Saturday, November 28, 2009

Weekend Movie: How Childbirth Works

YES, it's totally annoying that yet again, the assumption is that mom will be supine, but still, it's a handy little visualization, if not as high tech as this 3D one I posted before. Worth a watch!


Thursday, November 26, 2009

Gratitude



Three generations in the kitchen. Lily & I wish you all a wonderful ritual sacrifice with pie. I'll be back to blogging when we return home next week!

Saturday, November 21, 2009

Weekend Movie, the Sequel: Ignorance Meets Knowledge

For the second week in a row, I cannot resist a double feature. This video on "extended" breastfeeding kicks some serious ass.



I unclasp my nursing bra to thee, Tori Caswell, creator of this video.

Weekend Movie: Mastering the Maneuvers

Okay, you really have to be a die-hard junkie to appreciate these two videos, but I found them to be very educational. Two maneuvers are known to help with shoulder dystocia, the difficult situation in which the baby's head has emerged yet the shoulder remains caught behind mom's pubic bone. One technique is the Gaskin maneuver, where mom turns over onto her hands and knees, named for the midwife of midwives, Ina May Gaskin. The other is the McRoberts maneuver, where the mother is supine, and her legs are flexed all the way back - think knees to ears, opening the pelvis as much as is possible on one's back.

Here's a 3D animation of this - it's REALLY short, blink and you'll miss it, but it shows exactly how this action works on mom's pelvis and the baby's shoulder.



With that in mind, watch this longer, real-life situation.



It seems clear to me that the change of position is the key thing here; in the video above, mom had already been on hands and knees, so the Gaskin maneuver is, well, moot. So McRoberts was perfect. On the other hand, if mom was in anything like lithotomy, switching to hands and knees a la Ina May could really do the trick.

The threat of cephalopelvic disproportion and thus risk of shoulder dystocia is a common scare tactic used to frighten women into unnecesareans. Whichever maneuver ends up being the appropriate one, what I love about the second video here is how clearly it demonstrates that, with a skilled care provider who is armed with the knowledge of these options, shoulder dystocia, while something to take very seriously and address swiftly, CAN be coped with. The midwife worked efficiently and confidently, and there was no sense of panic or dire emergency. I can't help but wonder how this would have turned out in a hospital setting.

Friday, November 20, 2009

From continuous support to a continuum of support

The third Healthy Birth Blog Carnival is nigh, and, following the other great Carnivals on Lamaze's Healthy Birth Practices, this time Science and Sensibility is calling for entries on the third practice: Bring a loved one, friend, or doula for continuous support.

Seems like a no-brainer for me to weigh in on, no? Well, you see, I am but a young padawan doula. Number of births I have attended in person thus far: one (mine). Much as I aspire to not only start attending births as a doula but eventually train as a midwife, I'm still very much inexperienced in the real birth world despite my book and web-learnin' on the matter. I am sure this Blog Carnival will offer up scores of excellent posts by birth veterans, detailing the benefits of that incredibly important continuous support during labor, as well as birth stories in which that labor support person (whether a pro or a family member or otherwise) plays a vital role in healthy, satisfying birth experiences, and I look forward to reading them.

But here's something that's been on my mind as a newbie doula (which I recently realized makes me a 'doubie'): I'm starting to feel that even within the midwifery model of care, the amount of support a woman gets drops off dramatically after the first few days postpartum. Forgive me if I'm playing Captain Obvious here, but I'm currently witnessing the impact of this firsthand, as well as starting to see this pattern in the birth, breastfeeding, and postpartum depression stories I read so voraciously, both in print and online.

Nowhere is this more apparent than in births that have taken place in hospital settings, of course. Let's take the matter of nursing for just one example of the value of postpartum support. A woman heads home after a birth which may or may not have gone smoothly, where she may have received terrible breastfeeding advice, where she may have been separated from her baby, where her baby may have been given formula from a bottle with or without her consent or even knowledge. She may have even been given a "gift bag" containing you-know-what. Think about this mother headed out of the hospital has been really been set up. She may already be on a downward spiral.

Let's say, though, for argument's sake, none of the negatives in the hospital scenario above have happened. Let's say that in every instance, she experienced the best case scenario: no artificial nipples, no separation, a good birth, and so on. The environment at home can vary WILDLY in terms of what kind of support she has, in terms of both quantity and quality. The father most likely only has a few weeks of paternity leave, if that. She may have extended family living nearby, but this is becoming rarer and rarer in contemporary society, so she might have her own parents or in-laws coming to visit and help out for a while. She may or may not have friends in the area who can help out here and there; sometimes a meal rotation has been set up for the first week or two.

Within whatever existing support system she does have, there may be experienced, knowledgeable breastfeeders - and there may not be. If many of the less desirable variables are present, any difficulty she experiences can be exacerbated. So many nursing relationships can be sabotaged by well-meaning but ignorant advice. If the mother had hired a birth doula, a few postpartum visits are typically included, which is a help, but is it enough to make up for regular, quality help from the rest of the mother's support system?

