Unnecessary Cesareans

A group called The Unnecesarean pointed out today that anesthesiologists, themselves, are aware that WALKING in labor (“ambulating” in medical terms) reduces cesarean rates. Though I am an advocate of natural hospital birth, I share the goal of reducing unnecessary cesareans. It seems to me that if “walking epidurals” are known to reduce the risk of cesarean in women who want epidural anesthesia, we should be offering these more often. (Please know that I say that with the belief that no woman should be offered anesthesia in labor that she does not want. Women who want a natural birth deserve FULL support for this!) As “The Unnecessarean” points out, the anesthesiologist quoted in this article is blunt in admitting that it is “easier” to manage laboring women in bed. But labor is not about ease. It is about birthing the next generation. It is worth the hard work of women AND hospital staff!

Here are some excerpts and a link to the article. Thank you to The Unnecesarean for pointing this out.

Most notably, only four of the patients who received a walking epidural experienced hypotension compared with 44 patients in the nonambulatory group. Only 113 in the walking group required bladder catheterization compared with 187 in the nonambulatory group. Motor block was seen far less frequently in the ambulatory group (14 vs. 145 patients in the nonambulatory group), and cesarean delivery was less common as well (53 vs. 65, respectively).

On the other hand, patients who received walking epidurals reported more pruritus and required more interventions, as demonstrated by higher total PCA volume and use of rescue doses of ropivacaine. The duration of labor was unaffected.

“Even with the benefits to the patient, walking epidurals are not used very often because they are more time-consuming in terms of patient management,” said study leader Shaul Cohen, MD, professor of anesthesiology at UMDNJ, in New Brunswick. “It’s much easier to keep them in bed with a Foley catheter. And it’s an insurance issue. Insurance companies pay for care not quality of care, and they won’t pay for the additional time and staff required by walking epidural.”

Dr. Cohen added that the increased use of cesarean delivery—nearly 45% of laboring women in New Jersey now undergo the surgery, he said—makes it more difficult, if not impossible, for obstetric anesthesiologists to offer patients the walking epidural approach.

Others in the field have a more tempered view of its benefits, however. “There is no ‘ideal’ epidural infusion regimen for labor analgesia,” said David Wlody, MD, chief of anesthesiology at the State University of New York-Downstate Medical Center, in New York City, and a specialist in obstetric anesthesiology. “Different patients, anesthesiologists and obstetric providers will have different expectations regarding pain relief in labor,” said Dr. Wlody, a member of the editorial board of Anesthesiology News, who was not involved in the latest research.

“Some patients may be willing to tolerate a greater amount of discomfort if it means enhanced ability to ambulate, while others will desire more pain relief at the expense of increased motor block,” Dr. Wlody added. “It is the responsibility of the anesthesiologist to balance these often conflicting goals in order to provide the best outcomes and the highest degree of patient satisfaction.”

http://www.anesthesiologynews.com/ViewArticle.aspx?d=Clinical%2BAnesthesiology&d_id=1&i=May+2013&i_id=956&a_id=23112#.UaSyPv1c7Q0.facebook

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The Power of Just the Word “Doula”: Bringing Natural Birth into the Mainstream

I see my main job not as a doula, but as a public advocate whose mission is to mainstream natural birth. That doesn’t mean that I PREACH about natural birth (unless I am preaching to the choir at a doula or midwifery conference). I’ve found that preaching doesn’t get me very far when I am talking to the uninformed, underinformed, or people who actually disagree with me. But I do try to take advantage of situations in which it makes sense to tell positive birth stories and bring up my profession as a doula. Just saying the word can be a powerful catalyst in a room of people who’ve never heard it.

I watched it happen today, except it was not me who said the word. It was a college student, just explaining to other students in a class why he had missed class the day before.

His wife is a doula. She had been attending a birth for twenty-four hours. He had to stay home and watch their toddler.

