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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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I stumbled across two reviews of my book today! Yay!

One is here at projectmommybrain. She JUST reviewed another book called Momma Zen that sounds great and I am ordering from my independent local bookstore Nicola’s.

The other is at http://didyouknow-cecette.blogspot.com/2011/08/natural-hospital-birth-section-one-part.html

where she, amazingly!, devotes four posts to reviewing specific sections of the book. Wow!

I admit that it feels wonderful to read positive reviews of the book that I spent so many years working on. I think I am especially happy to find these amazing words by women I do not know because I received my first pretty bad review at amazon a few weeks ago. I knew it would happen eventually — and I also know that the birth world is full of strong opinions because we are all such unique strong mamas! — but understanding that intellectually and facing my first bad review in reality are two different things. I remain grateful and excited about all the mothers, fathers, doulas, midwives, doctors, and childbirth educators who are expanding the circle of natural birth every day, everywhere.

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A Very Interesting Article.

I ran across this the other day and shook my head. As an anthropologist, I have to answer back! You see, anthropologists (including archaeologists) are humans who are shaped by the culture in which they grow up. So from about 1880-1960, archaeologists and cultural anthropologists from the United States and western Europe happened to notice aspects of so-called “primitive” cultures that confirmed their belief that there has always been a clear and firm gender division of labor. They gathered all kinds of evidence that men “hunt” and do “public” work while women “gather” and do “family” work. (Later anthropologists found that this clear, easy divide was often made up by the anthropologists who somehow failed to see things like men doing lots and lots of gathering because hunts were so few and far between. And, my favorite, is a recent article by an archaeologist who examines body weight and determined that men (fathers and brothers) must have done most of the carrying of toddlers and small children on frequent, long walks.)

These happen to be the same years that homebirth midwives were being pushed out of their profession by medical doctors. Birth was moving more and more into hospitals until, after WWII, there were more hospital births than homebirths in the United States. (The UK and Canada had a slightly different, but similar, history.) Women were increasingly drugged during labor and the rates of cesarean section climbed through the 1900s (and SOARED at the end of the century). Birth was increasingly seen as “dangerous” and “risky.” Hiring medical specialists to intervene in the process was a sign of prosperity and progress.

So it is no wonder that archaeologists (mostly men!) of the time interpreted the fossil record in light of this insight that birth is “risky” for human women. Indeed, human pelves are significantly different in shape from those of our nearest relatives (other apes). This “story” about the trade-off between bipedalism (walking upright on two feet, which ultimately changes the shape of pelvic bones) and giving birth to our young has been the dominant story for a long time.

Luckily, some anthropologists who grew up with feminism have taken a second look at that fossil record.  I love reading the work of Dana Walrath, an anthropologist who studies the evolution of human pelves (the plural of pelvis — cool, eh?). She believes that it has been pure sexism in archaeology and medicine that created this “birth is dangerous because of bipedalism” story (though understandable, given our cultural history). The feminist story is that we human women are amazing creatures who are incredibly highly-evolved to give birth to our babies. She’s got the bones to prove it! Check out her articles such as
1. Walrath D. (2006) Gender, Genes, and the Evolution of Human Birth, in Feminist Anthropology: Past, Present, and Future. PL Geller and MK Stockett (eds.), Philadelphia: University of Pennsylvania Press.
2. Walrath D. (2003) Re-thinking pelvic typologies and the human birth mechanism. Current Anthropology 44(1):5-31.

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It always feels so awesome to feel like you’ve made a difference in someone’s life. I met Heather Boyd last year as a student in one of my classes at Eastern Michigan University. I always offer “alternative” projects in my classes and in my medical anthropology class that fall I said that students could take a training program in becoming a doula, homeopath, herbalist, etc in lieu of a final paper. Heather took me up on the idea and became a doula that semester. She told her classmates all about the first birth she attended. I think they were all a bit in awe that she was out there, supporting a family at a hospital birth, while they were researching things like ADHD treatment in on-line journals. Last semester, she and two other students helped collect over 200 letters to representatives in support of Michigan midwives. This year, Heather is creating a non-profit “Students For Midwifery” and writing a workbook for teens who are pregnant. Check out her project on RocketHub and consider donating what you can. Twenty-five dollars? Ten? Five? It all adds up to better birth. http://rkthb.co/4703

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If you are in a committed relationship with the parent of your child, hire a doula so your partner can be scared!

