Accepting the Unexpected

I prepared for my first birth (and am preparing for my second) with the help of Hypnobirthing, the Mongan Method.  Part of the practice “regimen” is listening to a 25-minute track of Marie Mongan reading birth affirmations–positive statements about birth–over and over again.  The idea of affirmations is that the more you hear something, the more you tend to believe it and the less resistance you have to its message.  Pregnant women are exposed to a plethora of negative messages about what their births will be like, and the positive affirmation track is there to counter that.

I suppose every woman has a few affirmations that speak to her more than the others.  For me, the crux of the collection was this:

I am prepared to calmly meet whatever turn my birthing may take.

I didn’t have a lot of expectations for my birth.  I wasn’t expecting it to be short or easy.  I kept an open mind about Mongan’s claim about birth not needing to be painful, and knew that I would deal with the birth beautifully whether it was painful or not.  But I really, really, really wanted my homebirth.  I was terrified of needing a hospital transfer.  I was terrified of needing a C-section.  I was terrified of letting go of my dream.

I am prepared to calmly meet whatever turn my birthing may take.

I just  couldn’t hear it enough.

But a few weeks before my birth, I came across a very unusual birth story.  It goes as follows.

Sivan was pregnant with her fourth child and preparing for a homebirth.  She was diagnosed with gestational diabetes in the middle of her pregnancy, but she did not let that worry her.  Her 39-week ultrasound estimated the baby’s size at an impressive 4.4 kg (9.7 lbs).  This did not bother her either; she knew how notorious ultrasounds are for being inaccurate.

But her midwife was concerned.  She took a good look at all the factors involved, and told her that with all the data she had, she did not feel safe accepting this birth at home, and with great sympathy told her that in her professional opinion, a C-section would be the safest course for this particular baby.

Sivan was shocked.  She trusted her midwife and knew that she would never recommend a planned C-section without a really good reason, but she couldn’t grasp the idea that her midwife would tell her such a thing.  What about the inaccuracy of ultrasounds?  What about the inaccuracy of the glucose tolerance test?  What about the idea that women’s bodies have been doing this for millenia and know how to birth big babies too?

Eventually she began to accept that her midwife was not just being over-cautious.  In the case of gestational diabetes, it is the shoulders of the baby that put on a lot of weight, and the risk of true shoulder dystocia in this case was too high to ignore.  She did not want to put her baby at risk.

But a C-section?  After all her hopes for a perfect homebirth?

Sivan described going to the beach and watching the waves and wanting to just give birth there, alone, trusting her body to do what it knew how to do, proving to everyone how wrong they were.  She cried for the loss of her dream birth, feeling helpless, hopeless and disempowered.

As she sat there, she got a call from her midwife.  “Just wanted to check in on you.  I know you will be okay.  You’re not the type of person who gets stuck in the past, I got that feeling from you long ago.  Just remember one thing: at the surgery, despite all the disappointment, you are still going to meet your baby.  Remember?  It’s a celebration!  Go in celebration!”

From that moment, something changed.

Sivan went home and informed the hospital that she would not be coming that day, but on Sunday.  And that her surgery would not be on Sunday, but on Tuesday.  Why?  Because that’s what she wanted.  She was taking this birth into her hands.  Who said a C-section couldn’t be an active birth?!

She and her husband arrived at the hospital like a pair of celebrities arriving for their premiere, all dressed up and full of joy.  They asked every staff member for his or her name and chatted with them.  Sivan insisted on sitting, not lying down, on the bed as she was wheeled into the OR.  As the surgeon prepared for the incision, she asked him to tell her exactly what he was doing.  She described the moments of joy as her son was born, and when he was brought to her from across the curtain and put next to her cheek; how she wriggled her arm out of the restraint and stroked him.  Her husband waited with the baby carrier, took the baby and never left his side as the operation was completed.  Sivan insisted on giving the surgeon a hug before she was wheeled to recovery.  Determined to recover and see her baby, as soon as she felt some sensation in her legs she tried to move them, and she expressed some colostrum to prepare her breasts for nursing.  She refused morphium for the pain and had them give her Ibuprofin instead.  The staff was in shock at her quick recovery and determination to function.  When her beautiful, 9.8-pound boy was finally brought to her, she didn’t wait even one minute before attaching him to her breast.  “Don’t you want to wait until we reach the ward?”  The orderly asked in amazement.  No.  Not a chance.

