The Best Care for Healthy Pregnant Women

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

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

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.

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

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!

On Surgeons and Normal Birth

"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

Response to ACOG's recent statement on Home birth

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.

The Making of Mothers

"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.

Has the remedy for prematurity been found?

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.