Out-of-hospital water birth

Reorienting

I've noticed that lately, my posts have tended more towards the "doula" (or lactation consultant) in "Public Health Doula". I blame it on two things: 1) My classes this semester aren't giving me a lot of excuses to go play in my literature of choice and 2) This semester, while not having reached the total fever-pitch of insanity I dreaded, has been pretty busy and my veg-out time has generally not been donated to PubMed. It's a lot easier to toss out my thoughts on someone else's post, tell a story, or pass along a link!

But I am hoping to circle back around and look at more issues from the public health/research standpoint - I have a post cooking on maternal mortality statistics in the U.S. and a couple on infant mortality. And I have some exciting plans for next semester that will hopefully tie in: I will be the "third facilitator" attending CenteringPregnancy sessions at a local health center. They're facilitated by an awesome midwife, and for my master's project I'll be working with her to develop and pilot her idea for a CenteringPregnancy module on health disparities, focused on taking ownership of knowledge about health disparities and on exploring solutions.

(Sometimes I just want to pinch myself and think "Am I really getting to do all this? How did I get so lucky?" Then I remember that not everyone would consider my copious opportunities to interact with breastmilk and amniotic fluid, and to have conversations about vaginas, birth control, and infant feeding, "lucky".)

Anyway, if anyone has requests for research topics/public health perspectives/other posts let me know, but if you missed them they will be coming back!

Doula-Man

I wrote once before about Keith Roberts, the first male doula certified by DONA. Here's another profile:

“This is the most important tool, this crock pot. It’s a towel heater,” he says. “It has been to 149 hospital births in the last 14 years.”

The soft-spoken, silver-haired 66-year-old tends to the laboring woman’s pain to free up her partner to pile on the emotional TLC. His massaging hands and hot towels lessen the need for drugs.

“I can’t take all the pain away,” he says, “but enough so it’s OK.”

It almost sounds too good to be true. Are you thinking what I’m thinking: “Where was this guy when I needed him?”

Male or female, bring a doula to your birth!!

Side note: the article makes mention that Vince Vaughan is developing a movie called "Male Doula" (not based on Roberts). No good can come of this!

Writing for Salon, Barbara Ehnrenreich does a nice job of asking whether the pink ribbon of breast cancer has replaced actual feminism and the fight for comprehensive health care.

I'm not cavalier about breast cancer; nearly all the women on one side of my family have had it. But I am icked out from a near-romanticization of breast cancer, and the "pinkwashing" corporations engage in. (I have been strongly influenced by the Think Before You Pink campaign.) And from a public health standpoint, the almost exclusive focus on breast cancer by many campaigns is a little strange: as the the American Heart Association notes: "Nearly twice as many women in the United States die of heart disease, stroke and other cardiovascular diseases as from all forms of cancer, including breast cancer." I think it's important to express to women that they need to take as least as much care with preventing heart disease as they do with breast self-exams, yearly mammograms, etc.

As Ehrenreich points out, while Hollywood stars flip out over new mammography recommendations, no one similarly high-profile is talking about Stupak, pushing for all women's preventive services to be covered in health care reform. No one is asking what kind of preventive care and public health funds in general are going to be aimed at the kind of basic public health interventions that affect not only breast cancer but almost every other disease you can think of: Exercise, healthy eating habits, social support, limiting environmental pollutants, etc. Women's health is not just breast cancer. (And that yogurt lid? You can just donate the cost of the stamp you'd have used to mail it; the breast cancer research organizations will get more money that way.)

Update - when the village nurses the baby

Early this year, I posted about a group of women in Michigan who were nursing the baby of a local family whose mother had died of an amniotic fluid embolism (a very rare complication during birth). Here's an updated story - looks like Moses is still being breastfed every day by local moms. So amazing.

Skin-to-skin vs. pushing latch-on right after delivery

"Breastfeeding initiated with in the first half hour" or "the first hour" (depending on what country you're in) is one of the important facets of the Baby-Friendly 10 Steps. While this is an admirable goal, Gloria Lemay has a very nice post up about the problems with aggressively pushing breastfeeding immediately after birth, sparked by e-mails with a lactation consultant in Israel. That LC, Leslie Wolff, writes:

I have a few of my own beliefs about breastfeeding immediately after delivery. I feel that skin to skin after birth for the first two hours is SO important -more important than making a big effort to get that baby to breastfeed.. MAINLY because I realize that it helps the diad - mother and baby - to recover from the birth experience, is a Win Win situation that requires no effort , there is nothing to “succeed” in - it is just a “being” situation that is beautiful for Mom and baby. And if the baby goes for the breast - great..and if not, or the breast is offered and the baby doesn’t GO FOR IT - that’s fine. ... I know that babies are “supposed to” “immediately” start breastfeeding beautifully - but I see so many mothers and babies that are SO content just lying there Skin to Skin, relaxing, bonding in their own special way. In the past, before I discovered the beauty of Skin to Skin ,I remember many frustrated Moms and babies doing their best to breastfeed, because Mom and Dad both knew that was the best thing to do immediately after birth...)

Gloria agreed and added:

I attend only homebirths and have the same attitude. It’s the skin to skin contact and little (or big) noises of the baby that cause the uterus to contract powerfully post partum. It is a sacred time right after birth that can never be recaptured. When the mother and baby have warmth and privacy they will “discover” each other and fall madly in love. This is the best child protection method both in the short and long term. We are mammals. We must sniff, lick, coo, cuddle, look at and hear our young. In turn, the baby does many “pre-nursing behaviours”-climbing, licking, looking, hearing, sniffing. . . who knows what they are doing because it’s dark and private, remember?

I think these are both beautiful and important reminders that the idea of initiating breastfeeding in the first hour is more about getting mom and baby close, practicing skin-to-skin care, and letting both "discover" each other. I don't think it's so important to - as some people do - make sure the baby is latched on, nursing vigorously, and has a perfect latch in the delivery room. (I have seen some very aggressive latching efforts by nurses that have made me very uncomfortable.)

But as a doula, I have often pushed breastfeeding in the delivery room, even when mom and baby could be happy just cuddling. Why? Because sometimes it seems like the only way to keep baby with mom. Now that (some) hospitals have placed importance on breastfeeding, it's considered an important (aka chartable?) activity. But skin-to-skin time, bonding, and relaxing are unfortunately not considered important, and thus are subservient to other important activities like weighing, measuring, eye gooping, bathing, newborn exam, etc. etc.

Itchy fingers are often waiting on the sidelines so that "when you're done nursing I'll take him up to the nursery to get checked out and then you can have him back". Or if mom needs a lot of stitches, itchy fingers are hovering to say "Since this is going to take a while, I'll just take him upstairs now and then when you get there, you can have him again to nurse." (What do you want to bet he's going to get hungry upstairs and be given a "just a little bit" from a bottle while waiting for mom?)

It's unfortunate that as a doula, I feel like I have to ask "do you want to breastfeed now? let's see if we can get her latched" - but when I sense itchy fingers waiting, I try to postpone them as long as possible and sometimes it feels like the only way to do it is to push breastfeeding. I will say that I try to be so careful to step back, not be very hands-on, and focus more on baby tasting, nuzzling, and "practice" latching than any measure of "success". (Unfortunately, parents sometimes have their own preconceived notions of "success" and the perfect nursing session, which can be hard to dispel.) I wish that all mothers were accorded the same sacred, private space that Gloria offers homebirth mothers, so this wouldn't be necessary.

New protections for nursing mothers in Senate health bill

From the Wall Street Journal Health Blog:

Here’s a detail in the Senate health-care bill we hadn’t noticed until now: Employers would be required to give nursing mothers “a reasonable break time” to express breast milk during work.

Employers would also have to provide “a place, other than a bathroom, that is shielded from view and free from intrusion from co-workers and the public, which may be used by an employee to express breast milk,” the bill says.

Companies with fewer than 50 workers would be exempted from the requirements if the rules imposed “an undue hardship.” You can read the provision yourself on page 1239 of the Senate health-care bill. Similar legislation has been introduced in Congress for years, but has never become law.

More than 20 states already have laws in place to protect nursing mothers in the workplace, according to a Kaiser Health News story that highlights several provisions in the Senate bill that haven’t drawn much attention.

There's plenty to say about ignoring extended maternity leaves in favor of lukewarm pumping protection, but at least this would extend some extra protections to women working in states that don't currently protect their right to express milk. It also shows there's at least one prevention-minded initiative in the health care bill!

Thanks for the link go to Adriane, my classmate and policy guru extraodinaire!

P.S. I just realized this is my 200th post to Public Health Doula. Wow! Thank you for reading, commenting, and sharing.

In which a medal comes in the mail!

Sheridan of Enjoy Birth was thinking about the oft-repeated phrase tossed at women planning an unmedicated birth “You don’t get a medal for natural childbirth.”

As she writes in her blog:

I started thinking, “Why Not?”

When you run a marathon, you prepare for months ahead of time and then the day of the race you run and run and run and work SO hard! I am sure when you cross the finish line you are just so happy and proud because you DID it, you accomplished your goal! You didn’t run the marathon FOR the medal. But you do DESERVE a medal!

She designed a medal for moms who worked hard and long and deserved a medal at the end of their labor marathons. But:

Then while I was in the process of doing all of this, I had a mom who needed a surprise cesarean for a breech baby. I realized that she deserved a medal just as much as the other mom. I thought about all the sacrifices different moms make and realize ALL moms deserve medals.

