July link party!

So many starred posts in my Google Reader! So much to share!

Science and Sensibility interviews Dr. Michael Lu on preconception care. Oh, does this warm my MCH public health heart! This man has done such amazing research and I am so excited to see his work getting connected to the birth advocacy communities via S&S:

Allen Rosenfield probably 30 years ago asked the question, “Where is the ‘M’ in MCH?” Where’s the “mother” in maternal and child health programs–because much of MCH has focused on children’s health and much less on maternal health. I think the question we’re asking today is where’s the ‘W’ in MCH—where’s the woman in maternal and children’s health? If we really want to improve maternal and child health in this country, we really have to start by improving women’s health. [Emphasis mine because this is SO IMPORTANT!]

I think it’s pretty much in alignment with what you’re saying; it’s not just about childbirth. If the natural childbirth movement is all about natural childbirth, it doesn’t have the kind of impact that it could have. The focus should really be on promoting women’s health over their life course continuum and how we would be a better society for doing that.

And he talks about reproductive life plans! Be still, my beating heart! Part One is here, Part Two is here, and I am eagerly awaiting Part Three!


The Gates Foundation did a blog series on stillbirth to accompany the publication of the Lancet stillbirth series.


From the Academy of Breastfeeding Medicine blog, a report from the Third Annual Summit on Breastfeeding.


Yup, US maternity leave policy really sucks.


Birth Sense talks induction for premature rupture of membranes when the mother is GBS positive - is it necessary? How soon does it need to happen?


Educational website on tongue tie, including a PowerPoint presentation to help train other doctors perform clips. The best part is lots of photos - there is nothing like seeing photos of tongue ties to help learn which type you are looking at and what are the more subtle signs of a tie. Crossing my fingers that this website helps more practitioners learn about and be willing to clip ties that are interfering with breastfeeding. I found the site via the Kellymom FB page where there are many stories of mothers struggling to find someone who will clip. (A post on tongue ties is coming soon in my breastfeeding-tips-for-doulas series.)


NPR's the Baby Project blogs about doulas! Check out the comments for stories from grateful moms who used doulas!


Another hand expression video. This one uses a similar although slightly different technique to the Jane Morton/Stanford technique, with the fingers slightly closer to the areola. It also shows breasts where the milk is in and engorgement is past. If you want to listen to awesome Norwegian, click on the first video; otherwise, scroll down for the second video with narration in English.

Letter for the last weeks of pregnancy

Lately, I've been wanting a link to an article or blog post that I could pass on to friends and doula clients in their last weeks of pregnancy. That is such an impatient, vulnerable time, especially because almost every mom I've ever worked with has thought their baby would come early. To think you're about to give birth any day starting at week 38...and then still be pregnant at 40+6...not fun, and ripe for induction (not the cervix - the mind). How best to counsel patience? This doula does it so well:

Dear I-feel-like-I've-been-pregnant-forever

(via Enjoy Birth)

Induction and perception

You all know how I feel about induction. Pinky has just posted about how tough inductions can be:

Like most L&D nurses, I hate to induce a primip with a long thick and closed cervix. Especially when she is not 42 weeks. Some babies go 42 weeks. We hate to see the 3 day induction. Which goes like this: 1st evening you get cervadil. Next morning we start pitocin even if you are still not ripe. Repeat cervadil in evening or maybe put in misoprostal next morning repeat pitocin. We might turn the pitocin off a few times if the floor gets busy during the day so you get set back a few times. By the 3rd day the woman and her partner are begging for a C-section. We hate to do this. Sometimes she pops into labor and delivers a baby no problem. But that is usually if she has a ripe cervix in the 1st place or by the end of 12 hours of cervadil. ...

Funny thing is no matter how much you tell folks about how the 3 day induction will suck, most will sign up for it. They must think, "Oh I won't be the 3 day induction and if I am I will get a c-section." I think most people down play the risk of c-section. Either they down play it or the catastrophize it. In my book a c-section is to be avoided if possible. It really is a big surgery but not a catastrophe. Most abdominal surgeries can be done by laproscopy. We have not figured out the laproscopic c-section.

