my food. How different from the models that are held up today as the perfection of beauty, I mourned to myself. The models from fifty years ago weighed far more than the stars of today. They weren't fat; they were healthy weights, with some curves, and actual flesh on their bones!

Angelina Jolie, thin limbs, gaunt and hollow face. Our culture has adjusted to thinking this is as good as beauty gets! Every magazine and billboard shouts out that sharp and stark cheek bones are more beautiful than gently rounded cheeks, legs are more beautiful with nothing but bone, and waists are most beautiful when they are impossibly small.

This is what our girls try to be. They starve themselves, live on diet sodas, protein shakes, low-calorie fillers… binge and purge because of the array of food set before them hourly. …Always feeling fat and ugly and hoping to catch a guy’s attention by getting as skinny as their friends. Size 4 jeans have almost become a status symbol.

Growing up in a culture that values an almost starved look (one that most people cannot obtain in a healthy way) carries over into motherhood.

A few months ago, I was visiting with a pregnant doula client and her husband. This beautiful woman who I’ll call Grace [details changed to protect her identity] is slender – 10-20 pounds underweight, and half-way through her pregnancy weighs less than she should as a non-pregnant person.

Grace was talking about her baby’s movement. I asked if I could touch her belly and feel the baby. She smiled and said, “Of course. He’s right here.” As I laid my hand on her nearly flat stomach (yes, she was half way through her second trimester!), she grimaced and said, “Sorry, there’s a huge blob of fat there. You’ll just have to ignore it.” Then she turned away and looked embarrassed.

Of course, I said something positive back to her about her body, but as I left I wondered how many other pregnant mothers feel the same way about their bodies, not because there is any truth to the way they feel, but because our culture makes them feel that way.

How many women feel like Grace? How many women are starving their babies for fear of “getting fat”?

I’m not advocating obesity or being overweight or gaining a huge amount while pregnant, or pigging out, or…

I’m advocating that women feel pressure to be healthy, not skinny!

New York City Midwifery Care - 1931-1961

2008-01-10T17:49:00.000-08:00

The Maternity Center Association, New York City ~ 1931-1961

From 1931 the Lobenstine Midwifery Clinic of New York City, in affiliation with the Maternity Center Association (MCA), offered home birth services to help meet the needs of the most economically deprived and needy families of the upper Manhattan tenements. Between 1931 and 1961, 5,766 mothers registered with the clinic, of which 87% gave birth at home, attended by midwives. Their maternal mortalities were less than one third the national rates of the time. Their average neonatal death rates were only 16 per 1,000, while that of New York City as a whole ranged from 28.9 in 1931 to 18.4 in 1961. These results by the MCA midwives are even more remarkable in light of the fact that poor nutrition was prevalent among their clients. 36.4% of them suffered from secondary anemia, 6.3% tested positively for syphilis and 6% were in their tenth pregnancy. The MCA discontinued its home birth services years ago, but retains its legacy of superior outcomes.

~ From Law, M., Report on the Maternity Center Association Clink, NY, 1931-1951, American Journal of Obstetrics and Gynecology, 69:178-184, 195S.

~ Faison, J., The Maternity Center Association Clinic, NY, 1952-1958, American Journal of Obstetrics and Gynecology, 81:395-402, 1961.

These data and additional studies which I will be posting and crediting to Dr. David Stewart's work have been excerpted from his book, The Five Standards for Safe Childbearing, by Dr. David Stewart, Ph.D. Dr. Stewart is a medical statistician with special education in obstetrics and is one of the leading world authorities in the area of midwifery and home birth statistics. He has been an invited lecturer at meetings of the American College of Obstetrics and Gynecologists (ACOG) and the National Perinatal Association (NPA) and numerous other childbirth-related functions throughout North America. He has served on committees of the American Public Health Association (APHA) and the American College of Nurse Midwives (ACNM). Dr. Stewart is the author or co-author of more than 200 publications, including 13 books. He serves as the Executive Director and co-founder of the International Association of Parents and Professionals for Safe Alternatives in Childbirth - NAPSAC International.

For more information, or to purchase The Five Standards for Safe Childbearing, contact:

NAPSAC International

Rt. 4, Box 646

Marble Hill, MO 63764

Phone/Fax: (573) 238-2010 or

(800) 758 - 8629

A Clearly Defined Risk of Cesarean Birth: Hysterectomy

2008-01-07T12:53:00.000-08:00

The American College of Obstetricians and Gynecologists’ “Green Journal” contains some enlightening news in the January 2008 issue that every pregnant woman should know. It’s contained in a report about a very recent study titled, “Cesarean Delivery and Peripartum Hysterectomy” -- Obstetrics & Gynecology, Knight et al, 2008; 111:97-105-

Check it out here: http://www.greenjournal.org/cgi/content/abstract/111/1/97

I hope you have a friend with access to the medical journal who can get you a copy of the complete study. It’s a great resource to keep on hand… and to give to anyone who has been told that “cesarean is about equally safe when compared to vaginal birth”!

The study was a population-based, matched case-control study that studied 318 women who underwent peripartum (around the time of birth) hysterectomy between February 2005 and February 2006 and 614 matched control women. The study was done in the United Kingdom, using the United Kingdom Obstetric Surveillance System.

