There was some internet buzz about Birth Models That Work, edited by Robbie Davis-Floyd, and since I wanted to get a copy of Birth as an American Rite of Passage, I went ahead and got them both.
I started the latter book, and am thoroughly enjoying it, so much so that I've broken my cardinal rule about finishing one book before beginning another and dug into Birth Models.
The first birth model described is the one practiced in the Netherlands. Danish midwifery has been a model that American midwives have marveled since the 70's, when the first renaissance of physiologic birth happened in the U.S. One of the primary driving reasons of the why's of birth management in that country is explained by a unique cultural perspective on the role of the birth attendant. The authors of this chapter explain, "In marked contrast to the U.S. [OBs] - who are inclined to heroic interventions, rescuing a laboring woman from protracted pain and life-threatening complication with surgery...or medication - [OB/GYNS] in the Netherlands shun the role of hero... The cultural disinclination toward obstetric heroism is sustained by a system that minimizes competition among [OB/GYNS] and between [OB/GNYS] and midwives. In market systems, [OB/GYNS] have an incentive to sell their 'superiority' as the heros of birth."
A Danish OB was quoted as describing the cultural character of the Netherlands as "emancipated" and "self-assured." Individuals have a culturally-instilled view of themselves as capable, which promotes a healthy sense of "mistrust," a kind of suspicion that proves how much one values oneself and compels one to ask a lot of questions before taking action.
I spoke with a pregnant mom recently who is having her first baby; she explained how happy she was when she was diagnosed with PIH, because suddenly, the quality of care she received was different. "Everyone [at the doctor's office] seems to actually care about me all of the sudden. When I didn't have any problems, no one took any time to explain anything to me."
I asked her, why didn't she ask them to take the time to explain things to her? She replied, "Oh, I ask questions, but sometimes I have to wait until the following office visit to really get answers." When I pointed out that she was often saying how she planned on asking questions at office visits, but put them off till the next visit, and how she'd been hoping to ask a particular question for about six weeks but it had yet to happen, she said, "They're just so busy, you know? That's why I'm happy to have their attention, now!"
This particular mom has also voiced to me her love of medical technology. "It makes me feel safe. I would have an ultrasound every day if I could." When I asked her why, she explained, "When I can see the baby, see him breathe and move, I feel like everything is okay, my baby is doing fine, look at him being active." I asked her if she has any faith in how her body works to grow and protect her baby, and she said she did on some intellectual level, but when a qualified medical professional tells her she and her baby are doing well, it makes more of an impact on how she feels than any self-possessed assurance.
Her deep desire to confirm her health through outer, technological means makes me wonder about her inner faith in herself. From the Netherlands, we have an account in Birth Models which tells us the cultural demeanor of its people is one of self-reliance. Where is the American woman's positive sense of self?
Sunday, November 28, 2010
Tuesday, March 30, 2010
Full Moon Musings
It's a full moon tonight, and I'm feeling a fizzy sensation in my body. Last night, I dreamed I was laboring alone in an unfamiliar hospital. It was like I wasn't me, in a way, like I was experiencing someone else's sensations. I was wearing a hospital gown, and my contractions rushed over me, making me feel high, like that spinning euphoria I used to get when I was a little girl and would turn in circles until I fell down giggling. I think I was laboring by myself, but strangely, in what seemed like the most unfriendly and intrusive laboring environment I could imagine (bright, florescent lights; blinky machines; unfamiliar bed and clothing), the hospital staff left me alone.
I woke before the dream labor reached any conclusion, but the impressions I retain were unforgettable, and possibly important. I've heard labor described by those who's experienced it in much the way it happened in my dream. Maybe it was my body's way of giving me something close to empirical to take with me to labors I attend as a doula.
Much of my time preparing for a labor is spent pouring over research and laboring techniques. When I'm in research mode, I have a hard time switching gears - for example, I can't seem to finish Birthing From Within because I get so distracted by a desire to go back to reading research studies and articles on evidence-based care.
There's something comforting in all of that science-based knowing in a world which demands that I be grounded, realistic, and factual. Sometimes I feel awkward when faced with the draw of something deeper, an intuitive sense which urges me to pay attention, become emotionally expressive and not rely so much upon words and numbers.
This reaction is probably because I was told by all of the people and influences in my life for so many years that my emotions aren't as important as making choices which are grounded in logic. Rein it in, said my culture, my teachers, my parents.
I never stop growing. All of these things, all of the four cardinal directions in which a human grows (physical, mental, emotional, spiritual) are always changing as we learn, and we learn constantly. So, I decided not to stress it - if I feel like it's time to grow in an emotional and spiritual direction, to honor the moon and feel a little fizzy, well... Nothin' wrong with that. In fact, I think I'll honor those parts of myself by cross-posting some of my birth poetry, which was featured over at the BirthActivist blog:
Birth Reflections: Clare
Spear
I woke before the dream labor reached any conclusion, but the impressions I retain were unforgettable, and possibly important. I've heard labor described by those who's experienced it in much the way it happened in my dream. Maybe it was my body's way of giving me something close to empirical to take with me to labors I attend as a doula.
Much of my time preparing for a labor is spent pouring over research and laboring techniques. When I'm in research mode, I have a hard time switching gears - for example, I can't seem to finish Birthing From Within because I get so distracted by a desire to go back to reading research studies and articles on evidence-based care.
There's something comforting in all of that science-based knowing in a world which demands that I be grounded, realistic, and factual. Sometimes I feel awkward when faced with the draw of something deeper, an intuitive sense which urges me to pay attention, become emotionally expressive and not rely so much upon words and numbers.
This reaction is probably because I was told by all of the people and influences in my life for so many years that my emotions aren't as important as making choices which are grounded in logic. Rein it in, said my culture, my teachers, my parents.