Even if we take the hospital out of the picture, continuity of postpartum care can be lacking. She might have even had a home birth. Midwifery care does provide for MORE postpartum care than a hospital birth provides, typically scheduling a visit for the day after, then the third day (often a day of reckoning), then a week later. It's definitely an improvement, but I feel that a lack of regular support at home, and lack of accessible and timely lactation support, can still be devastating. Midwives who attend home births (primarily CPMs but also some CNMs) may or may not be skilled in lactation support. I think it's fair to say that most know the basics, and the type of sabotage that sometimes occurs in hospital settings is highly unlikely, but when serious issues come up, the variation in skill becomes much more crucial.

When more lactation help is needed, then, outside help needs to be called for, creating a new set of variables in terms of skill and accessibility, as not all lactation consultants are created equal, and the best ones may not be in the area, or may be out of a price range. Days or even weeks can go by before help arrives, time during which the breastfeeding relationship can be damaged in a number of ways.

I don't know if there are existing studies comparing the connection between breastfeeding success rates and better postpartum support, but from what I understand, many developed countries which have universal health care also provide for home health care visits for all new mothers. Here's one glance at different countries and their breastfeeding rates from the
State of the World's Newborns Report 2001 via Kellymom:

Breastfeeding Rates Around the World

Country % of mothers who start % who continue 6 months or longer

Sweden 98 53
Norway 98 50
Poland 93 10
Canada 80 24
Netherlands 68 25
Britain 63 21
United States 57 20


Is it asking too much of midwives that they also be well-versed in breastfeeding support, and that they spend more time devoted to postpartum care? I don't mean to ask this as an accusing rhetorical question. It really may be too much, given the depth of their expertise in birth and the devotion it takes to acquire their skills, not to mention the considerable existing demands on their time - and if that's true, then we need to start thinking about finding ways to pass that baton to another support provider much more regularly and smoothly than we currently often do.

There is La Leche League, if you have an active chapter in your area with good leaders who will do phone consultations, which is not a guarantee, and honestly not a substitute for one-on-one help from a trained professional. Speaking of, then there are the lactation professionals, the gold standard of which is the IBCLC. Fantastic people, most of them are - if you have access, and even still, there is a break in the continuity of care, a disconnect, a stranger stepping in.

Another factor in postpartum support of the friends & family variety: it tends to peak within the first few weeks, which is when such support IS most needed (particularly in terms of breastfeeding), true, but many mothers find that they really could use help beyond that initial period. Suddenly, dad is back to work, family returns home, friends have gotten their fill of the novelty of the new baby, and the meal rotation comes to a close. Suddenly mom finds herself more alone than ever, which brings me to another area where postpartum support is vital: postpartum depression, or more accurately, the spectrum of postpartum mood disorders.

Isolation is a huge risk factor here, and feeling 'abandoned' once the baby is 3 or 4 weeks old can feel devastating to a mother. In my DONA postpartum training, listed within the services that a postpartum doula provides, right alongside education in newborn care, aid in mom's emotional and physical recovery, light housework, and breastfeeding support, is "companionship". Simple as that. This is not an insignificant or trivial thing. Having another adult around to relate to can really be a lifeline to a mom who is sleep-deprived and struggling, especially if that adult is trained in recognizing the symptoms of postpartum mood disorders.

You can see where I'm going with all this. My bias as a new and eager postpartum doula is showing, I know. But I think there's a case for shifting our view of the journey to motherhood. The moment of birth IS profound and amazing and deserves the most devoted support throughout that experience as possible - but can we start to see that this is just one part of the journey, climactic though it may be? Can we start to see it as more of a continuum? What would it be like if something resembling continuous support (though obviously not as intensive or constant as labor support) lasted throughout what has become widely recognized as the "fourth trimester"?

After the long buildup of pregnancy, and the transforming apex that is birth, with much societal (not to mention medical) attention paid to both, many women often get the relative equivalent of a handshake and a "good luck!" Women and babies deserve more. WE as a whole deserve more. I'm not sure what form this would take. I like the concept of reframing care as, perhaps, perinatal, rather than divided into prenatal, birth, and postpartum. I absolutely think postpartum doulas are one way of finding a solution, of course, but I don't mean to make this post one big sales pitch for them (especially, again, as a novice). I'm open to more solutions. Maybe the concept of Freestanding Maternity Centers, as Rixa of Stand and Deliver recently pointed mentioned recently. and as Dr. Stuart Fischbein has endorsed, could include more extensive postpartum support that flows out of existing relationships, and could thus move towards more of a continuum concept, to twist a phrase.

I've focused here on breastfeeding and to a lesser degree on postpartum mood disorders, but even if neither proves to be a problem, mothers still deserve to have much more support during their "babymoon" than they often get. These were just examples of postpartum needs - there are so many others, too. Adjusting to our brand-new identities as mothers is an world-shattering experience - hopefully mostly in the best possible ways, but in the event that challenges arise, I think mothers with newborns deserve to have the equivalent of counterpressure on their sacrums, cool cloths held on their foreheads, and strong, caring hands to hold when the going gets tough.