She turned one of the worst nightmares of any homebirther into a positive, happy experience.  A celebration.  After all, a birth is a birth.

I am prepared to calmly meet whatever turn my birthing may take.

After I read that story, something changed in me as well.  I realized that the lack of control I had over my birth did not mean I was helpless.  There is always a choice, and the choice is in your response to the situation you are in.  You can choose to see a C-section as a failure, a nightmare.  Or you can choose to see it as a birth; not what you wanted, not ideal, but a birth nonetheless.

Suddenly, I was able to let go.

And my birth was amazing.

Induction Increases the Risk of C-Section

Well, the journal of duh strikes again – it’s being reported that induction increases the c-section rates for first time moms.  This is nothing new to those of us who have been around the birth world for awhile, but the medical acknowledgment of this is still rewarding.  The issue really relates to what do we do now?

If we take this study and put it on the shelf, not changing the practices that have led to the high induction rates – does it really matter?  And just what can the birth activist do to help lower induction rates, particularly the elective, “I’m tired of being pregnant.” inductions?

_{Photo © iStockPhoto}

Preparedness

Preparedness refers to the state of being prepared for specific or unpredictable events or situations. Preparedness is an important quality in achieving goals and in avoiding and mitigating negative outcomes.

While working on a mural I am painting for my daughter’s room this week, I was thinking about how I am in the “nesting” phase of pregnancy. I am actually preparing a new space for my older daughter and the new baby will move into the current nursery after a period of co-sleeping with my husband and I.

This got me thinking about how women prepare for birth. Do many pregnant women feel they are prepared for labor? Do women enter labor in a calm state of mind and feel confident that they know what to do, their partner knows what to do, and they have full trust in their care providers?

We prepare everything else for a new baby. We buy mass amounts of baby gear after doing hours upon hours of research about the “safest” and the most functional brands. We gather tons of baby clothes and blankets and wash them before hand. We buy an infant seat and put it in our car weeks before our due dates AND we prepare the baby’s nursery.

But do many American women feel prepared for labor? How about the ability to labor naturally, without intervention?

The answer is no. American women are scared of birth. Fear has been set into us at an early age. Pitocin, epidurals, and C-sections are part of our culture. Why would we try to birth naturally when we don’t have to be prepared? We go to the hospital and they take care of things for us. The job is out of our hands once the heavy contractions start. And we aren’t allowed to make decisions when we are “in that state” anyway.

What if we made child birthing classes mandatory? What if we showed all those wonderful natural birthing videos that birthing advocate mommas and caregivers have seen? What if women left feeling empowered to have the strength and courage to labor naturally? There may be less medical interventions and c-sections! There may be less premature babies and babies may be born in a less traumatic way! Breastfeeding may be easier! Why, it may just turn the healthcare industry upside down!!

Fear and helplessness is running our birthing community. Shout it from the rooftops, and educate women that they are strong, birth is empowering, and most importantly, that they have a choice. Tell them it is a good idea to prepare your mind and body for birth, just like you prepare the baby clothing and a place for the baby to sleep.

Preparedness refers to the state of being prepared for specific or unpredictable events or situations. Preparedness is an important quality in achieving goals and in avoiding and mitigating negative outcomes.

My daughter's mural

Wedding Analogy

I woke up the other morning thinking about an experience I had last summer.  I was following a mommy blogger who was preparing to have her first baby.  She was talking about her 36-37 week prenatal visit.  She was hoping that the baby would stay breech so that she could schedule a c-section and be done with it.  Her whole post mad me feel sad.

