A few links to start the New Year

Happy New Year! Here is a total mishmash (not even sorted! only sort of related!) of interesting links for your enjoyment. It feels good to start clearing out my starred list in Google Reader, at least!

Many perspectives on why to have a doula for your homebirth (and a few on why you might not have one).

Doulas serving the expat community (as well as locals) in South Korea

The Well-Rounded Mama posts a list of obesity and birth/breastfeeding research on her Christmas wish list. Any public health peeps out there want to get on it?

The amazing Cathy Genna has a page on tongue tie including pictures and posterior tongue ties.

One mother's struggle with getting her daughter's tongue tie (and lip tie) properly diagnosed and treated - she ended up traveling to Dr. Kotlow to get treatment. "My prayer is that it will not always be this difficult for tongue-tied babies and their mothers. It should not require so much time and so many resources to simply feed your baby."

Interesting and varied responses to the updated UK guidelines on c-section availability.

Knit your own baby-wearing coat extender!

A post on cultural issues and breastfeeding, specifically on diet. My preferred way to deal with this (right now) so as not to contradict any breastfeeding cultural traditions: when people ask me if there are foods they should eat/not eat, I say "Every culture seems to have their own foods that they say are good or bad!" and then I name some examples. Hispanic mothers are often surprised to hear that Americans think broccoli is bad, for instance. I say "If there are foods that your culture thinks are good or bad, then go ahead and do what is recommended. Unless you hate the food! Then you don't have to eat it."

Nope, I won't bring you to a birth

Doulas and midwives probably get this a lot, and I get my share: "I am so fascinated by birth. I'm interested in becoming a midwife [or doula], but I'm not sure yet whether or not it's right for me. Can you help me find a way to attend a birth?" Sometimes people are asking specifically, "Can I come to a birth with you?"

My answer is always the same, "If you'd like to go to a birth, you should definitely do a doula training!" Doula training is a relatively low-cost and low-time investment, gives you a taste of learning about pregnancy/birth, and offers valuable knowledge about labor support if you plan to go into midwifery. Where I live, there is a local volunteer doula program that makes it easy for novice doulas to find their first clients. I tell people who ask that I am happy to be their "mentor" doula in the program (since the first birth they attend as a volunteer is always with a doula who has experience with the program), or to ask one of my doula clients if a doula trainee can come along to the birth.

I am surprised by how frequently people say "Oh yeah doula training, I thought about that, but..." The "but" usually has to do with lack of time or trouble scheduling or wanting to go to a birth sooner than the few months it will take to do the training and get set up with the volunteer program. They just don't have time, because they want to decide about midwifery real soon and go to a birth real quick.

I hear this enough and it starts to wear on me a little bit. I try to impress on the people who want to go to a birth, but skip the doula training, to think logically about the situation. There are a lot of people who want to be at a birth. Think about a hospital birth (since most births are hospital births). There's the mother's own family/friends/support people; there's the medical staff who need to be there (OB/midwife, nurse(s)); then there are other people who need to observe including medical and nursing students. For a midwife or doula to try to bring someone who's just curious to see a birth is usually not practical (and will probably exceed the hospital's visitor limits, which are often capped ridiculously low.)

Furthermore - and this is what I try to put gently to the people who ask me - to ask to attend a birth just because YOU want to see one, particularly just to ask to attend a birth of someone who is a stranger, is also unrealistic in terms of respecting the birthing woman's space. There are a few birthing women who have a welcoming "all-in" philosophy of birth - they don't mind having their whole extended family, neighbors, and FedEx guy watch them vocalize and pull off their clothes and push out a baby. Fantastic! It's their birth and they should have whoever they want there.

But most women want and DESERVE to hold a smaller space for their birth. They ask selected people to be there for a reason - because that person will have a lifelong connection with the baby, or because they rely on that personal for emotional security, or because that person offers them a great back massage and hip squeeze. Like I said, for a few women your curiosity in midwifery is reason enough to invite you to be present. I think that's totally fine. But for most, they're going to need something more.

I think the questioners do understand this on some level. That is why they don't generally call up pregnant women they happen to know and ask "Can I come to your birth?" They ask me to ask for them. And this is my bottom line: I won't ask. There's something that question that rankles in a way I had to separate out: beyond just trying to elbow into a private experience, it's specifically imposing on me as a doula. The questioner is asking me to use my experience as a doula and the trust I've built with a family for their own purposes, but is not going to invest their own time and energy to make that possible. To do a doula training gives you something to offer the birthing woman and a reason to be present; and it also gives me something important: honestly, I want to see, before I put myself out there, that you are serious about this interest in midwifery/doula-ing. Midwifery school and midwifery as a career are a huge commitment. It's not so much to ask to put in a couple months of prep as a doula to see if that's what you really want. If you won't, then I question whether this is just a passing idea.

Sticking to this policy, I've seen it pay off. The people who were serious and have continued to pursue midwifery, or doula-ing, became doulas without hesitation; the people who hemmed and hawed have discarded or put off the idea of birth work as a career.

Reading back over this post, I realize it sounds pretty negative to the idea of "just anyone" showing up for a birth. I want to re-emphasize that I am not opposed to a woman inviting whoever she wants to her birth - including someone she doesn't know very well, who has a passing interest in midwifery. And if someone out there has had the experience of asking and being happily invited to a birth in that scenario, more power to you - you're pretty lucky! But think hard before imagining that just getting to see a birth will help you decide about midwifery. After all, you can watch a million births on YouTube (I know, it's not the same, but still.) It's possible that what will really help you decide whether you want to be a midwife is not the 12 or 18 hours you watch one woman labor and birth; it is the experience and preparation that get you to that point.

What's different about being a doula outside of the hospital?

When I posted about attending my first home birth, one commenter asked:

"As a doula did you feel that your role was very different? I had both of my children at home; looking back I wish I had a doula. My midwives, are amazing but they are very hands off and quiet. I think a little more direct verbal support could have greatly shortened both of my labors."