It got me thinking about a blog I was following recently. Sometimes my google alerts kick up blogs of expecting moms and I end up scanning through them. This woman decided on an induction at 41+2 and wrote "I know I know, there are a lot of people out there that are against inducing, but [husband] and I are not." There are many ways the story could unspool, but the way it ended up was an induction beginning Sunday night, lasting through Monday night, and ending with a c-section on Tuesday morning due to exhaustion and slow progress. So, pretty consistent with Pinky's description.

This woman seemed OK with having ended up with a c-section, and I think it's great that she felt happy about her experience. But to me, it was illustrative of how choices with real consequences can start being treated as philosophic differences. I'm sure I would be placed into the class of one of the "lot of people out there" against inducing, but I am not "for" or "against" induction. Rather, I think that induction, particularly used electively and/or when the body is not ready (as measured by a Bishop's score), carries risks and that individuals should be aware of these risks.

Making the choice to use or not use an intervention involves a set of risks and benefits that every individual has to weigh for themselves. And one of the risks of induction is that it will be long, exhausting, slow, and result in a c-section which, as Pinky points out, carries real risk of its own. That's easy to ignore, though, when the discourse becomes whether people are "for" or "against" epidurals, inductions, c-sections, etc. That obscures the reality that these are not "chocolate or vanilla" choices of personal preference. It makes it easy to ignore the 3-day inductions and c-section complications, or at least to perceive them as common outcomes of labor (and so not consequences of the induction) vs. common outcomes of induced labor. It's hard because I think many people are trying to spread the word about the risks of induction. But if it's coming across as another "pick your flavor" choice, it's obviously not coming across correctly.

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.

How to make a birth plan

Notice I didn't say write a birth plan! Why? Labor Nurse has a great post up about why writing your birth plan for hospital staff should be the last step in getting your needs met. It's a long and very comprehensive post about what questions to ask your care provider and on a hospital tour, why choosing the right provider and birthplace is so important, and what parts of your birth plan you should negotiate with your provider before ever walking through the hospital door. All this ultimately informs what you need to write down for hospital staff - and it's probably going to be a lot more user-friendly and helpful than some stock plan you print off the internet.

Oh, the induction

A Twittered induction-turned-cesarean. A cesarean for a baby who is just "too big" - at 7 lbs. 12 oz.

One more story to add another little nudge to our culture's perceptions that babies are too big, that all c-sections are necessary, that induction has nothing to do with it.

Link round-up

I've fallen off a bit in posting, mostly due to the fact that I went to the Midwifery Today conference over spring break. That alone gave me about a hundred ideas for new posts, but since I was gone/busy all of break I came back to a large amount of homework/groupwork/work in general. Then I had a birth in the middle of the week, which threw off my already nearly-destroyed sleep schedule!

So I thought until I could sit down and write more, I'd do a link round-up. As I go through my Google Reader I star posts to come back to later, or that put me in mind of a topic I want to write about. Now I've got so many, I think I just need to clear that list out. Here we go:

The Well-Rounded Mama on why it's so important for women of size to get the right size blood pressure cuff. I just learned at the conference how important it is to have the correct size and how to measure for it, but I have worked in many clinics and never once seen anything but the "standard" size.

Radical Doula's piece in RH Reality Check on The Cost of Being Born at Home. It can be very challenging, depending on the state you live in, to get Medicaid to cover all or even part of your home birth. How can we promote birth alternatives while ensuring equal access?

Blood and Milk's round-up of Favorite Posts of the Year. This is a blog about international development and there are some good posts on voluntourism, and how to make sure you are doing more good than harm when engaging in projects overseas. Being in public health, we are asked to think about this often, but probably not often enough.

Research you can use when "Saying No to Induction". Saying no to things is a huge step for women. I am surprised by the number of women who aggressively educate themselves, but when push comes to shove, they back down even with all the evidence on their side. To say no, you sometimes have to piss people off, inconvenience them, be belittled, questioned, or threatened. Women are socialized to avoid causing a scene in any way. It's hard, but with evidence to back you up you can feel more confident.