She had started blogging, as many women do, around her wedding.  She had countless posts with paragraph after paragraph about the intricate details of which flower for which bridal party member and why.  She talked for hours about the flavors of the cakes.  And let’s not forget the wedding dress – that needed the be exactly what she wanted.  It had to be perfect.

To be fair this mom was an event planner.  This was what she did for a living.  She took one day and turned it into something really special for her clients.  She said that a marriage should start out on a perfect note, that it set the stage for the marriage.

So when I heard her talking about how birth was only a day and that it didn’t really matter, I knew she was wrong.  And more than that, her own statements about marriage, when applied to her thoughts about birth were incongruent.  How could she say that how you gave birth didn’t matter?  That it didn’t deserve the same amount of planning that her wedding did.  All she wanted to do was to get it over with…

My heart broke for her.  She is certainly entitled to her opinion and I said nothing to her.  But what I wanted to say was that you could get an amazing sense of empowerment through birth.  That giving birth to your baby was every bit as important and empowering as stepping into the limelight in a beautiful dress as you walked down the aisle towards your husband-to-be. And please note, I’m not saying that you can only achieve this through one type of birth, because that’s not what I believe.

So, if in her world, a marriage that was not carefully planned could start your marriage out on the wrong foot – why couldn’t a birth that wasn’t prepared for also cause similar issues?

In the end her baby turned, much to her dismay.  She decided to “try” a vaginal birth via scheduled induction.  She had an early epidural and what sounds like (via Twitter) a violent instrumental delivery.  She had a really rough recovery and gave up breastfeeding early so that she could rest and heal.  She intends to breastfeed her next baby after her scheduled c-section with baby number two.  I can’t help but thinking if a bit of planning for her birth, like a childbirth class might have helped her a bit.  I think it would have helped her achieve her breastfeeding goals at the least. Her birth certainly impacted her beginning into parenting.

So what I had wanted to say to her before her baby was born, but never posted, was that just because you elope and don’t plan for your wedding, doesn’t mean that your marriage is doomed.  It means you missed out on a beautiful experience, the support, the thrill of planning and the joy of walking down the aisle…

A Weighty Issue

Americans have been warned for years about the perils of being overweight or obese.  Indeed the risks for a host of complications increase steadily as the pounds pile on.  For many people, the risks can be temporarily ignored; after all, it takes years to develop heart disease or Type II diabetes.  But for one segment of the population, the risks are immediate and grave: Pregnant women.

For obese women expecting a child, the nine months of gestation bring with them potentially life-threatening complications (to mother and child).  Chief among the issues related to obesity in pregnancy are pre-eclampsia, gestational diabetes, and cesarean section.  The New York Times published an article the other day outlining the risks and providing the real-life example of one woman and her ordeal with a 29 week preemie.

So what are we to do?  Weight is such a sensitive issue for so many women, even those without excess pounds.  Doctors are often hesitant to bring up the subject of a patient’s weight during an office visit, for fear of offending the patient or “pointing out the obvious.”  And the short time allotted for an office visit, for general practitioners as well as OB-GYNs, means that little time is able to be devoted to counseling in nutrition, exercise, and weight loss or maintenance.  Traditionally, midwifery care focuses more on nutrition and holistic pregnancy care, but midwife care is not available to all women, nor is it the end-all, be-all solution.

We need greater outreach to obese women of childbearing age, both before and during their pregnancies.  In fact, we may need to start sooner than that.  According to the CDC, almost 1/3 of American teenagers are overweight or obese.  Outreach needs to start as early as middle school, and continue throughout high school.  We also need community resources to reach across all income strata, in the form of outpatient clinics/support groups as well as education for Medicaid and WIC recipients.  We need to work to take away the shame and stigma of weight issues, while still providing empowerment for all people to take charge of their weight, and ultimately, their overall health.

We need more people thinking about solutions beyond “wider, sturdier” examining tables (as the NY Times article mentions).  What are your ideas and experiences?