I have been thinking about my response to that comment since attending another out-of-hospital birth and another hospital birth since then. Below are some thoughts, some of which were included in my reply to the original comment:

It has been most interesting to experience the feeling of having to do zero "defense", to not even have to prepare myself for the possibility of running interference. When all of a sudden I no longer had to have my guard up, I realized how much energy and attention I was spending on it. I didn't have to tense myself to find out if the next nurse or OB or midwife on shift was friendly or hostile, flexible or rules-obsessed. I didn't have to explain any birth plans to nurses or nag anyone to get the monitors off or try to soften the impact of discouraging words. I didn't have to help navigate decisions where the woman couldn't be sure whether she should trust her caregivers' recommendation. And in terms of my role, I knew I was totally welcomed and my role was perfectly understood by the midwives there. It was amazing just to toss all that defense aside, know that both the families and I were in a place they could trust, and be 100% focused on labor support.

I also felt very confident that I could let the midwives take over the role of suggesting position changes, etc. when they were around - that was a new feeling. Sometimes in the hospital, I feel like I am the only one taking responsibility for suggesting proactive things to progress labor, ensure optimal fetal positioning, etc., and again I am always on guard that those will be met with negative feedback by the nurses ("what's she doing on the TOILET?") or resistance by the mom ("do I have to move??") Outside of the hospital, the midwives were on top of that stuff, and they had the trust and authority to say "It's really important and I think it would help you, let's get you walking again". I sometimes suggested things as well if I sensed it was the right moment, but I never worried that I would be the only one or that the midwives would be reluctant to try anything the mom was up for.

So I would say the main difference has been in feeling real trust and confidence in the caregivers - that they were on exactly the same page as the family, that they had and used skills that I consider very important, and that everyone who would be there throughout the labor and birth would share those goals and skills.

While one of the reasons I encourage everyone to have a doula for a hospital birth - that guard/buffer role - was not necessary for the out-of-hospital births, I look back and think how much that freed me up to simply focus on the woman and fulfill all the other parts of my doula role. I think a helpful role that I played was in being there before it was time for the midwives to arrive: encouraging rest, suggesting position changes, giving feedback on where I thought labor was at, helping get the tub set up, etc. Many people are ready for some trained labor support before they're really ready to call the midwives. And after they got there I was still doing verbal support/encouragement, taking turns doing counterpressure, and of course the "gofer" role that doulas do so well. And like the commenter mentioned, sometimes your midwives give you wonderful care but their labor support is just not the kind that helps you the most. I would encourage anyone to have a doula at a home birth!

A childbirth educator's take on the state of birth and birthing classes

I enjoyed this short but spot-on interview with Erica Lyon, a childbirth educator in New York. Everything she says is both true and clearly from deep experience, as well as full of compassion. Here are a few of my favorite quotes:

I’ve heard complaints that childbirth classes end up making women feel guilty or like failures if they get pain medication or c-sections. That’s no fun. What’s going on here?

Many childbirth educators work from a place of believing that if they give a woman enough information she will make the decision that the educator thinks is best—doctors and midwives and many clinicians do this as well. A truly educated and experienced health educator in this field no longer cares what you do, she only cares about her students’ compassionate growth and ability to participate in their own care. Its not empowering to be told how to do something. It’s empowering to make conscious decisions and receive support for them and realize one’s own potential by doing that.


What are some of the biggest misconceptions among your students about what will happen in childbirth?

That it will be short, that tearing is the worst thing ever, that husbands/partners will be grossed out or turned off or useless, that the epidural makes it totally a pain free experience, that providers who are dismissive and brief are the standard (and that they wont be like that in labor), that this is the worst pain one will ever feel, that she will be in control during the labor.

Something in me wants to take that last paragraph, blow it up to poster size, and laminate it and put it up on a wall somewhere...not sure why, maybe so I can add a tick mark next to each item every time I encounter or counsel someone about that particular misconception. Maybe because each surface concern speaks to a deeper issue in terms of our society's ideas about labor and birth.

If it was acceptable to cut and paste another person's entire post, I would do it! So instead I ask you to just click over and read it all.

Home birth on the rise in the U.S.

When I heard Eugene Declercq speak at the CIMS forum, I jotted down some notes on his data, but it was one of those "scribble it on the back of the conference program because you forgot to bring a notepad" situations, and he talked about so much interesting stuff I didn't have room or time to write it all down. One thing I was intrigued by was his statement that 1% of all births to white women are now happening at home. That seemed high to me, but he co-authored a new article out in the journal Birth, and it has that statistic plus a lot more info.

Some excerpts that were particularly interesting to me:

Large differences occurred in the percentage of home births by maternal race and ethnicity, and these differences widened over time... In 2008, 1.02 percent of births to non-Hispanic white women were home births, representing a 28 percent increase from 2004, when 0.80 percent of births to non-Hispanic white women were home births. In contrast, the percentage of home births declined slightly for non-Hispanic black women from 0.30 percent in 2004 to 0.28 percent in 2008. In 2008, the percentage of home births was 0.20 for Hispanic women and 0.38 for American Indian women, statistically unchanged from the 2004 figures. In 2008, the percentage of home births was 0.27 for Asian or Pacific Islander women, up from 0.24 percent in 2004. Approximately 94 percent of the increase in the overall percentage of home births from 2004 to 2008 was because of the increase for non-Hispanic white women. In 2008, 83 percent of home births were to non-Hispanic white women, compared with 54 percent of hospital births. [emphasis mine]

In 2008, Montana had the highest percentage of home births (2.18%), followed by Vermont (1.96%) and Oregon (1.91%). Three other states (Alaska, Pennsylvania, and Wisconsin) had a percentage of home births of 1.50 percent or above. An additional 10 states had 1.00 to 1.49 percent of home births. In contrast, 18 states had less than 0.50 percent of home births.

