New protections for nursing mothers in Senate health bill

From the Wall Street Journal Health Blog:

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

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

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

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

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

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

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

In which a medal comes in the mail!

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

As she writes in her blog:

I started thinking, “Why Not?”

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

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

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

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

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



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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What an induction looks like

Want an induction? Ask yourself if you want this:

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

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

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

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

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

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

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

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

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

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

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

---

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

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

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

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

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

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

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

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

Friday night movie

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

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


(Via Birth Routes.

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

Milk's up! The breastfeeding gang sign

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



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