It can wait for tomorrow…

I had one of those days where I had a list of things to do while out on the town, had my 10 month old in tote, and because of forces out of my control, got none of them done. I planned my outing to go something like this: get the oil changed in my car, go to the bank, and pick up dog food. NONE of this happened. I was waiting around way too long at the oil change shop when they said I was next in line (they lied). During this time the baby got cranky and by the time we were out there (without the oil change), it was nap-time so we did not proceed to the bank or the dog food store. What a HUGE waste of my day. When I got home I was really worked up and frustrated and then yelled at my husband who unfortunately works from a home office and is available to yell at whenever the mood strikes me, poor guy. On top of this, the baby would not go down for her nap when we got home so she was still cranky. Great.

When daddy stopped work for the day and was able to lend a hand in childcare, I was able to breathe and reflect a bit. My anger subsided and this feeling of  ”it’s okay, it can wait for tomorrow” took over me.

This got me thinking about all those mommas that are being persuaded into labor induction and this made me sad. In my first pregnancy my OB asked me if I’d like to schedule a cesarean when I was about 17 weeks along. There was no medical reason for this, it was for convenience! This is when a light bulb went off for me and I got the momma sixth sense that something was very, very wrong here. I immediately proceeded to change providers and practically ran to a natural birthing center where ended up having a non-complicated, peaceful, water birth.

What about the mommas who do not know that there are birthing choices? Do women think that it is normal to schedule a date to induce labor? To schedule cesareans?

It seems that many young, healthy women that I’ve had conversations with recently do not believe it is possible to have a natural birth. They were told for one reason or another that they aren’t “allowed” to. That they “have to” schedule inductions to not pose any “risk” to the labor process. These women pack their bags, do their hair and makeup before they leave for their scheduled date at the hospital, get induced and often receive an epidural when they get there, and with one or two pushes the baby is out.

Is this what birth has become? Do we have our babies like we shop online? For convenience? If there is no MAJOR medical reason why you need to have your labor induced, please stop to to think of the risk you are really putting your baby in by inducing.

Why would labor be induced?

There are several possible reasons. Those nearer the top of this list are cases where the benefits may outweigh the risks. Those nearer the bottom of this list,  the risks are more likely to outweigh the benefits.

1. If the baby or mother has a SEVERE health condition which makes it riskier to continue the pregnancy than to induce;  severe pre-eclampsia, diabetes with complications (it is estimated that this rationale for induction only applies to 3% of pregnancies)
2. Water breaking. If mom is more than 35 weeks pregnant, and it’s been more than 24-48 hours since membranes ruptured, most caregivers recommend induction to reduce risk of infection.
3. A baby that’s “overdue” – pregnancy lasting over 42 weeks.
4. If baby or mother has a MILDER health condition.
5. A pregnancy lasting over 41 weeks.
6. The baby is “too large.” (Although this is a common reason for physicians to recommend induction, research seems to indicate that there are not significant benefits to inducing labor)
7. Convenience or preference. Of the mother, or the caregiver. The risks outweigh the benefits.

Summary of induction risks.

All of the forms of induction can lead to stronger, more painful, and more frequent contractions, which may lead the mother to use pain medications she might otherwise not require. These powerful contractions may also limit oxygen supply to the baby, so increase the risk of fetal distress. Also, due to the uncertainty of due dates, and the variation in the amount of time any given baby requires to reach maturity, early induction carries a risk of causing premature birth. There is a significant increase in the chance of cesarean.

Questions to ask your provider if induction is recommended:

1. Why? What are the reasons why it would be better to deliver the baby sooner?

2.  How? Could we start with one of the non-medical options and see if that works?

2.  When? Is this something that needs to happen today? What would happen if we waited a few more days? Another week? Is it possible that it can wait for tomorrow….

Think about it, challenge providers, do your research. Only you know what’s best for yourself and your baby. 

Much love,

Amy

Happy Cesarean Awareness Month

April is Cesarean Awareness Month!  I am here to talk about my experience today, and why cesarean awareness is such an important subject for women to get involved with, even if you have not had one!