Tuesday, November 17, 2009

Vitamin D deficiency -a risk factor for c-sections?

I just yoinked this thought-provoking bit of news from Bellies and Babies: Vitamin D deficiency leads to a fourfold increase in cesarean births.
"Women with a vitamin D deficiency were almost 4 times more likely to have a cesarean than those with [normal] vitamin D levels," says senior study author Anne Merewood, an assistant pediatrics professor at Boston University School of Medicine. "Vitamin D is definitely involved in muscle strength…. contractions of the uterus [which is made of smooth muscle] may not be performing as well as they could be," making it difficult for the woman to help push the baby out herself.
I think it would be a huge mistake to not continue to evaluate labor protocols and policies that work against women, of course, but this may be another big part of the picture, and should be investigated much further. I also had a bit of a gut response to the concept as potentially being yet another mother-blaming strategy, but I do think the information is too important to dismiss.

From everything I have experienced and read, standard obstetric attention to nutrition tends to begin and end with a prescription for prenatal vitamins and perhaps a photocopy of some (possibly questionable) healthy eating guidelines. Folic acid and DHA have gotten more attention in recent years, which is a help, but clearly doesn't go far enough. Midwifery care often pays much more attention to nutrition (though still, one's mileage may vary), looking at each woman's diet in detail and talking about beneficial food sources of nutrients, not just supplements, th0ough there is certainly a place for them in most American diets.

Be sure to check out the full post at Bellies and Babies. She then talks more about the further ramifications of cesarean birth on the baby's health and future - all potentially connected to nutrition.

I'm reminded of a favorite quote from Hippocrates favored by my holistic lactation consultant: "Let food be thy medicine." What will it take for more people to start really taking nutrition seriously?

Sunday, November 15, 2009

Formula-Fed America

Weekend at the Movies Part 2: I guess I'm having a double feature this weekend, but I couldn' t possibly wait to share this.




The info on the site is a little bit lacking, but hopefully there will be more soon, as it's very new. Could this be "The Business of Being Born" for breastfeeding? (Or perhaps a "Food, Inc." for babies?)

"Formula feeding is the longest lasting uncontrolled experiment lacking informed consent in the history of medicine." -- Dr. Frank Oski

UPDATE Monday 11/16: I emailed them, asking about release dates and screenings and such, and got this reply: "We are still in the process of filming and hope to wrap by early April, we are also still looking at different avenues for promotion and release, nothing is set in stone yet. Thank you for visiting our site! We will keep you updated!"

So, we'll have to wait a bit, but I am sure it'll be more than worth it. I'll pass along anything I hear, of course!

HALP. Book recommendations for dads?

A newly pregnant mom just asked me for, like, the ONE book recommendation I cannot make. Seriously, when it comes to bellies, birth, babies, and boobs, I have shelves upon shelves of book recommendations. But one topic eludes me: the best book for new dads-to-be. I've checked out a few, like She's Having a Baby and I'm Having a Breakdown, The Caveman's Pregnancy Companion, and The Expectant Father, and I gotta say, I have yet to be blown away.

Help me out, readers! Any really good ones hiding out there? I'd prefer it to be at least slightly crunchy, or at least OPEN to natural birth options, pro-breastfeeding, and maybe, just maybe, something that doesn't get bogged down in lazy, tired old aren't-the differences-between-genders-hilarious and isn't-birth-freakish-and-terrifying attempts at humor. (I know I probably can't have it all.)

Saturday, November 14, 2009

I Believe the Children Are Our Future

Weekend at the Movies: Just watch, it's less than 2 minutes.




Mouths of babes, eh? I can only hope Lily will be giving similar interviews in a few years.

Friday, November 13, 2009

Postpartum Doula FAQ

. . . Or, "The Best Baby Shower Gift of All Time".

I put these two documents together last weekend for a health expo, the first part giving general info about postpartum doulas, and the second getting into some more FAQ detail, and thought I might as well share it here! It still needs some tweaking, and I'll be jazzing it up with a logo and some coherent color schemes and all, but I think the content is decent. Feedback?

*****

What IS a Doula?

From Doulas Organization of North America (DONA): “The word ‘doula’ comes from the ancient Greek meaning ‘a woman who serves’ and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.”

So what exactly is a Postpartum Doula?

She is a specially trained woman who comes to the home of a new mother and provides evidence-based educational, emotional, and physical support after birth. This allows the new mom to rest and bond with her new baby during her much-deserved “babymoon”, and helps the whole family transition into their new roles during the first three months of life, sometimes referred to as the “fourth trimester”.

What can a Postpartum Doula do for our family?