I never stop growing. All of these things, all of the four cardinal directions in which a human grows (physical, mental, emotional, spiritual) are always changing as we learn, and we learn constantly. So, I decided not to stress it - if I feel like it's time to grow in an emotional and spiritual direction, to honor the moon and feel a little fizzy, well... Nothin' wrong with that. In fact, I think I'll honor those parts of myself by cross-posting some of my birth poetry, which was featured over at the BirthActivist blog:
Birth Reflections: Clare
Spear
Monday, March 22, 2010
Security
Birthing Beautiful Ideas recently posted a transcribed copy of a "patient safety update" sent to all patients at an OB practice in her area. The letter focused on VBAC, and essentially served as a notice to that practice's patients that VBAC was not an option offered by some of the practice's providers.
BBI was concerned about the flawed information being sent to those patient about the safety of VBAC. I can't blame her. Read her explanation and you'll see.
For the better part of last year, I found myself thinking about the mothers who choose to allow someone else to control their birth experience. I was baffled. Why are some moms more at ease in a 'technocratic' birth environment, and why are some moms afraid of it? So, I set out to have as many conversations with moms as I could about birth experiences, a sort of informal poll, in an effort to understand their decisions. All of my talks with moms have been interesting and enlightening.
The constant theme in these conversations was this: everyone wants a healthy baby. That may seem like a 'duh' statement of the obvious, but it was actually a very important fact. Remembering this helped me keep their decisions in perspective. Some mothers look back on their birth experience and point out things that could have been better, but as long as their child benefited (or at least, wasn't harmed in any perceivable way), then the choices made were just fine.
Another theme was the way moms returned to the value judgement, 'Does this choice bring me a sense of security?' For some moms, there's a sense of security gained from working with a care provider who calls the shots. I had women express how much they liked their care provider because s/he seemed to always know what was best for her, and following his/her advice resulted in a healthy baby.
A very close friend, whom I consider one of my three heartsisters, discovered recently that she's pregnant again, and is now facing the challenges of deciding whether or not to pursue a VBAC. I'm watching from the sidelines as she's faced with the same situation that's been posed to the patients of the OB practice who wrote that letter, because the provider she used for her last birth has a no-VBACs policy. Her choices are even more limited due to another set of policies followed by nearly all of the care providers in our area which label women of size as high risk mothers. I know she'll weigh her options carefully, but in combination with the level of struggle she believes she can endure to get what she wants, these policies may cause her to choose an elective repeat cesarean.
Dr. Bradley wrote, in Husband Coached Childbirth, about his observations of laboring mammals on the farm where he grew up. Animals need specific things to make them feel safe, and engage in behavior which ensures safety. They often hide in darkened barn stalls, and need to be undisturbed; their instincts tell them that any disruption of the birth process could be an opportunistic predator attacking. For humans, our understanding of what security means can be influenced as much by our personal experiences and the cultural collective from which our experiences stem as by what's written into our genetic code as instinct. And we're social animals who rely upon our interactions with others of our kind in order to function and evolve.
Mothers are put into a unique decision making position by our culture and individual care providers who exist today. Mothers are asked to trust everyone and no one at the same time, to make decisions based on the consensus while appeasing their individual and instinctual needs. What an overwhelming expectation to have to fulfill. Is it any wonder, then, that some mothers find security in placing the safety of themselves and their child in the hands of something or someone else?
I understand that sometimes, the decision is more about what is safest than what seems safest. No one can argue with a choice made to save a life or prevent irreversible harm, especially one which is made in an emergency situation. That being said, in cases where the research evidence says that certain options are reasonable and should be available to mothers, it's concerning that care providers will not support their patient's decision. If you read the evidence report from the recent NIH VBAC conference, it's clear that the risks of cesarean section (which is a major abdominal surgery) are higher than the risk of uterine rupture during a VBAC attempt.
I have so many other thoughts about this, I may have to do another post.
BBI was concerned about the flawed information being sent to those patient about the safety of VBAC. I can't blame her. Read her explanation and you'll see.
For the better part of last year, I found myself thinking about the mothers who choose to allow someone else to control their birth experience. I was baffled. Why are some moms more at ease in a 'technocratic' birth environment, and why are some moms afraid of it? So, I set out to have as many conversations with moms as I could about birth experiences, a sort of informal poll, in an effort to understand their decisions. All of my talks with moms have been interesting and enlightening.
The constant theme in these conversations was this: everyone wants a healthy baby. That may seem like a 'duh' statement of the obvious, but it was actually a very important fact. Remembering this helped me keep their decisions in perspective. Some mothers look back on their birth experience and point out things that could have been better, but as long as their child benefited (or at least, wasn't harmed in any perceivable way), then the choices made were just fine.
Another theme was the way moms returned to the value judgement, 'Does this choice bring me a sense of security?' For some moms, there's a sense of security gained from working with a care provider who calls the shots. I had women express how much they liked their care provider because s/he seemed to always know what was best for her, and following his/her advice resulted in a healthy baby.
A very close friend, whom I consider one of my three heartsisters, discovered recently that she's pregnant again, and is now facing the challenges of deciding whether or not to pursue a VBAC. I'm watching from the sidelines as she's faced with the same situation that's been posed to the patients of the OB practice who wrote that letter, because the provider she used for her last birth has a no-VBACs policy. Her choices are even more limited due to another set of policies followed by nearly all of the care providers in our area which label women of size as high risk mothers. I know she'll weigh her options carefully, but in combination with the level of struggle she believes she can endure to get what she wants, these policies may cause her to choose an elective repeat cesarean.
Dr. Bradley wrote, in Husband Coached Childbirth, about his observations of laboring mammals on the farm where he grew up. Animals need specific things to make them feel safe, and engage in behavior which ensures safety. They often hide in darkened barn stalls, and need to be undisturbed; their instincts tell them that any disruption of the birth process could be an opportunistic predator attacking. For humans, our understanding of what security means can be influenced as much by our personal experiences and the cultural collective from which our experiences stem as by what's written into our genetic code as instinct. And we're social animals who rely upon our interactions with others of our kind in order to function and evolve.
Mothers are put into a unique decision making position by our culture and individual care providers who exist today. Mothers are asked to trust everyone and no one at the same time, to make decisions based on the consensus while appeasing their individual and instinctual needs. What an overwhelming expectation to have to fulfill. Is it any wonder, then, that some mothers find security in placing the safety of themselves and their child in the hands of something or someone else?