Interestingly, the recent increase in home births in the United States began before the release of a series of documentaries and newspaper articles about home birth... Such a development is not without precedent. In the United Kingdom, a government-endorsed movement called Changing Childbirth has been credited with leading to a growth in home births that has continued until the present. However, the home birth rate in the United Kingdom had already been increasing for five consecutive years before Changing Childbirth came into being... Women choosing home birth may be a harbinger, as much as a result, of increased activism related to childbirth...

These make me think about the highly culturally specific nature of the homebirth movement in the U.S. White women (in states with small minority populations) are accessing, promoting, and creating change around homebirth, and I would say I see a culture of normalcy arising around out-of-hospital birth in a certain segment of the population. (Overheard outside a prenatal yoga class: "Well, you don't have to pack a bag since you'll be staying at home, but what are YOU packing to bring to the birth center?") There is clearly a lot of privilege at work here...there are so very very few voices speaking to the non-educated-middle-class-white-woman demographic. I often think some of the Hispanic women I work with in CenteringPregnancy would be interested in having their babies in a setting other than the hospital - out-of-hospital birth with midwives being the standard in many countries they/their families come from - but there is simply no way for them to even know that homebirth is possible in the U.S., much less sort through the complicated process of finding and accessing it, insurance-wise. (And I can't pitch homebirth to them in my role, unfortunately!)

It comes back to my frustration that the people with privilege seek out the nurturing, mother-friendly, midwifery care; and the people who need that care the most, so frequently get a prenatal care through a health department or community health center, every visit with a different provider and then labor and delivery with another set of strangers, usually the general OB service at the hospital. I see basically zero outreach to low-income/minority communities from the birth community, and walking my delicate line between working in the system right now, I am guilty of that too. How do we fix this??

Mollie's birth story

My lovely friend Mollie just had her baby last week and I am so happy for her! She just posted her birth story on her blog. Before she had it written, she e-mailed me a teaser:

Chris is dozing in the room, I'm in the hall with the Doula, midwife had gone to lie down. We walk down the length of the hall, back to the other end, about half way back and then...
Chris tells it as "I was about to doze off, and then I hear her yelling, 'I can't do it, I can't do it, I'm pushing, make it stop, something came out!'"

Doesn't that make you want to read the whole thing? (Plus you get to see photos of that cute little baby.)

Stay tuned for a guest post by Mollie on how she went about choosing her care providers and place of birth, laying the foundation for a positive (and exciting - in the good way) birth experience!

My first homebirth as a doula

Yesterday I was privileged to attend my first homebirth as a doula! I've been to so many births, and none outside of the hospital - until now. It was such a lovely experience for me and, I think, for the family - although, like any birth, a lot of hard work for the laboring woman! And she was a rockstar!! It ended with a perfect healthy happy baby (born in the caul - another first for me!) and an amazing healthy happy new mother - the best outcomes possible.

The family and woman-centered-ness I saw in the midwives' care was so exceptional. What the midwives needed to do, they did as quietly and unobtrusively as you could imagine. Most conversation between the birth team took place in hand signals or sub-whispers. Every question and transition was explained simply, quietly, and calmly. And being a healthy, progressing labor they didn't need to do much - so they didn't. There wasn't constant pressure to monitor progress (except by observing and listening), no restrictions on movement or food or with cords and wires, and there wasn't a constant battle to fight those things off either. It was just labor, unique to that particular person, but a familiar sight.

I can't express how different in tone and attitude it felt from a hospital birth. Having experienced it, I see why some doulas have a hard time going back to hospital births after attending home births. (The only hospital birth I've been to that has ever come close is this one, which had a fortuitous constellation of a fast labor, great nurse, two doulas, and one of my favorite midwives ever, at the most mother-friendly hospital I've ever seen. And even then - just not the same.) The respect, the privacy, the autonomy, the gentle guidance, the comfort and calm and normalcy, I have never seen replicated in any hospital (although I so deeply wish they were). It was a powerful experience.

In case you can't tell, I'm still riding the lovely wave of good feeling and harmony that comes with seeing a new life come into the world. Thank you to my friends for inviting me to be present. I was honored to be there. Your new family is great and I can't wait to see this baby grow up!

100% real life, as seen by doulas

Gina at the Feminist Breeder posted a most excellent angry rant about the Lifetime TV show L&D reality show, "One Born Every Minute". She had some issues with the way a couple planning an unmedicated birth was portrayed in the documentary, but this is what she had to say about the medical staff's attitude towards them:

And now thankfully the show is over, and I never have to see that nonsense again. Except that I do — in real life — every time I attend a birth at a hospital with a high rate of unnecessary interventions. As a doula, I can tell you that Lifetime’s “One Born Every Minute” is 100% REAL LIFE, and the things happening on that show are absolutely representative of what’s going on in EVERY labor and delivery unit where the staff and providers do not practice evidence-based medicine or the midwifery model of care.

YES. YES YES YES.

You can read the post for a blow-by-blow of each interaction these parents have with the nurse Gina terms "Nurse Dread". In a follow-up post, Gina has a clip of one of their interactions with said nurse - or more accurately, their doula's interactions with the nurse. If you are planning to give birth in a hospital setting you suspect or know will be hostile to an unmedicated, low-intervention labor, you need to watch this:



This is what doulas want you to understand: as Gina puts it, this is 100% REAL LIFE. The nurse's tone, attitude, demeanor, were so intensely familiar to me.

This is how it is. Bleeding from a thousand passive-aggressive cuts. "I'm trying to take care of ALL of you, especially your BABY, and I can't do my job! Haha, I'm laughing, YOU'RE RISKING YOUR BABY'S LIFE. Here's the monitors laid out nicely [those are the belts she's messing with], why don't you get back in the bed now." And I guarantee you she'll be back every 10 minutes with a variation of the same speech. "You know, when you're making such slow progress, we just get very worried about the baby. We want what's best for both of you, you know that. Right?? Mommy and baby, we care about you both so much! We just really need to be able to know what's going on in order to do that." And on. And on. And ON.