*Basic breastfeeding support
* Instruction in newborn care, such as bathing, diapering, babywearing, and infant soothing
* Teaches coping skills for both parents
* Aids in mom’s physical recovery from birth
* Meal preparation
* Household organization and light housekeeping
* Errands such as grocery shopping
* Infant and sibling care
* Emotional support and companionshipInformation and professional referrals

Why should we hire a Postpartum Doula?

The postpartum period is a time of recovery and transition for the new mom. Surrounding her with emotional support, attending to her physical needs, and caring for her home and family allows her time and space to rest and recover from the birth, learn to feed her new baby, and smoothly transition into her new role with genuine self-sufficiency.

The bottom line: the presence of a postpartum doula has been shown to reduce the incidence of postpartum depression, increase the development of successful breastfeeding relationships and enhance ALL relationships in the family as they welcome their newest member.


*****

Postpartum Doula FAQ

For how long does a mother usually hire a postpartum doula?

This depends on the needs of the family. A postpartum doula is typically engaged from between 2-6 weeks, starting as soon as possible after birth (easiest if arranged ahead of time), but this care can extend through the first three months - the “4th trimester”.

It’s not a test of competence or strength to be able to "do it all by yourself." New moms were not meant to be alone during the postpartum period. Much attention is paid in our culture to prenatal care, and to birth itself, but postpartum care is lacking in many form. Many new mothers feel overwhelmed and isolated in the first few months of motherhood, even if they do have family nearby - and especially if they don’t.

It’s important to gather support for this significant period in your life so that your newborn can be welcomed into an environment where the mother is calm, as well-rested as possible, and supported.

When do we arrange for this service?

Meeting your postpartum doula and planning for care ideally happens prenatally. This gives mom and the doula plenty of time to talk about goals and expectations, and discuss scheduling. When you first make contact, you’ll be given an intake form to fill out at your leisure, which will be reviewed at your consultation, which is free of charge. Of course, postpartum doula care can absolutely still be arranged after the birth, but scheduling may be a bit more challenging, and may miss out on the first few critical days and weeks, when help is most needed and effective, especially regarding breastfeeding support.

The best case scenario is where mom receives a gift certificate for this at her baby shower, and she sets up a plan and gets to know this new support person in advance of the blessed event, secure in the knowledge that this extra support will be awaiting her!

How long does a postpartum doula spend with a new mom each day?

Again, this depends upon the needs of the mother. Many women schedule a four-hour visit 3 to 5 times per week. Some doulas are able to do longer shifts with enough advance notice. A few also do overnight shifts.

My husband has two weeks of paternity leave. With his support, wouldn’t a
postpartum doula be unnecessary?

Don’t underestimate the impact of sleep deprivation on both parents, nor the learning curve for both father and mother. Having an extra set of experienced hands to reassure, teach, and support can make all the difference in the transition that the whole family is making. This is particularly true for first-time parents, though families with older children also need the extra help in different ways – see below.

My mother and mother-in-law (or other family) are coming to help out for the first 2 weeks. Won’t they cancel out postpartum doula care?

Care from friends and family is incredibly valuable. Feeling connected to your family at this time in a new mom’s life is wonderful. There’s no “substitute” for it. Doula care can still enhance this time for the entire family, helping everyone to adjust to their new roles, and also offers evidence-based information to the new mom, something which some family members may not always have. Care from friends and family tends to peak within the early weeks, with lots of visits and casseroles, and then dies down, while mom may still need just as much help. Doula visits can then be scheduled more frequently to make up for the difference.

What if this is not my first baby? I already know how to breastfeed and care
for a newborn--why would I need a postpartum doula?

The needs of a first-time mom are different than those of a mom with an older child or children, but postpartum support can still be vital. In fact, many members of her own support system may think exactly what was posed in the question: She’s done this before; she won’t need as much help this time. On the contrary, mom may find herself in need of more support than ever, learning to balance the needs of her other children with those of the new baby.

Additionally, mothers who had an easy time breastfeeding their first baby may still encounter some challenges with subsequent children, and mothers with older kids can still be susceptible to postpartum mood disorders. All of the above can be eased by a postpartum doula.

This is the perfect baby shower gift for a family with existing children, as many of the “big ticket” items like car seats and breast pumps and high chairs have already likely been purchased with previous babies, and many clothing items and the like will be hand-me-downs.

None of my friends ever had a postpartum doula—so why would I need one?

Chances are, the reason they didn’t have one is that they simply didn’t realize this type of support is available. Ask your friends who have had a baby if they would have liked to have had the kind of help postpartum doula offers. Try asking them. They’re likely to tell you exactly why you would want one!

What do you offer for multiple births?

For reasons both obvious and subtle, the transition into motherhood can be even more challenging for a family bringing multiples into their lives. On top of the usual education, emotional and physical and support (all doubly needed now), the postpartum doula can help the new mom discover strategies to make her life easier with her new little ones, particularly in the realm of household organization. The doula can also help the new parents find resources especially for parents of multiples.

We have not budgeted for this expense--how could we justify it?

