My Heroes

I'm sure you have heard it said that every birth is unique, each its own story. But no one talks about how deeply that story is written into women. Each woman's birth story is carried in their bones and sinews. It has put its stamp on their bodies and breasts and the very energy contained within their cells. This is how they know "birth" to be.

I have been very lucky in my life to able to attend women in birth. I am constantly in awe of womanhood, its power and its grace. Every birth IS a story. I have so many stories jammed in my head and packed into my heart. Some are private stories only shared with a sacred circle. Others are meant to be shared with the world. Some demand to be shared. So it was with my preemie twin vaginal birth. Now I want to speak about cesareans. Next post I'll share a recent positive cesarean birth story.

For many years I struggled with each cesarean birth my clients had. I took it as a personal failure. If I had just been a better doula this wouldn't have happened. I could have, should have, rescued her. Over time I grew to understand that these stories weren't my stories to write. They belonged to the birthing woman. They were her story. I tried to let go of my arrogance in thinking I held the power and turned it back to the mothers. I am there to help a mother find her own path. Success or failure is in her hands not mine. This attitude helped me, but did it help them?

Recently I have begun to question and be more critical of the whole idea of cesareans as being failures. I have never been with a mother who just gave up. Every one struggled mightily; pushed themselves to the edge of their personal precipice and beyond. How can that be labeled a failure? Who is to blame for this stigma?

The ugly truth is the blame lands squarely at the feet of the natural birth movement. A movement which is near and dear to my heart. A movement which sprang up in direct response to the over medicalization of birth. A movement which wanted to give women back their power; their belief in their bodies.We wanted women to be in awe of their own strength and abilities. A movement I signed on to many years ago. It gave me strength to do my work and replenished me when I was tired, weak, or hopeless. A movement which has branded the heart of every woman with a big fat F who began labor with the intention of birthing vaginally and ended up in the operating room . You failed at the very essence of womanhood. Enough.

I want all the mothers who have courageously fought to win that medal of female honor, only to see it fade from their grasp, to know they are heroes. They are the walking wounded who gave it all in battle for their comrades; their partner and child. Many suffer with post traumatic stress disorder. Some face on-going health issues. All of them have had their bodies invaded by friendly fire and have the scars and internal adhesions to prove it. Why do we treat them as shoddily as the returning Vietnam Vets? If you are for the war, people who believe in the medical model, you are numb to their tremendous sacrifice. If you are an anti-war protester, pro-natural birther like me, you actually have the unbelievable gall to question their loyalty to the cause. Enough!






Isn't it enough that she stayed the course for 9 hours at 8 centimeters without ANY pain medication? What about the fact that the last 4 hours were with pitocin to make her contractions even harder? What if you knew she was in active labor for 26 hours with back pain from a posterior baby? Enough?

Isn't it enough to join the club of "successful" birth if you labored with no medication and then pushed with ALL your strength for 3 hours at home AND THEN had to face your fears of transferring to the lion's den? Your midwife, your doula, your husband, your mother, didn't they all do everything they could? Why isn't that enough?


What about the mothers who train for the war but never get to feel their mettle tested? Herpes outbreaks, breech babies, high blood pressure, intrauterine growth retardation, or their baby's size can have them falling on their sword and relinquishing their bodies to be invaded for the sake of their children before a single shot has been fired. Their birth dreams laid waste upon the surgical table as the fog of war descends upon them.

What about this mom so great fully full of life? First she was told she would have to have a cesarean because her baby was breech. Then she went through an external version to turn her baby, only to have her water break with no labor. She did everything she could to make labor start. She and her husband held off the medical staff for hours and hours and finally, with time running out, submitted to one of her biggest fears; pitocin. After many hours on pitocin her baby's heart rate climbed. Could this be from infection? No mother wants to risk her baby. So she said yes to her deepest fear; a surgical birth and was wheeled off to the operating room. Surely she did enough. Would you have had her say no? She allowed them to cut her body open for the sake of her son. Isn't that enough?

                                             It should be enough.

Welcome home to ALL the mothers who began their births with the bright shiny intention of a natural un-medicated vaginal birth. As you marched off to do battle, you hoped against hope you would come home whole. You raised the banner of natural birth high above you. You held tight to your talismans of homebirth, nurse midwives and doulas believing they could bring you home safe from the war. You counted on your training from Bradley, Hypnobirth, or yoga to sustain you in the trenches. Bravo to those of you who made it through; war weary, battle hardened and whole. But let us not forget the walking wounded that sacrificed it all. Our highest motherhood medal of honor should be reserved for them for their bravery and selflessness. My heroes.

Welcome Home

Hayley D.      Annie W.       Kim S.      Laurie E.      Emily P.

Ruth M.      Miriam M.       Rebecca P.       Megan B.       Larissa H.

Yselle L.      Kelly B.          Kristina G.        Suraya S.       Wendy M.

Fara H.      Rochelle W.       Shelly F.          Sarah M.R.         Shannon L.

Katelen F.    Anna R.           Jenna M.          Star A.           Colby L.

Janet M.        Eva N.         Gwendolyn S.     Amy E.         Kambria D.

Stacie S.     Jennifer W.        Bridget B.       Georgie W.       Amy O.

DeAna C.     Amy H.           Jennifer K.         Traci C.        Heather S.

        Kat K.        Michelle L.        Tomi M.            Cindy L.          Linda S.       

                      

   Patti D.         Steph W.        Sarah R.          Kendra W.       Lisa N.
 
Sabrina S.       Anna T.       Glo       Stephanie A.       Annie R.

Kathryn D.       Sara M.      Spencer O.      Katelyn L.      Susan K.

Jessi C.     Beth S.

Do you have a hero that belongs on my memorial wall?

After 20 years of listening to mothers and witnessing births;
I have more names than I can remember.
Each is an important story.

If you or a loved one or friend belong on my wall please let me know and I will include them.

Thank you to the mothers who allowed me to use their stories and photos.

Next post will be a mother facing down her fears 
with a planned cesarean birth!

What's a Mother to Do?

Normally I take photos at births and write notes throughout the process. I think it is important to chronicle this important family event. I give them to my families and hope that they will treasure them forever. After two back-to-back high risk preemie births I felt these special stories needed to be shared. I had never experienced any births quite like these before. I learned an incredible amount and my hope in posting these stories is to educate future parents. Hopefully it will take some of the fear out of an incredibly fearful situation. 

Yesterday Ada Rose came into this world.
All 1 pound 10 ounces of feisty little girl. 

Thank you to Ada's parents for allowing me to share a part of their birth story. 

When babies come unexpectedly in the middle of pregnancy it is quite challenging for everyone involved. Suddenly needing to have a surgery to save your little one's life is scary as hell. Being separated from your new child fills a mother with fear and grief in every fiber of her being. Not being able to put her baby to her breast is an additional sorrow. Keeping it together under these conditions is heroic.

So what's a mother to do? Like every other mother she is going to do the best she can for her baby at that moment on that day. In this situation nothing helps a mother more than getting her colostrum to her baby. And of course the colostrum is VERY helpful to the baby. The colostrum of the mother who just gave birth to a premature baby is designed specifically for them. It has a special balance of nutrients to help their brains and bodies continue to grow outside the womb.

Getting the colostrum out of mom and into a teeny weeny baby who can't suck, swallow and breath yet is quite a trick. So what's a mother to do? Pump! Ada's mama was pumping by the time Ada was 2 hours old. The nurse at Sierra Vista tracked down a hospital grade pump. She brought it to mom's bedside and showed her all about it. I talked to her about tricks to help her let down her breastmilk to a pump.  We had just gotten started when dad got the word he could come be with their daughter in the NICU. I told dad to take photos and send them to mom. 

Poor mom looked devastated after he left the room. Of course she wanted him to go be with Ada. Of course she wanted him to not to leave her yet. After all she just went through major abdominal surgery; a really scary experience. Of course she felt it was totally wrong for him to be the first to touch and see her. Of course she felt horribly guilty for all of these conflicting thoughts. So what's a mother to do? Pump out way more colostrum than anyone expected!

Many mothers of preemies are able to only produce a few drops the first day or so. Vickie, the lactation consultant who came in said, "every flood begins with just a few drops. Don't worry how much you get. Just keep at it and your body will eventually respond." Wise words from a woman who works with breastfeeding moms every day.

While mom was pumping dad sent photos and a video back to the room of precious baby Ada. The photos were hard for mom to see; all the tubes and wires. Seeing her wiggle in protest weighed heavy on a mom's heart. I pointed out her perfection. That her color being so pink was a good sign. It meant she could get the oxygen they were giving her into her lungs, into her blood and circulate it through her body. How much better that she was trying to push them away than lying there limp. What a strong little girl she created. 

So what's a mom to do? Why pump out 3 whole milliliters of colostrum. That's what! It wouldn't all fit into the teeny weeny syringe the nurse had brought. They had to go get a larger one. The nurse exclaimed. The lactation consultant exclaimed. The NICU nurse exclaimed. They said, "Why that's about a week's worth of food for such a tiny little person." Yippee!

Mom sent the milk down the hall to her baby. They carefully put some on a swab and ran it around inside her mouth. Now mom's immune system is protecting her baby even though they are apart. Her colostrum is stuffed full of antibodies which can help give her the best chance on life. Right now she is too young to be able to suck, swallow and digest breastmilk. That day is coming though. It is just around the corner. Not to worry, mom will be ready. At 24 hours from birth she pumped out this much liquid gold. Priceless!

so the flood begins...

Every day in the nicu is a scary, hopeful, exhausting roller coaster ride for a family. Neonatal Intensive Care Units across the country are filled with babies and families every day. Please take a moment to hold them in your heart.

Read Eleanor and Caroline's premature twins story

When Home Birth Intentions Meets High Risk Birth

Thank you to Amanda and Jose for allowing me to share their story. 

Amanda hopes it will help other parents.

My third set of vaginal twins has a unique story. Like many of my clients Amanda came to me committed to a natural vaginal birth free of medical interventions, including pain medication. She wished for a home birth but she knew that wasn't possible in our area because she was carrying twins. So she settled on hiring a doula and planned to turn down as much medical "help" as possible.

But of course life rarely goes as planned...

One day, WAY too early in pregnancy, she begin to be concerned about how her body was feeling. Being a smart mama she listened to her intuition and took herself in to see her OB. Yes, her blood pressure was climbing dangerously. Before she could really grasp what was happening she was admitted to the hospital and begun on medication to bring it down.

I begin to capture Amanda's journey with my phone camera.

I came to the hospital and we talked for a long time about all the natural ways she could support her system and help bring things into a better balance, including her blood pressure. I reassured her I would come to give her birthing classes in the hospital. We strategized over how to deal with a long hospital bed rest.

One week later her water broke. Her body decided it was time to have her babies, 26 weeks or not. With contractions came climbing pressures. When I walked in Amanda was laying in bed surrounded by and attached to more medical contraptions than I have ever seen before. Blood pressure cuff, IV meds for blood pressure, IV fluids, heart monitor for mom, contraction monitor and 2 baby heart rate monitors. A bewildering array. The nurse was glued to the screen giving her all the info from all the machines. Amanda had to remain horizontal for her labor.

Let me explain. I have seen lots of moms hooked to LOTS of things but NOT a mom who was birthing without labor stimulants and/or pain medication. Here was Amanda in the midst of a high tech, high risk birth doing it "au natural".

So we labored. We breathed. We visualized. We relaxed. I sprayed the room with lavender and smoothed essential oil on her feet. We massaged her shoulders and gave her sips of water. Absolutely no food because of the high potential of an emergency cesarean. When her back began to ache I showed Jose how to use my purple rebozo to provide counter pressure with a mom on her back in bed.

The sensations were coming closer and getting more intense. With such tiny babies, with tiny heads the magic number of 10 as a goal for dilation goes out the window. You are ready to push whenever the cervix is pulled back far enough for a head to slip through. I was pretty certain we were closing in on pushing. Then Amanda began to make pushing sounds and spoke of pressure. I alerted the nurse and she did a vaginal check. Yep. No more cervix. Time to push out baby A.

Now everyone began to scramble. I don't know why they were all so surprised.

Vaginal twins are unheard of in some areas of the U.S. but here moms can birth vaginally as long as the babies are positioned right. Amanda's OB, stuck to that promise although he had plenty of opportunity to use the situation to send the birth down a cesarean path. He never once brought it up. When things got tricky he stayed calm and talked mom through exactly what needed to be done, including the urgency of the situation, enlisting her help without scaring her.

But twin births are required to take place in the operating room, just in case. So here we go...

Heading down the hall at Sierra Vista on the way to the OR.

On our way to push out two babies sans pain medication or pitocin.

  

At the last moment they separated us and made Jose and I wait in the waiting room while they got mom "prepped". I nervously wondered what they were prepping her for? Usually they make us wait outside while they put in an epidural before a cesarean. Poor Amanda was told to not push, even though you can't stop your body from pushing once it begins. A doula can really make a difference when this chaotic circumstance arises, but there I sat in the waiting room, waiting. So I snapped this handsome photo of dad sporting his hazmat birth suit.

At last we were reunited. The room was FULL of people. They had to have the whole OR team as if she was having a surgical birth just in case it suddenly became a surgical birth; obstetrician anesthesiologist, surgical nurses, labor nurse, plus 2 sets of recovery teams for the babies, respiratory specialists, Neonatal Intensive Care Unit (NICU) nurses, and pediatrician. Jose and I squeezed our way in next to Amanda's side.

Pushing in the OR is very difficult. A mother has to block out everything going on around her and stay focused on her body's sensations. At the same time she has to tune into the directions she is given by her OB. It takes a tremendous amount of concentration. Plus she is flat on her back. Not an ideal position for pushing something out of one's body.

Keeping lovingly connected is also a challenge with so many on lookers; especially when your heart is racing with fear for your little girls. Jose's physical presence was a powerful support.

Soon a slippery teeny tiny Eleanor is born...
                                                                                 





 to a room FULL of people ready to help.

 

A relieved Jose; one down, one to go!

2 pound 4 ounce Baby Eleanor gets help getting started

        Is there a baby in that bundle?

Mom meets Eleanor outside her womb room.

   Now we wait for Caroline to make her entrance...

Mom's blood pressure is up; Baby's heart rate is dropping.

Time to get serious about birthing this baby.

Forty minutes after her sister tiny Baby Caroline arrives;

 raising her fist in the air to say, "I made it!"

A very short cord makes for a very rough trip.

                                           
         Whew two babies born!            A relieved mom and grateful dad celebrate.

Two pound Caroline gets help getting started.

Preemies have no body fat and lose heat fast.  Saran Wrap traps heat.     
 Daddy gets as close as he can.

First father daughter photo with Caroline.

It's official! They're here.
I'm so blessed to be part of miracles.

I am grateful to all the many people who helped at this birth and who continue to help provide care to these teeny weeny babies. When I first began working as a doula these babies would have been flown to a hospital with a higher level of care than we had in the county at that time. Mom and dad would have been left behind to wait and worry until Amanda was healthy enough to discharge from the hospital.

Don't get me wrong. I still feel way too many babies born at Sierra seem to "need" to be taken to the Neonatal Intensive Care Unit. Almost all my clients have their babies spend at least a short period in the NICU for observation before being given the "all clear" to reunite with mom and dad. Please keep in mind most of my clients are not high risk and birth their babies vaginally. The conundrum for me is when a baby truly needs NICU care I am eternally grateful they can receive high quality, high risk care right her in our community. I am also grateful they are trying to move the NICU in a more family-centered, baby-friendly direction. 

Three days later I snapped this photo of an exhausted dad getting skin to skin time 

snuggled up with Caroline in the NICU.   

Shhhhh!!! Don't wake the baby.

        

Throughout it all Amanda has stayed strong. Threading her way through her increasingly complicated birth and postpartum period. She stuck to her goals of having as natural a birth as possible while never forgetting to safeguard her babies. The nurses at Sierra are blown away. They say, "You birthed preemie twins vaginally with no pain meds? Amazing!" It brings home for me the difference in our frame of reference because I never doubted Amanda a bit.

Twelve days old 

Cuddle time with mom at last!
 With all the stress Anna unfortunately ended up with a cold. 
She had to delay the sweetest of moments in a mother's life.

                                                                     

What a VBAC Calculator Shows

This morning I noticed this intriguing post in our local ICAN group's Facebook page:

I know this isn't an active group, but this is the only one of my groups where it seems appropriate to post this. Does anyone know where I can find info about the VBAC rates for home births and hospital births? I found this cool VBAC calculator, but it doesn't account for birth setting.https://mfmu.bsc.gwu.edu/PublicBSC/MFMU/VGBirthCalc/vagbirth.html

A Vaginal Birth After Cesarean calculator? Really? So I decided to try it.

It is always important to know who you are playing with so I investigated who created this calculator. OK it says it is based on data collected from an article "Development of a nomogram for prediction of vaginal birth after cesarean". A nomogram? Huh? That is just a geometric way of looking at multiple variables. The data set came from the Maternal-Fetal Medicine Unit Network. Here is their mission statement: "The MFMU Network conducts clinical studies to improve maternal, fetal and neonatal health emphasizing randomized-controlled trials. The aims of the Network are to reduce maternal, fetal and infant morbidity related to preterm birth, fetal growth abnormalities and maternal complications and to provide the rationale for evidence-based, cost-effective, obstetric practice." They are a network of university based hospitals. These teaching hospitals are where the births happened that form the statistics to base this calculator upon.

First the questions they ask to help them calculate are telling. They want your age and body mass index. Don't know your BMI? Don't worry they'll calculate it for you. They want to know if you have a "proven pelvis". What's that? It is a woman who has either had a vaginal birth before or after a cesarean. In other words at some point a baby "fit" through. They want to know if your cesarean was for lack of progress dilating, lack of progress moving the baby through your pelvis or some other reason. Other reasons could be twins, breech, high blood pressure, fetal distress, maternal fever, etc. They just lump all the other reasons into one category. Most distressing to me are their questions about race. They break it down by African-American, Hispanic and all others lumped together. What the hell? What on earth should race have to do with it?

So here is what I found when I did some calculations.  I kept all other factors the same except the one I was looking at. Trying to compare apples to apples. Let's look at age first.

Age 
They obviously feel age matters. I changed the age from 18 to 30 to 35. 
I had between 7% to 10% less chance of successfully VBACing at 30 than at 18 years old. The low end reflects women who progressed on their predetermined schedule. The top end reflects women who fell off the time chart plus were heavier. At 35 it drops again. Now I have 10% to 15% less chance depending on the other factors. Ugh! Obviously age is NOT something you can do something about or can you? How many 35 year-olds do you know? I have worked with many and some have the physical health of a 40 year old while others could pass for being in their twenties.

Weight
By adding 70 pounds to a white woman with no previous vaginal births and allowable progress during labor/pushing she has lowered her chances of VBAC success by 12%. If she had a "failed" labor the numbers move down to 16% because of the additional pounds alone. This may make some sense because weight can cause confounding health issues, such as high blood pressure.So if you want to VBAC stack the decks in your favor by starting at a healthy weight. Oh wait! If you want to avoid that first section be a healthy weight before you get pregnant and then work with someone who knows about pregnancy nutrition to stay on track.

Arrest of Labor
This is defined as absence of progress. So of course one must FIRST note that progress is a very subjective animal. The good news is this calculator says if you had a surgical birth for arrest or "failure" either during dilation or pushing your chances are only 9% to 12% less than the woman who didn't. As a doula I know it is critically important to look at WHY you stopped progressing or weren't progressing fast enough. Was the baby in a poor position? Was this a failed induction? Why were you induced? Too long past due date? How far was too long? Baby "suspected" of being too large? How large was he or she really? Induced for other health concerns, blood pressure, diabetes, etc.? Perhaps your water broke and labor didn't start quickly enough so you were given labor initiating drugs. Did you have an epidural? At what point in the labor? I can't stress how important it is to obtain ALL your records and to go over them with an experienced doula or midwife. Perhaps your "failure" to progress was actually THEIR failure. 

Race
Here is where they doubly fail women. Be prepared to get angry.
I went back and changed only race as a factor. So let's look back at the age issue WITH race added in. If I am a 30 year old woman of color I had a 10 to 16% less chance than an 18 year old. While a white 30 year old has a 7% to10% less chance.  And at 35 I as a white woman would have 10% to 15% worse odds but as a woman of color it plummets to a 21% less chance of success. Excuse me? What about race with weight? If I am a 30 year old white woman with healthy weight, no vaginal births and no "failure" the calculator predicts I have a 80% success rate in their hospitals. That same woman of color? 67.2%! That is a difference of about 13%. If  I am 70 pounds heavier I have a 16% worse chance of success than my white sister. 

So now I compared the best case scenario; 18 years old, healthy weight, no arrested labor c-section, vaginal birth before and after surgical birth, White to Black or Hispanic. Shockingly the numbers say a woman of color automatically gets 4% worse chance of birthing vaginally. That my friends is systemic racism in its most insidious form. It is in how they are treated from the moment they are in their doctor's offices until the moment they are discharged from the hospital. I have witnessed this unequal treatment. Every time it has angered me. Usually it appears to anger me more than the woman trapped in it. Perhaps because she has only her own experience to compare, whereas I can compare her to the white women I have supported. But here the numbers are; in black and white for all to see. A disgrace.

I did not intend for this to be a post about race. I started in thinking I was going to check out this calculator and compare hospital stats with homebirth stats. But the numbers took me a different direction. Here are two links for those of you who wish to compare homebirth and hospital birth numbers. They were posted by Terri Woods of SLO Doula Connection  in response to the ICAN query. She rightly warns that homebirth midwives automatically risk out a variety of complications and so it isn't exactly apples to apples. Still it is worth noting that out of 1,354 VBAC women 87% were successful. There is no way for me to do a straight comparison because I don't know anything about age, weight, reasons for prior sections or if they have had a vaginal birth either before or after their surgical birth. 

Science and Sensibility looks at the MANA homebirth study 

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

Planning to VBAC? Hire a doula. Plan a home birth. Hire a midwife. Get healthy and stay healthy. Finally question, question, question; especially if you are a Black or Hispanic woman. 

Consumer Reports: Cesarean Births

“How you deliver your baby should be determined by the safest delivery method, not which hospital you choose.” 

I couldn't agree more with this statement. Consumer Reports is beginning to tackle the issue of our disproportionate cesarean rate. The World Health Organization has determined that NO region, area or country should have a higher rate than 15% rate. Currently the US has a rate twice that and California's is even higher. The rate is "up 500 percent since 1970. All those C-sections have not translated into substantially better outcomes for mothers and babies. The infant death rate in the U.S. is higher than that of most other industrialized nations. And the maternal death rate actually increased slightly from 1990 to 2013, according to an analysis published May 2, 2014, online in The Lancet medical journal."

So What? 
Why should we be concerned? C-sections are safe right? Usually when they are done it is because they are safer for mom, baby or both, than a vaginal delivery right?
"A C-section—the second most commonly performed surgical procedure in the country, requiring a 6-inch incision in the abdomen and a second through the uterus—is major surgery, and thus takes longer to recover from than a vaginal delivery and also carries additional risks." 

Consumer Reports is also concerned that hospitals within a few miles of each other with similar populations can have such drastically different rates of surgical births. "And unfortunately, it’s usually much easier to find a hospital with a high C-section rate than a low one." 

Our Local Hospitals
To earn top marks a hospital had to have a c-section rate of between 5-9.5%. None of our local hospitals earned this ranking. Twin Cities comes in at the next best level between 9.5 and 11.5%. French is in the average zone at 11.5-15%. Both Marian and Sierra show up in the next to lowest ranking with between 15-21%.

Hey That's Not Fair 
You may be thinking Sierra Vista should have a higher rate because they have the high risk mothers. Consumer Reports tried to correct for this. "To level the playing field, the measure controls for some things that affect C-section rates, such as not including multiple gestations and breech births. However, this measure does not account for all differences in patient characteristics (such as chronic illness) that might affect the C-section rates of an individual hospital." So yes their rate should be higher because the high risk moms with chronic illness appropriately deliver there. The question is how much higher? Both Sierra and Marian are just a few percentage points away from being given the worst rating.

“We think it’s time those hidden numbers are brought to light,” said John Santa, M.D., medical director of Consumer Reports Health. 

Well said! Pregnant consumers and their families deserve this information in order to make true informed choices about their births.

Quotes were taken from the following 3 articles by Consumer Reports.

What Hospitals Don't Want You to Know About C-Sections:
Very good in-depth article with an excellent section on things to do to avoid a surgical birth.

Hospital Ratings; Avoiding C-sections: 
Their statistics

Safety Scores:
Finding your hospital's score.

More Research and Reading

What to Reject When You are Expecting
Good list of prenatal and during labor procedures to avoid

My Birth Statistics
Comparing my stats with our local hospitals

Dear Anatomy & Physiology Professor

Yesterday I finished a 12 week anatomy and physiology 2 part course. At the end I posted my professor a note in the discussion area.

I have enjoyed both Anatomy classes and have learned lots of information valuable for the various things I do. I am a birth doula, birth educator, La Leache League Leader, parent educator and more. I do have some ideas about the labor and birth chapter which I meant to contact you about. I'll still try to do that before the discussion areas get closed. 

Thank you,

Jennifer

The professor responded, "I'm glad you enjoyed the course and look forward to your input!"

So I spent a considerable amount of time yesterday going carefully through her lectures and formulating my response. I posted it into the discussion area as I had no other way to connect with her. I found out this morning that she took it down and sent me this reply, 

"To Jennifer,

Thank you for the information.  I am not able to keep that type of post up in the Discussion Area, but I read it carefully and copied and pasted it into a Word document for further review.  I am looking forward to checking out the references you included.  I think the pendulum has swung some on medication during childbirth.  When I was having my children (my oldest is 33 and my youngest is 18), women were encouraged to avoid medication if possible, while women in my mother's generation were significantly medicated.  Now, it seems that epidurals are used almost routinely, rather than reserved for special situations.

http://americanpregnancy.org/labornbirth/epidural.html

I think it's very important for women and their partners to learn as much as they can about pregnancy and childbirth, understand the pros and cons of different types of pain relief, think about their ideal situation for labor and delivery, and then discuss their wishes and concerns with a physician who comes highly recommended and who they trust.  

Thanks again for the info!"

I couldn't agree more. Women should learn all about the pros and cons, safety and risks of ALL medical procedures before they give birth but NOT in an anatomy and physiology class. In an anatomy and physiology class they should learn how a woman's body works without any outside interference. How her musculoskeletal, integumentary, sensory, hormonal, chemical and nervous systems work in concert to bring a baby into this world. 

Here is what I posted on the discussion board:

I have some thoughts about the sections in your lectures which cover normal vaginal birth. Let me explain my background. I have been a doula for over 20 years. In case you aren't familiar with this profession, a doula supports couples during the entire birth process and into the early postpartum period as well. I have been at over 100 births. Some have happened in homes and birth centers, but the majority of my clients have chosen to birth in a hospital setting. I have seen lots of babies come into this world vaginally and some via cesarean section. Along with this I am a birth educator and La Leche League Leader. La Leche League International has been educating and supporting breastfeeding women for over 50 years. They have the most up to date information and studies on lactation, breast milk, and breastfeeding. As a Leader I am trained to support mothers who desire to breastfeed through facilitating meetings and providing one-on-one support.

Throughout your classes I have been impressed with how well you explain the body's systems both anatomically and physiologically. The more I know about the human body the more amazing its abilities seem to me. I am very passionate about women, birth and families. It is very important to me that women are given accurate information about their body's birthing and breastfeeding abilities. Unfortunately in our culture women know very little about birth and what they are told is not at all from an anatomical and physiological stand point. Instead it is heavily mixed with cultural beliefs with no regard for science. Unfortunately I believe your section on birth is skewed in this manner. Women need to know how we were designed to give birth. If they then choose to use medical and pharmacological props or interventions that will be an educated cultural choice. As this is an anatomy and physiology course, I am hoping you will consider taking a more physiologic approach to how you present birth to women. Please understand I am NOT advocating women should birth without skilled help at the ready. How much they use or need that help will depend on their unique situation. I want them to learn what their bodies are capable of doing. 

Here is what I have learned from watching women, keeping up with the latest science, and opening my mind to see past our current birth culture. Women are designed anatomically to labor and birth in upright positions. Left to their own instincts it is very rare indeed for a woman to choose to lie down to birth, especially on her back. Imagine a woman choosing to lie flat on her back to defecate or urinate. Most un-medicated women will choose to stand, semi-squat, full squat or be on their hands and knees. Unfortunately all of your graphics clearly show the supine position. This position is brought about through the use of pain medication and for doctor and hospital convenience. It is considered normal only because of cultural influences on the physiologic birth process. Anatomically it flattens the pelvis and doesn't allow for the sacrum and coccyx to move out of the way of the descending head. It also immobilizes both of the illiac bones making it harder for them to spread laterally giving the additional space needed for the baby. You mention the doctor placing the woman in a semi upright position but as long as her bottom is against the surface of a bed she will be hampered in her abilities to birth unassisted, but unassisted is what we are anatomically and physiologically designed to do.

In your course you say the doctor will tell the mother when second stage has begun. But anatomically when a mother is un-medicated she does not need to be told when to begin pushing. When the baby descends to a certain point in the pelvis he naturally triggers the fetal ejection reflex in mom. Just as when you need to vomit you know you are about to vomit. No one needs to tell you it is time or how to do it. No one needs to say how long each vomiting session should last. This is exactly like the 2nd stage of labor. The mother, even a first time mother, will spontaneously begin to push with her diaphragm and abdominal muscles. She will not be able to help it. She will not be able to stop herself. She will naturally tend to push 3 times during each contraction for approximately 6 seconds. This amount of time works physiologically for the baby. When a mother is pushing she tends to hold her breath to bear down. This breath holding reduces the available oxygen to the baby. Six seconds is an amount of time that babies tolerate well. Longer than that can cause a drop in oxygenated blood with a corresponding rise in fetal heart rate as they physiologically struggle for homeostasis. 

The un-medicated mother will know when she is crowning from the burning sensations she will feel. Most mothers stop pushing and cry out. This releases the vaginal muscles and allows for the last stretching. I agree with you that it can be helpful for a provider to gently put counter pressure on the head to keep it from coming so quickly mom’s vaginal tissues tear but this is not how the system was designed. It was designed for the mother to birth like other mammals, without assistance. Further there have been many studies done that show that an episiotomy does not keep a woman from tearing. As a matter of fact they all agree that a woman is more likely to have a 3rd or 4th degree tear if she has an episiotomy. Currently most doctors only do an episiotomy if the baby's heart rate is dropping into the danger zone. In this situation it can be life-saving.  

When the baby's head appears the supine or semi-reclined position necessitates a care provider to hold the head so the head doesn't flop backward, hyper extending the baby's neck. When a mother births in a squat the head stays perfectly in line with the body as it hangs down. In your lecture you say the doctor will rotate the baby's shoulders but most babies rotate without any assistance. It is part of the anatomical fit between mother and baby that causes them to sort of cork screw out. It is only if their shoulder is stuck under the pubic bone that this doesn't happen. Finally rather than a doctor needing to catch the baby as you suggest, the mother is capable of reaching down and catching the baby as it pops out after the body rotates into position. I have witnessed this. 

As to the physiological process, you mentioned the hormones oxytocin and prostaglandin but equally important in the process are dopamine and endorphins. This combination of dopamine, endorphin and oxytocin is the same combo released during orgasm which causes intense pleasure and a feeling of floating. In labor this powerful chemical combination changes the laboring woman's perception of the pain allowing her to endure much more than she would otherwise. On top of that she is chemically driven to bond with her new baby as soon as he or she emerges. This is a very important feed-back loop which pitocin and an epidural disrupt. It has consequences for the next phase, mothering the baby outside the uterus.

The latest studies all show conclusively that immediate skin-to-skin contact is what we are physiologically designed for rather than taking the baby away even briefly and presenting it back to mother as a wrapped bundle. The mother and baby should continue to be considered one biologic unit. They share bacteria, hormones, body fluids, antibodies, fats and proteins. A neonate has no ability to self-regulate. He does this through his mother. Hearing the mother's heart beat and feeling the rise and fall of her breath regulates his heart rate and respiration. It keeps the levels of adrenalin and cortisol at their appropriate levels; enough to cause the baby to be hyper alert without causing him physical stress. Science has proven babies should not be taken away or wrapped in blankets. This is part of the WHO Baby Friendly Initiative. Their goal is to have all babies go immediately onto their mother’s abdomen or chest unless they need life saving measures. Normal suctioning doesn't count as life-saving. If needed this can be accomplished quite easily on the mother while baby remains skin-to-skin. They are to stay this way undisturbed for the first 2 hours of life so that all of the above sharing and regulation can occur. If you haven't watched a video on delivery self-attachment yet you will be amazed! We are much more like other mammals than we have given our babies credit. When un-medicated, undisturbed, and left skin-to-skin with mom they move themselves into position and find the nipple, latch on, and begin feeding. I just attended a conference where I was blown away by the latest info about epigenetics and breastfeeding. Breastmilk contains, histones, lepten, and microRNA, which all pass to the baby. They attach into their genes and change how the genes are expressed. This is an important further step in passing on genetic information from one generation to the next.  

The third stage is more easily accomplished if baby stays with mom. This triggers further oxytocin release, especially if the baby latches and begins to nurse, which stimulates the placenta to fully separate and then keeps blood flow to the amount which brings mom back to homeostasis. She loses the extra blood she created to maintain the pregnancy which she no longer needs. There is no need for "a little bit of pitocin" as you have taught unless the mom actually IS bleeding too much. Again our physiology is miraculously designed to take care of most contingencies. Only when it is not able to do its job successfully should we vary from this amazing design which you clearly have so much respect for.

Finally I want you to imagine what would physiologically occur if the mother and neonate were all alone immediately after birth. What would the mother do? Would she immediately clamp and cut the umbilical cord as you have stated the is done in our hospitals? Highly unlikely. Therefore what is supposed to occur? As you detailed so well, the baby's circulation and respiration have major changes that need to happen. These will generally take place quite peacefully without any gasping or stress to the baby. There is significant pressure around the baby's chest when it is squeezing through the vagina. When the baby is born there is therefore a significant drop in pressure which causes air to try to rush into the lungs. Also there are nerves in the skin of the neonates face which, when exposed to air for the first time, trigger him to breath in. This is why babies can be born under water and not drown. They do not attempt to breathe until their face is lifted out of the water. Further as long as the cord and placenta are intact and still pulsing the neonate continues to receive oxygenated blood from the mother through the placenta. The cord is covered with a substance called Warton's Jelly. When the air hits the cord it dries this out and triggers the cord to slowly stop pulsing. Meanwhile inside the baby his body is working to close the foramen ovale and reroute the blood. Most cords will pulse for 5 to 10 minutes after birth and placentas stay adhered to the wall for anywhere from 15 to 30 minutes. This gives the baby buffer time. I don't believe in this scenario there is a fall in blood PH, but I could be wrong. This also gives the mother/baby system time to bring their blood exchange into homeostasis with the neonate receiving exactly the right amount of blood. If you clamp the cord too soon you will leave 1/3 of the fetal blood in the placenta. This blood is needed by the neonate for many reasons. They are discussed in one of the links below. 

Thank you for listening and thank you for expanding and deepening my knowledge of the human body. I'm very glad I took this class. If you wish to ask me further questions about labor, birth or breastfeeding please email me at jenniferstoverdoula@gmail.com.

A standing unassisted birth video: https://www.youtube.com/watch?v=zFMHB4RqpjI  

An MRI study of Pelvimetry in 3 positions:

http://www.ajronline.org/doi/pdf/10.2214/ajr.179.4.1791063

Further explanation about up right positions: http://www.givingbirthnaturally.com/birth-positions.html

Discussion of labor hormones and how catecholamines disrupt the natural hormonal cascade:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595201/  

Fetal Ejection Reflex: http://www.wombecology.com/?pg=fetusejection

Delayed cord clamping: http://www.scienceandsensibility.org/?p=5730

The requirements for a hospital to become Baby Friendly certified:http://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative/the-ten-steps

Importance of skin-to-skin contact: http://www.medscape.com/viewarticle/806325

Breast Crawl video: https://www.youtube.com/watch?v=zrwfIcPB1u4   

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