Sunday, February 26, 2012

Parenting in Labor

The Decision to Use Pain Medication in Labor:

For most of us from the very beginning being a mother is hard. It requires you to give of yourself in ways you never dreamed possible. It requires you to make difficult decisions every day. We make these decisions on the best information we have at the time and what we judge as the best balance between our needs and our child's. At the end of the day we need to try to let go of mistakes we may have made and understand we are human and mothering is hard. 

Parenting begins in earnest once we are in labor. The more a woman can stay connected to her baby throughout the process the better she will be able to understand and accept what her body needs to do.

If you decide to use pain medication: "Even if medication becomes necessary later on in labor, the longer a mother can postpone it, the better it will be for the baby and for her and for their recovery afterward. Each hour without it is a step in the right direction." ~  "On Becoming a Family" by T. Berry Brazelton, M.D. (pediatrician)

I love this quote because instead of feeling like a failure if a mom decides at some point in labor she needs pain medication she can focus on the hours she gave to her baby drug free. Mothers need to start mothering with as little guilt in their heart as possible. We will load ourselves down with guilt a plenty in the days, weeks and years of mothering to come.

Labor Pain Medications Affects:  Have you ever wondered how women were able to successfully breastfeed before there were lactation consultants? As much as I love our local lactation consultants and their passion for helping women and babies you need to understand why so many of your friends all needed professional help to achieve what should be a normal biologic function.

"The evidence that drugs given to relieve labor pain affect breastfeeding outcomes is rapidly accumulating." ~ 'The Impact of Birthing Practices on Breastfeeding' by Linda J. Smith & Mary Kroeger

"For breastfeeding to succeed, the baby must emerge from its internal gestation ready and able to feed, the mother must be able and willing to let her baby feed, and the stages of lactogenesis must proceed normally."  ~ Smith & Kroeger

For many years I have listened to anesthesiologist tell mothers not to worry because an epidural won't affect her baby, doesn't even reach her baby. I wish this were so but the uncomfortable truth is that this has been disproved in studies starting back in 1995.

"The route of administration-local, IV, or injected into the epidural space-has less influence on drug transfer to the fetus/infant than previously thought. IV drugs quickly enter the infant blood stream via placental profusion. Local injections also reach maternal circulation in a matter of seconds and are detectable in the newborn's urine at high levels. Injections into the epidural space are quickly detectable in cord blood." 'Impact of Birthing Practices on Breastfeeding'

Did you know that what goes into an epidural are the same drugs that go into an IV for labor pain relief? The only difference is where they are putting it in your body. For you it feels profoundly different but not so much for your baby.

Understanding Risk

Whose Risk are We Talking About?

"We must never underestimate the power fear of litigation holds over obstetricians. In my experience, as a motivational force it over shadows their desire to lower the maternal mortality rate." 
~ Dr. M. Wagner

The "Risks" of Home Birth: Why haven't we heard about this? 

"We now have good, solid scientific evidence that makes clear that planned home birth attended by a midwife is a perfectly safe option for the 80 to 90 percent of women who have had normal pregnancies...This study is by far the largest scientifically valid study of planned home birth ever conducted...In summary this prospective, highly reliable study, which followed the course of more than 7,000 pregnant women planning home births attended by CPMs (Certified Professional Midwives), collected data on more than 5,000 who intended home birth at the initiation of labor. Among these women, the obstetric intervention rates were far below the rates reported in low-risk hospital births. The combined intrapartum/neonatal death rate (babies dying during labor, birth or shortly following birth) was as low or lower than rates reported for low-risk hospital births. And the maternal mortality rate was zero." ~ Dr. Marsden Wagner Born in the USA

When I looked up this study I found that 12.1% of the women ended up needing to be transported to the hospital but many of the transported women still didn't need a cesarean. Of the total low-risk home birth women in the study only 3.7% needed a c-section. How does that compare with our hospitals? Visit my Hospital Statistics post to find out.

If this study was published in the Boston Medical Journal in 2005 (six years ago!) why don't more people know about it? Why isn't the whole medical community talking about it, trying to understand what this means about how hospital-based birth is conducted? Why aren't they trying to understand the lessons that can be learned from home birth and how to incorporate those lessons into their practices? To read more about this study visit the Boston Medical journal web site. 