The conclusion of the study was:

Peripartum hysterectomy is strongly associated with previous cesarean delivery, and the risk rises with increasing number of previous cesarean deliveries, maternal age over 35 years, and parity (number of pregnancies carried to over 28 weeks) greater than 3.

Here are a few of the most interesting and relevant findings of the study:

Women who were having their first cesarean delivery were approximately 7.13 times more likely to end up with a hysterectomy (as compared to an equal control group having a vaginal delivery instead) by the time it was all over.

By the time it was the woman’s second or more cesarean delivery, her risk of hysterectomy was over 18 times greater than the woman having a vaginal birth!

~Women undergoing their first vaginal delivery were found to have a
1 in 30,000 chance of having a peripartum hysterectomy

~Women undergoing their first cesarean delivery were found to have a
1,700 chance of having a peripartum hysterectomy.

~Women undergoing their second cesarean delivery were found to have a
1 in 1,300 chance of having a peripartum hysterectomy

~Women undergoing their third or more cesarean delivery were found to have a
1 in 220 chance of peripartum hysterectomy.

ACOG’s journal said it themselves:

“This study has confirmed the significant risk of peripartum hysterectomy associated with prior cesarean delivery. These data provide evidence that cesarean delivery leads to a greater than seven times increase in the odds of having a peripartum hysterectomy to control hemorrhage. A similar risks was noted in a recent U.S. study using the Nationwide Inpatient Sample. We have also been able to identify that the risk also then extends beyond the initial cesarean delivery into subsequent deliveries; women who have more than one previous cesarean delivery have more than double the risk of peripartum hysterectomy in the next pregnancy, and women who have had two or more previous cesarean deliveries have more than eighteen times the risk. This full quantification of these risks provides the evidence needed to comprehensively counsel women about the risks of primary cesarean delivery and to counsel against cesarean delivery without a specific medical indication.”

The article winds up with a statement:

“Although fortunately a rare condition, peripartum hysterectomy nevertheless represents a catastrophic (and sometimes fatal) end to a pregnancy for any woman, regardless of whether she considers her family to be complete.”

Kudos to your obstetrician if s/he brings up this info when informing you of the risk of Cesarean section birth!

Frank Conversations on Cesareans

2008-01-07T05:54:00.000-08:00

Most of the “risk” that we hear discussed for Cesarean section includes the possibility of

~post-operative infection,

~blood clots,

~anesthesia complications,

~damage to the bladder and bowels,

~potential problems with future pregnancies like infertility, miscarriage, placenta accreta

and placenta praevia

~and in some rare cases, even death.

Yet, few obstetricians really cover these potential complications in a way that will give a birthing mother a realistic view of what all her C-section could entail – a whole lot more than her idea of “I’ll be kind of sore for a few days or weeks.”

A friend of mine who recently had an elective cesarean developed blood clots afterwards and was shocked to hear that they could have been a result of how she chose to have her baby. Of course, she could have read up on the potential complications and figured that out herself ahead of time, but really, physicians should either thoroughly inform their patients themselves or see to it that they are reading books and doing research and getting informed during their pregnancies. And more than just reading, “What To Expect When You’re Expecting” or watching birth stories on TV.

Sure, of course, the anesthesiologist comes in and rattles off the usual, “you could die, be permanently paralyzed, etc.” stuff as the laboring mother is doing her best to hold herself together and prepare for the long ride down the hall to the OR, wondering if her baby will be okay. Of course, she nods and says she understands and scribbles her name on the paper in between contractions. But does she really understand what she’s signing up for?

That’s what I wonder. What kind of conversations do doctors have with their pregnant patients about the possibilities of a cesarean? …Not only that it could happen to them for various reasons (some good and some not so good), but that by simply having a cesarean, they are increasing their risk for many more complications.

Do they have frank conversations with their patients about weighing risks and benefits of a cesarean for a non-life threatening issue that comes up in labor (i.e. labor isn’t happening as fast as usual) if they are planning to have more children in the future? Or do they just imply that, “If you end up with a cesarean, trust me, it will be for a good reason to make sure you have a live, healthy baby. Vaginal births are great, but don’t get your hopes too high. You don’t want to be disappointed if it doesn’t work, because, really, your goal is a healthy baby, not how you have your baby.”

What Are the Risks of Cesarean Section?

2008-01-05T04:44:00.000-08:00

What are the risks of having a Cesarean section? …The risk of having two, even three C-sections? …For the mother, for the baby?

What are the risks of vaginal birth? …For the mother, for the baby?

If you are the typical American woman wondering about these questions, you’ll probably ask your doctor, perhaps check out a few resources online and see what the most popular pregnancy guide book, What to Expect When You’re Expecting has to say. You might even ask your childbirth educator about c-sections, and she would probably help you feel more prepared for it, by explaining when it is likely to happen and how you may feel about it if/when it happens to you.

Hearing women talk about cesareans has often made me wonder exactly what the average pregnant woman does and doesn’t know about having a c-section when she walks into the hospital to give birth. I’m on a mission to find out…

Is she adequately informed of the risks? Does she have a clear idea of the risks and benefits? Does she know as much about this procedure on her and her baby’s body as she does about purchasing her new car and comparing models?