When I was 22 I gave birth to my first child via an unnecessary cesarean because my my physician wanted to go home for the day.  I never knew how much that experience would impact my life not only as a woman, but as a mother, and my mothering skills. I look back often and know that had I taken the time to take a childbirth education class, it would have prevented that experience completely, and honestly I would have never stayed with the OB/GYN practice I was with at that time.

When I got pregnant with my second child, only 9 months postpartum from my first, I knew that it needed to be different and I set off to find a midwife for a VBAC.  After the experience and postpartum emotional toll my first surgical birth took on me, I knew it would be best for my family to not deal with the emotional and physical repercussions of a repeat cesarean.

My Birth Journeys from Danielle Elwood on Vimeo.

But after over 26 hours of a VBAC labor, doing everything right from staying in shape, exercising, preparing for birth, having a doula, and receiving regular Chiropractic care for the duration of my pregnancy, my second child was born via a medically necessary cesarean that saved not only his life, but my own.

It gave me a different perspective on being a birth activist, and cesarean awareness supporter. I went from angry, bitter, and sad insisting most of cesareans were unnecessary (which statistically most still are) to grateful for my experience the second time around knowing and giving me the understanding behind a medically necessary cesarean birth.  It still sucked big time, it was painful, my recovery was much worse than the first time around, and emotionally it was devastating because of the hard work and commitment I had to working towards a VBAC.

I am thankful for both of my experiences as it helps me to know I can help women on all sides of the cesarean spectrum because I have been there myself.

I hope everyone takes some time to get involved this April in some way!

A couple great events taking place this month :

ICAN will kick of Cesarean Awareness Month today with a Radio show about Cesarean Mothers Experiences

I Will also be on The Feminist Breeder’s radio show this coming Sunday Night at 10pm CST discussing the recent Cesarean Feelings Survey I worked on with the Healthy Baby Network.

The ICAN Blog will be having birth stories from Cesarean Mothers, and VBAC Mothers all month long, so take some time to check that out.

C-Section Births Up 53% since 1996

Today the NCHS released a briefing on the c-section trends from 1996-2007.  Here you can see that after a brief dip in the early 1990s, the c-section rate is skyrocketing – 53% increase in the national cesarean rates in these 11 years alone.

C-Section Trends from 96-07

Next we have the issue of ethnicity.  There are some groups that have lower cesarean rates, though all groups climbed.

C-Section Rates by ethnicty: 1996-2007

Here you can see a state by state break down of the 1996 c-section rate and the 2007 c-section rate, with the percent change. You will also note from Jill at the Unnecesarean that Florida, in 2008, had a 38.2% c-section rate, so the numbers are higher. That is what I expect we will see when the birth data for 2008 (preliminary) comes out in April.

C-Sections by State 1996-2007

Thoughts on Informed Consent, Refusal and VBAC

If you’ve been listening to the news lately, you’ve probably heard a lot about vaginal birth after cesarean (VBAC). The NIH held a consensus meeting to decide what was appropriate in VBAC care. The general thought was that the overall VBAC rate should increase and that the rate of primary cesareans should decrease due to the risks of surgery to the baby and mother. The panel had several recommendations that can be boiled down into:

• ACOG and ASA should revise their guidelines on the “immediately available” guidelines.
• The decision to do a VBAC or a repeat c-section should be made between a woman and her practitioner, after an informed discussion.

The problem with the last statement is that true informed consent and discussion is very rare in obstetrical care. The closest that we tend to come is the woman who is choosing a VBAC. She is likely to spend the last several months of her prenatal care being told of the risks of VBAC and the parameters in which it will happen. In contrast, had that same woman chosen to have an elective repeat cesarean, she would simply be handed an appointment card for her scheduled surgery and then sign a sheet of paper that would have to suffice as informed consent, all done a few minutes before her surgery. Neither of these is truly informed consent.