Which Local Hospital is the Safest?

Why would the same OBs who delivered babies at Sierra Vista for years, before they had a Neonatal Intensive Care Unit, now being telling women that French Hospital is unsafe because they don't have a NICU? They never told women in the past they needed to go out of town to a hospital with a NICU to safely deliver their babies. Just saying??? Did you know both hospitals have special baby respiratory therapists at births as a safety precaution? Did you know the same pediatricians and neonatalogists will go to either hospital if a baby arrives in need of their services? 

Hospital Versus Home Birth: Accepting the fact of risk

"If the obstetric tribe says that out-of-hospital birth is not "safe", the implication, of course, is that a hospital birth is safe, which is not true. Newborn babies die in hospitals every day, sometimes because someone made a mistake. When the obstetrics establishment implies that this doesn't happen, the family naturally feels deceived when it does happen." More from Marsden Wagner's 'Born in the USA'.

One of the hallmarks of a good out-of-hospital midwife is that she explains that there are risks to birth and is clear that the parents need to be willing to accept those risks. The reality is with life comes the risk of death no matter where you are or who you are. 

Inductions & Due Dates: Things to think about for the women of San Luis Obispo!

Listen to Ina May Gaskin, master midwife, author and recipient of the Right Livelyhood Award, shares her wisdom about  induction and due dates.

Convenience Masquerading as Risk: Have you ever thought about induction from the doctors' and hospitals' management perspective? 

~ Marsden Wagner, MD "Induction of labor is an important convenience not only for obstetricians but also for hospitals, as it allows hospitals to organize an induction assembly line, with slots into which doctors can fit their patients."

Let's face it, spontaneous labor is inconvenient in lots of ways; from doctors’ sleep, time off and office hours interrupted, to hospital staffing, room availability, and work flow. This was made blindingly clear to me years ago. I had a doula client who was between 41 and 42 weeks pregnant. At her prenatal visit her Certified Nurse Midwife told her how dangerous it was for her to continue simply waiting for spontaneous labor to start. After a long discussion and lots of pressure the pregnant mother gave in and agreed to be induced. The midwife went to call the in San Luis Obispo hospital to schedule the induction for later that day. When she came back into the room she said there were no rooms at the hospital, so my client couldn't be induced that day. She said she was scheduling her for 3 days later. Why? Because we were there on a Friday and it wasn't convenient to induce her on the week-end!

My thoughts: What happened to the danger? If there were no rooms for an induction what were they going to do with women who spontaneously came into the hospital that day in labor? To schedule an induction means having enough nurses to cover the more time and labor intensive work of an un-natural, drug driven labor so perhaps it wasn't room but staffing that was the problem? I was angry, as was my client, and so grateful to be given a reprieve to go home to Grover Beach. We worked hard on creating the elements she needed to go into labor spontaneously and were rewarded with a spontaneous, un-medicated vaginal birth before Monday.

Due Dates~Inductions~Cesarean Sections: making the connections

Dr. Marsden Wagner's "Born in the USA"
"Now we are in big trouble, because forty-one weeks is entirely within normal pregnancy limits, and when we start inducing at forty-one weeks, we put large numbers of normal pregnancies at risk with an unnecessary procedure. At this point we have a situation in which the treatment is worse than the disease." 

Connecting the dots: This book was published in 2006. When I was pregnant with my son in 1990 my nurse midwife told me to EXPECT to go to 42 weeks, that this was NORMAL for first time mothers. Over the last 2 decades this assumption of 42 weeks as being normal has been replaced with an ever increasing fear based medical perspective for each day that the mother goes past 40 weeks. Perhaps it is just a coincidence that since 1990 the national cesarean rate has been climbing every year until reaching a rate of a whopping 32%! I don't think Dr. Wagner thinks it is just a coincidence. Do you? Compare my cesarean rates to our local hospitals in San Luis Obispo, Templeton and Santa Maria.

Baby Bonding and Attachment: Getting parenting off to a good start.

Food for Thought: "In the early months, in most families, the mother-infant attachment is more obvious and more intense than that between father and infant. This does not mean that fathers do not become deeply attached to their babies, but it is a different type of attachment. It's neither of lesser quality than a mother's nor better. It's just different." 

~ William Sears, MD and Martha Sears, RN, ‘The Attachment Parenting Book’. 