I checked out What to Expect When You’re Expecting, and no where in its 437 pages could I find even one paragraph informing mothers of the potential risks for themselves when undergoing Cesarean delivery. The most I found for mothers was information on what a C-section would be like and how to be calm as you were wheeled back to the operating room for an emergency c-section, and then what recovery would entail – pain around the incision, possibly nausea and vomiting, possibly referred shoulder pain for a few hours and possible constipation, then it should be 4-6 weeks before you feel completely back to normal.

And this quote to put everyone’s fears to rest –

Question: “My doctor told me I will have to have a cesarean. But I’m afraid the surgery will be dangerous.”

Answer: “Today…cesareans are nearly as safe as vaginal deliveries for the mother, and in difficult deliveries or when there’s fetal distress, they are often the safest mode of delivery for the baby. Even though its technically called major surgery, a cesarean carries relatively minor risks – much closer to those of a tonsillectomy than of a gall bladder operation, for instance.”

Hmmmm…I’ve heard a few other things about cesareans recently. I’ll post them here as I get a chance…

The Making of Mothers

2007-12-29T21:06:00.000-08:00

"It's not just the making of babies, but the making of mothers that midwives see as the miracle of birth."

-- Barbara Katz Rothman,
Sociologist, Author of The Tentative Pregnancy,
Genetic Maps and Human Imaginations and other books.

Ina May Gaskin has this quote up on her site: http://www.inamay.com
as the "quote of the week," and I just couldn't resist posting it here.

It's so true. People ask me how midwifery care is different from seeing an OB for a monthly prenatal check-up. Sometimes it's hard to articulate exactly what it is about the Midwives Model of Care that compels mothers who have experienced it to do almost anything to find a midwife for their next pregnancy. People in the medical field are baffled as they almost never come back to the obstetrical model of care. Why?

This quote sums it up, I believe.

A Christmas Wish for Birthing Women

2007-12-24T18:48:00.000-08:00

As everyone rushes around, gathering with family and friends for Christmas, baking cookies, piling their cars high with gifts, and eating more than ample portions of Christmas candy and sweets, I’ve thought about what I really want this Christmas.

What I want isn’t tangible, and I won’t get it tomorrow morning as a Christmas gift.

But I still wish for it, for my future, and that of every young woman who will someday face the prospect of pregnancy, birth, and motherhood.

I dream of the day….

~ When pregnant women are honored and treasured by society as life-givers and very special people.

~ When all women will be informed and educated about their bodies, birth, and babies.

~ When maternity care providers will believe that parents are good decision makers when presented with accurate information.

~ When every woman will have access to a midwife, a doula, a physician, a circle of supportive friends and anyone else she needs or wants to give her the best pregnancy possible.

~ When pregnant women walking through the grocery story will hear, “You can do it!” instead of, “I hope you signed up for an epidural! You have no idea how bad it hurts!”

~ When women aren’t expected to have perfect bodies that show no signs of having carried and birthed a baby.

~ When birth and babies again belong to mothers and fathers…. Not the state, not the American Medical Association, not the insurance companies, or the hospitals or obstetricians.

It won’t happen overnight, but it can happen when committed people work to change their own little corner of the world.

You may not be able to transform your local hospital’s policies, but you can educate your daughters, the girls in your neighborhood, your classmates and colleagues about birth.

You may not be able to stem the rising C-section rate, but you can help this mother avoid an unnecessary one.

You may not write a book that improves birth for other women, but you can write a letter to the newspaper about women’s birth options in your area.

You may never get everyone to breastfeed, but you can convince some people of the huge difference it can make in the future health of any baby.

You may never appear on a talk show about birth, but you can talk to your friends about improving birth.

You may never change the world, but you can change your world!

Broccoli flavored amniotic fluid and breastmilk?

2007-12-19T07:30:00.000-08:00

There is a growing body of evidence that before you ever stick a bite of mashed carrots or peas in your baby's mouth, the way you have eaten during pregnancy and while breastfeeding your infant may greatly influence their eating preferences as babies and toddlers.

In a study reported in the December issue of Pediatrics, babies whose mothers regularly eat veggies and fruits while breastfeeding them, find that their babies are more likely to accept vegetables and fruits when tasting them for the first time as well as consume larger amounts. Sometimes it's obvious that a mother's consumption of various foods is passed on through her breast milk - like when she eats too much garlic, and the next morning the baby screws up his or her face and turns away from the breast. But this research shows that perhaps the baby can also taste green beans and peaches and learn to like them.

Research also shows us that babies tend to have the eating preferences that their mothers had during pregnancy as food flavors from a mother's diet are transmitted to the amniotic fluid that a baby lives in and drinks while in utero.

The 2004 Feeding Infants and Toddlers Study showed that 1 in 4 US toddlers did not consume even 1 vegetable on any given day. They were more likely to be eating fatty foods and sweetened snacks and beverages than any vegetables. And none of the top 5 vegetables consumed by the toddlers was a dark leafy vegetable. I bet their mamas preferred sweet snacks and beverages and fatty foods when they were pregnant.

So, yes, eat your veggies and avoid junk while you're pregnant and on through the breastfeeding phase of your child's life, if you want your baby to grow up happily eating squash, broccoli, and apples instead of Twinkie cakes and Mountain Dew!