I understand that sometimes, the decision is more about what is safest than what seems safest. No one can argue with a choice made to save a life or prevent irreversible harm, especially one which is made in an emergency situation. That being said, in cases where the research evidence says that certain options are reasonable and should be available to mothers, it's concerning that care providers will not support their patient's decision. If you read the evidence report from the recent NIH VBAC conference, it's clear that the risks of cesarean section (which is a major abdominal surgery) are higher than the risk of uterine rupture during a VBAC attempt.
I have so many other thoughts about this, I may have to do another post.
Saturday, February 27, 2010
"Welcome to the Last Three Weeks of Being Pregnant."
So sayeth the midwife to my March client, who called her tonight to tell her about the wild and wooly Braxton-Hicks she's having.
This client has been a fun one; she's a feisty go-getter who's been a research hound since day one of her pregnancy. She had a loss several years ago, which she mourned; this is a very welcomed pregnancy and baby, and she's done everything she can to improve her physical life and educate herself, working toward the goal of a birth that's as un-medicalized as possible.
Her text messages tonight have been making me grin - "Am I just being silly and blowing this out of proportion??" she asked me when her body decided to practice squeeze just one section of her stomach. I replied that it's her first time around this block, and anything new and unknown can be frightening, then suggested that she try drinking some juice, lie on her left side and do some kick counting to reassure herself that her little one is okay in there. She did, and he's moving just fine.
Carry on, mama - you're performing a miracle!
This client has been a fun one; she's a feisty go-getter who's been a research hound since day one of her pregnancy. She had a loss several years ago, which she mourned; this is a very welcomed pregnancy and baby, and she's done everything she can to improve her physical life and educate herself, working toward the goal of a birth that's as un-medicalized as possible.
Her text messages tonight have been making me grin - "Am I just being silly and blowing this out of proportion??" she asked me when her body decided to practice squeeze just one section of her stomach. I replied that it's her first time around this block, and anything new and unknown can be frightening, then suggested that she try drinking some juice, lie on her left side and do some kick counting to reassure herself that her little one is okay in there. She did, and he's moving just fine.
Carry on, mama - you're performing a miracle!
Wednesday, February 24, 2010
The Weight
My first paying client had her baby about a week and a half ago, and I'm 99.9% certain her little guy was posterior. She had all of the typical signs, and it was a really hard labor. In second stage, she pushed for literally hours, and it was like there was no end in sight.
I've been anxious and worried about her ever since; some things she said after the birth really concerned me that her lasting birth impression was a negative one. I feel like this is the first birth where I didn't do a good enough job as a doula, and now my client has a terrible opinion of her birth experience. I keep replying the birth in my head, looking at all the points where I could have done something and didn't - for example, I should have urged her to have her midwife palpate her belly to try to get a better understanding of the baby's position. Signs said she was experiencing a posterior baby, but her water wasn't broken until she got to about 8.5 cm's and finally asked the midwife to break it in hopes that it would bring the birth to a faster conclusion. Before that, when we asked the midwife if she could help us figure out baby's position, she said she had no real way of knowing until she could do a vaginal exam after the release of membranes, when she'd be able to feel the fontanels of baby's head.
A fellow doula (whom I'm working with in a dual-doula birth next month) tried to help me keep it in perspective by pointing out how difficult and painful it can be to labor with a posterior baby. "Does she realize how amazing she is for giving birth without any medication in that situation?"
I tried to tell my client exactly that, but I don't think she was very receptive at that point, which was less than 24 hours in the wake of the experience. She said she'd call me when they got home, but I haven't heard from her. I'm acquainted with friends of hers, and they've been kind enough to let me know how she's doing - I won't go into detail, but this poor mom has her hands full, so while I'm respectfully waiting for her to call me since that's what she asked me to do, I can't stop worrying about her.
The Weight - The Band made famous a song by that title many moons ago, and my favorite interpretation of the last verse is so very appropos right now in my doula life:
I went into that birth thinking I had the message right - that I was educated and experienced enough to help her - but I left it carrying a heavy load of doubt in my abilities and concern that I didn't give enough. Since her birth, I've been pouring over posterior labor resources, especially Spinning Babies, in hopes that I'll be more proactive and better prepared for a posterior labor in the future.
The one thing positive I can say about my assistance was that they would probably have been worse off without me if for no other reason that no one could be expected to rub a mom's lower back continuously for the entire length that her labor ran - so at least I was able to help her husband alleviate her pain in that way.
I've been anxious and worried about her ever since; some things she said after the birth really concerned me that her lasting birth impression was a negative one. I feel like this is the first birth where I didn't do a good enough job as a doula, and now my client has a terrible opinion of her birth experience. I keep replying the birth in my head, looking at all the points where I could have done something and didn't - for example, I should have urged her to have her midwife palpate her belly to try to get a better understanding of the baby's position. Signs said she was experiencing a posterior baby, but her water wasn't broken until she got to about 8.5 cm's and finally asked the midwife to break it in hopes that it would bring the birth to a faster conclusion. Before that, when we asked the midwife if she could help us figure out baby's position, she said she had no real way of knowing until she could do a vaginal exam after the release of membranes, when she'd be able to feel the fontanels of baby's head.
A fellow doula (whom I'm working with in a dual-doula birth next month) tried to help me keep it in perspective by pointing out how difficult and painful it can be to labor with a posterior baby. "Does she realize how amazing she is for giving birth without any medication in that situation?"
I tried to tell my client exactly that, but I don't think she was very receptive at that point, which was less than 24 hours in the wake of the experience. She said she'd call me when they got home, but I haven't heard from her. I'm acquainted with friends of hers, and they've been kind enough to let me know how she's doing - I won't go into detail, but this poor mom has her hands full, so while I'm respectfully waiting for her to call me since that's what she asked me to do, I can't stop worrying about her.
The Weight - The Band made famous a song by that title many moons ago, and my favorite interpretation of the last verse is so very appropos right now in my doula life:
- And what's all this "take a load off Fanny" riff? The whole thing becomes only a little less cryptic when we learn, in the very last lines, that the pilgrim is traveling under instructions, has, in fact, been sent by the mysterious Miss Fanny. The "weight" of the title is the load of her obligations the pilgrim has been sent to discharge. The irony, of course, is that he leaves with a heavier load than the one he brought with him - "my bag is sinkin' low."
