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

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

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

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

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

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

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

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

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

Notes from the NICU

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

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

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

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

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

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

Breastfeed: be a star

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

Above is Clare, 20, from Morecambe:

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

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

What do you think?

How to make a doula feel loved

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

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

Dr. Kennell: Yes it is.

NLJ: Why do you feel doulas are so important?

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

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

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

Sowing the seeds of distrust

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

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

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

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

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

Descriptive studies & routine fetal monitoring

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

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

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

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

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


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

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

Feminists, reproductive rights, and VBAC

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

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

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