How much do nurses learn about natural birth?

2007-12-13T11:34:00.000-08:00

A week or so ago, I heard from my friend, "Julie". She's a newly trained doula, finishing up her certification and has been attending births since last summer.

Julie had been invited to speak to a nursing class about the role of a doula* in the delivery room, and comfort measures that can help women cope with the pain of labor. I was excited for her and hoped that she would be a part of helping this whole class of nursing students understand and promote natural birth. I was shocked when she emailed with a report of how it had went...

"The nursing speech went well. I was surprised to learn that even though it's a maternity nursing class, the students never see a mom in labor, never do any type of labor support. Their clinicals cover newborn tests and postpartum work - not actual labor work. The professor said that she has to cover IV medications and epidurals because that's what's on the state exam. They don't have time to work on other comfort measures. It was hard to relate my info to the students since they've never seen a labor[and] can't fathom why anyone would do it without pain meds...
When I mentioned that they can really set the tone for a labor and can really influence how a mom feels, there were lots of nervous giggles. When I said something about how moms look to them for reassurance that everything is ok and that many moms feel like the nurse is in an authority position -- they actually looked panic stricken!
It puts the nurses in a slightly different perspective for me. Maybe they aren't anti-natural birth as much as they just really don't know what to do [for a mother attempting a natural birth]. They aren't trained in it at school."

These are RN students, getting a 4 year nursing degree from what is considered a top nursing school in the midwest. This class is the Maternal/Neonate one that everyone is required to take.
Julie learned that their clinicals include coming in as a women is in the final stages of pushing, just in time to do the baby's Apgar scores, weight, etc. They also do the next day post-partum vitals for the mother (blood pressure, temperature, etc).

They are not required to have any hands-on experience with a laboring woman. The actual non-pharmacological labor support, what happens during labor, etc. is one or two class periods. The professor said that she has to focus on pain medications, when to give them, when to wait, who can have what, etc. because that is what they will be tested on during their state exam. When asked about other comfort measures for laboring women, the professor told Julie that the text book does a "nice job of explaining" comfort measures.

Makes me wonder how much birth - natural or medicated or surgical - the average nurse has seen when she finishes her nursing degree and graduates as an RN! Any nurse readers, please chime in with comments and let me know how much birth you had experienced when you finished nursing school!

Maybe I shouldn't have been so shocked a few years ago when I was working as a doula in a small town hospital, and labor quickly picked up for my client. Before we knew it the mother had gone from being 3 cm dilated to 10 cm and pushing in less than 30 minutes - and the OBs had all gone home for the night.
The young labor and delivery nurse who was covering my doula client for the evening started to scream, "Noooooo! Don't push! You have to hold it in for the doctor! I can't catch a baby! I don't know how! Don't do this to me. Nooooo!" She looked positively terrified, and was visibly shaking.
She didn't catch the baby - he landed at the end of the bed, and she still shaking, picked him up and said, "Well, I guess he's okay." Then she looked at me and said, "This is my first birth as a nurse."

I was shocked. Maybe I shouldn't have been.

* A doula is a professional labor support person who stays with the mother through labor to provide physical and emotional support.

Blood Volume of a Pregnant Woman

2007-12-10T07:47:00.000-08:00

In a conversation with a
perinatologist recently, I found
out a couple of neat facts that
you might find interesting....

~A full-term pregnant woman has an
approximate blood volume of 10 liters.
That's five 2-liter soda bottles!

~The uterus has 1/2 liter of blood
flowing through it per minute at the
time of birth/full term.

What is Good Prenatal Care?

2007-12-01T18:08:00.000-08:00

Awhile ago I was sitting in a seminar/class for people who work in the world of midwifery and/or obstetrics.
A very wise woman was articulating what prenatal care is all about. She said something profound that I've never forgot. In her words,

"Being a midwife or an obstetrician is not just about catching babies. Being the primary caregiver for a pregnant woman is teaching the mother to be the primary caregiver for herself and her baby. We cannot give prenatal care. We can only give a lot of information to the mother to help her give herself better prenatal care."

US ranking in maternal mortality

2007-11-30T20:03:00.000-08:00

TIME magazine recently reported that the United States ranks 41rst out of 171 countries, of women who die from complications in pregnancy or childbirth. The death rate in America - one in 4,800 - far surpasses other developed countries where they average one in 16,400. 1
The notable difference between these outcomes is the extent to which other developing countries provide access to midwifery care for their citizens. In those nations where midwives attend a significant portion of births, their intervention rates are lower and maternal outcomes prove
safer. 2

1. TIME, October 29, 2007, p18
2. Marsden Wagner, MD, MSPH; Fish Can't See Water: The Need to Humanize Birth;
International Journal of Gynecology and Obstetrics, 75, supplement s25-37, 2001

Has the remedy for prematurity been found?

2007-11-12T12:30:00.000-08:00

The March of Dimes has done a wonderful job of convincing people that prematurity is a tragedy and must be stopped. In the twenty-first century, it’s so vogue to be fighting prematurity. Who wouldn’t want to be listed as a donor to such a noble cause?

It is a noble cause.