It is important to encourage both parents to connect with their baby, each in their own unique way. Each parent brings something wonderful to the growing relationship, something a child will treasure for a life time.

Doctor or Midwife: How to Chose Which is Right for You

Food for Thought: I have thought a lot about how women decide whether to use a midwife or doctor for their birth. I think it really comes down to life perspective. Do you focus on what can go wrong in life or on what can go right? This will be the defining reason for your choice. You will seek out and feel most comfortable with a care provider who mirrors your view of life. 

Here is Marsden Wagner, Ob-Gyn on the different perspectives of doctors and midwives. "Though midwives know what can go wrong during pregnancy and birth and know how to identify problems early and to cooperate with doctors in managing complications, their focus is on birth as a life-enhancing experience." This makes midwives a good match for women who naturally gravitate to a world and personal life view of staying in touch with everything that is right in the world and their bodies.

"Obstetricians, on the other hand, tend to focus on what can go wrong during pregnancy and birth. All doctors are trained to look for trouble (diagnose a problem) and decide what to do about it (decide on a treatment), and that is what comes naturally to obstetricians." So if your way of interacting with the world is to keep your eye focused on what can go wrong in life so as to prevent it from happening, then a doctor is a better fit for you.

Each choice can come at a price though. For a woman choosing a midwife it can be very difficult if the midwife finds an actual problem with the pregnancy or birth. The pregnant or birthing woman may have a hard time switching gears to focus on the problem in order to address it. Here is what Dr. Wagner says about the price the woman choosing a doctor pays, "In prenatal care they [doctors] take the same approach, focusing on what can go wrong and ordering numerous tests and screening procedures. This attitude casts a shadow over the maternity care a woman receives. When an obstetrician runs a test or gives a preemptive treatment, it is an unspoken vote of no confidence in the woman’s body.” I know women often feel each prenatal visit is like a pass/fail test. This is especially stressful on women who are high achievers. If they run into a perceived “failure”, at an office visit it can shake their confidence to their core and they may become obsessed with their fear of failure. This can lead to a rise in stress hormones which can spiral into more “failed” tests.  

I am a Community Lactivist

I believe in breastfeeding both for the healthy growth of a child and the healthy growth of a mother. When a new mother breastfeeds she learns to watch and listen to her child's cues. These simple facial expressions, body movements and vocalizations which trigger our innate response to nurture are the start of a life long conversation.With support the new mother comes to trust her baby's ability to know when they have a need and what it is they need. As she learns she can meet these needs through breastfeeding she gains confidence both in her mothering abilities and her baby's abilities. As she learns to let go of the need to quantify these abilities through weighing, measuring or lines on a chart she starts down the path of mothering wisdom. This path can teach her to relax. It can teach her to rely more on her child's wisdom than on professional experts. It can teach her she is more a witness to her child's life unfolding than a director. She is more an access to the resources needed  for her child to play their unique heart song than the leader of the band. Breastfeeding can be the key to a new way of parenting for life.

It is because I believe this in my heart that I am a Community Lactivist. I express my commitment to all the breastfeeding mothers out there by being an active member of several organizations that support breastfeeding in our community; La Leche League, Birth & Baby Resource Network and Central Coast Breastfeeding Coalition. I am proud to say San Luis Obispo has a very high breastfeeding initiation rate. Unfortunately like most of the country there is a steep drop off from the second week to two months. We have lots of support groups and resources in our community and yet women still can't seem to make it through the challenging first six to eight weeks and into the months of breastfeeding bliss. As Lactation Consultant Julie Merrill said at Thursday's Farmer's Market, "It breaks my heart to see so many babies in strollers with bottles." The Coalition has just printed a new breastfeeding resource brochure full of places, people, books and web sites mothers can turn to for guidance and encouragement. Look for their green and white cover around town, at your doctor or midwife's office and baby stores. 
This baby wants all new mommies to have this brochure!