Suddenly my idea was so much bigger than what it started as.
But that is how all great things start, with a small idea. So hence Moms Deserve Medals was born. Because ALL Moms Deserve a Medal!

I was surprised and touched to receive an e-mail from Sheridan a few weeks ago saying she appreciated my blog and the info it offers women, and offering to send ME a medal! And pretty soon, it arrived:



I love this medal and am honored to get one, and I am already thinking about how I want to hold onto this for a little while and then pass it along to a doula client who deserves one. And I know one will come along, because thinking back on recent doula clients, I realized that as Sheridan points out ALL moms really do deserve medals! Every one of the moms I have worked with this past year has their own reason for deserving a medal! Women who trusted and listened to their bodies, women who researched their options and made their own decisions, women who bravely endured frightening medical complications, who underwent long and difficult inductions, who did everything they could to protect their babies' health. As Sheridan points out, they don't do it FOR a medal, but they DESERVE one!

Sheridan, thank you for this great idea and for the medal!

Reply turned post: Warning: this post contains the word "rectal"

Jill at the Unnecesarean recently wrote about out-of-bed birth and the Captain Morgan aspects of one of her births (you have to read it to fully appreciate). MidwifeNextDoor commented:

"Good for you! I am a CNM presently (reluctantly) working in the hospital. I've only done two out of bed births so far, but it freaks the nurses out! One nurse's chart notes on a patient went like this (the woman was pushing when she arrived at the labor ward):

"Patient REFUSES to give urine sample. She is standing by the side of the bed. I have repeatedly told her to get up on the bed, but she refuses. She stated, 'Women have been giving birth standing up for thousands of years and SO CAN I! And then she pushed the baby out. I did put gloves on before the baby was born."

This client of mine was a VBAC client, by the way! I didn't make it in time for the birth, obviously. I've done one bathroom birth, with mom on hands and knees, and one side of the bed birth with mom standing. There is so much fear surrounding anything different from the cockroach position (flat on your back, legs in the air) that it makes me stressed.

Would love to see more women refuse to get into bed."


This jogged a doula memory for me and I contributed my own comment/story. Since several people thought it was pretty funny I thought I'd repost it here:

"MidwifeNextDoor, your comment about the nurse's charting was so funny!! It reminded me of a birth one of my fellow doulas attended when we were in AmeriCorps together. There was a new CNM at the very by-the-book, public hospital we often attended births at, and she had trained in birth centers down in New Mexico. I can't imagine she's still there but at the time she was fighting to carve out a little sphere for normal birth, and we loved her for it.

One day she paged for one of our doula team to come in to a birth there because she knew the mom wanted to go unmedicated and felt like the nurse wasn't going to give her enough support. My teammate was on-call and told us the whole story later. I can't remember the exact details anymore, but it went something like this: When it came time to push, the unsupportive nurse really couldn't handle the hands-off approach. Mom began pushing standing up next to the bed and the nurse freaked out and said "She's pushing!" "Yes," the midwife said calmly, "she is." The nurse began to get huffy and started charting about the patient pushing STANDING UP. "What's her dilation?" the nurse asked. "Oh, she was almost fully dilated," the midwife said, "I'm sure she's complete now." The nurse went back to charting about how the midwife did not check but just SAID the patient was complete. The nurse at this point swings the computer around so her back is to this travesty. Whenever the midwife asks for a chux pad or anything else she needs, the nurse gets it for her and then goes back to charting with her back turned, so the midwife starts asking the doula to hand her things. As the baby descends, the midwife takes note of signs of progress and says "Could you please chart, 'positive rectal bulging'?" "WHAT?!" says the nurse. "POSITIVE RECTAL BULGING," the midwife says loudly, and she and the doula grin at each other. (Fortunately mom was Spanish-speaking and probably not paying any attention anyway so she wasn't privy to all this banter.) Shockingly, baby is born without any need for mother to get into bed, or for nurse to do much but stand with her back turned and chart ;-) "Positive rectal bulging" became a catchphrase around the office for a while.

Side note: after the baby was born, mom did get into bed to rest and cuddle with the baby, and the doula told the mom what a great job she did, how impressed she was, etc. She asked half-jokingly, "So, do you feel like you could do anything now?" and the mom looked up and very matter-of-factly said, "Oh, YES." "

Why I'm a doula, and what a doula can do for you

Posted as part of the Science and Sensibility Healthy Birth Blog Carnival #3. I've meant to participate in the previous carnivals, but I just couldn't miss this one: on step 3 of the Lamaze Six Healthy Birth Practices, "Bring a loved one, friend, or doula for continuous support."

By way of talking about continuous support is so important, I want to talk about some reasons that I am a doula.

I am a doula because of the woman I worked with whose husband drew me into the corner as she went through transition. He was worried. "Is this normal?" he asked. "Is this OK? She'd really like to know how much longer this will go on." I reassured him she was completely normal, doing beautifully, and that while no one could predict the course of labor, she would probably be done soon. He went back to his wife's side with renewed conviction and was constantly whispering encouragement and praise into her ear. Their baby was born just a couple of hours later.

I am a doula because of the first VBAC I attended. I was working as a volunteer doula, and her nurse paged me in because this woman became nervous whenever the medical staff would leave her alone. I sat with her, brought her cold washcloths, watched her rock back and forth furiously in the rocking chair, and let her crush my hand. (She kept asking "Am I hurting you?" and I lied and said no.) She said, "No one told me how to do all this last time to bring the baby down. They just said I wasn't making progress and did the surgery." Later that night, she pushed her baby into the midwife's hands.

I am a doula because of the young woman who labored so instinctively despite being restricted to a hospital bed. She spontaneously flipped to her hands and knees, to her side, rocked her hips and made noise. I just watched and told her what a beautiful job she was doing and that she should listen to her body. Her labor lasted longer than any of us expected it would, but she remained strong through the end.

I am a doula because of the woman who was so anxious about her labor that she couldn't relax and rest. I sat next to her and talked quietly to her, visualizing a beautiful labor, a healthy baby, trying to put a smile on her face and let her welcome the next stage of labor. The next morning, her baby was born and placed directly into her arms.

I am a doula because of the family who forgot their camera in their car - I ran down to get it and came back just in time (on the way promising the ladies at the front desk that someone would be back down to move the car as soon as the baby was born!) Baby was born quickly and there were beautiful pictures galore.

I am a doula because of the woman who, as soon as her baby was born, began asking "When can I breastfeed her? When will they give her back? When can she start nursing?" I sidled over to the pediatricians several times to say, "You know, she'd really like to start nursing, whenever you're ready..." When they finally got the baby back to her delighted mom, she latched on like a champ and went on to breastfeed for over a year.

I am a doula because of the family I spent 26 hours straight with, sleeping sitting up in a chair. They went through multiple shifts of nurses and midwives and doctors, but I was there to say "This morning she was feeling nervous about ____, can you discuss it a little more?" They had a long and difficult labor to contend with, and I have never been gladder that I didn't call my back-up and stayed through to the end.

I am a doula because I can make a hot pack out of towels and chux pads, I know where to find the extra stretchy disposable underwear, and I carry lanolin sample packets in my doula bag in case someone forgot their chapstick.

I am a doula because somehow, the things I offer are so simple and yet seem to mean so much. Someone to be a familiar face, to be a reassuring presence, to offer a little extra information, to facilitate with care providers, to bring food or forgotten items, to provide touch and ice water and hot packs, to be a hand to hold, to press in just the right spot, to just be there. It seems like a miracle sometimes that such simple things can mean so much, and yet it does; even the research says so, and just as importantly so do the women who are served by doulas. I have to trust them, because it's hard to believe I can do so much, and have so much fun at the same time!

A loved one or friend can be a fantastic doula, and many people will swear by their husbands, partners, mothers, or friends as doulas. The important thing is to have someone who can provide those simple and necessary things, and who understands the importance of their active participation in the process. Don't bring spectators who will sit in a row on the couch and watch you like a TV show; or people who will undermine your confidence; or people who bring their own issues or focus to the room. If you can't find that person among your personal support circle, or want more back up, consider hiring a professional doula. But no matter what guise they come in, bring doulas to your birth!

What an induction looks like

Want an induction? Ask yourself if you want this:

Monday 9 p.m.: Arrive at hospital. Change into hospital gown, get in bed, be connected to contraction and fetal heart rate monitors (external belts). Cervix hard, thick, and high. Receive one dose of Cytotec (medication to soften the cervix, an off-label use of this medication which has serious risks).

Monday night: Sleep, intermittently interrupted by the nurse to adjust monitors, take temperature and other vitals, etc. Another dose of Cytotec around 3 a.m.

Tuesday 7 a.m.: Checked by incoming shift. Little change. Place another dose of Cytotec.

Tuesday during the day: Some contractions. Skip a dose of Cytotec to be able to go off the monitors, shower, eat, and walk the halls for an hour or so.

Tuesday 7 p.m.: Checked by incoming shift. 1-2 centimeters. Agree to Foley bulb catheter to expand cervix. Two hours later, Foley bulb falls out. Now 3 cms. and ready to start Pitocin. No more eating, drinking, or going off the monitor (so no walking around, limited movement).

Tuesday night: Sleep, with intermittent contractions, as Pitocin is ramped up.