The presence of quality postpartum support can make a huge impact on a mother's physical recovery, emotional state, and success with breastfeeding. Getting the right start can be truly priceless. Another doula says: “The best response to this question was one I heard from a set of grandparents who were paying for a postpartum doula for their daughter: ‘We put aside money for our child's college education years in advance--but is not this postpartum period, and the experience the child has in these first months, just as important?’”

Family and friends who want to help, but are unable to offer much if any postpartum support themselves, are often very grateful for the chance to hire a doula to go in their place. It should be noted here: a gift certificate for a postpartum doula is one of the best baby shower gifts of all time!

Also, be sure to submit to your insurance. Some insurance plans will cover part or even all of postpartum doula services. Speaking of:

Does insurance cover the services of a postpartum doula?

Many insurance plans will reimburse for some or all postpartum doula services. We can provide sample letters of authorization from your doctor or midwife to help in this process.

Sources: DONA International, Postpartum Doula Services of Northern Virginia

*****

Oh, and I finally decided on a business name. It is FAR FROM original, but in the area I'm currently living, I needed something that would clue people in immediately as to what's being provided, and inspire them to look further into it, as well as something that could also cover labor support eventually. So I went with:

BABYMOON
Postpartum support at home for mom, baby, and the whole family.

Like I said, NOT ORIGINAL, but it gets the message across. I can also tweak the tagline to include labor support once I'm ready to start attending births. Someday . . . *sigh*

Wednesday, November 11, 2009

Letters to a young homebirther

I got permission to share a recent exchange with a several-degrees-removed family member, a terrific, sharp, lovely young woman who is expecting her first baby by the end of November. Her recent training as a physician's assistant included a rotation in labor and delivery - and the experience made her extremely disillusioned and uncomfortable with a hospital setting for her birth unless it becomes medically indicated. We talked about all this for a while while I was visiting family this summer, and exchanged a few emails as well. She had found a great midwife and things were going smoothly. And then, like many moms experience, especially first-timers, she went through a questioning period. Here's what she sent me:

Okay, Anne. I need your help. I am having a hard time feeling 100% confident with the home birth. Did you ever second guess- what if her heart rate drops and I need a c-section in 2 minutes instead of 10? This is my biggest obstacle. [The father] and I met an awesome midwife and I honestly feel really good and at peace with the whole thing. And the thought of going to the hospital just makes me, well, not want to deal with it. Can you help me out. Since you had your first at home too, maybe you could give me some good advice...

Now, before I share my responses, I want to make clear that I would never, EVER try to "talk someone into" a home birth. At least I hope I never come off that way. I would never want someone to feel pressured, and women should absolutely give birth where they feel the most authentically comfortable. And for some women that is going to be the hospital, period. I can help support their informed choices no matter where they are. IF, however, a mom is intrigued, and curious and, maybe eventually, leaning towards a home birth, I can share my own reasons why it was the right choice for me, and why it is a good choice for many others.

So! My responses, in two parts:

PART ONE

Hey there!

I just wanted to let you know I DID get this, and plan to reply to it in more detail, but I am just in the middle of an insane week, starting with my first postpartum doula client, and tomorrow I start a 3 day weekend of doula training! Yikes! Anyway, absolutely I have some thoughts for you and will elaborate soon.

Hang in there! I'm so glad you met an awesome midwife. In the meantime, before I can write some more, here are some other links [I had emailed her a bunch before] you might find interesting and reassuring:

Recent Canadian study, the most comprehensive yet: http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20090831/home_birth_090831/20090831?hub=Health

And here's another study that came out earlier than the Canadian one, from the Netherlands: http://www.nhs.uk/news/2009/04April/Pages/HomeBirthSafe.aspx

You also might really like this blog, it's one of my favorites: Stand and Deliver. The author happens to be LDS, too, and is a PhD in the study of American medical care and environmental issues. Browse around!

More to come . . .

Anne

PART TWO:

Okay! The dust has settled a bit. Sorry, you just caught me at a particularly crazy time!

Did you have a chance to look at those studies and the blogs? How did you feel about them?

But ya know, I can inundate you with tons of compelling blogs and studies and articles, and it still may not quell the deep-seated fear you're worried about. Right? I totally get it, I do. Like, yes, it may have been shown in a number of studies (and it is) that for low-risk women with qualified CPMs, home birth outcomes are just as good if not better than their hospitalized counterparts - but . . . what if YOU are the one exception? WHAT IF? And that's a valid question, and I think it does a disservice to both you and, less importantly, to home birth advocates to act as though it's not, or, even worse, pretend to give you any kind of guarantee.

The first thing I would tell you is to talk about it with the great midwife you said you found, or, if you've already talked about it, heck, talk about it with her some more, seriously. Midwives are very used to this, and any good one should be willing to take their time with you on this matter (or any matter that concerns you - this is one of the best things about midwifery care; I got a MINIMUM of an hour per visit, often more, as opposed to the 5-10 minutes you typically get with an OB*). I talked with Nancy quite a few times about transfer and how that would work, and under what circumstances.