I have friends, actually quite a lot of them, who have suffered from the modern day plague of babies born far too early and far too small. I have friends whose babies only lived a few days as a little struggling bit of humanity, enclosed in glass, full of wires and tubes. As their frail little bodies failed and slowly gave up, their mothers were left only with memories of barely touching their baby’s fragile skin, wishing that for one moment their baby could have nursed at their breast.

I have never been the mother or sister of one of these babies, and I’m sure that being such would make me far more sensitive to the grief that accompanies loosing such a baby. Or even watching the baby survive, but with many struggles to overcome – loss of eyesight, brain function, emotional disorders… and the list could go on.

Babies, even those with remarkable stories of survival, always pay the price for the weeks and months that they had to spend growing in the harsh world outside the womb, before they were ready.

The March of Dimes continues to shout “Find the causes of prematurity! Stop it! No more premature babies!” With such a noble and heart-stirring mission, millions of dollars are donated to the cause. Many of the donations probably come from fathers and mothers who have personally been affected by the bitter memories of their own premature baby, struggling to survive.

And yet, where are the answers?

Our prematurity problem is only growing.

March of Dimes has not found the answer… The world’s most noted obstetricians, perinatologists, and neonatologists don’t know how to end the plague. They sadly tell grieving mothers who wonder if it was their fault that their baby was born at 26 weeks gestation instead of 40 that “nobody knows why. Sometimes these things just happen.”

But some interesting and very promising research is under way.

I spent the weekend with some international scientists and researchers who have spent over a decade focusing on various kinds of maternity care and the resulting outcomes to mothers and babies.

They are not ready to go public with their discoveries yet, as there is still more research to be done, and statistics to looked at, but so far they are finding a correlation between greatly lowered rates of prematurity when a pregnant woman sees a midwife as her primary maternity care provider.

In looking at large populations of low-risk, healthy white women, they noted that:

Of those who received typical obstetrical care, approximately 11.2 % gave birth to babies at less than 37 weeks gestational age.

Of those who received care from a Certified Professional Midwife (planning for a birth in an out-of-hospital setting), approximately only 4 % gave birth to babies under 37 weeks gestational age!

The research is still being done, but the preliminary results are showing a drastic difference in the care of a midwife vs. the care of a physician when it comes to preventing prematurity.

Maybe the March of Dimes should start to look outside the box. Instead of looking to high-tech, high-cost care, maybe they should take a glance at what happens when people use high-touch, personalized care.

Protecting Your Pelvic Floor

2007-10-30T07:54:00.000-07:00

Researchers grouped seventy women according to whether they exercised regularly, did postpartum exercises only, or never exercised, and measured the strength of their pelvic floors one year after childbirth.
Regular exercisers fared the best, postpartum exercisers fell in between, and non-exercisers had the weakest pelvic floors. Exercise regimens included fitness classes, walking, jogging, running, dancing, swimming, and yoga.

Gordon H and Logue M;Perineal muscle function after childbirth.
Lancet 1985; 2:123-125

Researchers evaluated perineal and pelvic floor outcomes in 460 first-time mothers according to how much they exercised. Women engaging in weight-bearing exercise more than three time weekly were equally likely to have an episiotomy, but only 16 percent experienced anal injury, compared with more than one-quarter of those exercising less often.

Klein MC, et al.; Determinants of vaginal-perineal and pelvic floor functioning in childbirth. American Journal of Obstetrics & Gynecology 1997; 176(2):403-410

What Do Women Really Want in Birth?

2007-10-23T19:10:00.000-07:00

What do women really want in birth?

The answer to this question influences billions of dollars of business in our country every year.

Every wise business person knows that in order to be successful, s/he must develop a product that is what the consumer WANTS and/or NEEDS.

If the consumer wants it, but doesn't need it, s/he may or may not buy it.

If the consumer needs it, doesn't really want it or find the product attractive, s/he probably will go elsewhere to get what they need.

When you combine need and want, you have a powerful product.

Our current maternity care system has convinced most of their customers that what they offer is what the customers need and want.
But is it really?

What basic things have they convinced the majority of mothers to need and want?

Safety

Avoiding unnecessary pain

If you ask nearly any woman why she's having her baby in the hospital, her biggest reason will be "safety."
Ask her what other reasons, and you may get an assortment of answers, but most likely the most frequent answer will be "for pain relief" if she takes a moment to think about what her hospital and obstetrician offer her.

These are two good things for women to want.
Who wouldn't want their baby to be safe?
Who wouldn't want to know that if anything goes wrong, someone will know how to fix it?
And who wants to suffer unnecessary pain?

But are women really getting what they think they are?

Sometimes I see many pregnant women in our society akin to a man who keeps driving his little Chevy truck that breaks down frequently, and is convinced that his truck is the best that can be had, because all of his friends say so. Even books about buying a good truck say so. The man who sold it to him told him that it was the best kind of truck he could drive. Sure, he doesn't like the breakdowns, but he's been told that his truck is the best, so he does his best to live with the aspects he doesn't like and pride himself that he is driving the best truck anyone could buy.

How many women are taken by the marketing that occurs in this country? We tell them that if they would only come to the hospital, they might experience a few breakdowns and inconveniences, but their experience will be the best they will find anywhere - safe and comfortable.