I went into that birth thinking I had the message right - that I was educated and experienced enough to help her - but I left it carrying a heavy load of doubt in my abilities and concern that I didn't give enough. Since her birth, I've been pouring over posterior labor resources, especially Spinning Babies, in hopes that I'll be more proactive and better prepared for a posterior labor in the future.
The one thing positive I can say about my assistance was that they would probably have been worse off without me if for no other reason that no one could be expected to rub a mom's lower back continuously for the entire length that her labor ran - so at least I was able to help her husband alleviate her pain in that way.
Sunday, January 31, 2010
Oh, Baby.
Flipping channels, I came across a show about some famous socialite named Kendra. I have no idea who this person is, and I really don't care - then, before I clicked to the next channel, I notice that this woman, Kendra, is in the hospital, and obviously pregnant. Like a train wreck, I couldn't look away as I watched the program's presentation of her labor, watched her lie in bed for 24 hours with Pitocin and an epidural, only to end up with a c-section.
Smiling doctor telling her the day before she was induced, "We've given her something to help her get some rest, since she'll have a big day tomorrow..." Every time marker in the footage, she's still lying in bed, in the same position... Smiling doctor reappearing at the 23 hour mark, saying "You've been a trooper, and baby looks fine on the monitors, but it's time to go have a baby..." Wheeling her to the OR five hours after that... Kendra saying, "9 pounds, 5 ounces, no wonder I needed a c-section!..."
I get so angry, sometimes, the way the medical system can manipulate parents into doing things their way. The calm, rational part of me reminds me that this is an example of parents who's birth experience was peripheral to the fact that a baby was born. I understand, and I respect that. But... I feels a deep sadness for the lost and beautiful experience they missed out on.
To bring myself back to a happy place, I came across news that Gisele Bundchen had her baby at home in the water. (-:
Smiling doctor telling her the day before she was induced, "We've given her something to help her get some rest, since she'll have a big day tomorrow..." Every time marker in the footage, she's still lying in bed, in the same position... Smiling doctor reappearing at the 23 hour mark, saying "You've been a trooper, and baby looks fine on the monitors, but it's time to go have a baby..." Wheeling her to the OR five hours after that... Kendra saying, "9 pounds, 5 ounces, no wonder I needed a c-section!..."
I get so angry, sometimes, the way the medical system can manipulate parents into doing things their way. The calm, rational part of me reminds me that this is an example of parents who's birth experience was peripheral to the fact that a baby was born. I understand, and I respect that. But... I feels a deep sadness for the lost and beautiful experience they missed out on.
To bring myself back to a happy place, I came across news that Gisele Bundchen had her baby at home in the water. (-:
Tuesday, January 26, 2010
Some More Perspective
Recently, I wrote about Samantha Burton being forced to submit to bed rest and a c-section, and I basically said that both parties probably made some poor decisions, and maybe it would have been better if both mom and OB had quit their working relationship and mom had found another care provider.
Then, Mom's Tinfoil Hat made a comment-turned-post in her blog, and had a point I found interesting: just because a woman is smoking doesn't necessarily mean she doesn't care about herself or her baby, or even that she's headed for disastrous consequences. I particularly like when she said,
"We all have our priorities. Exercise has also been associated with pregnancy loss. I wonder what you think of women who are selfish enough to take epilepsy meds."
Whether Samantha was making the right decisions or not isn't the focus of the court; the point to her case is that she was barred from exercising her right to choose her own course of action. The writer of another article about Samantha's situation (which I can't put my fingers on right now) said something to the effect of, "At what point do women's decisions render them incubators and wards of the state?"
I've been thinking a lot about smoking in pregnancy, and a client of mine recently let me know that she was smoking through probably about her 20th week of pregnancy, tapering back slowly until she had quit altogether. My personal decision to not serve women who are pregnant and still smoking seemed to dissipate suddenly when she told me this - I had been offering her support through her pregnancy already, and her smoking status didn't change the fact that I've helped her thus far by providing research, information and resources to her. Maybe she needed my support in these ways while she worked through her decision to quit smoking, and maybe without my support she wouldn't have made it to the point of quitting. And even if she didn't quit, she still needs me at her birth, I'm her primary point of support (after her medical care provider).
This is all very thought provoking. I think I'll go ruminate upon it all some more.
Then, Mom's Tinfoil Hat made a comment-turned-post in her blog, and had a point I found interesting: just because a woman is smoking doesn't necessarily mean she doesn't care about herself or her baby, or even that she's headed for disastrous consequences. I particularly like when she said,
"We all have our priorities. Exercise has also been associated with pregnancy loss. I wonder what you think of women who are selfish enough to take epilepsy meds."
Whether Samantha was making the right decisions or not isn't the focus of the court; the point to her case is that she was barred from exercising her right to choose her own course of action. The writer of another article about Samantha's situation (which I can't put my fingers on right now) said something to the effect of, "At what point do women's decisions render them incubators and wards of the state?"
I've been thinking a lot about smoking in pregnancy, and a client of mine recently let me know that she was smoking through probably about her 20th week of pregnancy, tapering back slowly until she had quit altogether. My personal decision to not serve women who are pregnant and still smoking seemed to dissipate suddenly when she told me this - I had been offering her support through her pregnancy already, and her smoking status didn't change the fact that I've helped her thus far by providing research, information and resources to her. Maybe she needed my support in these ways while she worked through her decision to quit smoking, and maybe without my support she wouldn't have made it to the point of quitting. And even if she didn't quit, she still needs me at her birth, I'm her primary point of support (after her medical care provider).
This is all very thought provoking. I think I'll go ruminate upon it all some more.
Movers and Shakers
There are two hospitals in my city, and the larger one has a birth unit called the Women's Pavilion. This weekend, that hospital put on a baby and family fair. When we doulas initially found out about it, we discussed it at our monthly meeting and were all like, How do we get in on this action!?