Wednesday 7 a.m.: Checked by incoming shift. 4 centimeters. Doctor breaks bag of water (=AROM, Artificial Rupture of Membranes). Intense, strong contractions immediately ensue. Intrauterine pressure catheter (IUPC) placed to monitor contraction strength. Hour-and-a-half wait for anesthesiologist, who is in back assisting at a c-section. Receive epidural. Labor slows down again, Pitocin is ramped up.

Wednesday during the day: Some wearing off of the epidural effects. Cannot get up or move around to help with pain because even somewhat ineffective epidural doesn't allow for enough control of legs. Still not allowed to eat or drink. Constant itching from epidural. Nurse comes in frequently to adjust baby heart rate monitor. Nurse checks cervix and says 5-6 cms.; doctor comes in later and says only 4. Now attached to 7 different wires: oxygen saturation monitor, blood pressure cuff (worn continuously, going off every 30 minutes), external fetal monitor, IUPC, epidural catheter, bladder catheter (can't get up to pee), and IV line.

Wednesday 7 p.m.: Checked again, 7 cms. Anesthesiologist has come in twice to try to fix epidural and comes in a third time for one last try. Re-upping medication helps slightly; sleep intermittently for 20-30 minutes and then epidural stops working well again. Still itching - nurse says she can offer Stadol for the itching, but that will cause a lot of sleepiness/loopiness and "out of it" feeling; decline the Stadol.

Thursday 12 a.m.: Checked again - completely dilated to 10 cms. Begin pushing. Back begins spasming, possibly from being in bed so long, makes it difficult to continue pushing but do so anyway. Push for 2 hours. Baby's heart rate begins to drop and doctors suggest a vacuum extraction. Also give oxygen - now connected to 8 different things.

Thursday at 2 a.m.: Vacuum extraction successful; baby is born crying and vigorous but immediately taken over to the warmer because of the heart decels and use of the vacuum. Doctor repairs perineal tears while peds team checks over baby. Finally get to hold baby after 45 minutes, but baby is not interested in nursing yet. Nurses impatient to take baby to nursery for first bath; give baby to nurses, be unhooked one by one from all wires and medical team leaves. Wait in empty room until it's time to be transferred to the postpartum floor.

---

I have attended many inductions, and this is based on a composite of multiple inductions I have witnessed. I think it accurately represents the experience of many women who are induced without any cervical readiness for labor (and even some who are induced with greater readiness).

It's not a very nice story. Do I write it to "scare" people? "ZOMG, if you get induced you will be in labor forever and in pain and your baby will need to be pulled out." That's not what I'm aiming for; there are inductions that go smoothly and quickly (although more often when the body is ready and willing).

Instead, I write it to inform. There was an online workshop offered this summer for doulas called "Do You Dread Inductions?" because the answer is YES! We only wonder why our clients don't dread them more, and the best answer I can come up with is that people don't understand what they're consenting to. I think the impression many women of an induction is that it's similar to regular labor, but you just get to pick your day. Let me be one of many doulas who can tell you: this is not the case!

When you start regular labor at term, it's because a complex set of signals and changes in your body say "This baby is ready; let's get it out." (One way to measure whether the body has begun preparing for labor is a Bishop's score.) When inducing labor, medical staff try to replace those natural signals and changes with manufactured ones: promoting cervical softening and dilation using prostaglandin gels or misoprostol (Cytotec), inducing contractions with artificial oxytocin (Pitocin).

As this cervical ripening and early dilation is generally the longest part of labor anyway, and is much less efficiently done by medications than by normal physiological processes, all of this takes a long time. Often by the time a woman in spontaneous labor would be showing up at the hospital (4-5 cms) you have already been in the hospital 12-24 hours, and still have a ways to go. You're also likely to experience a more intense, painful labor because induced contractions are different from natural contractions, so you're more likely to need pain medications.

In addition, when you induce without your body being ready (aka a low Bishop's score) you increase your chances of a c-section, and even if you avoid a c-section you increase your chances of a long, drawn-out experience that may not be what you are prepared for. Don't be electively induced, and understand the legitimate reasons for induction vs. the convenient excuses.

If you need an induction for medical reasons and your body is not ready, be prepared! Eat and drink as much as possible while you are still "allowed" to. Advise family and friends that it will be a long wait and make sure everyone gets a lot of rest whenever possible. Don't accept phone calls from people asking "Is that baby OUT yet??" As long as baby is doing OK, don't be afraid to ask for assists like telemetry (wireless) monitoring so you can move around more freely, and breaks to go off the monitor while nothing is actively being done. Get out of bed as much as possible whenever you can, because it can be hard to avoid an epidural and that will restrict your movement later on. Delay breaking the water as long as possible, because it starts the clock ticking for delivery. Use different positions for pushing - even if you have an epidural, it's possible to move around in the bed, and it helps counteract the position problems that can arise from a long stay in bed.

If you have to be induced, be informed. But if you don't HAVE to be induced - don't take the decision lightly. Wait for your baby and your body to tell you it's time.

Friday night movie

I have a lot of posts that I want to write, am writing, or am revising. But in the meantime the end of the semester is coming up, and I have to remind myself that I don't get any credit for blogging! (Darn.)

In the meantime, here's a beautiful movie of a baby born underwater and in the caul (with the amniotic sac still not ruptured).


(Via Birth Routes.

As somewhat off-topic side note: You can see the baby hanging out for a while after the head is out, until a midwife reaches in to help bring the body out. While this baby does not to my eyes seem to have anything resembling shoulder dystocia, seeing this patience and willingness to wait for the body made me think about shoulder dystocia...this is pursuant to a birth I was at recently. I'd like to learn more about the importance of when and how it's "diagnosed" and whether attendants give baby the opportunity to rotate properly before becoming aggressive.

Milk's up! The breastfeeding gang sign

It's always nice when I notice a mom nursing in public (challenge those norms!). But, being paranoid, I worry that if someone notices that I'm noticing that she's nursing, she'll interpret it as disapproval. So usually I go for a brief glance and a big smile. But this is a cute idea too: a sign to give props to moms who are out, about, and nursing. You can skip to around 3:10 to see the sign in action:



Would you use it? I'm going to wait for it to become more widespread before I spring it on anyone, but I think it's a really nice concept.

Not-good-things that nurses do

I love some L&D nurses; they can be awesome, a huge help to the patient's goals, an advocate with the doctors/midwives, a doula's best friend. But I have a few pet peeves:

* Nurses who tell women they have to be in bed because they can't trace the baby otherwise. You know what happens after you get the woman in bed? You still have to mess with the monitor to trace the baby. Why didn't you try doing that when she was on the birth ball, instead of assuming the baby would be untraceable that way?

* Nurses who tell women they have to be in a specific position (ahem, on their back) because they can't trace the baby otherwise. You know what else could help? If someone was holding the monitor on where it needed to be. I've seen nurses be that "someone" - why not you? Or if you're willing, I can do it; it's not rocket science. But when I walk out and see you chatting at the nurses' station, I wonder if you could have done it after all.

* Nurses who tell women it's good to change sides in bed, and don't actually come in and encourage her to do it regularly, which an exhausted mom will probably forget to do. Or don't come in to help her at all, instead letting a mom with an epidural struggle to move herself around.

* Nurses who tell women how good it is to walk and move around, while doing all of the above.


Can you tell I'm frustrated? I promise to write a good post about good things that nurses do too!!

Giveaway - Breastfeeding with Comfort and Joy

Ooooh I want this book. I have checked out some of it via "look inside" on Amazon, which makes me want it even more! I would love to have a really beautiful breastfeeding book to show and share. (Who am I kidding - I give away my birth/breastfeeding books almost as soon as I get them because I see someone who I think needs them more than me - but I'd try to hold on to this one for a while!)

Kathy at Woman-to-Woman Childbirth Education is hosting a giveaway - check it out!

The Stupak amendment.

[Note: I posted this yesterday, then heard an NPR piece that made me think I hadn't understood the Stupak amendment's restrictions. I was heading out the door, so I didn't have time to revise; I took the post down until I had time to research and make sure I was right. This is something I feel very passionate about and I wanted to make sure I was as accurate as possible. Slightly revised version below.]

I called, on Saturday, but what more could I do? Mostly I just tracked the news and crossed my fingers. The fact that this came out of nowhere (at least for me) and was over with in a day feels so utterly unfair.

In case you are not familiar with the Stupak amendment, it is part of the recently passed House version of the health care reform bill. The amendment restricts the ability of public and private insurance plans, offered in government health exchanges, to provide coverage for abortion.

Read that again: AND PRIVATE. This is where I was unclear yesterday, but it is clarified today by this extremely helpful post from legal experts at Planned Parenthood. I'm quoting it extensively because given what I heard on NPR yesterday, I think there is still some confusion out there about the realistic effects of the Stupak amendment on abortion coverage availability in the exchanges:

The Stupak-Pitts amendment prohibits any coverage of abortion in the public option and prohibits anyone receiving a federal subsidy from purchasing a health insurance plan that includes abortion. It also prohibits private health insurance plans from offering through the exchange a plan that includes abortion coverage to both subsidized and unsubsidized individuals.

Thus, if a plan wants to offer coverage in the exchange to both groups of individuals, it would have to offer two different plans: one with abortion coverage for women without subsidies and one without abortion coverage for women with subsidies. These private insurance plans would need to be identified as either providing or not providing coverage for abortion.