This is not because the nurses are evil horrible people bent on ruining birth. I bet this nurse is a wonderful person and takes excellent care of her patients. But she is made so profoundly uncomfortable by a labor that goes off her standard script that she cannot handle the situation respectfully or gracefully. She is constantly trying to nudge it back to what she's used to seeing, so she can get back on-script and go on with her life.

And this is why you need a doula. In this clip, the the parents aren't even seen; the doula's the one to deal with the aggro, then go in to communicate the situation to the parents (and probably discuss with them how to negotiate the next steps). Listen to how the doula is working to defuse the situation, acknowledging the nurse's concerns, reminding her the parents' priority is a healthy baby, and offering her some alternative ways to think about the situation ("people have different pathways"). The mother portrayed talks in an interview with Gina about how the doula was, in fact, the person handling most of the stressful interactions with the nurse:

[talking about her disappointment with the way the show handled things]:

I wish two things: 1. that they’d portrayed our doula in a better light. She was incredibly supportive, and had to field the majority of our conflict with Pam. AND, she did everything on zero sleep, since she came directly from another long birth, and 2. that they hadn’t insinuated that Eleanor was in trouble, and that we were putting her at risk. Every time we were on the monitor (which was 20 minutes of every hour), she was tolerating perfectly well, and even when we were pushing, her heartrate stayed up. There was never any danger.

From now on, whenever I'm trying to explain to someone why it's important to have a doula when you're planning an unmedicated and/or low-intervention birth, I'm going to point them to this show. You need someone between you and those negative attitudes to absorb as much as possible for you, and to keep the comments that do hit home from sapping you of your confidence and energy. Please, please, don't try to do it alone - find someone who can help protect you, and keep you feeling in control and confident, no matter how things go.

The doula's first-time mama advice kit

Just about everyone who knows me knows I like to talk. Very quickly they generally find out that I am especially talkative on some of my favorite subjects of birth and breastfeeding. (I am so proud of myself last month that I went to a New Year's Eve party and only ended up talking about breastfeeding once, and very briefly at that!)

So when friends and acquaintances get pregnant, they often come to me for advice. (Sometimes I hear in their voice a kind of loving "OK, know-it-all, NOW you can tell me" tone!)

While I always try to tailor my advice to their specific questions (in part so as not to overwhelm them!) I do find myself answering similar questions and requests more than once. I've been thinking about putting together a set of the links, books, and resources I recommend to the newly pregnant woman (as opposed to the packets of info and resources I put together for my doula clients). That way I won't forget anything and will have it all conveniently in one place, so I can answer specific questions and then say "If you want more information, here's the link".

Here's a preliminary set of the info I'd give to a newly pregnant woman:

Suggested for everyone before they do anything else

The very first thing to do - before ANYTHING else - is read my post on What I Want My Friends to Know.

Next, unless said friend has put up with a lot of my rants or been following my blog for a long time (hi guys! hope you have been!), it's time to start researching options for birth.

So secondly, watch The Business of Being Born (also available on instant view from Netflix). Seriously, this is the first thing I think any pregnant woman and her family can do to help them understand the lay of the land in the U.S. right now, birth-wise.

(Reading "Pushed" by Jennifer Block is also great but not as easy as sitting down to a (very well-made) movie for a couple hours.)


Choosing a care provider and birth setting:

Often the first care provider someone goes to after finding out about the pregnancy (or to confirm pregnancy) is the person's regular GYN provider. That may be a gynecologist, an ob/gyn, a nurse practitioner, a family practice doc, a midwife, etc. If that provider offers obstetric services, the woman may begin her prenatal care with that provider, but wonder if she should investigate other options. If that provider does not offer obstetric care, she'll definitely be looking for a place to get prenatal care and deliver (since the two generally go hand in hand). So people frequently talk to me about how to go about researching and choosing a provider and birth setting.

What I say is that when looking for a care provider and birth setting, it's important that they match YOUR philosophy and what YOU want out of your birth experience... which can be hard to formulate when you're all of 5 weeks pregnant and have never thought about this before! So it's OK to establish care with someone knowing you might switch later.

In the meantime, gather your information and investigate your options carefully.


Why it's important to investigate and choose carefully

The First Birth - No Do-Overs Currently Available - just found this via Birth at Home in Arizona and love it. Make sure to read the comments as well.

You buy the hospital ticket, you go for the hospital ride by Navelgazing Midwife is an honest assessment of why it's so important to look very closely and be realistic about whether a particular birth setting will be right for you.


Information to gather and questions to ask about a care provider/setting

Their state's hospitals' c-section rates if available, from The Unnecesarean.

From Childbirth Connection:
Choosing a caregiver
Questions to ask a health care provider
Choosing a place of birth
Tips and tools for choosing a place of birth

From Birth Sense:
In Search of Dr. Right: 11 Questions to Ask and One More Question to Ask

Considering a home birth? Here are some links for thought specifically to help you interview potential homebirth midwives:

A short discussion and links about the fact that all midwives practice differently, and you will still need to find someone who has the right practice style for you.

From Navelgazing Midwife, advice on interviewing homebirth midwives: Part 1, Part 2, Part 3, Part 4, Part 5, and the finale. A commentary she wrote while posting the series is here. This is another post she wrote about interview questions, critiquing a list of suggested questions. Please read them all if you are planning to interview homebirth midwives!


My biggest piece of advice is to find experienced local doulas and talk to them about your options. They will know not just what local maternity care providers say they will do, but also what they actually do, which can help avoid the problem of the doctor or midwife who seems lovely and then becomes a totally different personality in the delivery room, or claims they practice one way and end up doing something very different. If you aren't ready to commit to hiring a doula or a specific doula, I think most doulas would be open to meeting with you for an hour or two, with the offer of compensation for their time based on the understanding that you may not hire them for the birth. (Doulas understandably feel poorly used when people act like they're going to hire them, spend a long time "interviewing" them while getting lots of advice/information/resources with no compensation, then never call again.)