Nancy's rate of transfer was about 15%, and most home birth midwives, from everything I've read, average between 10 and 15%. I was actually kind of pleased to hear that she was on the conservative side - to me, that meant I could be reassured that she wouldn't be taking any chances. Really, I think that CPMs who do "take chances" are extremely rare, but it's always good to talk to your own and find out what her rate is, and what that means. Many CPMs will share their statistics right up front. With Nancy it was right in the materials she gives out to every client on the first visit. (Try getting an OB to disclose the same.*)

We talked in detail about what kinds of things would warrant a transfer. Some things are absolutely non-negotiable and obvious, like the rarity of a prolapsed cord (I can give you examples of when and how a transfer under this circumstance would work if you like). Some are very common, such as persistent late decels; it's just a matter of timing, and deciding when to leave. There are a few things that actually will vary: Nancy would transfer any time there was meconium in the amniotic fluid, even if there were zero other signs of distress, whereas some other midwives don't feel that this is always necessary. Again, talk to your midwife about this! I think it's important to feel comfortable with her philosophy, not to mention that you can always tell her, as well, that you absolutely want to err on the side of caution (which they do anyway, but you know what I mean).

One thing Nancy also made clear to me is that within that 15%, very, VERY FEW of these transfers are actual emergencies. She has only had to call for an ambulance a few times in her entire career, and she's extremely experienced. MOST transfers can be done in a calm, if not exactly leisurely fashion. Ask her about this as well.

That reminds me of one other point: I blogged recently about the difference between a freestanding birth center and a home birth,. A midwife wrote this: "When a dad/partner/relative tells me s/he/they would have no problem having a baby in a birth center, but wouldn't be comfortable at home, I let him/them know that I carry the same equipment that is at the NACC-certified birth center downtown (minus the sedatives). The difference is *I* carry the equipment into their house instead of them getting up, in labor, and heading out into the elements, driving to the birth center. It often comforts them to know this. I have even gone so far as to open my kit up to show a skeptical nursing relative. It is very important for everyone (who will be at the birth) to feel 100% comfortable with the parent's choice to have their baby at home."

So it's the same 'stuff'. Either they schlep the stuff to you, or you schlep yourself to them. And thus, forgive me for quoting myself, but I think it's relevant: "I could see myself choosing a birth center for one of two reasons: if it were closer than my home to a good hospital; or if my home at that moment were not a good setting for whatever reason - recent move leaving the place in a shambles, tiny apartment with thin walls, something along those lines." So I would factor the former into your decision as well. Is a birth center closer to the hospital than your home, by more than a few minutes? If so, that IS something to consider.

Still, the central fear in your gut: What if you need a c-section in 2 minutes instead of 10? Okay. Again, I feel you. It's so hard to distinguish sometimes, how much of that is a real, genuine, authentic gut feeling, and how much of that is the fear that comes from our conditioning and our culture, and the medicalized model of care that has been so deeply ingrained in us all? That's not easy to shake off. I CAN tell you, as I suspect your midwife would, that a real, out-of-the-blue, code RIGHTNOW - without ANY prior warning - is very rare. In the vast majority of cases, there are going to be signs, and a qualified midwife will be vigilantly watching for them (you know that intermittent auscultation is every bit as effective as cEFM, and in fact reduces morbidity resulting from increased c-section rates) and will recognize when to make a timely transfer.

But does it happen? Yes it does. INCREDIBLY rarely, but it does. So what happens if you're in a hospital? Let's say there is a cord accident (soooooo rare), and, as you said, you need a section in 2 minutes instead of 10? Well, you've spent time in a hospital rotation. What's the minimum amount of time it takes to scrub in and set up? Rixa of Stand and Deliver (which I mentioned to you earlier) wrote this (in the comments on that thread):

It's important to know that not all hospitals can respond similarly to obstetric emergencies. It's not like there's a generic "hospital" experience when you need a crash c-section. ACOG's rule is that you need to be able to perform an emergency c/s in 30 minutes or less.

My local hospital does not have an in-house OB or anesthesia; if there's an emergency, they have to be called in. During my hospital tour, the nurses said the fastest they have ever seen a c/s done is 10 minutes from decision-to-incision (for a cord prolapse). That's probably not typical nor normally reasonable; it depends how far away the OB and anesthesiologist are at the time of the emergency. Really, if the only "safe" way to give birth is to have access to a crash c/s in 10 minutes or under (and really, if the baby's oxygen supply is totally cut off, 10 minutes is too long), then all women should have to give birth in a tertiary care center with 24-hour in-house OB and anesthesia (which ACOG has recommended for women doing VBACs, despite the lack of evidence that this round-the-clock access improves VBAC outcomes). Of course that's not feasible or reasonable at all. In short, the public has this impression that if you're in a hospital, the staff can immediately respond to any emergency--which is not the case. It takes time to set up the OR, to assemble the surgical team, to prep the mother.



So, from decision to incision, you're not going to get a c-section in 2 minutes no matter where you are. These are the extreme minority cases where, sadly, being in the hospital would not make a difference.