I teach anthropology at a working-class state university in Michigan. My students are a DIVERSE group, though they are usually poorer and come from more disadvantaged backgrounds than the students at the fancy state university (University of Michigan).  That tiny spark — a man saying the word “doula” to fellow students — resulted in several conversations right there in front of my eyes. I didn’t start the conversation. I just stood there, basking in the glow of people talking about birth and realizing that there are more options than they knew. Ripples. Seeds planted.

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University of Michigan Hospital and Natural Birth

I got to speak at University of Michigan on Saturday to a packed room of what looked like 100 people or more. Wow! There were nurses, midwives, doctors, doulas, and pregnant women conversing together. Again, wow! It’s so great to be HAVING these conversations. Here’s an article from the University of Michigan website:

Hospital can provide safety net without pushing interventions; expert panel discussion planned at U-M March 24

Nadine Naber labored with a midwife, who guided her through her pain. Her husband was at her side, holding her hand, as she gave birth to her youngest son in a water-filled tub.

It was everything she dreamed a natural childbirth could be. But it didn’t happen at home — her son was born in the hospital.

Naber is one of many women who find that a natural hospital birth — a childbirth without medication or other intervention — is possible at Von Voigtlander Women’s Hospital at the University of Michigan. U-M has eight nurse midwives on staff and encourages women to set a natural birth plan that still offers the advantages of being in a hospital setting.

“I truly and deeply experienced what I would dream of with a natural birth, in every way possible, without any sense of it being medicalized,” says Naber, a 42-year-old mother of two and Ann Arbor, Mich. resident.

Naber says the natural hospital birth offers the best of both worlds: a birth plan without unnecessary medical intervention but also the safety net of the hospital setting.

U-M and Douglas Care will host a panel discussion, “Supporting Natural Birth in Hospital Settings,” on March 24, featuring author and professional doula, Cynthia Gabriel. Gabriel’s book, “Natural Hospital Birth: The Best of Both Worlds,” features a forward written by U-M’s Timothy R.B. Johnson, M.D. , who is professor and chair of the U-M Department of Obstetrics and Gynecology.

 http://umhsheadlines.org/20/natural-births-possible-encouraged-in-hospital-setting-at-university-of-michigan/

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I’m going to speak at DONA International Conference

This is a quickie post to let you know I will be speaking at the DONA International Conference in Cancun, Mexico as a keynote speaker in July 2012. Come to Mexico with us! I’m so excited!!!! Here’s the link to the conference site: http://www.dona.org/Conference2012.php

I’m planning a session on “Secrets to Support a Natural Hospital Birth” and “Regifting the Gift of Birth By Developing Empathy for Hospital Staff.”

Who’s coming???

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Fourth in Series: Why Hire a Doula (Reasons that don’t usually make the top ten)

Hire a doula because…

She will come to your house. None of the rest of your hospital birth team will do that.

If you are planning a hospital birth, one of the hardest decisions is “when to go to the hospital.” Your doula will come to your house in early labor and help you decide when is the right time to head to the hospital. Believe me, you will trust her judgment in this far more than you will trust your partner’s (unless s/he happens to be a birth professional!). This important decision can affect how you how your labor progresses and how many interventions you may encounter.

Most women go to the hospital TOO EARLY in labor! There’s nothing worse than getting sent back home in early labor.

Why do we go to the hospital too early? Because we all want to believe that we have progressed further than we have. When we have experienced labor for three hours, we want to believe our cervix has dilated to eight centimeters and delivery is immanent. However, especially for a first baby, this is unlikely.

An experienced doula can gauge your labor progress better than you can (unless you are an experienced mother). That’s not to say she knows your labor better than you do, but she has seen and heard other women in labor. She knows what active labor sounds like and looks like. It’s quite distinctive. There are some women who do not fit the usual pattern, certainly. But in my experience as a doula this is rare. Active labor sounds surprisingly similar for most women! I know midwives who can diagnose active labor quite accurately from listening to women during contractions on the phone. Having a doula help you decide when to go to the hospital helps you avoid getting to the hospital too early.

Why Going to the Hospital in Active (Not Early) Labor is a Good Idea:

Hospitals do not like to admit women before they have reached active labor. The hospital staff, and your doula, know that if you are in early labor you are more susceptible to having your labor slow down (sometimes slow WAY down!) if you change locations. Because we are mammals, our bodies are designed to slow or stop labor if we need to use our brains. Our bodies cannot tell the difference between having to use our brains to figure out how to escape a hungry lion and having to use our brains to answer the triage nurse’s questions. Either stimulation can cause our hormones to change and our labors to slow down or stop.

This is less likely to happen once we have made it to active labor (defined loosely as the cervix dilated to around 5 centimeters). Then, hungry lion or not, our baby is probably going to come pretty soon.

It is especially important to arrive at the hospital in active labor if you are planning a natural hospital birth. The later you arrive, the less time there is for interventions! If your labor is progressing at a leisurely pace, you do not have to worry about beating a clock or losing a favorite nurse at a shift change when you are at home.

Your doula helps you decide when it is the right time for you to get to the hospital. She knows what kind of birth you are planning and she can help you optimize your chances of achieving the birth you want.

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Third in Series: Why Hire a Doula (Reasons that don’t usually make the top 10)

Hire a doula because, when all is said and done, she is the only one at your hospital birth (besides your family and friends) who answers to you as her final boss.

Your midwife, doctor, and nurse are probably wonderful and probably they want to help  you achieve the birth you want. But midwives, doctors, and nurses who work in hospitals have to answer to a lot more people than just you. They have to answer their colleagues. If they manage births in an unusual manner, and in today’s world, “unusual” may mean “more natural” just because of the statistical realities of interventions, their colleagues can exert subtle or not-so-subtle pressure to get back in line. And they have to answer hospital review boards and insurance companies. Insurance companies have a lot of impact on our medical institutions. Since obstetricians are the most-sued doctors in America, you can imagine that insurance companies care how they are practicing!

But doulas do not answer hospital review boards or insurance companies. They answer to mothers. Doulas are there for mothers. It is their entire job. One hundred percent. They do not have to spend time during your labor inputting lots of data into computers. They are focused on how you feel.

So it is definitely a good idea to make sure that your entire birth team is on board with your birth vision. It’s a great idea to make sure your care provider can handle whatever comes up (even if that means transferring your care. Transferring is still great care.). But it’s also helpful to hire someone who answers only to you. When you look in her eyes for reassurance in your decision-making process, you can be certain that she is reassuring YOU. She is helping you make the best decision for YOU.

Do you have any stories that exemplify this? I’d love to hear them!

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Second in Series: Reasons to Hire a Doula (that don’t usually make the top 10)

Reason #2: The Five Minutes You Will Remember Forever if You Don’t Have a Doula

Some pregnant couples hire me and I know throughout the pregnancy that I have been a valuable resource to them. Others hire me and I don’t do much during the pregnancy, but I play a crucial role during labor. And still others hire me and I do very little for them during pregnancy or labor. They are well-informed, well-prepared, and labor goes smoothly. Mom and her partner are tucked away in a private world I can barely touch. I am basically superfluous.

Yet sometimes even these couples get their money’s worth from hiring a doula. They can get hundreds of dollars of value in just five minutes. I have learned over time that one of my most valuable gifts to new parents in a hospital setting (and even, once, at a homebirth) is the connection I can facilitate between mother and newborn in the first five minutes of the baby’s life. Unfortunately, at many hospital births, no matter how natural labor might have been and no matter how dedicated to natural birth the parents might be, babies are often whisked away from the birth canal straight to a warming bed across the room. Sometimes the reasons for this are clear (such as the presence of the baby’s first poop, called meconium, during labor, which must be prevented from entering the baby’s lungs) and sometimes the reasons are not at all clear. The problem, however, is that the new parents are virtually powerless. Worse, they are scared.

That’s what I mean by the “five minutes you might remember forever if you don’t have a doula.” Because when babies get taken across the room to be “worked on,” usually there is no explanation given but there is a ton of fear. All medical attention in the room is on the baby, the mother’s uterus, and the mother’s perineal area (managing the birth of the placenta, getting ready for stitches, etc.). Because the nurses and neonatal team may intend to keep the baby only for a few minutes, they do not think about how those five minutes feel to the new mother. The nurses and doctors are extremely busy in those minutes: measuring, assessing, rubbing, using a syringe or other tools to clear airways, etc. These professionals are probably experiencing time as rushed. The new mother, across the room, however, is likely experiencing time in quite the opposite way. For her, these moments after hours of contractions and pushing feel like openings onto eternity. If she does not hear her baby cry and see her baby move, she can panic. Those five minutes can be full of the worst fears of her lifetime: her baby has been born dead. Mutated. Not human. She will never hold this baby alive. If there is silence, she may hope for the best, but some animal part of her that is supposed to be soothed by touching her newborn will pull up the ancient fears of death-at-birth.

Knocking on wood, all of the babies I have watched wiggle into this world have been born alive. But many of them needed some help in the first few minutes to adjust to breathing air, pumping blood through their hearts, and feeling comfortable in our world.

So, in those critical first five minutes, I have given myself the task of narrating the baby’s life to the mother. If the baby is taken away from Mama, I stand somewhere in between the two and relay details of what I see. “Oh, I see your baby’s feet kicking! Oh, this baby looks mad that these nurses are cleaning him off!” I say. Or “Oh, your baby is so beautiful! She has so much gorgeous hair (or she hardly has any hair, but I think it’s brown).” Or “You probably can’t hear him, but your baby is making some noise over here! He has something to say about what’s going on.” Anything. Anything at all. Anything concrete about this new child. I try to convey a sense that this baby is here, this baby is alive, this baby is a person.

This fulfills two purposes simultaneously. I do this narration for the mother, so she can focus on the details I am describing and not on her fears. She may, this way, avoid the worst five minutes of her life, worrying needlessly that her baby is not all right. Secondarily, this narration affects the hospital staff. It reminds them that the mother is waiting, WAITING!, for her baby, and that getting the baby back to the mother is of utmost importance. I like to believe that this narration — this reminder that a human mother is waiting to meet her new child — helps the staff put off the unnecessary tasks (like weighing the baby, washing the baby’s skin more thoroughly) until later. If the baby’s life is not in critical danger, s/he belongs with Mama. Everything else can be done on her chest or it can be delayed.

I have found this process to be equally helpful whether I am attending a vaginal birth or cesarean birth. If I cannot be in the room at a c-section, I often pull the father/partner aside and suggest this idea. The new mother on an operating table can feel even more helpless, even more scared about how her baby is. She needs instant reassurance that her baby is real, her baby is here, and she will touch her baby soon.

As doulas, we can sometimes prevent babies from being taken away from their mothers in the first moments of life. But we can always, always commit to narrating this time. Most of the time, doulas do a lot of important work prenatally and during labor. But I think we can earn our keep, even if this is practically all we do. Have you ever been in this situation?

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First in a Series: Why Doulas Are a Good Idea (Reasons that don’t usually make the top 10 in books)

Reason #1: A doula can relieve your partner in a long labor. Sometimes the tasks required of a partner during a labor can be impossible without backup support from a doula. A labor that lasts through several mealtimes or all your normal sleeping hours can wipe out not only mom-to-be, but her support team, too. Doulas can allow partners to take 20-minute naps (or in really long labors, two or three hour naps) and visit the bathroom without being worried about leaving you alone. I once played back-up doula for a long labor in which the first-line doula AND the father needed relief. They had been supporting the mom-to-be for almost 36 hours straight and neither the doula nor the dad had slept for more than about 30 minutes. I came in the middle of the night for a four-hour relief stretch. I barely knew this couple, but I slipped into the dark room and quickly learned how to give back pressure the way this laboring mother needed. Her doula and partner went to the lounge to sleep. Mom and I worked together without saying much, just in the rhythm of labor. She was handling her contractions well; she was just exhausted. She, too, slept in between sensations. At dawn, the doula and father returned and I said good-bye. The doula and father agreed to take one-hour shifts after that so that they didn’t burn out. The baby was born, healthy and beautiful, about six hours later.

As a post script to this story, I ran into this woman two years later and found out that she had become a doula herself. She said she was so amazed at the support the two of us had given her and her husband that she wanted to give that gift to other families. She gushed about how incredulous she was that I had come in the middle of the night to offer relief to her support team. It was nice to hear, but it was also easy to say, “That’s what doulas do!”

BTW: here’s a link to a “10 Reasons To Hire a Doula” article by Ann Douglas. They are all good reasons. Excellent reasons. But I am going to try to write down the “other” reasons here in this series. The reasons that it’s GREAT to have a doula, but that most people don’t think about until after the fact (or, often, until it’s too late!): http://www.ohbabymagazine.com/prenatal/why-doulas-are-a-moms-best-friend/

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Who Should Come To My Birth?

A: whoever will give the laboring mother a sense of calm and expectation. She thinks about being in active labor in the presence of a particular person (her mother, her best friend, her sister, her father-in-law, etc). When she imagines that person with her in labor she smiles. She knows that she will feel more energized, more secure if this person is with her. Invite this person!

Conversely, if a pregnant woman thinks about being in active labor around a person and finds herself wondering what that person will think or how that person will behave, if she frowns even just slightly while she imagines this person there, this is not a person to invite.

This process changes from birth to birth. The right birth team for your first labor is probably different from the right birth team for your third labor. We change. We grow. We need new kinds of support.

Anyone who wishes they could be with you in labor but who is not invited should have a special job to do during labor. Some of my favorite assignments for such people (grandparents, often):

1. Bake a birthday cake for the baby

2. Purchase the day’s newspaper and a lottery ticket

3. Have dinner ready for the family when they arrive home

4. Send them to the store for some absolutely necessary supplies: more diapers, more wipes, more baby blankets, whatever you can imagine needing. Just make it sound IMPORTANT!

5. Serve as the conduit for information to the rest of the world during labor. The dad or doula can make one phone call or send one text to this person who can then broadcast any information to the world that the birthing family desires.

6. Write a letter to the new baby on its birth day to welcome her or him to the world!

Why do I believe that a woman’s intuitive knowledge of who will support her best is the way to decide? I have a simple answer. A woman’s body is designed to shut down labor if she perceives even the smallest threat to herself. It doesn’t matter how much you love your mother or your friend. If you feel judged by this person in any way, you can compromise your labor. It’s not worth it. Be selfish! Consult your inner wise self and no one else.

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Informed Consent Thoughts

My sense is that informed consent is only as good as the people enacting it.

After my last post (inspired by an obstetrician’s blog post about how inane the IC process feels to him in its current form), I remembered a recent experience during which the informed consent process seemed especially silly. The anesthesiologist was required to get an IC form signed by a woman in early labor who was planning a natural birth. She rolled her eyes as she gave it to him. She was very angry that she had to see an anesthesiologist during her natural hospital birth. It sort of negates the whole plan of “not being offered pain medication unless I ask for it,” eh? Given that informed consent is, in part, about acknowledging the decision-making power of the patient, it felt especially ironic that she had no power to make the decision not to be offered pain medication. (Our hospital requires this in early labor.)

It  made me think about a distinction we make in anthropology between “ideal” and “real” forms. In its ideal form, informed consent is supposed to help all the parties involved. There is a certain expectation that information will be presented neutrally, I think, so that the Decision Maker (in this case, a laboring woman) will be able to make her own (uninfluenced) decision.

But that ideal is impossible to attain because the person asking the patient or laboring woman to sign a form is exactly the person who is advocating a particular course of action/treatment. There’s no neutrality there by definition. So as some doulas and midwives say, it can feel more like “informed coercion” than “informed consent.” When it works like that, it can feel inane to all involved, I think. Why go through the motions if they are nothing more than motions?

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