A depressing post from Gloria Lemay with e-mails from OB nurses. I don't think they reflect all hospitals or all nurses, but they show how bad things are in some places.

Why all expectant parents should tour a birth center even if they don't plan to use one.

A lactation consultant talks about how breastfeeding is not the best, or special, ideal, or optimal. It is normal - the norm for feeding human babies. Not some mountaintop pinnacle we should be aspiring to.

Why you should do your homework - not just "wait and see" - before birth. Homework is the mother of prevention!

That's all I have time for (that's probably more than I had time for but it gets addictive...)

A doula pet peeve

I would like to invite all people attending a birth to practice a special piece of compassion for laboring women. It bugs me in ways I can't quite express when someone shows up in hour 6 of an induction and starts nagging at the mom to "get that baby out!" I know it's usually said all jovial and maybe sounds like it's a joke, but it's based in this idea that "getting this baby out" any time soon is possible. One of induction's (many) drawbacks is that it takes a really, really long time and you have to spend that entire time in the hospital. When most people in spontaneous labor would be arriving at the hospital, you have been there for at least 24 hours. And to be honest, the same thing gets said to women who show up at 3-4 centimeters.

I know it is well-meaning and intended to be encouraging. I also know it comes from television/movie/media impressions of birth where a woman doubles over with sudden, intense contractions, is rushed to the hospital and seemingly immediately delivers her baby. (It's funny that people love to tell "horror" stories of births that last for days, but they are not cinematic enough and don't seem to get imprinted on the subconscious quite so well.)

But birth takes time. Birth, most often, takes a lot of time. It takes prelabor contractions, early labor, start-and-stop contractions, walks around the block, trips to get checked out at the hospital and come home again, triage, getting checked into the delivery room, and settling in and then often you STILL have hours of labor even with the hospital's (very) conservative estimate of 1 centimeter per hour. With inductions, add a night of cervical ripening, and then sometimes another day and night of Pitocin and THEN get to the part where you still have hours of labor.

There are lots of clocks hanging over women's heads in the hospital. There's the 24-hours-after-rupture clock, the 1-centimeter-per-hour clock, and the I-want-to-go-home-for-dinner-let's-call-a-c-section clock. And if a woman is fearing (or justly trying to fight) these clocks, don't add your own impatience, even jokingly.

So friends and family members (and nurses, and midwives, and doctors, who should know better!), do a favor to moms and partners and doulas who are trying to keep a positive-yet-realistic attitude: come in with the same attitude. Come in saying supportive complimentary things, discuss topics that aren't how-long-do-you-think-it-will-be, and leave saying more supportive complimentary things. (And for family/friends, also don't stack up like planes circling O'Hare in her delivery room, hoping she'll magically give birth like NOW and telling her she "has to have the baby by 11 because I have to leave then".)

The evidence base against induction

Why do I discourage women I talk to from being induced?

Many reasons. But most importantly:

Induction greatly increases your risk for a cesarean.

"Elective induction of labor is associated with a significantly increased risk of cesarean delivery in nulliparous women. Avoiding labor induction in settings of unproved benefit may aid efforts to reduce the primary cesarean delivery rate." Abstract here.


Induction greatly increases your risk for a cesarean.

"Elective induction significantly increased the risk of cesarean delivery for nulliparas, and increased inhospital predelivery time and costs."
Abstract here.


If you body is not ready to give birth, induction greatly increases your risk for a cesarean.

"Compared with spontaneous onset of labor, medical and elective induction of labor in nulliparous women at term with a single fetus in cephalic presentation is associated with an increased risk of cesarean delivery, predominantly related to an unfavorable Bishop score at admission."
Abstract here.


Unless you have a very pressing medical indication, induction is not indicated, because induction greatly increases your risk for a cesarean.

"While these interventions often are medically indicated for the well-being of mothers and infants, the evidence supporting their benefits when used electively is controversial."
Abstract here.


There is no benefit to induction because "the baby looks big". Be skeptical of offers to induce because "the amniotic fluid looks a little low".

If a doctor says that there is no difference in risk between an induction and a naturally occurring labor, that person has not read their own professional literature, or is lying.

Because induction greatly increases your risk for a cesarean.