That's what we say.
But is it true, or is our modern maternity care system not all its cracked up to be?

Research on the Stillbirth-Cesarean connection

2007-10-20T07:54:00.000-07:00

From the Lancet 2003; 362: 1779-84:

Stillbirth linked to cesarean section

Investigating the relationship between previous cesarean delivery and subsequent stillbirth.

Cesarean section can increase the risk of stillbirth in subsequent pregnancies, claim researchers, in findings that add to the growing debate over the acceptability of elective cesareans.

Professor Gordon Smith (University of Cambridge, UK) and colleagues studied data on 120,633 births in Scotland between 1992 and 1998. They found that the proportion of stillbirths was greater in women who had previously delivered by cesarean section (2.4 per 10,000 women) than among women who had only delivered vaginally (1.4 per 10,000 women).

The increased risk of stillbirths with unknown causes began at around week 34 of the pregnancy in women who had undergone a cesarean for a previous birth, regardless of the reason for the procedure.

The association is "biologically plausible," the team comments, reasoning that previous cesarean delivery may influence uterine blood flow and mechanisms of placentation in future pregnancies.

An OB's opinion on C-section

2007-10-19T18:20:00.000-07:00

From www.obgyn.net

There are many benefits of vaginal delivery, for both mother and baby. During a vaginal delivery the amniotic fluid is squeezed from the baby's lungs, making it easier for him or her to breathe. This does not happen as much during c-section.

Furthermore, it is a misconception that c-section is always safer for babies than vaginal delivery. Scalpel injuries and trauma to babies during c-section, although rare, can certainly occur. In most cases vaginal deliveries are safer for mothers than c-sections, with some medical studies indicating that the chance of death for a mother is 7 times higher when delivered by c-section versus vaginally.

Contrary to popular belief, a c-section is a major operation, not unlike a hysterectomy in it's complexity and potential complications! These complications may include infection, hemorrhage, scar tissue formation (which may produce lifelong abdominal or pelvic pain), anesthesia complications, opening of the skin incision leading to a very large scar, damage to the bladder or intestines, and the formation of blood clots within blood vessels or the lungs.

These complications are usually much more common with c-sections than vaginal deliveries, although as with all medical issues the patient's individual situation will dictate which complications are more, or less, likely.

An unfortunate side effect of our legal system is that many women are led to believe by malpractice lawyers that a c-section will prevent any and all problems for their baby. This is simply untrue and is a very unsophisticated way of looking at this major operation and pregnancy in general.

D. Ashley Hill, M.D.
Associate Director Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency Orlando, Florida

Cesarean section - the way to go?

2007-10-18T17:40:00.000-07:00

More and more women are choosing to go the "cesarean route." After all, most plan to have only one or two babies, and they'd rather put up with recovery after major surgery once or twice than "ruin a perfectly good vagina" as one woman put it.

But does cesarean really preserve a woman's body more than vaginal birth?
Is it really less painful?
Are the risks the same?
If I had all the information on risks and benefits, would I choose a C-section for myself?

A doctor friend of mine whose wife recently gave birth by cesarean to her only child, remarked over dinner the other day (as I was discussing natural birth with someone else), "There's nothing quite like a c-section. Slit it open. Take the baby out. Sew it back up and you're done. No sweating, and moaning, and hours of misery. No natural birth for me. I don't find it compelling!"

Is a c-section really akin to just "unzipping," pulling the baby out and sewing the uterus shut again?

Well, not exactly, according to some nursing students who I was visiting with a couple of weeks ago. They were just finishing their eight weeks of Labor and Delivery in their RN training. One of them was lamenting that she had only seen c-sections, during her clinical days, and never witnessed a vaginal birth in the hospital. (She had seen vaginal births in South America, totally unmedicated, and unassisted by any "professional.")

"So," I said, "What do you think of C-sections? Would it scare you to have one, or does it look better than vaginal birth?"

"Oh, my goodness!" she replied. "If women only got a ten second 'behind the scenes' look at c-sections, they would never opt for one. They look awful! The whole uterus, tugged out of the body, lifted up and set on top of the abdomen for repair. The blood loss... it just looks like you tipped over a cup of water and it's pouring out. And then they stuff a rag inside the uterus and..." she shuddered. "I've helped people with severed limbs and stuff, but a c-section was just really gross."

My friend, Jason, and his wife just had an elective cesarean this week. He called to tell me the baby's weight and all the "proud father" news. I asked him if his wife was into recovery yet.
"Oh, yeah, C-sections don't take long. It only took about 10 minutes and we had a baby!" he exclaimed.
"Except that the c-section looked really awful. She didn't feel a thing. But it took the doctor pulling on the baby's head for all he was worth and three people holding her down on the table to get the little six pound guy out! Afterwards, it all looked... uh, just gross. I tried not to hurl, and couldn't watch the rest of it."

Dr. Deirde Lyell, assistant professor of Maternal-Fetal Medicine at Stanford University in California, has this to say:
"Unless a woman has a compelling reason for needing a C-section, vaginal delivery is still the way to go. A C-section is major abdominal surgery and carries a greater risk of severe bleeding, infection, re-hospitalization and blood clots."

Why Do Women Put Up With Birth the Way We Serve It?