We had a few challenges to overcome... Not only were we trying to figure out how to pony-up $250 for a table at the last minutes, but also, in the past, this hospital has denied a table to the local ICAN group (the leader of which is a doula), and we were concerned that we'd be barred, too.
Then, a light bulb went off over the heads of one of the doulas at the table. She works with a government program and managed to secure a table (on the last day of registration - we got lucky, and got one of the last two tables available). So while the major theme of our booth was the services offered by that program, we were also able to slip-in information about other local resources (such as the doulas!) and stuff about informed consent, avoiding a c-section, nutrition, breastfeeding, and more. A whole booth-ful of doulas, dispensing lots of great info, laughing and talking with moms - it was awesome!
We doulas got together at the end of last year and applied for a Lamaze mini-grant to start a birth network - and they awarded one to us. Again, a last minute effort, but it paid off. At this point, I'm thinking, the sky's the limit - imagine what we could do if we weren't operating on the last-minute protocol...
It'll get better, as we figure things out and get a structure going. It's always a little bumpy in the beginning of any endeavor, but with so much talent and skill among us, we're slated for success. It's very exciting.
We had a few challenges to overcome... Not only were we trying to figure out how to pony-up $250 for a table at the last minutes, but also, in the past, this hospital has denied a table to the local ICAN group (the leader of which is a doula), and we were concerned that we'd be barred, too.
Then, a light bulb went off over the heads of one of the doulas at the table. She works with a government program and managed to secure a table (on the last day of registration - we got lucky, and got one of the last two tables available). So while the major theme of our booth was the services offered by that program, we were also able to slip-in information about other local resources (such as the doulas!) and stuff about informed consent, avoiding a c-section, nutrition, breastfeeding, and more. A whole booth-ful of doulas, dispensing lots of great info, laughing and talking with moms - it was awesome!
We doulas got together at the end of last year and applied for a Lamaze mini-grant to start a birth network - and they awarded one to us. Again, a last minute effort, but it paid off. At this point, I'm thinking, the sky's the limit - imagine what we could do if we weren't operating on the last-minute protocol...
It'll get better, as we figure things out and get a structure going. It's always a little bumpy in the beginning of any endeavor, but with so much talent and skill among us, we're slated for success. It's very exciting.
Monday, January 25, 2010
Perspective
Everyone's shaking a finger, either at Samantha Burton or her OB.
Ms. Burton experienced something many of us would consider a worst case scenario: she lost her baby at 25 weeks gestation. And as if that isn't terrible enough, she was held against her will at the hospital when a court ordered her to comply with her OB's recommendation of bed rest. Finally, her OB performed a cesarean in hopes that her baby could be saved - only to discover that fetal demise had already occurred.
A big question echoing in many conversations about this situation is, at what point does a pregnant mom become incapable of deciding what is best for herself and her baby? Ms. Burton was smoking during pregnancy, which is acknowledged by pretty much every care provider out there to be a bad thing. But even if she was making a bad decision, isn't it still her decision to make? That's the crux of the arguements against her OB's decision to initiate a process to hold this mom against her will: freedom to choose.
Last year, I interviewed with a potential client who had two older children, both born premature and with physical and mental abnormalities, who was also a smoker. I didn't contract with this client, simply because I knew, after our interview, that I was not the right person to help her. There were a few reasons why, but the second most important one was because I'm so utterly opposed to smoking, whether one is pregnant or not. Cigarettes are laden with chemicals that are not supposed to be in the body in any amount.
This became a deal breaker for me; my personal feelings about smoking aren't something which can be negotiated around, I can't support someone who wants to continue to smoke when I believe it's a bad decision which puts the lives of both mother and child in danger. I wonder why Ms. Burton's OB decided to go through all of the effort to keep her in the hospital and eventually perform surgery - was it not an option to refer her care to another doctor?
Maybe it's not that simple, I don't know.... The Hippocratic Oath does basically say you can't refuse to help someone when you become a doctor. I know there's probably many more details about Ms. Burton's situation which caused her OB to steer her care in the direction it went. It was a bad situation for both mother and care provider, and maybe both of them could have made better decisions along the way. I find it difficult to take sides with either the mother or the care provider (providers, really, both the OB and the hospital) when both acted in ways with which I don't agree.
I think it's worth noting that this sort of thing is rare, and as frightening as it can be to have something like this happen practically in my own back yard, it's important to keep things in perspective. A pregnant mom in preterm labor is a challenge to any care provider; and a care provider who doesn't agree with a mother's choices during pregnancy is a challenge for that mother. It seems a little paradoxical, but rising to the challenge sometimes means walking away.
Ms. Burton experienced something many of us would consider a worst case scenario: she lost her baby at 25 weeks gestation. And as if that isn't terrible enough, she was held against her will at the hospital when a court ordered her to comply with her OB's recommendation of bed rest. Finally, her OB performed a cesarean in hopes that her baby could be saved - only to discover that fetal demise had already occurred.
A big question echoing in many conversations about this situation is, at what point does a pregnant mom become incapable of deciding what is best for herself and her baby? Ms. Burton was smoking during pregnancy, which is acknowledged by pretty much every care provider out there to be a bad thing. But even if she was making a bad decision, isn't it still her decision to make? That's the crux of the arguements against her OB's decision to initiate a process to hold this mom against her will: freedom to choose.
Last year, I interviewed with a potential client who had two older children, both born premature and with physical and mental abnormalities, who was also a smoker. I didn't contract with this client, simply because I knew, after our interview, that I was not the right person to help her. There were a few reasons why, but the second most important one was because I'm so utterly opposed to smoking, whether one is pregnant or not. Cigarettes are laden with chemicals that are not supposed to be in the body in any amount.
This became a deal breaker for me; my personal feelings about smoking aren't something which can be negotiated around, I can't support someone who wants to continue to smoke when I believe it's a bad decision which puts the lives of both mother and child in danger. I wonder why Ms. Burton's OB decided to go through all of the effort to keep her in the hospital and eventually perform surgery - was it not an option to refer her care to another doctor?
