Sunday, February 22, 2009

Faced with a doctor gap, more hospitals turn to "Laborists" to deliver babies

Please click on the title above to read a Boston Globe front page article, published 2/22/09, about how hospitals are dealing with a shortage of OB's. This is exactly the reason why we need more birth choices, particularly in Massachusetts. Midwives, both CNM's and CPM's, can ease the burden on L&D units by creating more birth center births and homebirths, as they do in most countries around the world! The midwives would be able to attend more births, and the OB's could care for the much smaller percentage of births that actually need obstetrical intervention.

I come from a family with a number of doctors, so I have a very personal understanding of the pressures MD's face because of liability and soaring malpractice insurance costs. Because of my family, I'm also not as quick as others are to blame OB's for the medicalization of birth. But imagine if birth in this country were not driven by fear -- the OB's fear of being sued and watching a life time of work go down the drain for themselves and their families; the expectant parents' fear that the totally normal and healthy process of birth will go utterly awry unless it is interfered with; the mothers' fear when they go post-dates, because they can't spare precious maternity leave days waiting around for labor to begin.

So who is benefitting from the 15 minute prenatal visit, from theVBAC bans, from the c-section rate that is nearly 40%? Who is dictating all these policies? This really is a call for a reform of the insurance and medical malpractice industry and how it has burdened health care and effectively damaged our understanding of birth.

Friday, February 20, 2009

Time Magazine discusses "The Trouble With Repeat Cesareans"

Please click on the title above to read about the theoretical and practical struggles between repeat cesareans and VBACs. The article references the International Cesarean Awareness Network, which is probably still considered "radical" for mainstream birth. But Time is the furthest thing from radical!

What is great about the article is that its conflicting viewpoints can encourage women to be more and more educated about choices they have for birthing.

Thursday, February 19, 2009

The Nature of Nature

As a doula, I have seen a million natural birth videos, showing women with glowing, ecstatic faces. Their births are peaceful and gentle, transcendent. Or the stories are of Homeric journeys, women whose bellies are their body armor, and in the mist of a new morning after a long, dark night, rise triumphantly. Women who cry out, "I never knew I had such strength!"

I engage in a fair amount of childbirth education with clients. While I worry about the woman whose idea of birth comes from reality TV or prime time dramas made for entertainment purposes, I worry equally about the woman who has only watched videos that promise her either bliss or empowerment -- in exchange, all she has to do is birth naturally. I do emphatically believe in the revolutionary idea that childbirth is not something we should be taught to fear; but as birth professionals it is critical that while we educate women to trust their bodies and trust the process of birth, we should also remember that the uninterrupted process of birth can be full of surprises. Nature - responsible for crystal streams, painted mountains, and skies spotted with sparkling jewels - is also responsible for hurricanes and gale-force winds.

As a pregnant woman anticipating my 3rd labor, I made all the right choices for a natural birth: I got prenatal care from midwives, chose a birth center instead of a hospital, and shook my head when well-meaning friends suggested that it was time for an induction as I got more uncomfortable. I was determined it was going to happen naturally, and it did. But my labor was naturally precipitous, and if I were to compare it to something in nature, it would be a riptide.

There are women whose birth stories have them, somehow, scanning the ocean in search of the crest of the wave, and once found, they ride it, shifting their weight here and there so that they don't fall if they begin to lose their balance. The sea water is spraying them in the face, and the mix of salt and perspiration on their skin is invigorating, affirming. And then there are other women in the riptide who are like me. I didn't fight it. I didn't navigate it. I didn't negotiate with it in any way. For weeks I have struggled with the mental picture of me being knocked down by a single wave; but I am starting to see that a woman's strength in birth is also in the letting go and allowing herself to tumble fearlessly with the current, never losing sight of the belief that, when the energy of the tide is through, she will find herself upright again on the shore.

Wednesday, February 18, 2009

Happy Birthday, to my Biggest Little Girl


She was born seven years ago today -- tonight, actually, at 9:10PM. Seven years ago, to riff off of my business name, a mom was born. And as a mom, I've learned so much, now that I'm a mom 3 times. With my youngest, a mere 23 days old, if she begins to cry while I'm in the shower, it's OK. If I opt to stay in bed, nursing while half asleep in the pre-dawn hours instead of changing her heavy diaper, it's OK.

But my oldest was colicky the minute she came out of my body, and she remained stubbornly so until she was about 4 months old. As she wailed for hours, I would rock her, nearly begging her to tell me how I could make things better, because if she would just tell me what it was she needed, I'd move mountains to get it for her. Nearly hallucinating from lack of sleep while riding a post-partum rollercoaster, I would look at her and be so overwhelmed by her tiny might, yet so frightened of the powerful love and obligation I felt for her. I would alternate between wanting to put her back in my body to protect her and then wanting to completely shut off my feelings for her so that I would never hurt for her, dream for her, hope for her, or disappoint her.