Health insurance plans are highly unlikely to operate in this manner, and it is not even clear that this is feasible under the administration of the exchange and affordability credits. As one alternative, the Stupak amendment purports to allow women to purchase a separate, single-service “abortion rider,” but abortion riders don’t exist. In the five states that only allow abortion coverage through a separate rider, there is no evidence that they are available.

Furthermore, women are unlikely to think ahead to choose a plan that includes abortion coverage, since they do not plan for unplanned pregnancy. In addition, it is not clear that health plans would even be allowed to offer two separate plans under other provisions of the act, such as the anti-discrimination and guaranteed-issue provisions. Those elements of the bill, which are very important to consumers, may make it impossible for plans to provide two separate plans, one that includes abortion and another that does not.

Realistically, the actual effect of the Stupak-Pitts amendment is to ban abortion coverage across the entire exchange, for women with both subsidized and unsubsidized coverage.

(emphasis mine)

Why the Stupak amendment? The argument is, as best I can tell, that those people who can't use all their own money to buy health insurance will be eligible for a government subsidy. This will probably be me at some point very soon (like after I graduate from school in May) so let's take me as an example. I could use the subsidy to buy a health insurance plan that covered abortion. Then I could use that money (along with my OWN!) to buy a private plan. Then, if I needed an abortion and that insurance plan covered it, the government would have somehow, indirectly, kinda sorta had a hand in making it possible for me to get a legal medical procedure.

Did I say legal medical procedure? I also meant abortion. They're the same thing, so sometimes I use them interchangeably.

We have had the Hyde amendment in place since 1977, exempting abortion from Medicaid. Poor women, expendable: check. Apparently health care reform is an opportunity to go even farther: to reach into PRIVATE health insurance, paid for with PRIVATE money, and effectively take abortion coverage out of that, too. This applies not just to individuals, but to businesses; companies that buy plans through the exchange? All their employees' families will lose any abortion coverage they had. All women, expendable: check.

The fact that this amendment comes from the party that has been ranting and railing about "government taking over health care" and using scare tactics like death panels and rationing of care...well, I guess irony has been dead to the Republican party for a long, long time, so we shouldn't be too surprised.

Besides women who need abortions, who else will this hurt? How about women who have miscarriages? Is maternity care next? Keep in mind, this comes from the same party that says health insurance shouldn't cover maternity care, because men don't need it.

This just...disgusts me. Last year I went to a talk by Dr. Nick Gorton and blogged about how he predicted this very outcome - that reproductive health care would be one of the issues to suffer when government stepped into health insurance. At the time, I mused about how we could protect abortion and other political hot button issues in health care reform - but reform seemed so theoretical. I guess I haven't been paying enough attention - but that's going to change. I agree, let's not just be satisfied with keeping Stupak out of the final bill - let's go after Hyde.

If you'd like to take further action now, this is a great place to start: While there's a wall of shame for Dems who voted for Stupak and against reform, there are some bright spots. Those are Democrats who voted AGAINST Stupak and FOR health care reform - despite being in highly vulnerable races next year. Click here to donate to those reps, reward their courage, help keep them in Congress, and send a message to the party: Do NOT allow the Stupak amendment into the final bill.

If you have a problem when you breastfeed, then you have a breastfeeding problem!

Recently I went to visit with former doula clients. (It was so nice to see them. They are such wonderful people and have such a cute baby. And I got to hold the baby for a long time! I know not all doulas/midwives/other birth professionals are baby fans, but I am definitely a huge sucker for an itty bitty baby. But I digress.) Their baby breastfed beautifully all through the hospital stay - frequently, happily, no concerns whatsoever.

Apparently when they got home the baby went in for a check-up. Due to weight concerns, the pediatrician told them to supplement with 1 oz of formula after each feeding, and they did, reluctantly. Fortunately baby soon became more wakeful and interested in eating (my guess is, the baby just got a few days older and grew out of the sleepiest phase). They weaned off the supplementation rapidly and are back to exclusive breastfeeding.

But ack! That was the first line of a tale too often told...weight problems, doctor recommends supplementation, leads to supply problems, leads to more supplementation, more supply problems, and now we're in the downward spiral.

I say to all my clients at our immediate postpartum visit, "Just call me if you have any problems or questions about breastfeeding." But this has happened more than once: I find out weeks or months later that the doctor recommended supplementation, and I don't hear about it until long after the fact. Mulling it over, I decided that maybe not everyone perceives the need to supplement as a breastfeeding problem. And I think it reveals the norm in our culture of: "It's good to breastfeed, but when it's not working supplementation is the answer". When instead, the norm should be "Women make enough milk and babies transfer it effectively, and if this does not happen there is a problem that needs to be solved".

If I had talked to them when they got that recommendation, I would have recommended they make an appointment with an LC to make sure baby was transferring milk effectively and that mom's supply was OK and being maintained. I would also have talked to them about ways to avoid confusion while supplementing with the bottle, and/or alternative supplementation methods to prevent nipple confusion. Am I glad that they didn't need this help? Yes, but it's that dodged-a-bullet feeling.

I asked one of the LCs about how she gets people to call when they get the order to supplement, and she said she tells parents, "If the doctor tells you to supplement, please call me so I can show you how to supplement without using a bottle." I think that's a good way to 1) avoid nipple/flow confusion and 2) get in to assess what other problems are contributing to the situation. I'm going to try that line in the future.

And pediatricians: Hello. You have a mother in front of you who wants to exclusively breastfeed. Her baby is not gaining enough weight on exclusive breastfeeding. Obviously, the first thing to do is always "FEED THE BABY" (as a page in my breastfeeding educator manual says in huge bolded letters). So now you have fixed ONE problem by ensuring the baby is eating enough. Take another step to get to problem number TWO: what is going on with breastfeeding and how can it be fixed? Yes, this is your responsibility, particularly since your fix to problem one is likely to make problem two even worse. It is so discouraging when pediatricians talk a great line on breastfeeding but don't do much to support it.

I'm not hating on all peds; there are great, supportive, knowledgeable pediatricians out there, and they can and do give excellent advice and refer to lactation consultants when needed. It just sucks when you run into the ones who do NOT.

IBCLC training update

Last week one of the LCs at the hospital was out sick, and I ended up not really being able to shadow and going home early. It reinforced to me how much I enjoy my LC shadowing and miss it when I don't get to do it!

But I did spend some time, while waiting around, thinking about how I want to structure my LC training. Our course gives us a basic framework, but as it's the first year of the course and there has been some instructor upheaval, a fair amount is on us to organize. And I do feel the need to make sure I am exposed to a the whole range of LC practice; we get to see interesting cases at the hospital, but it's a little catch-as-catch-can and I feel it's important to seek out exposure to problems I might not encounter there. In addition, going once a week I miss the continuity and follow-up process. One of the LCs at the hospital (who, like us, came from a non-nursing background) showed us a "blueprint" notebook she used to organize and document her learning and training. It seemed so useful for making sure all the pertinent issues are covered; I'm thinking about getting one myself. Anyone have thoughts/other suggestions on helpful ways to make sure you're covering what you need to in IBCLC observation?

So far I haven't been putting in the suggested extra hours each week outside the hospital, at LLL meetings or other venues. I started the semester overwhelmed by my class load, assistantship, and extracurricular commitments, but now that things have stabilized a little it would be good to get the outside observation going. I am also laying big plans for next semester, when I will only be taking my LC course, one online course, and writing my master's paper (additional info on master's paper to come, but hopefully I will be working with a local Centering Pregnancy program!) That's when I really want to set up a schedule shadowing outside (non-hospital-based) LCs, attending breastfeeding support groups, and generally maximizing my exposure to lots of different breastfeeding concerns/situations. Once graduation rolls around (May) I will have two months left until the certification exam, and I am hoping to pack more observation and experience into that time...along with studying. Lots and lots of studying.

The week before last I had my first "hands on" experience. The LC had me go in and do the assessment and assistance with the mom, while she observed. Fortunately it was a sweet mom who was so excited about her new baby and about breastfeeding, and just needed a little reassurance and teaching. I forgot a couple of teaching items (I need a checklist), but fortunately the LC was right there to fill in those gaps. I corrected a couple things about the latch (lower lip tucked in, jaw not down well) and the LC agreed with me and we got the baby latched on and eating great.

I was feeling good until we went to the next room. The LC stepped out to get something while I helped the mom latch on one side. She seemed to feel OK and baby seemed to be sucking fine. When the LC came back, she helped the baby latch on very deeply to the other side. "Oh, wow, this latch feels so much better!" the mom said. So I think I missed seeing a shallow latch on the first side, and it felt discouraging to have missed something that simple, something I generally feel very confident about assessing in my doula role. Looking back, I think I was not assertive enough about getting in there and checking. The women I'm working with know I'm a student, and it makes me nervous about being too hands-on and taking over the LC role too early, especially if my preceptor isn't right there. I need to either step back until I get that confidence, or call up some of that confidence and use it! Anyway, hoping for more hands-on experience this week... and a confidence boost.

Getting the flu vaccine

I've gotten the flu vaccine every year for a while now (my mother calls me every fall to make sure.) I've already gotten the seasonal flu vaccine this year, and as a health student with direct patient contact I'm being offered the H1N1 vaccine as well. (I'm glad that as a research assistant at my school, I'm considered a university employee and am offered both vaccines through Employee Health, because H1N1 vaccine is tough to find right now.)