Maybe it's not that simple, I don't know.... The Hippocratic Oath does basically say you can't refuse to help someone when you become a doctor. I know there's probably many more details about Ms. Burton's situation which caused her OB to steer her care in the direction it went. It was a bad situation for both mother and care provider, and maybe both of them could have made better decisions along the way. I find it difficult to take sides with either the mother or the care provider (providers, really, both the OB and the hospital) when both acted in ways with which I don't agree.
I think it's worth noting that this sort of thing is rare, and as frightening as it can be to have something like this happen practically in my own back yard, it's important to keep things in perspective. A pregnant mom in preterm labor is a challenge to any care provider; and a care provider who doesn't agree with a mother's choices during pregnancy is a challenge for that mother. It seems a little paradoxical, but rising to the challenge sometimes means walking away.
Tuesday, January 12, 2010
Making the Best Decisions Possible
I recently posted about being called to a birth-in-progress on New Year's Eve, and mentioned that mom was admitted for low amniotic fluid based on an AFI of 4.5 (0.5 of a point below the 'low' assessment rankings).
It's sort of been bugging me, and I wanted to see what research was out there about this kind of testing. So, I pulled out my handy A Guide to Effective Care in Pregnancy and Childbirth and did a little reading.
Effective Care mentions the AFI somewhat obliquely in chapter 12, section 5.5:
Basically, what I took from that was, researchers believe the biophysical profiling approach is an effective means by which to see how mom and baby are faring, but the research may be flawed or incomplete when one reviews it, and so Effective Care authors believe it's difficult to say whether it's an effective method or not.
I think this is another instance where care providers try to lump all women into categories, like making an IF/THEN/ELSE statement. (Well-Rounded Mama is dealing with a similar situation with her health care, so it's not unfair to say that this sort of thing happens all the time in other instances of health care.) It makes me wonder what my last client's experience would have been like if she had made different decisions, and decided to place her trust more in her (very healthy) body than in (uncertain) risk assessment testing.
Humanity is on the search for "true indicators", but life isn't always consistent in its outcomes and occurrences. So, here's the approach I'll have when I'm a pregnant mom: I'll make the best decisions possible with ALL of the information available and won't forget to listen to intuition and feelings as well as intellect.
It's sort of been bugging me, and I wanted to see what research was out there about this kind of testing. So, I pulled out my handy A Guide to Effective Care in Pregnancy and Childbirth and did a little reading.
Effective Care mentions the AFI somewhat obliquely in chapter 12, section 5.5:
- 5.5 Fetal biophysical profile
The ‘biophysical profile’ was derived from a study of serial ultrasound examinations and antenatal cardiotocography (non-stress test) in high-risk pregnancies. Combining five biophysical ‘variables’ considered to be of prognostic significance (fetal movement, tone, reactivity, breathing, and amniotic fluid volume) into a score, reduced the frequency of false-positive and false-negative results compared to the non-stress test alone. An additional advantage of the biophysical profile over the nonstress test is that it permits assessment of the possibility of major congenital anomalies. This may be important, as detection of a serious anomaly may on occasion help to avoid a cesarean section when the baby is clearly abnormal.
Only two controlled trials of biophysical-profile testing have been performed. Both were conducted in women referred to units specializing in fetal biophysical assessment. They compared care based on biophysical score results with that based on non-stress test results, following a management protocol. In both studies, the biophysical profile score was a better predictor of low 5-min Apgar scores than the non-stress test. The biophysical profile was both more sensitive and more specific in predicting overall abnormal outcome than the nonstress test.
Despite the better predictive value of the biophysical score than the non-stress test, its use did not result in any improvements in outcome for the baby. Outcomes measured included perinatal death, fetal distress in labor, low Apgar score, and low birth weight-for-gestational age. Compared with cardioiocography alone, biophysical-profile testing showed no obvious effect (either beneficial or deleterious) on these outcome measures. The available evidence provides no support at all for the use of biophysical profile as a test of fetal well-being in high risk pregnancies. However, the number of women included in these studies is so small that any estimates of effect are extremely imprecise.
Basically, what I took from that was, researchers believe the biophysical profiling approach is an effective means by which to see how mom and baby are faring, but the research may be flawed or incomplete when one reviews it, and so Effective Care authors believe it's difficult to say whether it's an effective method or not.
I think this is another instance where care providers try to lump all women into categories, like making an IF/THEN/ELSE statement. (Well-Rounded Mama is dealing with a similar situation with her health care, so it's not unfair to say that this sort of thing happens all the time in other instances of health care.) It makes me wonder what my last client's experience would have been like if she had made different decisions, and decided to place her trust more in her (very healthy) body than in (uncertain) risk assessment testing.
Humanity is on the search for "true indicators", but life isn't always consistent in its outcomes and occurrences. So, here's the approach I'll have when I'm a pregnant mom: I'll make the best decisions possible with ALL of the information available and won't forget to listen to intuition and feelings as well as intellect.
Friday, January 8, 2010
More Catch-Up: Links in Review
The Case Against Reasoning, by Morgan Gallagher
Morgan sums-up something I've been struggling to explain to others: formula is suboptimal. She says,
There is less in formula milk, than there is in human milk. There is less physiological growth in bottle feeding, than there is in breastfeeding. Combine the two, and add in that modified cow's milk destroys the natural flora in the new born gut.. and you have an activity that increases health risks in homo sapiens: formula feeding.
She also expresses aptly the way business drives culture, and how advertisers manipulate us so effectively into believing that something that is suboptimal is normal, and something normal is achievable only if you're Superwoman. It's a cleverly devious bit of psychology: breastmilk is "best" so formula is "okay" claim the formula companies - but it's not true!
Yoga for Hip Discomfort: Eka Pada Rajakapotasana (One-Legged King Pigeon Pose)
BirthActivist recommends this pose for hip pain during pregnancy. Those loosening joints are sometimes uncomfortable, so this may help.
I interviewed a client several months ago who was experiencing hip pain, and I wish I'd known about this back then!