I mean it. Your partner deserves to feel all the emotions that come with labor and that includes the very normal fear that usually arises when we see loved ones in pain. You know the faces of the families of Olympic athletes? While the athlete looks cool as a cucumber, her husband’s face looks drained of color, her father’s eyes are darting nervously here and there, and her mother can only watch through tiny holes she makes between the hands covering her eyes. The family is full of emotion. Does the athlete look to her family members for reassurance that she can really, truly do this? No! She looks at her coach for that reassurance. She looks to her family members for something else: for their love and support. It just wouldn’t be fair to require her family to be calm and collected.

And it’s not fair to ask your partner to be calm and collected during your labor. This is the person who loves you most of all in the world. They deserve to feel all their feelings, including their fear and anxiety and worry, during your labor. It doesn’t mean that those feelings will eclipse all the other feelings they will have in labor. They will also feel excited, elated, proud, inspired. But asking these people to be superhuman, to be able to reassure US while we are in labor even when they may be feeling worried themselves, is asking them to suppress their own experience so that we can have a better one. I think it is more loving to acknowledge that you are in this together and the TWO OF YOU need support.

Of course there is a role for partners, a very important role. These wonderful people can say, “I love you” during labor and it is like magic. When my husband said those little words I swear the contractions melted away. I felt buoyed for a few seconds in the ocean of LaborLand. 

But my husband was scared when I was in labor. What he offered me in labor and what my doula offered me in labor were completely different. When I got scared in labor and asked questions like, “How much longer will this go on?” or “Is this normal?” I did not turn to my husband. He has never seen another birth, so if he answered those questions, frankly, I wouldn’t believe him. But my doula I believed. When she said, “You’re safe. Everything is going perfectly,” I could let go of my fear and hold tight to my husband’s hand. 

My husband and I rode our roller coaster of emotions through labor and birth. For him, as well as me, there were moments of sheer terror. As a doula, I often say things like, “You’re safe” at a birth and I know that I am speaking to a couple, not just a laboring woman.

 

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Hire a doula to avoid an induction!

There is an epidemic of inductions occuring in the United States and Canada right now. The Listening To Mothers II Survey found that, “More than four out of ten respondents (41%) indicated that their caregiver tried to induce their labor. When asked if the induction caused labor to begin, more than four out of five of those women (84%) indicated that it did, resulting in an overall provider induction rate of 34%.”

(You can read more about it at http://www.childbirthconnection.org/pdfs/LTMII_report.pdf)

At the end of pregnancy these days, there are a host of potential reasons your caregiver might suggest an induction. UNLESS YOU HAVE SOMEONE TO TALK TO about it, you are likely to go along with the suggestion. Think about it: at 38 weeks, most of us feel DONE with being pregnant. We’re ready to meet our babies! So when someone offers to make that happen, like, tomorrow, it’s hard to resist. Especially if they add a medical-sounding reason to the idea.

But the fact is that most women do not grow babies too large to birth and most women have plenty of amniotic fluid. But these reasons to induce are offered to many, many, many women nowadays. It’s just not possible that 41% of North American women have suddenly developed narrower pelves and have less amniotic fluid. We have more information (like estimates of amniotic fluid levels) because of more technology. But more information is not leading us to make better decisions. Instead, our caregivers feel compelled to give us the information and the “worst-case scenario” associated with that information. That worst-case scenario is likely to sway us toward induction.

But if we are able to wait a few hours, breathe, relax, think it all through, we can make the decision that is right for us. Of course, there are some situations that call for an induction. But there are many, many more that do not.