2007-10-02T10:45:00.000-07:00

The question deserves raising: Why do women put up with [the options they are offered for childbirth]?
"Americans trust doctors and they trust hospitals, and they equate the two with health. And people want what's best for their babies. They assume that you decrease your risk by going to a hospital and having a top-flight doctor. What they don't understand is that obstetricians are surgeons, and they know pathology, but they really suck at wellness." (-Judith Lothian) They are trained to sew up a tear, but not to prevent one.

- Excerpted from "Pushed: The Painful Truth About Childbirth
and Modern Maternity Care,"
by Jennifer Block

Photo Credit: photographer Lindsey Woessner, copyright Molly Remer

Physician Liability

2007-09-25T08:57:00.000-07:00

I heard Dr. Marsden Wagner, a perinatologist and former director of Women's and Childrens' Health for the World Health Organization (WHO) talk about liability risks for obstetricians who are finding themselves getting sued every time someone doesn't end up with a perfect baby.

Dr. Wagner made a statement that I will never forget. He said,

"If you're going to play God in the delivery room, you're going to get blamed for natural disasters."

Herein I believe, lies the biggest solution to our liability crisis. Doctors have led people to believe that they are "God" and if their patients will only come to the hospital where things are "safe" and where the "best medicine in the world" can take care of them, they can sit back and relax and wait for the doctor to produce a pink, squalling baby.

People are no longer being good healthcare consumers. It is implied at their very first visit that the doctor is in completely in control of everything that could happen and has a drug for every problem at his/her disposal and the eventual outcome will be secured if the doctor is allowed to "work their magic."

"So, honey, hop right up here on the exam table and put this paper gown on... We'll take a peek and tell you exactly what is happening inside you..."

Of course, people are angry and disillusioned when they obeyed all the rules, and did things the "safe" way - only to end up with this - a damaged or dead baby.

What is the solution?

The solution is better informed consumers. It's partly the health care system's fault and it's partly our own fault as consumers if we don't "read the labels" on what we're ordering.

The C-section Epidemic - Jennifer Block

2007-09-24T17:15:00.000-07:00

A fabulous op-ed piece, published in the LA Times, written by Jennifer Block, author of "Pushed: The Painful Truth about Childbirth and Modern Maternity Care."

More women are dying in childbirth thanks to the high numbers of doctors and mothers who opt out of normal delivery.

By Jennifer Block
September 24, 2007

Pre-term births are on the rise. Nearly one-third of women have major abdominal surgery to give birth. And compared with other industrialized countries, the United States ranks second-to-last in infant survival. For years, these numbers have suggested something is terribly amiss in delivery wards. Now there is even more compelling evidence that the U.S. maternity care system is failing: For the first time in decades, the number of women dying in childbirth has increased.

The Centers for Disease Control and Prevention last month released 2004 data showing a rate of 13.1 maternal deaths per 100,000 live births. For a country that considers itself a leader in medical technology, this figure should be a wake-up call. In Scandinavian countries, about 3 per 100,000 women die, which is thought to be the irreducible minimum. The U.S. remains far from that. Even more disturbing is the racial disparity: Black women are nearly four times as likely to die during childbirth than white women, with a staggering rate of 34.7 deaths per 100,000.

These high rates aren't a surprise to anyone who's been investigating childbirth deaths. Physician researchers who have conducted local case reviews across the country consistently have found death rates much higher than what the CDC has been reporting. In New York City between 2003 and 2005, researchers found a death rate of 22.9 per 100,000; in Florida between 1999 and 2002, the rate was 17.6. Other reports by CDC epidemiologists have acknowledged that deaths related to childbirth are probably underreported by a factor of two to three.

What's to blame for the poor U.S. showing? True, we are the only industrialized country without universal healthcare. But when it comes to childbirth, we basically have it. Ninety-nine percent of women give birth in a hospital with access to all the bells and whistles -- high-tech machines that continuously monitor the baby's heart rate, drugs that can control the speed of contractions like the volume on a stereo, instruments that can coax a reluctant head out of the birth canal, and surgeons at the ready to perform the mother of all interventions, the caesarean section.

The C-section, now used to deliver 30% of American babies, is such a norm these days that, in some places, doctors and women have taken to calling it "C-birth" or even just "having a 'C.'" Pet names aside, the procedure is major surgery, and although it saves lives when performed as an emergency intervention, it causes more harm than good when overused. Here's why: Caesareans are inherently riskier than normal, vaginal birth. They also lead to repeat caesareans. And repeat caesareans carry even greater risks.

Placenta accreta is one of them. The placenta embeds into the uterine scar from a previous surgery, causing a catastrophic hemorrhage at the time of delivery. Most women with placenta accreta lose their uteri; as many as 1 in 15 bleed to death. In 1970, accretas were so rare that most obstetricians never encountered one in their career. Today, according to a University of Chicago study, the incidence may be as high as 1 in 500 births. And that is all because of caesareans and repeat caesareans.

Obesity plays a part as well because obese women are more likely to have health problems that make a caesarean more likely, and more likely to suffer surgical complications. Still, it all comes back to the "C," which could easily stand for "culprit."