Clean Eating Magazine: Recipes and Meal Plans
I am quickly becoming a BIG fan of this magazine. Wholesome food recommendations, awesome recipes, informative nutrition articles... The meal plans alone are worth the price of the magazine - each day's meal plan has a sum of total calories, fats, fibers, sodium and proteins consumed.
There's a link between eating well in pregnancy and avoidance of eclampsia and HELLP syndrome. Most pregnancy nutritionists recommend eating between 80 and 100 grams of protein daily, among other guidelines - and these meal plans could be a big help to the mom who doesn't regularly track her food intake.
Calm Birth, by Dr. Robert Bruce Newman
I ordered both the Calm Birth book and CD recently. The book is more or less a review of stuff I already knew, but I found the history and research-backed information about the effects of meditation very interesting and potentially helpful for my clients. I've been recommending the Hypnobabies "Relax Me" scripts to my clients, but for those who think hypnosis is hooey, I think Calm Birth may be more approachable.
Two new blogs on my blog feed: Kayce's Doula Journey and Doula Momma
Doula Momma is a DONA doula and Lamaze childbirth educator; Kayce is a self-described birth junkie and future midwife. Both offer lots of stories and data worth looking at.
Morgan sums-up something I've been struggling to explain to others: formula is suboptimal. She says,
There is less in formula milk, than there is in human milk. There is less physiological growth in bottle feeding, than there is in breastfeeding. Combine the two, and add in that modified cow's milk destroys the natural flora in the new born gut.. and you have an activity that increases health risks in homo sapiens: formula feeding.
She also expresses aptly the way business drives culture, and how advertisers manipulate us so effectively into believing that something that is suboptimal is normal, and something normal is achievable only if you're Superwoman. It's a cleverly devious bit of psychology: breastmilk is "best" so formula is "okay" claim the formula companies - but it's not true!
Yoga for Hip Discomfort: Eka Pada Rajakapotasana (One-Legged King Pigeon Pose)
BirthActivist recommends this pose for hip pain during pregnancy. Those loosening joints are sometimes uncomfortable, so this may help.
I interviewed a client several months ago who was experiencing hip pain, and I wish I'd known about this back then!
Clean Eating Magazine: Recipes and Meal Plans
I am quickly becoming a BIG fan of this magazine. Wholesome food recommendations, awesome recipes, informative nutrition articles... The meal plans alone are worth the price of the magazine - each day's meal plan has a sum of total calories, fats, fibers, sodium and proteins consumed.
There's a link between eating well in pregnancy and avoidance of eclampsia and HELLP syndrome. Most pregnancy nutritionists recommend eating between 80 and 100 grams of protein daily, among other guidelines - and these meal plans could be a big help to the mom who doesn't regularly track her food intake.
Calm Birth, by Dr. Robert Bruce Newman
I ordered both the Calm Birth book and CD recently. The book is more or less a review of stuff I already knew, but I found the history and research-backed information about the effects of meditation very interesting and potentially helpful for my clients. I've been recommending the Hypnobabies "Relax Me" scripts to my clients, but for those who think hypnosis is hooey, I think Calm Birth may be more approachable.
Two new blogs on my blog feed: Kayce's Doula Journey and Doula Momma
Doula Momma is a DONA doula and Lamaze childbirth educator; Kayce is a self-described birth junkie and future midwife. Both offer lots of stories and data worth looking at.
Playing Catch-Up
Ach, I've been so out of touch lately. It's been a whirlwind since the beginning of the holiday season, and I've been struggling to keep up.
New Year's Eve, I found myself hanging out at my buddy Kim's house. It was around 1:00 PM, and she was telling me how one of the couples in her last class (which I attended) was in labor, and called her very early that morning to talk through some stuff. In the middle of our gossip session, my phone rang - to my surprise, it was the daddy of the couple we were discussing! Our conversation went something like this:
Dad: Well, we're in labor, and have been for a long time...
Me: How are things going?
Dad: Honestly, I'm not sure... I mean, we've been here since Wednesday, and [Mom] is having a hard time managing her pain."
Me: How are YOU holding up?
Dad: I'm exhausted. All of us are.
Me: Do you need some help?
Dad: [big sigh of relief] I would be grateful for anything you could offer us.
Me: I've gotta run home and get my bag, but give me 20 minutes and I'll be there. What's your room number?
(Mom told me later after the birth, "That was the shortest phone conversation I'd ever heard.")
When I got there everyone looked deflated, and the room was in chaos, stuff was everywhere. How could anyone be comfortable laboring in this environment? I thought to myself. While I helped clean up, I explained that we had a plane to catch to go to my cousin's wedding in another state, and I would stay as long as I could, but I might not be able to be there for the birth. They said it was okay, and any help was better than none!
I immediately started the work of assessing the situation; mom, dad and baby's grandmother filled me in on what I'd missed. At 41 weeks and 2 days, mom went to an appointment with her OB and never got to go home. She was admitted for oligohydramnios (based on an AFI of 4.5), induced with Cervidil (which was removed after she reached 4 cm), membranes released (SROM) at around 5:30 AM that day, and she'd been laboring for around 24 hours without any other medical interventions. The Cervidil induction was painful and frightening, and mom was happy to have it removed - but since that time, her contraction patterns were sketchy, and her tone and demeanor were like that of a woman condemned to Sisyphus' fate. "I feel like it's never going to end," she confessed.
I got mom out of the bed; dad fell into it and immediately went to sleep. Baby's grandmother went out, brought back food for the family, and went home to get some rest.
After some dinner, mom seemed to be getting her energy back, so I started to pep talk her, during which we changed positions, tracked contractions together, and focused on approaching labor one rush at a time. I knew she was still in early labor because she was able to talk easily between her contractions. Every time a contraction was nearing or had ended, she would affirm, "Contractions are good..." And I would reply, "Contractions make a baby come out," or, "Contractions go away and then we can rest." As we talked, it became clear that the intensity of her pain was due to her fear of that pain, and her feelings of inadequacy about herself as a laboring mother.
When dad woke, he was amazed by the change that had come over his wife. "You're a new woman," he said, and hugged and kissed her.