Stepping out of the shadows
Breastfeeding mothers need our support. We need to step out of the shadows and take a stand that breastfeeding is normal; formula feeding is abnormal. Babies need to feed when they need to feed and mothers need to feel comfortable attending to those needs; even in public. This is a national health issue. By continuing to pay money to formula companies we are draining our economic resources, environmental resources and our nations future health. Don't be blinded by the "Well I was formula fed and I turned out ok", way of thinking. Look around you we have an obesity epidemic, while cancer, diabetes, and heart disease run rampant in our nation. We are overly dependent on antibiotics and medications. While these may not be the direct result of formula feeding the studies clearly indicate that all of these could be lessened if we only chose to breastfeed for the first few years of our children's lives. I firmly believe some day we will look back on these years of our nation suckling at the teat of the Nestle Corporation and compare it to the time of America's romance with cigarettes.

Our bodies grow smarter healthier babies.

August is National Breastfeeding Awareness Month. If you see a mom nursing her child, give her a thumbs up and a friendly smile. Each day she chooses to breastfeed she is giving her child a wonderful gift and performing a patriotic duty.

We gave a new meaning to "flash" mob at SLO's popular Thursday night Farmer's Market.An special thank you to Robyn Berry Photography.

Lactivistas come in all ages.
Educating the public on the benefits of breastmilk.

Demonstrating the miraculous work our breasts were perfectly designed to do.
Every baby deserves a booby!
Learning one generation to the next.
 Thank you to the mamas who chose to bare it all last night to demonstrate what breasts were actually designed to do.

Inspiring a new mommy.                BREASTFEEDING It Rocks!
Read about how I managed to juggle working and breastfeeding here.
This month's La Leche League meetings:
Monday, August 13th at 10 am:
Santa Lucia Birth Center 4251 S. Higuera Street in San Luis Obispo
Topic: Nutrition and Weaning

Monday, August 27th at 7 pm:
Santa Lucia Birth Center
Topic: Baby Arrives

Look for Los Osos meetings to start back in September!

Labor & Birth

Expectant mothers in my birth classes often worry about how long labor will last. Some of my doula clients fear labor will be like the San Luis Obispo marathon and others worry it will be a fast and furious sprint. Ina May Gaskin, master midwife, lecturer, author, and recipient of the Right Livelyhood Award shares her wisdom on the labor race and how long labor "should" take.

Saturday, February 11, 2012

Think Twice Before You Say Yes to a C-Section Because Your Baby is Arriving Prematurely

Last week in the New York Times Roni Rabin reported on a new study coming out of John's Hopkins School of Medicine which throws a wrench into the machinery of conventional medical thinking. Until now doctors have believed that it is safer for your premie to be born via surgery. The study included 2,560 babies. When they compared babies born mother nature's way to those born in a surgery suite the babies delivered by C-section were 30 percent more likely to develop respiratory distress syndrome, a serious breathing disorder that can lead to organ damage.

It must be tough to be an Obstetrician. You are constantly practicing medicine on women with the best of intentions only to have studies prove that what you are doing is not only medically unnecessary but harmful. No doctor goes into medicine to harm women, so I have to wonder how they feel about it each time one of these issues comes to light and they have to reverse course. Do they think back over the women they sectioned who had complications? Do they remember the babies who ended up with serious respiratory infections and wonder if their belief in the "preventative" cesarean may have caused that baby to suffer? What about the extra stress on families separated even longer from their babies? What about all the money families spent on additional NICU care for premies with breathing issues? I wonder if someone will try to figure out what that bill was for our nation?

So how did OBs get into such a mess? It is grounded in the systemic belief which underlies much of the medical model thinking about birth that women's bodies are essentially unsafe for babies, especially the vagina. To understand where this bedrock of the medical view of the world came from you have to go back to male dominated religion, Eve, sin and the apple, the Greek belief in the perfection of the male body, and an unwavering belief in man & technology over nature and women's bodies. Time and time again this flawed way of thinking has led them into relying on drugs to fix problems only to learn later that they were harmful to mothers or babies. They rely on machines, tests and statistics to give us flawed due dates which lead to inductions of accidentally premie babies, continuous fetal monitoring which led to many more c-sections for fetal distress with no lowering of the fetal death rate, and windows of normal so narrow that fewer and fewer women can thread the needle of pregnancy & birth without being labeled as high risk. So this line of thinking led them to believe, without any studies being done, that it would be safer for premies to be saved from the rigors of a vaginal birth. It apparently never entered their minds that traveling through the vagina served a purpose in a complex system of birth, growth and life long health. Or that being squeezed would push fluid out of the lungs and that the sides of the vagina would coat the baby with beneficial flora. These two items may be why there are less respiritory infections in vaginal birth babies. Instead as the medical provider they donned their super hero robes and stepped in as saviour. The problem with being a super hero is the responsibility. So now they are left to face their responsibility. Of course I'm not looking for some kind of loud national apology. That never happened in the past and it won't happen now. Read the Times article below and then take Dr. Werner, the lead author of the study's advice and have a frank discussion with your doctor.