If I know you personally, I'll usually get on a doula forum or two and ask for local suggestions from the doulas there - so hit me up!

Finally, go into this keeping an open mind. You may think you've found Dr. Right and then when you finish your birthing class at 32 weeks, realize that person is not the right fit for you. That's OK; there is still time to switch. Please don't fall into the trap of thinking that you can't switch after some magic number of weeks! Every doula can tell you the story of the client who switched at [34 weeks, 37 weeks, 41 weeks, in early labor, in active labor, etc.] It's only too late to switch after you've had the baby... and are regretting not switching before.

Here are the instructions for how to switch if you need them.

I'm not done talking about switching care providers, because I can hear people saying "I know I COULD switch, but it just seems too complicated/confusing/difficult/scary... I don't love this person, so I think maybe for my NEXT birth I will choose someone different/a home birth/a new hospital/etc." Do you hear yourself saying that? Stop and go back and read The First Birth - No Do-Overs Currently Available.

Now read the Unnecesarean's post of mothers who did (and didn't) make the switch.

Have you done those two things? Go and do them right now. Okay, REALLY done them now?

Then one more thing to remember: you may never have as many options as you do now - carrying scars, emotional or physical, from your first birth may impact your second in ways you may find hard to think about right now. Do not make excuses for care that does not live up to what you know you want and need! Do not put yourself and your needs off into the future - address them now in whatever ways you deserve.



Books

Along with advice about bras, probably the most frequently asked question - what to read?

Standard warning: NOT "What to Expect When You're Expecting". 'Nuff said.

My favorite suggestion lists for books: What Not to Read, from Bellies and Babies. Along with each book she thinks women should avoid, she has 3 suggestions for better books on that topic.


Childbirth classes

I can't emphasize enough not taking the hospital classes. No matter how great the teacher is or how much freedom she seems to have - she is limited by hospital policy and you cannot be sure exactly what those limitations are.

An independent childbirth class with at least 5-6 sessions is a far better choice. Research a little bit about the philosophy of instructor and the class before signing up - there are many options (e.g. Bradley, Hypnobirthing, Hypnobabies, Lamaze, etc.) This post at Bellies and Babieshas a nice overview of the most common/popular childbirth ed programs.

If you live in an isolated area and can't find local classes, some independent instructors offer DVDs of their classes, and Hypnobabies has a full home study kit.

I have heard several childbirth educators recently saying plaintively that parents are looking for a small number of sessions, or preferring weekend workshops with a lot of information packed into 1-2 long days. I agree with them that it's very challenging to get all the information you need AND (more important) absorb and process it with these kinds of classes. If that's all you can do, go for it - but really try to make the time for something with a slower, calmer pace.

If you have trouble finding affordable birthing classes, ask around for childbirth educators in training, and talk to your local health department and/or community health center - they sometimes offer low-cost options.


Bras

By far one of my most frequently asked questions. Fortunately I wrote a series on this!


Breastfeeding

I recommend, if the mom feels comfortable, going to a couple La Leche League meetings while pregnant. They are a great place to see other women breastfeeding, hearing their questions, and getting advice. And they're free!

You might also think about taking a breastfeeding class. Oftentimes local maternity stores, hospitals, private lactation consultants, etc. will offer them. I currently teach one at a local yoga/wellness studio. No matter who teaches it, you can almost always look forward to practicing latch and position with baby dolls!

Rixa at Stand and Deliver has some excellent suggestions on A Proactive Approach to Breastfeeding.

You'll see a note from me in the comments encouraging confidence. Many of my friends ask me tentatively "How often do women have problems nursing?" or "What percentage of women can't make enough milk?" These are normal concerns coming from a culture where so many women seem to struggle with latch and supply. These are real issues, many stemming from institutional and systemic factors like birthing practices and hospital policies (see more at Rixa's post). But the biggest predictor of breastfeeding success is confidence, and the perseverance to overcome whatever challenges arise.

(And again, if we know each other you know you can call me any time about any breastfeeding question! Seriously. Any time. I have a bizarre sleep schedule anyway.)

**

Phew! That's all I have for now. Readers, what would you add to this list? What are your first recommendations for a newly pregnant mom?

Defensive medicine and the c-section assembly line

Apologies for the long posting silence. I have so many drafts in progress. In the meantime, I want to direct people to the excellent and thought-provoking posts and comments at the Unnecesarean's series Defending Ourselves Against Defensive Medicine.

I thought I would tell a little story to go with it. My last CenteringPregnancy group had their reunion today. The midwife organizes it so that the reunion takes place at the meeting of a group who is about to have their babies. Then the new moms can share their experiences of birth, breastfeeding, and baby care with the moms-to-be.

One of the reunion moms had quite the story. She had 3 days of labor and was finally at the hospital making very slow progress with a posterior baby. The midwife who facilitated the group was working with her and the doctor came in to tell the midwife that the woman should have a c-section.

The midwife took him out into the hallway to discuss it. Turns out he had a morbidly obese patient who was also going to need a c-section, and would need the OR and a number of staff for a significant amount of time. The doctor's take was, "Let's get this one out of the way, then we'll do the more complicated surgery." The midwife went to bat and said "No. Mom is fine and baby is fine. I know my patient is stalled, but you do this longer surgery and THEN, if she's still not progressed, you can take her to the OR." They argued and (thankfully!) the midwife won. She went back in and put mom in a knee chest position (keep in mind this was a mom who had an epidural! these positions are possible under many circumstances!) The baby rotated to OA, and after that labor progressed and baby was born easily.

Thank goodness for guardian midwives in the face of not just defensive but assembly-line medicine.

Surprise breech story

An amazing story from a classmate of the student midwife and L&D nurse At Your Cervix:

There are several nurses in the room readying for delivery. I lower the bottom of the bed, glove up and Mary hands me the amniohook. Nice hard vertex presentation, large bulging bag, just a bit of an anterior lip, then AROM, and clear fluid. It was going to be easy. Ana bears down, my fingers still in. But… something is just not quite right, palpate around, what is that at 3 o’clock? Lips? Nope. Ear? No. Scrotom? Yep!
I glance over to Mary and in a remarkably calm voice, say:

“Glove up”

“Huh?” says she.

By this time Mary is taking in the rather “unable to ignore” saucer- sized eyes that I’m exhibiting.

“We’re breech”

Read the rest here.

And if you have thoughts about who should get donor milk, or ideas for Blessingways, I am still happily welcoming comments on either!

Breastfeeding links

To get some links out of the way that have been piling up, and to celebrate my new IBCLC certification, a breastfeeding link party:

Normal Newborn Behavior, and Why Breastmilk Isn't Just Food" from the Lakeshore Medical Clinic

The Academy of Breastfeeding Medicine conference was last week - you can read conference updates and winners of their "clinical pearl" contest at their blog. (One of my favorites: "Give baby until 4 days past his due date to get the hang of breastfeeding." Not that you should give up on a baby after 4 days, but that with moms who are easily discouraged and with our epidemic of slightly early babies, this is a good target date to keep people moving forward until everyone catches on.)

Elita at Blacktating on whether her birth experience set her up to fail at breastfeeding. (Check out the comments for a lot of personal stories from others with the same question.)

The Motherwear Breastfeeding blog posts an ad to educate women in India about the importance of colostrum. (I love all the women going from store to store asking to buy colostrum!)

Reply turned post, on a 360-degree view of the doula's role

Birthday Nurse wrote a post recently on, in part, the role of the doula in the birthing room:

One thing I always seem to struggle with when I have patients who have doulas is when they ask their doulas for "permission" before they do anything. The patient was thinking about getting an epidural after 10+hrs of backlabor and no real cervical change. She had been talking about it and going back and forth and I asked her if she wanted me to start her fluid bolus prior to her block. She looked right at her doula and said "what do you think?" When her doctor wanted to start pitocin a few hours later after she was comfortable and still not changing her cervix...again she looked at her doula and said "what do you think?" (after waking her doula up from the nap she had been taking on the pull-out mattress) HELLO!! This is not your doula's labor! This is your labor, your baby, your body, your experience! You don't need your doula's permission!!! Doula's are great support people, they're awesome, don't get me wrong. But (most of them...and especially not the one in the previous scenario) they're not trained medical personnel...they're not your doctor or your nurse...don't ask their "permission"!

My reply turned into a post of its own, here in somewhat edited form:

I have a couple perspectives to share on the "permission" thing. Sometimes as a doula I get clients looking to me for "permission". I understand what they're doing, they hired me in part to be a sounding board and an independent voice, and they want to know what I think. Because it's not my role to give them medical advice, I generally try to turn it around and talk them through the situation and ask what more information THEY need to make a good decision. I wouldn't want a client asking me for actual permission if her doctor told her she needed a c-section. But if she turned to me and asked what I thought, and it meant I could help her talk through the facts that baby was showing no distress and that her progress was slow but was happening, that might be a good thing for her having what she needs to make an informed decision about whether or not she wanted to consent to the section. If you have the independence as a nurse to give her the space, time, and support to potentially question her doctor's recommendation, that's fabulous! But many nurses don't, or won't, and I feel that's where the doula's ability to be an independent sounding board comes in.

And sometimes I also recognize that as someone they shared their birth plan with, and trust, they just need emotional validation for the path they're about to choose. It would be nice if they could get that validation from the medical staff, but unfortunately many people who hire doulas are doing so because they do not completely trust the medical staff - and sadly, with good reason in some cases (this brings us back to the need for an independent sounding board.) They need someone who they know is totally on board with their birth plan to affirm that it's OK to deviate from it. So in those cases I can be the one to say "You seem so exhausted, I agree an epidural sounds like a great idea", or whatever it is they need to hear to feel good about their decision. A doula friend told me recently that she actually asks her clients, "Do you need me to give you permission to _______?" as in, do they just need some help to feel OK about their decision?

I have experienced this from the other side (albeit less often) doing lactation support where the mom looks to her doula when I recommend, for example, a nipple shield. "Do you think I should try it?" And I get this flash of irritation - "Your doula didn't train for this work and take the LC exam and work with hundreds of breastfeeding dyads, why are you asking HER?" - and then I go "aha, this is what the L&D staff must feel like when my doula client turns to me!" So in that moment I remind myself that I have just met this woman - why should she trust me? She trusts the person who she met and has been working with for weeks, and just went through many hours of labor with, and she is trying to make an informed decision that (gasp) may not be what I recommend. She is going to consider her options and make a decision instead of just agreeing with what I suggest, which is a strange feeling for me but a good one to get used to. I may not agree with her decision but she will be the one who lives with the consequences, not me, and I have to make room for the possibility that I am wrong and she is right. That this is so uncomfortable for me to do has been an excellent learning experience and given me a lot more sympathy for all sides!

The NY Times on direct-entry midwifery legislation in Illinois

Use of Midwives Rises, Challenging the State to Respond:

Each year, 700 to 1,000 babies are born at home in Illinois, many of them in rural locations, according to the Illinois Department of Vital Health Statistics. Licensed home-birth practitioners work in just 7 of the state’s 102 counties, and most are concentrated in Lake and Cook Counties, leaving the majority of Illinois home births unattended, or attended illegally by someone whose education and licensing are unregulated.

That could change as early as November. After 30 years of trying to get the legislature to license direct-entry midwives, Illinois’s midwifery organizations are guardedly optimistic. In May, the State Senate passed the Home Birth Safety Act. A House vote is pending.

Check out the rest of the article, including their allusion to the fact that not all DEMs want licensure, and a choice quote from the OB/GYN on "natural birth plans". Hey, he's tellin' it like it is!