And even though today we celebrate her seventh birthday, she will always be my first, taking me on my first trip around the block of motherhood. It's a burden she must carry, as the child whom her parents learn off of, who in the mix of sisterhood and birth order will always be the one who should "know better."

But she is also the one who holds my heart captive, who opened my eyes to miracles and all that the world has to offer, who taught me what it means to belong wholly to another human being. She split my heart open like the little bean plant she grew from a seed in her science class, reaching out and upward for the sun.

Happy Birthday, to the one who made me a mother.

Saturday, February 14, 2009

High-Tech vs. High-Touch Maternity Care

Please click on the title above to read a simple, straightforward summary about the benefits to keeping interventions low in childbirth, from Consumer Reports -- a fairly benign publication that reaches out to a wide segment of people, not just alternative health or alternative birth populations!

In the Company of Midwives

2AM, January 25 (Sunday)
My 7 year old is sleeping beside me. Last temperature check was 102F. We are both tossing and turning, keeping each other awake. I feel a slight, quick gush in my underwear and go to the bathroom, anxious that my water has broken. But it is blood, bright red like a period, and some of it thick.

My husband is sleeping in the 7 year old's bed, which is downstairs beside the 4 year old's bed. I wake him up to tell him what is happening; he doesn't tell me for a few days that this frightened him.

But I'd seen blood before in this pregnancy. I already knew what came next. Call the midwife on call, go to triage - which is in the hospital, and not the Birth Center where I was aiming to give birth when the time came - be placed on an external fetal monitor for an hour or so, and then go home because the baby is fine, I am fine. The blood is a mystery, but then it goes away. And so it went, just like that. During the whole thing, while waiting for the midwife on call to call me back, while waiting for the cab, while in the cab going to the hospital, I have a contraction or two. Nothing big, nothing regular.

8PM, same day. Same thing.
My dear friend comes to put my kids to bed, and this time my husband comes with me. Bleeding stops, the baby is fine, fine, fine; the midwife on call acknowledges the continuing mystery, cautions me with specific instructions on when to return, then says I can go home. We are heading out the door, jackets on, when the attending OB says no. She says I should stay overnight for continuous fetal monitoring, but adds "If I could make you do what I really want you to do, I'd induce you now." She says, despite the baby being fine, despite my not having any pain, despite the bleeding which has again stopped, despite the absence of any immediate certain problem, "What's the point in being pregnant anymore? You are already full-term." I know if I stay, even if the baby continues to be fine throughout the night, that in the morning I will be faced with induction. She says if I insist on going home, I must sign a waiver that I have signed out Against Medical Advice.

The problem she is concerned about - that the midwives and I and she are all concerned about - is that my placenta is abrupting. The midwives have cared for me with due diligence. And even though it cannot be ruled out with 100% certainty, this would be an atypical presentation of abruption. I am a good patient; I follow instructions well, and I am not unreasonable. I just want to go home and let labor start on its own, and I know it will soon. The OB states frankly that I'm probably not abrupting, but because she cannot guarantee it, she'd rather keep me close by. She states that sometimes if abruption happens it maybe can happen really quickly. I appreciate that she wants to keep me safe, but I also feel that in the absence of any other symptoms, normal birth prevails. She is pretty and young with eyeglasses that are trendy but not so funky as to undermine her authority. She says "You're also over 35. Statistically you are at high risk for many problems."

I sign out AMA.

1AM, January 26 (Monday)
Bleeding again. I am a good patient; I follow instructions well, and I am not unreasonable. I return to the hospital and settle in for the night, fetal monitors belted to my belly. I know I will not be leaving this hospital again, not with this baby still inside my body. I know I will be induced by morning.

8:30AM, same day
It is a new morning. I never hear from the OB again, but the shifts have changed, and now my midwife is on duty. She sits beside me and holds my hand to tell me gently that she's sorry, but I can't give birth at the Birth Center anymore. It's easy to let that go, as my big concern is with induction. I am having contractions, but if they come regularly, they are mild and barely a distraction. Conversely, if they are strong and require my full attention, they last only 30 seconds. Meanwhile, the bleeding has not subsided like it has every time before. In fact, though it is not a hemorrhage, perhaps it is even slightly increasing.

My midwife explains the reasons why induction is warranted, and I believe her, not only because she has seen me more than a dozen times through the course of this normal and healthy pregnancy, but because she is presenting me with induction options. She has not dictated my care, then placed orders with a nurse and disappeared. She has remained sitting beside my bed and holding my hand, and she explains each choice to me, knowing what my hopes and preferences have been for this labor. In fact, when my husband walks in to the room, she explains it all a second time, for his benefit. Contractions are still coming, but they remain inconsistent. So we choose a course of action together, my midwife, husband, and I, one that will allow me to have as normal a birth as possible.