I know that there are questions about vaccine safety, particularly for children, and I know that some health care workers are refusing the H1N1 vaccine. Personally, I get the flu vaccine for 3 reasons:

1) I don't want to get the flu. It sucks. I've only had it once as an adult, and it was so much worse than I remembered. I had a fever, was very achy, could barely sleep because I couldn't breathe through my nose, was coughing terribly, missed days of work, and could only lie on the couch and stare at the TV. (I watched the same episode of "The Ashlee Simpson Show" three times. 'Nuff said.)

2) Whatever risks the vaccine has, I believe them to be very small for me. Whatever else one's feelings about vaccines for children, I feel comfortable getting vaccines as an adult. I've never had an allergic reaction to a vaccine, and I've done all my growing and developing. Beyond that, it's just an achy arm.

3) Since I think any risks are small, I'm willing to take them on, both to protect myself and also to reduce my chances of passing on the flu to the pregnant/postpartum women and infants I work with. If I can't get the flu, then I can't transmit it either.

To me, vaccines for parents/caretakers/health care workers are a no-brainer. One thing I learned this summer is that new parents are now recommended to update their whooping cough (pertussis) vaccine, as immunity can fade over time and whooping cough is back on the rise. Re-upping this vaccine helps "cocoon" infants until they can be fully vaccinated, and I think it's all the more important if you're not planning to vaccinate, or use an adjusted schedule. I get the concerns of parents who resist vaccinating their children, but it can't hurt to at least vaccinate yourself and offer them protection through your immunity. Why pass it on if you don't have to?

Nestle-free week, Oct 26-Nov 1

Angela at Breastfeeding 1-2-3 posts about how you can join the Nestle boycott this Halloween season. She has some excellent links including why you should consider boycotting Nestle, and what products are Nestle products (short answer: a lot).

Even if you're not able or prepared to boycott Nestle 52 weeks a year, consider joining the boycott for this week...especially when considering candy purchases. Which can't be that hard, because they don't sell Snickers or Milky Way or 3 Musketeers or Almond Joy or...mmm, I'm getting distracted just thinking about Halloween!

(Side note: Speaking of Halloween, my department is doing group costumes again this year. Last year we were all different forms of contraception (I went as the Pill). This year we are flu-related costumes - Spanish flu, swine flu, etc. I'm going as the flu vaccine, which could be scary depending on your take on vaccines and/or giant syringes. Is anyone else out there doing a health-related costume/theme?)

I haven't been great about avoiding Nestle products in the past, but looking at Crunchy Domestic Goddess' list, I actually think it wouldn't be so hard to cut out the Nestle products I do sometimes purchase: PowerBars (I stick them in my doula bag, but there are lots of other brands), certain cosmetics (since I probably buy make-up once every two years), and bottled water (again not often, but sometimes when I'm traveling or at an outdoor event). So I think I can go all Nestle-free long-term if I keep an eye out! I'll admit shopping at Trader Joe's makes this easier because they have so many of their own store brands.

Let me know if you're boycotting Nestle this week! And enjoy all those mini-Snickers! Mmmmm...

Links - how important is birth? problems with research, VBAC questions, and more

Enjoy Birth and Stand and Deliver and Talk Birth all meditate on the importance of birth - how it shapes women, how it shaped them - and whether or not it is important in shaping women as mothers. All provoked by this post at Sweet Salty. Excellent food for thought.

No Fat Talk Week - I personally celebrate this 52 weeks a year, and invite you to join!

Winning entries from the National Advocates for Pregnant Women writing contest. How's this for a title: “In the Manner Prescribed By the State”: Potential Challenges to State-Enforced Hospital Limitations on Childbirth Options. I like!

Melissa lists questions to ask a VBAC provider.

Amy at Science & Sensibility asks Do We Need a Cochrane Review to Tell Us That Women Should Move in Labor?. She says, "Somehow, things have gotten turned around, and the normal condition is now the “experiment” and the intervention is the “control”. In addition to being irrational, this is a set-up to perpetuate conventional obstetric care, which imposes unhealthy and unfounded restrictions on women in labor. This is because in “intervention versus control” research, you have to show that the intervention performs significantly better, otherwise the control condition remains standard practice." Read the rest on how this is a bass-ackwards way to go about things. It's alerted my eyes to look for the same issues in breastfeeding research.

Aaaand a new favorite (via, as so often, The Unnecesarean), Arwyn explores the analogy between athletics and childbirth:

"Everyone has heard of and no one doubts the existence of “runner’s high”, so why do we start plugging our ears and rolling our eyes and flapping our tongues when we speak of “birthing high”? ... Even discounting that, or in its absence, there is potential for pride and a sense of accomplishment: something we value so much in athletics, yet scoff at in childbirth, where our effort benefits both us and another. We deny women that pride in accomplishment (for which support of athletics is so vital to girls’ sense of self and women’s equality), that boost in self-esteem and feeling of competency, right when we need it most: at the start of parenting, one of the most demanding journeys a person can undertake."

And that's enough for tonight!

Reply turned post, on the comments sections of feminist blogs

I posted a week or so ago about the comments on Joy Szabo's case over at Feministing. Dou-la-la noted that the same story, and similar comments, have gone up at Jezebel. I wrote a comment that started turning it into its own post, and Anne said it should just become its own post, so here it is! (slightly revised.)

It seems like so much birth guilt/trauma/processing comes up in those discussions by women who had c-sections. I feel like I see a lot of "My c-section was NECESSARY and I have decided to STOP FEELING GUILTY about it." Hooray! What does that have to do with this case? "My c-section was NOT A BIG DEAL so stop equating it with RAPE!" So glad to hear you were happy with it! And yet your consented c-section has nothing to do with this other woman's situation. So why are we talking about it?

I browsed by (as I occasionally do when I forget my better judgment) Dr. Amy's site and she had reposted from a piece about breastfeeding written by a mother who had supply issues and decided that terrible mean people were making mothers feel guilty about not breastfeeding. Cue dozens of comments like "Thank you, I had to feed my baby formula and then I felt guilty! Shut up, breastfeeding promotion!"

I feel like our culture gets women juuuust far enough ("vaginal birth good", "breastfeeding good") and then dumps them at the gate. "Good luck with your vaginal birth in a country of 30% c-sections and breastfeeding in a country with low breastfeeding rates and no paid maternity leave!" No further education, no support, nothing. And then when those things don't happen, they feel guilty and like failures (because why we encourage women to blame the system when they could blame themselves/each other?) And then to feel like less of a failure, they have to hate on the things that make them feel guilty (see above re: blaming each other). And they process all those feelings in the comments sections of these posts.

If I had a c-section and couldn't breastfeed for some reason, I'd be upset and pissed. But I accept that c-sections and formula feeding (OK, I would probably search out all the donor milk I could, so mixed feeding) are reasonably safe things, and were the best options available to me. That doesn't mean they are a universal good and it doesn't mean they're equal to the alternatives. Nor does it mean that other people need to STFU and do what I did without complaint so that I can feel better.

Just today in class we had a guest lecture by my breastfeeding/LC professor. She does a fantastic job of showing nothing but the evidence and demonstrating that formula kills, in this country and around the world. She showed a slide saying that our attitude in this country is "Breastmilk is best, but there's nothing bad about formula." One of the regular professors said something to the effect of, "Well, that seems reasonable - I mean, is formula poison or something?" You could see the breastfeeding advocate stiffen and then she looked around and said, "What do other people think?"

And me, because I have a big ol' mouth, I raised my hand and said (I paraphrase), "First of all, there have been cases of formula poisoning. The melamine case in China, other instances of formula recalls and formula poisonings. So no artificial feeding method is without risk. However, I would say that I and a lot of people in this room were raised on formula and feel perfectly fine. We are healthy. But as public health professionals, we cannot ignore the evidence. At an individual level, formula feeding may be fine. But we have a responsibility to admit that lack of breastfeeding contributes to infant mortality and that we have to work to promote breastfeeding. You can find someone who smoked every day of their life and never had a health problem, but as a public health professional you know and see that tobacco use is harmful. Similarly, at a population level, YES, formula IS dangerous."

Guilt and mothering and feminism are all tangled up in these issues and I don't want to deny them or say they are not important - they are important and obviously need more outlets for reasoned, informed discussion. But we can't deny the evidence either. We don't ignore the evidence about smoking because someone is addicted to nicotine. We don't ignore the evidence about exercise because someone doesn't like to get off the couch. We shouldn't ignore the evidence about breastfeeding, or c-sections, or anything else just because we do a piss-poor job of supporting women to be as healthy as possible and then make them feel guilty about it.

And that's my rant for the day!

EDITED TO ADD: I read this over and it was appropriately rant-y for a rant, but I failed to say that while I do get frustrated with women who process their guilt by blaming others, I sympathize with them, hugely. They were the ones who got taken just far enough and then dumped. Their pain and regret and anxiety are real, and like I said above I'd feel similarly if the same thing happened to me.

I would also NEVER, EVER tell a formula-feeding mother that artificial feeding kills or any of the other crazy crap people say to formula-feeding moms because they think they know what's going on in another person's life. Like I said in my little rant in class, I was raised mostly on formula and so were a lot of people. It's not a death sentence. It's just a risk, and I am speaking from a public health standpoint, not an OMGZ UR BABY WILL DIE crazy person standpoint.

Vaginal breech birth: yes it is possible!

I was talking with a woman recently who had a c-section for her first baby, who was breech. I said something like, "Yeah, almost all breeches are c-sections now, although in Canada they're starting to do them vaginally again." She looked surprised and said, "Really? I thought they COULDN'T be born vaginally. I thought they would be strangled or something."

This woman was totally happy with her c-section, and it seemed like that was the right choice for her. She said she'd even consider a repeat c-section with her next baby, breech or not, so my guess is that given a choice between a vaginal breech and c-section for her first baby, she'd have chosen c-section.

But she didn't choose; what's more she didn't even know she had a choice. She thought her baby could never have come out safely vaginally. I worked with a client last year who found out at 36 weeks that her baby was breech. A doula friend had e-mailed me a series of photos of her friend giving birth to a breech baby, and I pulled them up on my computer just so my client could see with her own eyes: Yes, a baby can be born breech. Before she could investigate vaginal breech more fully (including whether there was anyone who would be willing to deliver her breech in the area), she ended up having a c-section for a combination of issues. Again, it was the right choice in her situation, but in my heart I thought "At least she saw what was possible, and she knew her options". I don't think it's OK for a woman who has a breech baby not to be informed that it is possible for her baby to be born vaginally, and to refer her to more information about that option. Would/could most women travel to find a breech-friendly provider? Probably not, but they can't if they don't even know about it. That's not informed consent.

Rixa at Stand and Deliver has just posted about her first day at the International Breech Conference. It is so wonderful to read about midwives and doctors talking about how to provide safe, skilled breech birth services to their patients. But it doesn't do much if women don't even know those options exist. Spread the word: vaginal breech is possible.

Which is more important: your birth plan or your provider's?

The Unnecesarean has a new post up, reposting a mother's copy of her OB's birth plan. (He handed it to her husband at the 26-week visit.) Here are some choice excerpts:

* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.

* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.

* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.

So much of what this guy has written is distorted or just plain wrong, it's incredibly paternalistic, and violates basic legal rights (the decision to perform a c-section is at his discretion? Um, actually it requires signed consent forms. Signed BY THE PATIENT.)

And I kind of love it. Why? Because it's honest and lays it all out. In the end, your care provider's birth plan carries a lot more weight in the hospital than yours does. This guy isn't kidding about rupturing your membranes at his discretion; at the extreme end of things, he can tell you he's "just going to do a vaginal exam" and then rupture them without ever asking you, and that piece of paper in the corner saying you want to wait until your water breaks spontaneously isn't going to protect you. Even a doula, your partner, or a committed nurse can only do so much ("Whoops! I guess they just ruptured by accident!") And that's why I would say it's more important to get your care provider's birth plan than it is to give them yours. I've said before that if you find the right care provider and birthplace, you don't need a birth plan, and that's because you have found a care provider and learned enough about THEIR birth plan to know that it matches what YOU want.

The mom who posted her OB's birth plan ended up running so far in the opposite direction that she ended up at a birth center with a midwife and was delighted with her choice. But let me say - as some of the commenters on the Unnecesarean were pointing out - that this isn't an argument for women just needing to choose different care providers. This guy is an honest jerk with non-evidence based practices, but he's still a jerk with non-evidence based practices (say that 10 times fast!), there are more out there, and many women don't have the choice to find a new provider. At the individual level yes, PLEASE, find out your care provider's birth plan and make a switch if you need to. But on a bigger level, we need to stamp this stuff out.

Because, seriously, "Delaying [cord clamping] is not beneficial and can potentially be harmful to your baby" - as one of the commenters to the original posting said, this birth plan would be modern obstetrics only if it were written in 1975.

Notes from the NICU

The last three weeks of my LC shadowing have been with LCs who cover the NICU. It's been very different from my previous experience with breastfeeding support; the work I observe in the NICU involves very little direct breastfeeding, more counseling on pumping, and a lot of logistics. Some recent experiences:

1) Conferring with the NICU head nurse on flu policies. This has been a constantly evolving discussion since I have started observing at the hospital. Right now the policy is that no one with flu symptoms, including the mom, is allowed to visit the NICU until they have been afebrile (without a fever) for 10 days. But moms are encouraged to continue pumping and send pumped milk for their infants with a family member or friend. The LC and the NICU head discussed what to tell flu-infected moms about pumping hygiene, how to clean the bottles once they arrive at the hospital, and where to store the milk. Interesting to see policy being worked out, and so nice to see the NICU valuing and encouraging pumping!

2) Boxing and moving left-behind milk. The overflow freezer for storing pumped milk was itself overflowing, so I helped the LC transfer some of the milk to yet another freezer. We used Enfamil boxes to store the milk - they're made to fit very similar size bottles - and joked about "redeeming" the boxes. I asked about the milk we were transferring and the LC said it belonged to a mom whose baby had died after several months in the NICU. The LCs are waiting to hear back from her about what she wants to do with the milk. The LC was crossing her fingers that the mom would be willing and able to donate it. After seeing it, I hoped so too - there were some bottles of beautiful golden colostrum, and bottles and bottles of mature milk - after moving it all I'd estimate there were over 300 ounces! What amazing dedication. I can't imagine how hard it would be for this mom to think about what to do with this milk she hoped to give to her own baby.

3) Seeing how breastfeeding/pumping can come in dead last on a list of priorities for any NICU mom. So, you've had a c-section in a hospital a hundred miles away, your baby was transferred emergently to this hospital with serious health problems, you've been trying to coordinate the care of your older children while trying to recover and hoping to be discharged ASAP, 4 days after the birth you've finally managed to get over to visit your baby, which someone had to drive you to because you're not allowed to drive, you have to understand what's happening medically with the baby and possibly make decisions with the doctors about care, and in the midst of this is this sick tiny infant who is hooked up to ten different machines who you can't hold. And then this lady comes in and asks you if you want to pump milk for your baby. Who can't even eat right now. Sometimes I think it's a miracle any mother says yes.

4) And then seeing how much pumping can mean to a NICU mom. It obviously meant a lot to the mom who pumped over 300 ounces. Sometimes, it is the only thing a mother can do for her baby. I learned last week about oral care, done to keep the baby's mouth healthy and hydrated even if they're NPO (nothing by mouth). The LC counseled a mother that even if she was just pumping drops of colostrum at the beginning, she could soak up the drops with a Q-tip and use the Q-tips for oral care. Then the baby could smell her and know that she's close by. The mom started to cry. She couldn't touch her baby, didn't know if her baby would live, but she could do this one thing.

I think I'm lucky to have this opportunity to see NICU LCs in action, although it seems unlikely that I would ever end up in that role given that I don't have a nursing degree (most of the NICU LCs are former NICU RNs). I am looking forward to getting back to some more hands-on breastfeeding support, but this has been a real window into what babies and families going through the NICU experience.

Breastfeed: be a star

I heard about the British Be a Star Internet breastfeeding campaign through my IBCLC class. I get the concept of it - reframe breastfeeding as glamorous (easier now that there are so many breastfeeding celebrities) - and target it at younger women (at least that's what I'm guessing by the age of the moms picked to profile).

Above is Clare, 20, from Morecambe:

Please explain why you’ve chosen to breastfeed.
Well, it’s convenient, it’s good for baby, helped me get my figure back quickly – there are lots of health benefits for both of us. To be honest I didn’t ‘choose to breastfeed my eldest son, in fact I planned to bottle feed him and I’d bought all the bottles and the steriliser too, but after he was born the midwife in hospital brought him over to me and asked if I’d like to try feeding him myself, and we just went from there: once I’d got going with breastfeeding I realised how easy it was, and that’s when I realised all the good things about breastfeeding! With my second son there was no other way I would have chosen to feed but breastfeeding, for me it was the natural choice.

The text is no-nonsense, simple, and hopefully accessible. Personally, I love the photos and the concept, but I wonder whether the photos are as accessible as the message. If teens moms actually click over to this site, are they weirded out by these pictures of women wearing sometimes weird get-ups and breastfeeding? Are they insulted by the implication that they need to be marketed to with shiny photos and fabulous make-up? Finally, does this just further the impression that to breastfeed you need to be a rich, glamorous woman? Would it have been better to show these moms breastfeeding in their regular lives - at family parties, at the bus stop, before they go out in the evening?

What do you think?

How to make a doula feel loved

I loved this interview with Dr. John Kennell - I had never heard of him before, but apparently he is a big doula supporter and a founding member of DONA (Doulas of North America):

NLJ: Dr. Kennell, you are an adamant supporter of doulas, and much of your research has focused on the benefits of having a doula present during the birth process. You are often quoted, having stated: “If a doulas were a drug, it would be malpractice not to use it.” That’s a pretty, strong statement.

Dr. Kennell: Yes it is.

NLJ: Why do you feel doulas are so important?

Dr. Kennell: When providing the mother with a doula, which is really bringing back an old, old practice, we found that it just made a remarkable difference in the obstetric outcomes. So that’s one reason. There are strong suggestions that mothers who have a doula feel much better about themselves and how they did during labor. ... So, something that makes mothers enthusiastic about their baby and about what they did themselves, that’s great.

Read the rest here - I only wish it were longer.

I will say, nothing warms my heart like medical staff who appreciate doulas. Attention supportive midwives, nurses, and doctors: give the doulas you see a quick welcome if you can. In the best hospitals I've been in, people say "Oh, you're the doula! We LOVE doulas here!" It will make your patient happier, her doula more comfortable, and everything can run more smoothly when everyone knows they're a welcome part of the team. Reading Dr. Kennell's interview made me think of all the wonderful hospital staff I've met who were excited to see a doula in the room and let everyone know it!

Sowing the seeds of distrust

I have been working on a post lately about why you shouldn't count on being able to advocate for yourself in labor. I worked on it a lot and then started rereading it and thought it, "This is too negative. It is based on fear. I don't want to write posts based on such deep suspicion of all care providers. Many of them are great, and since I want people to be confident and trust in their birth, why should I write a post based in distrust and fear?"

Then I read At Your Cervix's post on delivering babies early because of inaccurate fetal lung maturity testing. I thought, Oh my god. What if those doctors were taking care of my friends or my relatives? And this happened to someone I know? As one of the commenters suggested in that post, there's absolutely a role for staff/public health people to play in establishing systems and safety checks so that no one can practice this way. But in the meantime, am I wrong for not wanting to go to everyone I know who will ever have a baby and say, "Please, please, please! Do your research and choose someone who will treat you with evidence-based care, with respect for you and your baby! And they may be the sweetest, nicest person you have ever met, beloved by everyone you know, and you may want to trust them - but please educate yourself and make sure you are FULLY informed before you consent to medical intervention."

When I was working as a bra fitter, women would come in during their last month of pregnancy to get nursing bras they could use right after birth. I probably worked with hundreds of them over the course of a year. They were beautiful, healthy, round, and looked whole to me in a way that made me sad. In a quiet moment at the store, I once asked the other doula who worked there, "Do you ever look at all these happy pregnant women and feel sad at what's likely to happen to them during birth?" She thought about it for a moment and said yes. We both felt sad, because one out of every three women was going to undergo surgery, perhaps without a good reason but still believing it was necessary. And even if they avoided surgery, most of these women were going to be tied to the bed with catheters and IVs, monitored, pumped full of drugs... and I sensed that even the ones who didn't particularly mind a medicalized birth, didn't fully realize the extent to which it was going to happen.

It is such a relief to me to meet someone who is planning a birth in a setting I know is trustworthy, if only because then I don't have to think about all the things I want to warn them about (but am not going to because they didn't ask). ("Don't agree to an induction unless it's absolutely necessary, drink lots of water before ultrasounds to avoid a diagnosis of low amniotic fluid, don't go to the hospital too early in labor," etc. etc. etc.) And now I've read the above post and I am adding to that mental litany, "Be cautious about an elective early delivery based on fetal lung maturity testing".

Since I usually don't say anything anyway, I can't just use that convenient X-Files line of "Trust No One". But if I was going to say something, and if I am ever going to finish that post, what should I say? "Trust someone, and make sure it's a good one"? "Trust yourself, and hire a doula"?

Descriptive studies & routine fetal monitoring

Sometimes the birth-related stuff shows up where I don't expect it. From an article for my research methods class tomorrow:

"...Another sad example in which misinterpretation of descriptive studies* hurt public health is routine electronic fetal monitoring in labour. A quarter of a century ago, temporal associations between the introduction of electronic fetal monitoring and falling perinatal mortality rates led to the conclusion that continuous fetal heart rate monitoring was a good thing. Moreover, authorities of the day predicted a 50% reduction in perinatal morbidity and mortality from its use.

Based on this rosy assessment from prominent obstetricians, this expensive and intrusive technology took obstetrics by storm. However, the initial upbeat
assessment did not survive scientific scrutiny. Years later, a meta-analysis of the randomised controlled trials showed that, by comparison with routine intermittent auscultation, routine electronic fetal monitoring confers no lasting benefit to infants, whereas it significantly increases operative deliveries; thus harming women.

Based on objective reviews, both the Canadian Task Force on the Periodic Health Examination and the US Preventive Services Task Force have given routine electronic fetal monitoring a D recommendation (fair evidence against its routine use). Despite this advice, about three-fourths of all births in the USA include electronic fetal monitoring. Failure to appreciate the limitations of descriptive studies has caused lasting harm and squandered billions of dollars."

*The authors define a descriptive study as "concerned with and designed only to describe the existing distribution of variables, without regard to causal or other hypotheses." An example of descriptive studies is early reports of AIDS, describing clusters of unusual cases and generating hypotheses as to their cause(s).


Citation: Grimes DA, Schulz KF. "Descriptive studies: what they can and cannot do". Lancet. 2002. 359:145-49.

(H/t to my roommate and classmate Katie, who found this passage and suggested I might want to get on that class reading!)

Feminists, reproductive rights, and VBAC

So Feministing also posted a link to the article on Joy Szabo's VBAC challenge, and the comments section has gotten - interesting. I don't want to say that every Feministing commenter is in fact a card-carrying feminist (what, you don't have a card? I keep mine in my wallet, it's laminated and everything!) but the reactions of some of the commenters really surprised me.

Despite my better judgment and a pile of other tasks I need to do today, I have gotten into the fray. It just raises my hackles when women who in many other contexts would aggressively question medical/legal authority and advocate for a woman's right to make choices about her own body go off on the "Well, if her DOCTOR says it why would she put HERSELF and everyone else at RISK" line. As if your reproductive autonomy ends when you choose to continue a pregnancy, and you must willingly hand your body over to the medicolegal system. As if VBAC access in no way equates to abortion access. As if it's OK for a hospital to threaten to get a court order for unnecessary surgery, because "She's the one who decided to get pregnant and decided to have a VBAC, so she's got to live with the consequences. The hospital has to protect themselves". I'm glad there are other commenters who see the irony here, but shocked that there are those who do not.

I have so much more to say about the relationship of feminists/the reproductive rights movement to birth, but that post would take longer than I have at the moment. Suffice it to say, I think reading the comments on that post is educational, if nothing else, and offers food for thought about how to appropriately illustrate to those in the movement that birth issues are not related to reproductive rights - they ARE part of reproductive rights and just as important as any other.

Arizona woman fights VBAC ban

Joy Szabo had a normal vaginal delivery for her first child, then an emergency c-section for her second, followed by a successful VBAC for her third. By the time she was pregnant with her fourth, the hospital in her town had banned VBACs. Yes, the same hospital where she had just had a successful VBAC two years earlier. So she decided to go out and make some noise about it.

Her local newspaper wrote an article about her situation. The Unnecesarean posted excerpts from her story and contact info for the hospital, prompting a Twitter response from the hospital's PR person (read all the way down the entry). Now the ICAN blog has Joy's story in her own words. Here's a bit from her second meeting with the hospital CEO:

...I asked why they are doing labor and delivery if they cannot offer a timely cesarean. She defended the hospital, saying that they can do emergency cesaereans, but did not want to accept the risk of VBAC. I asked what the hospital policy is if I show up and just refuse to consent to a cesarean. She said they would seek a court order. She repeated to me that Page Hospital does not have the facilities nessasary to handle an emergency.

(My translation: "Can Page Hospital handle an emergency c-section?" "Yes! No! Depends on who's asking! Go away or I'll get a court order!")

The newspaper article features a photo of the kick-ass message she's painted on her minivan, equating her hospital's threat to get a court order for a cesarean with rape. Because of the VBAC ban not only in her hometown, but on multiple hospitals closer to where she lives, as of now Joy Szabo has decided to try to find an OB/hospital in Phoenix - a 5 hour drive from her home - that will work with her VBAC.

The ICAN blog has links for "mom-sized" activism (or really, any busy-person-sized). Tell Page Hospital and the Banner hospital system that forcing a mom with 3 children to travel hundreds of miles just to give birth as her body intended, and threatening her with a court order for unwanted surgery...well, that's just Not Cool. And yes, that last part does sound a lot like rape.

The best birth plan

Tiffany at the Midwives of Bethany Women's Healthcare blog posted one of the best birth plans I have ever read. I was giggling the whole time I read it.

I was asked to give feedback on a birth plan the other day, and spent some time crossing out things that didn't really need to be on there, explaining that other things should really be discussed in advance, etc. etc. Maybe I could have just suggested they xerox this plan and use it. If nothing else, I think it would put the staff in a great mood!

Physiologic birth and breastfeeding

I went to a very fast birth recently! Mom called me to tell me she was in labor, an hour later to say they were going to the hospital. I didn't believe from the tone of her voice that she was really so far along (although I just said, "Sounds good, see you there.")

I arrived at the hospital thinking she might be 4-5 cms, max. But when I walked into her room they said "You're just in time!" I said, "Just in time for what?" "For her to have the baby!" Yep, she walked in at 10 centimeters and pushed the baby out about 45 minutes later. Until she was checked she fooled just about everybody about how far along she was, including her husband and the midwife - everyone was shocked by how far along she was. Fortunately mom tuned into her own body and ignored the rest of us!

Because she walked in ready to go, and didn't want drugs anyway, mom really got absolutely nothing - no IV, no injections, nada. She just sat down on the bed and pushed her baby out. And after days of rounding with the LCs on a floor full of post-epidural babies, it was so striking to see a baby from a totally unmedicated labor! This baby was so alert from the beginning - eyes open, looking around - and latched on and nursed beautifully within half an hour. When I went in the next day it was the same story - awake, perfect latch, nursing frequently and effectively. This on a floor full of babies with bad latches, breast refusal, ineffective suck.

Birth practices affect breastfeeding. It just gets brought home to me over and over. The LCs all know it. They dislike epidurals and other interventions not in any holier-than-thou, you're-a-worse-mom way. One LC needed to have all her babies by c-section. But just like the others, she sighs in frustration over how all those meds are affecting the babies that she's trying to get onto the breast.

We so rarely see a baby who has experienced a physiologic birth, we forget what it looks like. This mom went into labor on her own, got zero meds, followed her body's urges to push (very minimal coaching), and when baby emerged it went straight to mom. Her placenta came out quickly, her uterus firmed up nicely, she began nursing, the end. Nobody did anything to speed her up or slow her down, and she moved and positioned herself however she wanted. Her body just did its thing. That's a physiologic birth! As a doula, I'm fortunate to attend more than my share. As an LC-in-training, I'm lucky to see them at all. All these nursing problems begin to seem normal...but they're not, or at least they don't have to be.

I don't want to sound all super crunchy, "Sure you can have your precious epidural...IF YOU NEVER WANT YOUR BABY TO BREASTFEED." Can you have an epidural and breastfeed successfully? OF COURSE! Can you have an physiologic birth and have feeding issues? Sadly, yes! I'm not talking here about individual choices - many birth-related feeding problems are transient and a determined mom can easily surmount them. But I'm speaking here from a public health standpoint. Not all moms are determined, or have the resources to draw on to overcome those problems. By messing with breastfeeding in any way, we tip more and more of those moms-on-the-edge right over it. And we're messing with breastfeeding big time via birth. Too many women see the fussy sleepy baby and/or the latch issues, and they just decide "This is not for me". Either we have to do something about how we provide pain relief for those who want it, or how we prepare and support moms who have high-intervention births.

A good first start, from what I've seen, is to make sure moms get two full days in the hospital with lots of LC (or other trained staff) assistance - instead of the hospital hustling them out the door. It's hard to fix or even wait out birth-related breastfeeding problems in just 24-36 hours. Yet all these moms are being whisked out the door because hospitals get paid the same for your postpartum care, whether you stay 1 day or 2 days. And of course there aren't enough LCs to give the intensive support some moms need. Sigh.

Beautiful breastfeeding PSA from Puerto Rico!

Breastfeeding public information broadcast from Puerto Rico, "Dar la teta es dar vida" ("To 'give the breast' (breastfeed) is to give life"):



I love how this shows moms nursing toddlers and older children, not just babies. So many women seem to have this idea that breastfeeding should end as soon as baby turns a year (or even less). This is a lovely way to show that the breastfeeding relationship can continue as long as both participants are enjoying it. If we can normalize toddler nursing, we've got it made!

Puerto Rico may be part of the U.S., but it's clearly a long way ahead of us when it comes to breastfeeding PSAs (although their breastfeeding rates are not very different, according to the scant statistics I could find.) I wonder what the reaction was there when it was broadcast?

The video was originally posted by the makers here here, and the notes at the right side of the screen give more information about the song, the production team, toddler nursing, and more. Unfortunately it's been flagged as "inappropriate" (puh-lease!) so you have to sign in to get to it. (I linked to a repost that has fortunately not been flagged, let's hope it stays that way.)

Mass media birth vs. reality

How many times have I said, "Birth is nothing like it is in the movies" or complained about how "A Baby Story" or "Maternity Ward" portray labor and delivery? (I just can't watch those shows any longer. I start yelling at the TV and then I have to turn it off.)

That's why the movie "Laboring Under an Illusion" looks both educational and fun. From the press release:

"There are more pregnant women watching TV birth scenes than attending childbirth classes. So when labor starts, they may be surprised by the real thing. ... A new documentary film, “Laboring Under An Illusion: Mass Media Childbirth vs. The Real Thing,” contrasts actual birth footage with the fictionalized commercial version. In over 100 video clips, anthropologist Vicki Elson explores media-generated myths about childbirth."

Here's the trailer:


This looks like a nice way - perhaps even a little more gentle than "Business of Being Born" - to introduce people to the difference between the way they perceive labor & birth and the way it actually is.

The website lists some events. I'm thinking about whether it's worth me investing in a copy (or better yet, finding some way for our breastfeeding student group to pay for it and screen it!) Has anyone seen this yet?

(h/t to Dou-la-la!)

Sen. Stabenow to Sen. Kyl: Oh SNAP!

United States Senator John Kyl (R. - Ariz) said in health care reform hearings: "I don't need maternity care", so health care reform should not require insurance companies to provide it.

Senator Debbie Stabenow (D. - Mich) fires back: "I think your mom probably did."



(Via Feministing.)

Sen. Kyl then snorts "Yeah, about 60 years ago." Perhaps someone should also show him the evidence that prenatal (AND preconception) health of the mother have impacts on the health of her baby, decades into the future. Or is that just an "I got mine" statement?

If we pass health care reform that does not mandate maternity coverage, we're not getting true health care reform.

IBCLC training update

This semester, it is busy. As usual, there are a million things I have sitting around waiting to be linked to. I haven't even talked about the Today show home birth ridiculousness yet! (But when so many other people have done it so well, now it seems repetitive).

Today is Wednesday, which is my lactation consultant observation day at the hospital, which is one of the things that is making me so busy: I'm there all day, and by the time I get home I am zapped and don't get a lot of schoolwork done (OK, any schoolwork done). If it wasn't for that I'd have the whole day free to do all the other things I have to do, which then get shoved into the precious open time in the rest of the week. But would I trade my LC observation days for more free time? Of course not. So, I am figuring out the semester as I go along. And I thought I would shake off my Wednesday evening sluggishness long enough to update a little on my LC observation so far:

The hospital I'm observing at is the same place I work as a volunteer doula, and in general I have found them to be a fairly mother- and baby-friendly hospital (they are actually working on getting their baby-friendly certification). The nurses and the pediatricians I have seen so far are very supportive of breastfeeding, even if they aren't always fully informed.

Lactation services is, unfortunately (maybe fortunately for me) not adequately staffed and in this era of budget cuts, unlikely to be increased any time soon. The LCs I work with are on their feet every minute of their workday, and usually can't even see everyone they're supposed to. Today the LC I worked with was supposed to see something like 11 patients, and made it to 6 - and that includes going to see all of those 6 multiple times - for some of them, we went to every feeding they did during the day. If you can't see everyone, this leads to some tough choices - prioritize the mom with inverted nipples, sleepy baby, and poor family support? Or see she doesn't seem that motivated, and think you should spend your time on someone who has a greater chance of succeeding? Much as these are unpleasant choices that shouldn't have to be made, they are real.

I say that the fact it's not adequately staffed is fortunate for me, only because I get to see so much in a day. There is zero downtime, unless you count when the LC dashes to the computer to chart, and I sit next to her trying to remember what I saw and record it in my observation notebook. I am getting to see so much - just a wide range of situations, anatomies, and medical conditions. I haven't done any days in the NICU yet, but I am really looking forward to my first experiences working with preterm babies & their moms.

One thing I've noticed is that my observation days seem to run in themes. For example, last week I was with an LC who was seeing a lot of outpatients, where overfeeding was the theme. This week, we were seeing all inpatients (most less than 24 hours) and the theme was sleepiness and breast refusal. I started to get a little leery as I saw the LC put on nipple shield after nipple shield. Was this her solution to everything? Then she told me, "I usually use one a week." She said she has been seeing more and more sleepy, fussy babies in the past few weeks and is getting concerned about it. Her concern is that they have apparently changed either the epidural dose and/or the medication; this being a typical American hospital, nearly everyone has had an epidural, and if it's seriously affecting the feeding behavior of the babies it's a big problem. I still don't know how I feel about the nipple shields for every problem she applied (heh) them to, but I am curious to know what she learns about the epidural meds.

In terms of the LCs I'm observing, I am learning a lot from observing different practice styles and different approaches. I try hard to check my judgment when I see something I don't want to emulate. It's so easy as an observer to think "I wouldn't do that" or "I wouldn't use that word the family probably doesn't understand" but I know how extremely hard it is to do in practice. And seeing how extremely rushed the LCs are, I can't entertain too many fantasies of long, empowering chats once my turn comes to do the consults. (Another good reason to find some LCs to shadow who are able to have a slower pace, for balance.) Still, I am trying to stay sensitive to places where I see overmedicalization, or creating dependence on the "expert". I am glad our class and professor give us space to discuss those issues.

So far, I love my LC observation days - I love working with families, having a new challenge every 20 minutes, keeping busy, and learning. And I love all those cute little babies! I know not every doula/midwife/other perinatal professional goes into the field from loving babies - sometimes they just love to work with women and don't find babies that interesting. But I have always loved babies, and I really love these tiny little newborns. It's amazing how they are simultaneously so dependent and helpless, and yet so capable. I haven't seen any true self-latching, but when a baby is hungry but not latching, the LCs will encourage the mom to put the baby upright between her breasts, skin-to-skin. The baby will right away start bobbing its head and throwing itself to the side, then move down her breast, and root for the nipple. And when they're done nursing, they'll just relax into a little pink ball on her skin and fall into the deepest sleep. It never fails to make me go "Awwww." So that's my mission these days: more empowered babies!