Linky goodness: to VBAC or not to VBAC, birth videos, and more!

Time to clear out the starred posts in my blog reader! Sorry, some of them are a few weeks old but of course, still great:

Robin Marty of RH Reality Check on the many reasons she's choosing an elective repeat c-section over a VBAC attempt.

Birth Sense introduces you to the handsome, charming Dr. Justin Case.

Video of baby born in the caul, via Homebirth: A Midwife Mutiny.

Video of frank breech home birth via Gloria Lemay.

Dou-la-la channels Don Draper in explaining why those nice formula companies are so darned excited about breastfeeding.

Why African Babies Don't Cry, via Blacktating.

Mom's Tinfoil Hat linked to a post on abortion and parental notification laws that, very sadly, is no longer up (the author decided to make posts about her work private - I struggle with walking the same line, and totally understand). However, you can still read an excerpt and a long comment from the author in MomTFH's post.

Not birth-related, but something that really touched me to see today: Dan Savage's It Gets Better Project: a collection of videos of adults telling gay teenagers that high school ends and their lives will improve. Read an interview with Dan Savage here, including the reason he decided to start this project.

Feminist reading group on pregnancy, birth, and parenting

Molly at First the Egg is starting up a Goodreads-based reading group on pregnancy, birth, and parenting from a feminist perspective. Books she suggests (click through for the full list) are a nice mix including memoirs, social/cultural criticism and academic texts, and a variety of different topics.

I am really excited about this (as you can see from my overenthusiastic suggestion of new titles for the list at every opportunity) and encourage others to join! As I said in my intro post to the group, I don't get a lot of opportunities to talk about this stuff with people in my offline life right now. That's not to say I don't have access to smart people who think critically about these issues, but we tend to be talking more about "how do we get more people to enroll in our study" vs. "hey, let's have a cup of tea and talk about gendered bodies in reproductive spaces". So having an online group for that is something I'm very much looking forward to.

To go directly to the Goodreads group, join, and introduce yourself, just click here.

"Help! My husband/partner/family doesn't want a doula"

If I had a nickel for every time I heard a mom say, "I would love to have a doula, but my husband [or partner, or mom, or whoever is going to be the primary support person] is against it" - well, I would be a much richer doula! In these situations, unfortunately, their support person's opposition usually wins out over mom's desire for a doula - and more unfortunately, I sometimes hear mom saying later that she regrets letting herself be overruled.

Much of the resistance seems to be based in the idea that the doula will take over the family's role. I think they envision the doula hovering around mom - getting her everything she needs, rubbing her back, talking with her - while her family sits in the corner watching, excluded from being hands-on.

What I try to express to people who envision that is that this is almost NEVER the picture you truly see at a doula-assisted birth - instead, it's what I see happening when I first walk in the room! Mom is often lying in bed, and her family/friends are lined up on the couch watching her like a TV show, wanting to help but not sure what to do; or slightly better, standing next to her as she vocalizes through a contraction but not sure what to say or how to help.

My goal is to change that picture, but not in the way the family is envisioning. In fact, my ideal picture is for the people who love the laboring woman the most to be the ones who are massaging her lower back, who are whispering encouragement in her ear, who she leans on during a contraction; if there's anyone sitting on the couch watching, it's me!

To get to this picture, there are a few key things I do as a doula that I think are so important: first, I help the support people understand what's normal. They may be very anxious about noises mom is making, or the length of labor, or baby's heartrate. I can help them understand that things are going normally, which gives them the space and confidence to reassure the laboring woman and keep her going. It sounds simple, but I think it's absolutely one of the most important things I do. You can watch a dozen birth videos and still find the actual process and presence of labor intimidating; it takes a little while to get comfortable with its rhythms and sounds and, ahem, bodily fluids. Just having a calm, confident presence frees up so much energy that is otherwise in anxiety and helps everyone enjoy the birth experience without fear.

Second, I know the ins and outs of the labor room. I know where the volume control is on the fetal monitor (and that it's perfectly fine to turn it down), where to find the birth balls (and how to get mom onto one without disturbing the monitors and IVs if she can't get them disconnected), how long that fetal monitor really needs to run before she can take it off and start intermittent monitoring (and I'll happily be the one to push the call button and ask the nurse to come in and take mom off).

Third, I remind and reinforce what they may already know. For example, I find more and more that there's some point in labor where I sense that mom needs to get in the tub or shower. She's starting to get totally overwhelmed and I can see incipient panic in the eyes of her support team. Sure, they learned that water can be helpful in labor; it's probably on their birth plan. But in the moment, they just don't think of it. Often, mom is reluctant to try it (remember, she's totally overwhelmed and even walking one step seems impossible), but I encourage her, get the tub all set up, she decides to give it a shot, and... aaaah. She relaxes into the water and gets her second wind. The bathroom is tiny, so her partner kneels by the tub to coach her through contractions and I retreat into the L&D room to just listen in case they need anything. This is often when mom is going through transition and I love getting to facilitate those last intimate moments between the parents before she starts to push and they get ready to meet their baby.

Finally, while I'm happy to sit on the couch and hang out if that's all that's needed, I should add I don't need to be hands-on to be busy as a doula! I can be running down the hall for more ice or to heat up the rice pack or getting snacks for mom/support people; bringing fresh washcloths for mom's forehead; catching medical staff at the door so if they've just come to "check in" I can update them without them having to interrupt the laboring woman's space; searching out birth balls, rocking chairs, squat bars, etc.; plugging and unplugging portable IVs, fetal monitors, etc. if mom is moving around/headed to the bathroom; and on and on. Again, these are things that the other support people might be hesitant to do or not know their way around well enough to do confidently; I can take care of that stuff and free the family up for focusing on mom and baby.

In short, a doula does not and cannot replace a woman's own family and friends - and doesn't want to! She is there to make everyone's experience better. Once your support team understands this, they're usually much more open to having a doula at the birth.