The hospital experience was a mixed bag; while the majority of the attending staff was supportive of their decisions (to varying degrees of approval and disapproving forbearance, though mostly the former), interruptions easily knocked mom out of her labor, and slowed her contractions. At one point, during a heavy discussion with the attending OB, her solid 1:00-1:30-minute / every 3 minutes contractions stopped altogether for 20 minutes. An encouraging nurse recommended that we try nipple stimulation, which helped get her back into the groove of labor, but mom would stop doing stimulation cycles (2 minutes on, 2 minutes rest with a contraction in between) and labor would slow again. Dad mustered himself long enough to convince the attending OB to get her off of continuous EFM, which he felt was interfering with her ability to relax and wasn't proving helpful (baby had a textbook perfect heart rate for the entire labor). After his confrontation with the doctor, his physical exhaustion and emotional stress got the better of him, and he was a little shaky. But the pay off was time in the tub, free from monitoring.
16 hours later, it was time for me to go. I felt terrible about it, but they were very understanding. Before I left, mom decided to try a small dose pain medication, but it was largely ineffective, so she asked to be prepped for an epidural. (For the second time, I missed a potential opportunity to witness an epidural being placed! Drat.) Even though this family was seeking an unmedicated birth, after 32 hours of labor, mom was just too tired to manage labor sensations anymore.
Baby's grandmother arrived a little while after I had to go, and 12 hours later, mom birthed her baby - vaginally!! Interestingly, they set her up with an push button epidural; she was able to chose when to have the next dose of the medicine, and she hit the button only once after the initial dose. She later told me that the rest she got during the first dose helped a lot, and then after that just having the option of pain relief was comforting.
New Year's Eve, I found myself hanging out at my buddy Kim's house. It was around 1:00 PM, and she was telling me how one of the couples in her last class (which I attended) was in labor, and called her very early that morning to talk through some stuff. In the middle of our gossip session, my phone rang - to my surprise, it was the daddy of the couple we were discussing! Our conversation went something like this:
Dad: Well, we're in labor, and have been for a long time...
Me: How are things going?
Dad: Honestly, I'm not sure... I mean, we've been here since Wednesday, and [Mom] is having a hard time managing her pain."
Me: How are YOU holding up?
Dad: I'm exhausted. All of us are.
Me: Do you need some help?
Dad: [big sigh of relief] I would be grateful for anything you could offer us.
Me: I've gotta run home and get my bag, but give me 20 minutes and I'll be there. What's your room number?
(Mom told me later after the birth, "That was the shortest phone conversation I'd ever heard.")
When I got there everyone looked deflated, and the room was in chaos, stuff was everywhere. How could anyone be comfortable laboring in this environment? I thought to myself. While I helped clean up, I explained that we had a plane to catch to go to my cousin's wedding in another state, and I would stay as long as I could, but I might not be able to be there for the birth. They said it was okay, and any help was better than none!
I immediately started the work of assessing the situation; mom, dad and baby's grandmother filled me in on what I'd missed. At 41 weeks and 2 days, mom went to an appointment with her OB and never got to go home. She was admitted for oligohydramnios (based on an AFI of 4.5), induced with Cervidil (which was removed after she reached 4 cm), membranes released (SROM) at around 5:30 AM that day, and she'd been laboring for around 24 hours without any other medical interventions. The Cervidil induction was painful and frightening, and mom was happy to have it removed - but since that time, her contraction patterns were sketchy, and her tone and demeanor were like that of a woman condemned to Sisyphus' fate. "I feel like it's never going to end," she confessed.
I got mom out of the bed; dad fell into it and immediately went to sleep. Baby's grandmother went out, brought back food for the family, and went home to get some rest.
After some dinner, mom seemed to be getting her energy back, so I started to pep talk her, during which we changed positions, tracked contractions together, and focused on approaching labor one rush at a time. I knew she was still in early labor because she was able to talk easily between her contractions. Every time a contraction was nearing or had ended, she would affirm, "Contractions are good..." And I would reply, "Contractions make a baby come out," or, "Contractions go away and then we can rest." As we talked, it became clear that the intensity of her pain was due to her fear of that pain, and her feelings of inadequacy about herself as a laboring mother.
When dad woke, he was amazed by the change that had come over his wife. "You're a new woman," he said, and hugged and kissed her.
The hospital experience was a mixed bag; while the majority of the attending staff was supportive of their decisions (to varying degrees of approval and disapproving forbearance, though mostly the former), interruptions easily knocked mom out of her labor, and slowed her contractions. At one point, during a heavy discussion with the attending OB, her solid 1:00-1:30-minute / every 3 minutes contractions stopped altogether for 20 minutes. An encouraging nurse recommended that we try nipple stimulation, which helped get her back into the groove of labor, but mom would stop doing stimulation cycles (2 minutes on, 2 minutes rest with a contraction in between) and labor would slow again. Dad mustered himself long enough to convince the attending OB to get her off of continuous EFM, which he felt was interfering with her ability to relax and wasn't proving helpful (baby had a textbook perfect heart rate for the entire labor). After his confrontation with the doctor, his physical exhaustion and emotional stress got the better of him, and he was a little shaky. But the pay off was time in the tub, free from monitoring.
16 hours later, it was time for me to go. I felt terrible about it, but they were very understanding. Before I left, mom decided to try a small dose pain medication, but it was largely ineffective, so she asked to be prepped for an epidural. (For the second time, I missed a potential opportunity to witness an epidural being placed! Drat.) Even though this family was seeking an unmedicated birth, after 32 hours of labor, mom was just too tired to manage labor sensations anymore.
Baby's grandmother arrived a little while after I had to go, and 12 hours later, mom birthed her baby - vaginally!! Interestingly, they set her up with an push button epidural; she was able to chose when to have the next dose of the medicine, and she hit the button only once after the initial dose. She later told me that the rest she got during the first dose helped a lot, and then after that just having the option of pain relief was comforting.
All's well that ends well. Baby had 1/5 minute Apgars of 8/9, mom had minimal tearing (not even a 1st degree), and they're breastfeeding really well. Three days after the baby was born, they moved to another city so dad could start a new job - I wish them all the best on their new adventure, and thank them for letting me share in their happy day. (-:
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