But here's the practical: So, let's say you are going to need a c-section, because such a need does sometimes happen, of course. Much of that setup and scrub-in can be taking place while you are en route to the hospital. Yes, there is prep that needs to happen to you, physically, but again, you've seen it yourself. A lot has to happen besides what happens to the mom. Talk to your midwife about how such transfers take place when they arise for her. This is one of many reasons good relationships between midwives and doctors/hospitals are so important, and they do need to be improved, no doubt, in some areas more than others.

How about one other scenario that is often raised as a concern? Let's say baby is born and doing fine, but mom has a postpartum hemorrhage? The immediate response from a CPM is the same as it would be in a hospital, including Pitocin (intramuscularly) and fundal massage, and if necessary, bimanual compression, which can be maintained during transfer if transfer is deemed necessary. From there transfusion could be done (if needed), etc. I am totally not trivializing this - it needs to be taken seriously, but do be aware that a common cause for PPH is cord traction (forcibly removing the placenta by intentionally pulling on the umbilical cord), causing placental separation before it detaches normally on its own, which happens far too often in an actively managed third stage. (Yeesh, right?) Again, talk to your midwife about what steps she would take.

Marsden Wagner (himself a perinatologist) wrote in "Born in the USA" that saying that you need to have an OB for a low risk, uncomplicated pregnancy is like saying that you need to hire a pediatric surgeon to babysit a normal, healthy kid. Because what if something goes wrong?? We get in our cars every day, with our children, knowing that there IS a risk that we will get into an accident. To say that there's not is just untrue, but we have weighed the risks and benefits and decided that in the context of our lives, it is worth the risk to be able to drive.

As I've said before, can you imagine if, every time you went to get into your car, people ran up to you and told you about the worst accident they've ever seen or heard of? Yet people do exactly that to pregnant women all the time. People choke to death eating food, but we don't go to the hospital every time we eat a meal, "just in case", because eating is a normal bodily function that, most of the time, goes just fine. But to deny that choking IS a possibility is dishonest. I can go on with analogy after analogy, but you get my drift.

I hope this all helps you sort this out! I really can understand having the concerns you describe, and I want to emphasize that though I tried to address your concerns and some specific scenarios, I still cannot give any guarantee. It really does boil down to recognizing that there ARE risks in either choice, as with life in general, and what you and you alone have to decide is which set of risks you are comfortable with.

Keep me posted! I wish you the best no matter what!

Anne


* P.S. I don't mean to rag on OBs too much - please know I'm aware that MOST of them are good people who genuinely believe they're doing the best thing for women, and I'm grateful we have them when we DO need them in high risk situations or with complications, i.e. when their care is most appropriate, even if I do disagree with many of their beliefs and practices regarding low risk, normal childbirth, a.k.a. "active management". There are many brilliant and wonderful ones out there, despite a few bad apples.

*****

I hope my fellow birth advocate readers out there approve! Especially any midwives or scholars - I pray that my information was accurate and fair as much as it was encouraging.

Saturday, November 7, 2009

Weekend at the Movies: Vive la difference!


The timing of this post I've been planning couldn't be better, what with the internet still abuzz and twitterpated from the birth streamed live by a woman named Lynsee just last night. But even earlier this week, a topic on Facebook was posited by Amy Romano: the great boon to the birth community that YouTube and other online video forums has been. We were all asked to share our favorite online birth videos, and there are a few absolutely incredible ones that are definitely my favorites (most notably the recent VBAC stories of Lindsey Meehleis and Alexandra Orchard, both of whom were so affected by their experiences that they became midwives themselves - truly transformative experiences in every way).

But the one that immediately sprang to mind for me was a black & white video that I had seen ages ago and tried to find again recently, to no avail. The film featured a blond woman, quite lovely, giving birth in a reclined but not supine position, alert yet relaxed, and best of all, looking absolutely, ecstatically amazed at what was happening! It's clear that she was watching herself in a mirror, and was totally enthralled and fascinated with her body and her baby, using her hands to feel what's going on, watching happily thrilled as the head crowns, rotates, and emerges. She pauses, in full, unpressured repose between contractions, no hollering to PUUUUSH or counting to freakin' 10, following only her own urges to push, including some pelvic shifting. It is astonishing to see, in a culture that focuses on the pain and angst and danger of birth - to see a woman filled with utter delight. The father (it seems clear) is guided through catching the baby himself, and when he brings it up to mom, the sheer, undiluted joy she expresses is equal parts infectious and touching.


(When you get to this video after you finish reading my waxings rhapsodical, take a moment: Can you envision what our birth culture would be like if THIS were the birth film they showed to the eighth grade health class?)

I had suspected YouTube might have removed it, and Ms. Unnecesarean confirmed this. Boo, hiss - I still have to give credit to YouTube for allowing so many birth videos, but it remains a bummer that they're censoring some. Luckily, the internet being what it is, I asked if anyone else might have seen this one, and might have any leads on other locations for it besides YouTube. Thanks to Amy's sizable following, someone procured it within MINUTES! I was floored and psyched - and I also got more than I bargained for.