11AM, same day
Somehow, I missed breakfast. I cannot go into labor on an empty stomach, and clear fluids certainly will not sustain me through the workout that is childbirth. My midwife orders me a lunch. She takes heat from the Attending OB. "She's not in active labor," she tells him, which is the hospital policy. "She's not in any labor at all, and she's hungry."

12:30PM, same day
There is a delay in the induction. Pharmacy hasn't delivered the drugs yet, and there are some patients in triage who need evaluation. I eat - plentifully. I put my fork down, push the tray away, and suddenly a force wraps itself around my mid-section. I close my eyes and breathe through it, and it keeps on going. A minute and a half goes by before the contraction lets go of me. The room is suddenly as hot as July, and I feel another one coming. I stand up, hold on to my husband, let my knees go weak and try to relax every single muscle in my body so that my uterus is the only muscle efforting. Another minute and a half goes by. My eyes are closed, and I hear my midwife enter the room. There is a small space between the surges of contractions, and just as I feel another one coming upon me, she says it. She says it for me, because the contractions have taken all my breath, and I can no longer talk. She says, "You're in labor, Maria. Let's cancel that induction. This is all you."

Same day, some time after 12:30PM and before 1:47PM
I take my face away from where I have buried it in my husband's neck, regain my stance and say calmly "I can do this," while catching my breath. My husband holds me and tightens his arms around me, telling me silently that he believes me. I hear my midwife's affirmation, "You can do this, Maria."

1:47PM, January 26 (Monday)
My daughter is born. Official time from start of labor to birth is 1 hour and 17 minutes. She is caught by my midwife, who later writes in the chart:
It stands for Normal Spontaneous Vaginal Delivery.

Wednesday, February 11, 2009

Precipitous Labor

"pre cip' i tous: adj. Like a precipice; extremely steep; abrupt or ill-considered. "

That is the definition found in the 2nd edition of the American Heritage Dictionary. Medically, a precipitous labor is a labor that results in a birth in 3 hours or less. We all have seen on the news the story of a woman whose baby was born in a car en route to the hospital, or whose kindergartener knew enough of his numbers to call 9-1-1. Like many doulas, I have a precipitous labor clause in my contract to ensure I get paid, even if I miss the birth. I suppose many of us, if we attend enough births, will experience (or miss experiencing, even) a preciptious labor or two -- but for the most part we wouldn't bet on it, and wouldn't want to.

Just over 2 weeks ago, I gave birth in an hour and 17 minutes. I have a friend who said that she had a quick labor, too, and then she described how she pushed for just 20 minutes. She had obvious pride in her birth story, so I didn't tell her that her labor wasn't anything even close to mine. My labor was rapid. Like, really rapid. Like at 12:30PM, I was eating lunch and chatting with my husband, and then by 1:47PM there was a baby in the room. The dictionary definition of "precipitous" is far more accurate than the medical definition; my labor was like being thrown off a very steep cliff with no chute, and I free fell all the way until my daughter exploded out of my body.

A goal of natural childbirth requires values clarification, a real sense of why you want to birth naturally: do you believe in normal birth, and that in the absence of true medical necessity, there is no need to intervene with its process? Do you believe in your own primal strength? Or do you want your strength challenged? I've even had a client flat out say she was so terrified of needles that in fact an epidural was far more frightening than unmedicated childbirth. Natural labor also requires planning and practice; in other words, lots and lots of fore thought. And all my plans were tossed out the window - there was no time to collect myself, no time to process, and I had to use only what remained: my instinct - to breathe and keep the air moving through my body; my husband - whom I held on to for dear life as he supported my weight and helped me rock and sway through this deft force of nature, and my midwife - who, despite the collective surprise of everyone in the birth room at such a swift and decisive labor, entirely believed as I did that nothing was ever wrong, and there was nothing to be afraid of.

I am left with the sense that I didn't so much give birth as I did give way to birth, and I am feeling far more humbled by nature than I am empowered or heroic. My "precipitous" labor certainly was "abrupt", though not "ill-considered," and yet, in the end, just as it was meant to be.

Selma Hayek promoting maternal/child health in Sierra Leone

Please click on the title above to see Pampers and Selma Hayek use their name and brand recognition for a truly humanitarian purpose in Sierra Leone.

Two things strike me here in this video: 1) often as breastfeeding advocates and educators, we begrudge the obstacles to our goals (think: mall foodcourt nurse-ins, Applebees demanding a diner cover herself up, Facebook banning photos of breastfeeding -- yet the struggle of a developing nation is so primary and undeniably, utterly humbling. It should serve as a reminder that American women are breastfeeding in luxury, regardless of what we encounter in our professional lives; 2) Selma Hayek breastfeeds an ailing baby, and it exemplefies generosity, selflessness, beauty, and grace in one gesture.