You could also try this quote on them, from an OB-GYN who had a doula at her first birth: "I can't say if having a doula shortened my labor, but it definitely lengthened my marriage!"

Do you have family and/or friends who are planning to be at your birth, but are resistant to the idea of a doula? Here are a few things for them to read to get educated about a doula's role at a birth:

From DONA: http://www.dona.org/PDF/DadsandDoulas.pdf

From Penny Simkin, doula extraordinaire: Myths about Dads and Doulas

Written by a dad: 5 Reasons Dads Should Demand a Doula

Do Doulas Replace Dads? includes a nice chart on what kind of support each person in the birthing room provides, and where doulas do and don't overlap.

(I apologize for the heteronormativity of all these links! I have tried in this post to use language that's inclusive of different types of family structures. Hopefully regardless of what label your support people fall under, they can find this information helpful.)

In the end, remind yourself and your support people - this is YOUR birth. Just as you have the right to say that no, your mother-in-law and all your second cousins are NOT welcome in the delivery room - you have the right to say that you WOULD like a doula there. If this is truly important to you, your support people should respect that and work with you to find a doula they feel confident will empower them, and you, during the birth.

Technically birth-related

I just thought this was so cool:

Evolution in Action: Lizard Moving From Eggs to Live Birth

Evolution has been caught in the act, according to scientists who are decoding how a species of Australian lizard is abandoning egg-laying in favor of live birth.

Along the warm coastal lowlands of New South Wales, the yellow-bellied three-toed skink lays eggs to reproduce. But individuals of the same species living in the state's higher, colder mountains are almost all giving birth to live young.

Only two other modern reptiles—another skink species and a European lizard—use both types of reproduction.

Evolutionary records shows that nearly a hundred reptile lineages have independently made the transition from egg-laying to live birth in the past, and today about 20 percent of all living snakes and lizards give birth to live young only.

But modern reptiles that have live young provide only a single snapshot on a long evolutionary time line, said study co-author James Stewart, a biologist at East Tennessee State University. The dual behavior of the yellow-bellied three-toed skink therefore offers scientists a rare opportunity.

"By studying differences among populations that are in different stages of this process, you can begin to put together what looks like the transition from one [birth style] to the other."

Score another one for the big babies!

I haven't had a lot of doula/birthy posts lately, probably not enough to justify the name of this blog! That's in part because I hadn't been to any births recently. But the past few weeks I've been waiting on two births, due about a week apart but of course delivered only about 24 hours apart. So it's been busy!

The second labor was definitely another score for the big babies. Fast labor, basically no pushing - more breathing the baby down while trying NOT to push (I was a little concerned baby might be born in the car, but I have yet to hit that doula milestone!) - and fast delivery. Well over nine pounds! The midwife said the shoulders were a little sticky but because mom was already on hands and knees (which she chose instinctively for labor and pushing), it all went very smoothly.

Let me say it again: Big babies can be born vaginally! They can be born quickly! They can be born easily! Don't trust scare tactics about a big baby - read the research, and hear the positive stories.

So now I am coming down off my post-two-births high and thankful to go off call for a little while. I know I'll start jonesing to attend another birth soon!

Doula memories

I've been puttering around today, catching up on some of the things I put off while getting ready for the exam. Some of my friends have been talking birth stories/birth plans lately and we talked a bit about wanting positive hospital birth stories since there are so many scary ones out there and yet there CAN be such lovely births at the hospital.

I started thinking about a birth I attended back when I was in AmeriCorps and went searching through my old birth stories (we wrote one up for each birth we attended, and when I left I kept a copy of all of mine and am SO glad I did - they are wonderful to look back through) to find what I wrote about it at the time. And I cannot for the life of me find it. I must have missed it when I was making my copies.

So, without that sheet of paper I can't remember all the information about the birth, like whether mom had an epidural or not, what # baby this was for her, even whether baby was a boy or girl! But I do remember that the family had a few older children, some of whom were present, and that they were very positive, friendly people - I really enjoyed being at the birth with them. There was a recently hired (but experienced) midwife at this hospital that I hadn't worked with before* and she was the midwife on all day as mom labored and I worked with her.

As the birth grew nearer, and mom was working hard and pushing, the midwife beckoned the dad over to where she was keeping an eye on the perineum. Baby began to crown and she said to dad, "Come here. Give me your hands." As the baby's head emerged, she laid his hands on the baby's head and guided him in catching his own baby - the first person ever to lay hands on his child. I watched his eyes widen, his face about to split apart with a smile as he did it. Together they handed baby to mom and she cuddled her new baby as they got baby cleaned off.

Afterwards, dad was just glowing, literally bouncing around the room, still unable to wipe that huge grin off his face. "Did you see that?" he kept asking everyone there. "Did you see what I did? That was amazing! It was AMAZING!"

It was even neater - to me - because these were not people who had sought out midwives to get greater control over the birth process. They were community health center patients who just needed quality affordable prenatal care, and ended up working with midwives because that's who did the births for the CHC at that hospital. And they were handed this really amazing gift of participating more fully in their child's birth.

Later the midwife told me that she had been watching me work with the mom all day, and had been going to offer ME the chance to help catch the baby, but could tell how excited the dad would be to do it. I was bowled over by that! I told her I was so glad she had the dad catch. I was just there for one day, but I hope that every year on this baby's birthday, that dad is still telling his child the story of how he helped catch him/her, and how proud he was to do it.

So that's your wonderful hospital birth story of the day, courtesy of my free association skills!

*Do any other doulas have the experience with new-to-the-system midwives that they're such a breath of fresh air? They haven't gotten trampled down by the system yet, they're not looking over their shoulders at the nurse who might "turn them in", they're just practicing how they want to practice. That's not to say that experienced midwives who know how to work the system aren't fabulous and valuable and just as subversive in their own ways - if not more - but being with a new midwife can be so...liberating.