The video I remembered is on there, starting at 3:40, and it's every bit as great as I remembered, but it's just one among 6 others in an 12 minute compilation - and all of the births offer something wonderful to witness. They are hospital births, but they are unlike pretty much any hospital birth I have ever seen (I imagine a birth with Dr. Wonderful or others in his rare, exotic species, would come pretty close). The women are mostly upright, many of them being supported in squats where their partners are acting as the birthing stool, and the doctors or midwives (my preschool level French couldn't distinguish this even if the audio were better quality) seemed engaged and positive, and largely hands-off. Young siblings are included in several of the births. Several fathers catch their babies with guidance, and one strips down nearly as much as his naked wife* (the mothers are all nude). Imagine an American hospital that encourages that much skin to skin not only with the mother, but the father, too. Imagine!

We get to see two perfectly vaginal, unhurried, relaxed births of twins. The first is a veritable feast. We start off with a gorgeous rotation shot at 1:06. As with most of the others, this one was extremely hands-off. Baby A lands softly on the towels, then a nurse gives the slightest possible bit of aid as the mother reaches down for the baby herself. Note: Meanwhile, no one is running around with instruments and towels and clamps and tables and suction bulbs. Daddy holds and talks to big sister about what she's seeing. Then Baby B backs into the world with absolutely zero sense of panic in the room, legs first and then rump, starting off with the same hands-off gentle landing that his predecessor got. (Speaking of, rather than being off getting weighed and measured and scrubbed, Baby A is simply being skin-to-skin on her chest, vernix and all.) Here the doctor, who we've barely seen up to this point, does step in with a little assistance as the head emerges - not yanking, but guiding the baby up in sort of a backward somersault. I'd be interested in seeing what people who attended the breech conference think of this maneuver - it seems gentle enough to my eye. Then Baby B, too, goes directly to the bosom. All this and we're 2 minutes and 10 seconds in! What a bounty.

The second twin birth, which follows the first, even takes place underwater. (I admit they had me biting my nails a bit on this, as they were quite leisurely in bringing the baby to the surface. I am all for not necessarily yanking the baby up as fast as possible, but this was just a bit too lackadaisical for me. Something between the two extremes would be my preference. Other thoughts? Please share.) Mom is the portrait of placidity.

And in the last video, though the birth itself was not a water birth, the baby is bathed in what I am assuming is a Leboyer bath shortly after birth - I have heard of (of course) but never actually seen this in practice before. I remember Peggy Vincent writing in "Baby Catcher" how Leboyer baths were a hot trend for a while among those families inclined to birth naturally, and how it was really mostly a headache for the nurses, trying to keep the water at the right temperature at the right time, and rarely went as smoothly as one hoped, with poor little ones squalling at the shock of a now-tepid bath. I can see how she would feel this way (though she appreciated how well-intentioned the idea was), and my impression is that the practice is basically obsolete today - but I can also see how this was part of the evolution towards birthing more gently, and I acknowledge its importance in that evolution.

I know, I know, quit yapping about it and show us the video already! Here's the thing, it's formatted so that I can't embed it here, and can't even directly link it, but the instructions are easy enough to follow. Go to this page, ignore all the other hospital videos on the page (or don't, but don't say I didn't warn you), and scroll down to #107. It looks like you may have to download this to Windows Media Player. If you don't have it, SRSLY, if you're interested enough in birth that you're reading this, it is worth it to install Windows Media to watch this. Get an upgrade if you have to, call Geek Squad, endure a tedious phone session with tech support, whatever you have to do. If it's not worth it, I hereby declare that I will pay you one million dollars**.

Laissez les bons temps roulez!

*If I recall correctly, this is also part of the Leboyer approach.
** Terms: one dollar a year for a million years.

Thursday, November 5, 2009

Birthapalooza?

I mused about this on Facebook and Twitter briefly, but thought I might as well ponder it further here. How cool would it be to have a huge, real-life Birth Blogger's Bonanza? Less of a conference, more of a festival. Birthstock, perhaps. Or a Gathering of the (Birth) Blogs. Birtharoo? Burning Woman? Labor Coachella? Anyway.

I'm relatively new to the scene, though. Has it been done? Just blogs, and only birth & related peri-natal issues? I'm not talking a big formal BlogHer-like event, I imagine more of a raucous potluck (though with people traveling, I know that's not literally possible).

I dunno. I just love the birth & baby blogs I follow, and their devoted mistresses, so much. I think it would be amazing to get to meet them in person. *fantasizes*

Wednesday, November 4, 2009

(Mostly) Wordless Wednesday

BEHOLD.



Every time I round a corner these days, I swear I see something like this. I know I should be savoring these days, as she'll soon be asking for keys to the hovercraft, but SHEESH. Toddlerhood gives me agita.

Sociable