So how can women get informed consent, particularly when it comes to a hot topic like VBAC? My advice is:

• Do independent research.
• Seek out information from neutral sources.
• Talk to other mothers who have had a VBAC.
• Talk to other mothers who have had a repeat c-section (planned and not).
• Prepare for your birth by childbirth class, doula support and emotional support.
• Consider alternatives including midwifery led care.
• Make a decision only after a lengthy discussion with many people, including your practitioner.

Providers have to consider multiple issues when recommending one mode of birth over another: health of mother and baby, liability for complications, availability of self and staff during uncomplicated and complicated births, personal beliefs, medical malpractice insurance (if they choose to carry it), what other practitioners will think of their choices, etc.

Women have their own issues to consider when deciding her mode of birth: health of baby and mother, likelihood of the success of VBAC, physical and emotional pain after the birth, personal beliefs, etc.

The final point is that of informed refusal. ACOG has a policy of informed consent and refusal. This states that they believe that a woman who has all the information, is allowed to make a decision to choose not to receive the recommended procedure or therapy that is being suggested by her doctor.

At the panel yesterday, when asked specifically about the policy of informed refusal as it included forced repeat c-section, either by practice policy or individual recommendation, they basically said that this was unclear. Some advocates took this to mean that the consensus panel was suggesting that women did not have the right to choose a VBAC if that wasn’t the recommendation of her doctor or that if she did, it was acceptable to coerce her with threatened legal action. In other words, a woman is free to make any decision she would like, unless it conflicts with what her practitioner decides.

That leaves us in a sticky spot. What’s a birth activist to do?

Related:

• Maternal Decision Making, Ethics and the Law
• Refusal of Care Based on Religious Beliefs
• Women Need a Chance to Avoid Repeat Surgery

But Why is VBAC so Important?

I am sure that I am not the only person to ask myself this with the announcement of the National Institute of Health VBAC Conference announcement.  But unlike most, I know more than my fair share about VBAC after having a cesarean with my first child it became more than a healthy obsession to me. But sadly the more I learned, the more sad I became about the access to VBAC nationally.

In a 2009 survey from The International Cesarean Awareness Network, it was found that nearly 50% of all hospitals in The United States has some sort of a VBAC Ban in place. Whether it be a formal policy written by hospital administrators, or a de facto ban, meaning there simply are no providers who will take on a patient who wishes to have a Vaginal Birth after Cesarean.

But what does this mean for women nationally? For the women who have had cesarean sections, whether medically necessary, or unnecessary?  It means that once they have experienced once cesarean birth, they have no choices regarding future pregnancies or deliveries. Essentially leaving them with no real informed consent.  To me, as a huge activist, that is not only a violation of a patients rights, but it is a major human rights and bodily anatomy violation.

Right now, 90% of women who have had one cesarean section will go on to deliver all of their children through multiple major abdominal surgeries, the next more risky than the last. When the safe and relatively low risk  option of a VBAC is not available.  But lets look at the numbers regarding the risks of VBAC as opposed to repeat cesarean sections.
The major risk associated with a Vaginal Birth after a Cesarean section is something most near the most not knowing the risk is so low. Uterine Rupture.  Not something we should discount or not worry about, but when we look at the statistics, the average healthy woman who has had one previous cesarean section has a 0.6% chance of experiencing a uterine rupture.

When I went through the process of filling out and signing my VBAC consent form for my second pregnancy, there was paragraph after paragraph panting VBAC in a scary pictre, then a small paragraph with the minor risks of a repeat cesarean, almost like the practice of Obstetricians backing my midwives wanted me to change my mind and run in fear.
This form was not informed consent by any means, it was skewed, biased, and provided misinformation, but sadly this is what we are seeing Nationwide today.

But I can hope with the NIH VBAC conference we can start to see a change in the way that VBAC is handled nationally.
Women have the right to real informed consent, and give birth vaginally if that is what they choose for their own birth.

For more information on Cesarean Awareness, and Advocacy, check out The International Cesarean Awareness Network.