New York Times
February 9, 2012, 3:22 pm
C-Sections Pose Respiratory Risks for Some Small Preemies

Small premature babies born by Caesarean section are at increased risk of respiratory distress syndrome, a new study has found.Very small babies delivered prematurely by Caesarean section because they were not growing properly in the womb developed more respiratory problems than those who had induced vaginal deliveries, a new study found. The study adds to growing concern over the high rate of Caesarean section deliveries in the United States, which reached 32 percent, or nearly one in three deliveries, in 2007.

On Wednesday, the federal secretary of health and human services, Kathleen Sebelius, announced a public health campaign to educate families that it is best for both the mother and the baby to let a problem-free pregnancy go for as long as possible, and to let labor start naturally. The campaign is a partnership that expands on a March of Dimes public awareness drive emphasizing that “healthy babies are worth the wait.”

The latest study looked at babies who were extremely small for their gestational age and not growing properly in utero, so waiting was not a medical option. But the findings raise new questions about the risks of Caesarean section.

For the study, researchers analyzed nine years of data from births in New York City, identifying 2,560 babies who were small for their gestational age and delivered between 25 and 34 weeks of pregnancy. Forty-six percent were delivered vaginally, and 54 percent by Caesarean section.

“The conventional thinking, though nobody really knew, was that maybe it would be less traumatic for this group to have a C-section, and they might benefit,” said Dr. Erika F. Werner, an assistant professor at Johns Hopkins School of Medicine and the study’s lead author. “Our study suggests that may not be true.”

In fact, the babies delivered by C-section were 30 percent more likely to develop respiratory distress syndrome, a serious breathing disorder that can lead to organ damage and that is more common in premature infants, Dr. Werner and colleagues from Brown and Yale Universities found.

The C-section deliveries were not associated with improved outcomes in terms of other complications, including hemorrhages, seizures, low Apgar scores and sepsis, the researchers found. Results were adjusted for differences in the mother’s age, ethnicity, education, health status and weight.

The findings are being presented today at the annual meeting of the Society for Maternal-Fetal Medicine in Dallas.

“The takeaway is that if you’re in this situation, you should have a frank discussion with your doctor that maybe a vaginal delivery is equivalent, or even better,” Dr. Werner said. “We need further research to determine if there is any benefit to C-section” for such infants, she said.

Another consideration is that when a woman has one baby born by Caesarean section, subsequent children are far more likely to be delivered by C-section as well.

As to why vaginal deliveries appear to improve respiratory function, Dr. Werner said, “We don’t have the perfect answer.” Some experts believe that the physical compression the baby experiences during labor helps remove fluid from the lungs and prepares the baby to breathe air.

Dr. Diane M. Ashton, deputy medical director of the March of Dimes, who has been overseeing the organization’s Prematurity Campaign to educate the public, said similarly improved outcomes are seen with infants delivered further along in a pregnancy.

“This is consistent with what is seen in infants even at 37 weeks,” she said. “They, too, have better respiratory outcomes when delivered vaginally versus C-delivery.”

Studies suggest that premature births of single babies have been increasing in recent years and that more are being delivered by Caesarean section, including C-sections that are not medically necessary. At the same time, recent research shows that a baby’s lungs and brain undergo important growth and development during the last few weeks of pregnancy, and that babies born just three to six weeks before their due dates are more likely to suffer disabilities or developmental delays in kindergarten.

Last year, the American College of Obstetricians and Gynecologists issued new medical guidelines meant to lower the rate of repeat Caesareans by making it easier for women to find doctors and hospitals that will let them attempt a vaginal delivery even when a previous baby was delivered by C-section. Although these women are at risk for a serious complication called uterine rupture, ruptures affect fewer than 1 percent of women, while C-sections, which involve major abdominal surgery, carry many other risks both to the mother and to the child.