According to a sweeping 2006 study by the World Health Organization, published last year in the medical journal Lancet, a hospital's caesarean rate should not exceed 15%. When it does, women suffer more infections, hemorrhages and deaths, and babies are more likely to be born prematurely or die.

Too many caesareans are literally medical overkill. Yet some U.S. hospitals are now delivering half of all babies surgically. Across the nation, 1 in 4 low-risk first-time mothers will give birth via caesarean, and if they have more children, 95% will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability.

American maternity wards are fast becoming surgical suites. We've become dangerously cavalier about it, but the caesarean rate should be a major public health concern. Universal care alone won't solve the problem; what pregnant women need is entirely different care. They need doctors and hospitals that promote normal labor and delivery. Of course, reducing obesity belongs on the healthcare agenda, and so does curtailing the scalpel.

http://www.latimes.com/news/opinion/la-oe-block24sep24,0,6378847.story?coll=la-opinion-center

Case Study Reveals Economic and Political Forces that Hinder Access to Midwifery Care

2007-09-21T17:18:00.000-07:00

Piercing the veil: The marginalization of midwives in the United States.

Social Science & Medicine, 65(3), 610-621. [Abstract]

Goodman, S. (2007).

Summary: This qualitative case study analysis illuminates the forces behind the underutilization of midwives in the U.S. maternity care system and the process of their professional marginalization. The researcher identified two prominent midwifery services that had good outcomes and were connected with prestigious and influential institutions. One was a university-affiliated hospital practice that had provided uninterrupted midwifery service to the community for nearly five decades. The other was a birth center in continuous operation for nearly 30 years and hospital-owned for the final seven. Both practices were threatened with closure in 2003. In the case of the university-affiliated practice, the midwives ultimately maintained their ability to practice but the hospital imposed restricted clinical practice guidelines resulting in an 84% decrease in the number of midwife-attended births and a number of midwives leaving the service. The birth center practice closed abruptly in a decision handed down by the hospital without the involvement of the center's Board of Directors. In order to understand the circumstances behind the closures, the researcher conducted 52 in-depth interviews with midwives, nurses, service administrators, childbirth educators, policymakers, and physicians and reviewed archival data such as email correspondence, policy statements and memos.

In both cases, the publicly articulated reason for the attempted or actual closure of the midwifery services appeared to be reasonable. In the university-affiliated practice, the hospital claimed that too many of the women in the neighborhoods served by the hospital were high-risk and midwifery care was therefore unsafe. In the case of the birth center, the hospital reported that the decision to close was prompted by a 400% increase in malpractice insurance premiums. In neither case did the hospital provide any documentation or other evidence to support these rationales for closure. Interviews and analysis of archival data revealed that the midwifery services represented competition to the hospital, local physicians, or both. The case of the university-affiliated midwifery practice was particularly overt: the hospital had recently paid a multi-million dollar fine for double-billing the Medicaid program for births attended by midwives - once for the midwife and again for the consulting physician. When this fraudulent practice was discovered and the hospital was censured, midwives became a source of competition rather than income. In the case of the birth center, five-fold growth in the number of birth center births over the time the hospital had ownership may have appeared to be siphoning business away from the hospital's labor and delivery unit. Despite these potentially powerful economic and political motives for closing the midwifery services, the public were led to believe that the decisions were driven by rational concerns about safety and liability. The author concluded, "In the cases studied, institutions successfully altered maternity care and diminished midwifery services without accountability for their actions. In fact, the elimination of midwives seemed to be a rational decision when framed in the context of patient safety and the rising cost of medical malpractice" (p. 9).

The author explored aspects of the U.S. health care system that facilitate professional marginalization of midwives. The most problematic is the way the U.S. medical education system is funded. Hospitals essentially get paid twice for care provided by medical residents because they can bill directly for the care and also receive large subsidies from the federal Medicare program in exchange for providing residency opportunities. The more residents a hospital employs, the more federal money they get, so there is a government-imposed disincentive for hospitals to employ midwives. Furthermore, in many states midwives must have formal practice agreements with physicians in order to obtain licenses, liability insurance, reimbursement, or hospital privileges. This requirement makes midwives dependent on their competition in order to gain access to employment. Finally, midwives' reliance on low-tech care practices result in lower utilization of medical devices and services that may be separately billable.

Significance for Normal Birth: Advocates for improvements in maternity care are often at a loss to explain why childbearing women cannot access care providers who support normal birth. Normal, physiologic birth, it would seem, must be less costly than technology-intensive birth. Solving this paradox requires an understanding of the political and economic forces that foster dependency on high-cost obstetrics to the detriment of women and babies. While this study is small and focused on two specific examples of midwifery service closures, it provides important insight into the systemic forces that hinder women's access to midwifery care despite a large body of evidence that midwives provide equal or better care than physicians with lower reliance on costly technical interventions. The study documents how our market-based health care system safeguards the interests of the medical profession which can often be at odds with those of women, babies, and society.

Radical, systemic reforms are needed if the United States hopes to achieve a high-functioning maternity care system, characterized by effective, high-quality care, universal access, and cost containment. Evidence from countries with excellent maternity care outcomes suggest that eliminating barriers to midwifery care must be a priority. Birth advocates can begin by calling for accountability and transparency from hospitals and maternity care providers.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17475381&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum