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"?
Monday, October 12, 2009
Wednesday, October 7, 2009
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!)
"...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!)
Monday, October 5, 2009
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.
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.
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.
Sunday, October 4, 2009
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!
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!
Saturday, October 3, 2009
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.
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.
Friday, October 2, 2009
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.)
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.)
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