Here’s where your doula comes in. Your doula will not be able to give you medical advice and she will not be able to make the decision for you. But she can offer help in YOUR decision-making process. She can ask questions. She can point you to resources. She can connect you with other women who have faced similar dilemmas who might be willing to share their wisdom. She can tell you stories. She can suggest a long list of natural induction methods you might try before going the medical route. She can guide you to think through how you might feel if this induction turns into either an epidural or a cesarean.

In short, she can help you make your best decision. It might be that the best decision is to induce. It might not. However, talking your decision over with your doula — someone who knows your birth plan, your birth vision, your birth dreams — will help you have peace of mind.

I run mom-and-baby groups in my hometown. So many new mothers come to our group with great sadness and regret about how their labors went. They say, “If only I had known…” a lot. A doula is like insurance against regret. She helps you make your decision fully and consciously so that, no matter what happens later, you have confidence that you made the right decision to begin with.

[P.S. Why does avoiding an induction matter? Because when women are induced, a host of other interventions often follow (called “The Cascade). A common drug for induction, Pitocin, makes contractions feel more painful. FOr a woman planning a natural birth, this can really get in the way! But even for a woman planning an epidural, Pitocin contractions in early labor can be a problem. If you get an epidural before active labor really kicks in, your labor can be long and slow. But if you wait until active labor is really going, you will probably have to weather some significant, unplanned-for pain. In other words, no matter what kind of birth you are planning, Pitocin gets in your way. (If you want to read more about this, I refer you to either Henci Goer’s book “The Thinking Woman’s Guide to a Better Birth” or my book “Natural Hospital Birth.” Both of these books talk about Pitocin in detail.)

Another important reason to avoid induction is that the rise in induction rates corresponds with a rising rate of babies born prematurely. If our dates are off (which they often are!) we could be asking our babies to be born a few weeks too soon. Nature has a fabulous plan for your baby’s birthday. Let a doula help you avoid an unnecessary induction and discover your baby’s “real” birthday!]

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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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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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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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Dear Academic OB/GYN,
I am new to reading your blog, but really enjoying it! The issue of “informed consent” is really a unique issue for us here in the United States. (For my blog readers, you can see Academic OB/GYN’s post on the surgical consent form which follows below or head over to her blog at http://academicobgyn.com/2011/06/20/on-the-surgical-consent-process/).

I’ve worked in Russian hospitals (as a midwifery apprentice and as an anthropologist) and in Canadian hospitals (as a doula) and their approaches were so very different in tone and feeling! There was no informed consent process in the Russian hospitals (in 2000-2001) and the process in Canada felt much more like what you describe at the end of your post: a friendly chat.

That said, I think it is a fault of how we all in America — doctors and patients, professionals and laypeople — imagine medicine that creates a problem. Doctors are people (I love reading books like “How Doctors think” or “Complications” to remind me of that!), but sometimes we all pretend that doctors are really computers. We do not expect human indecision or unknowing or, God forbid!, human error. We expect perfection. This is true in many arenas, not just medicine. Our culture is very black and white. If something goes wrong with anything, someone must be blamed. Shades of gray or the idea of joint responsibility don’t fit our cultural expectations so well.

Finally, I am not sure that all doctors are capable of talking the way you describe. Some are; many are not. It is not just the moment of getting a signature on an informed consent form that matters. How doctors talk (or don’t talk) with patients matters all the time.

At the last birth I attended as a doula, a medical resident took over from an experienced midwife when the baby’s heartrate was non-reassuring for too long. She never introduced herself to the woman giving birth or her husband. She cut an episiotomy and put in an internal monitor and started using a vacuum with not one word of explanation. There were several seconds of silence in between contractions, so it was not because of lack of time. My client will never see that doctor again in her life. That doctor will never know how her treatment felt to those of us in the room. But as the doula, I have listened to three conversations in which my client is trying to understand what happened to her “beautiful birth” in those minutes. With just a few words, I think my client could have had it all: medical help in a possible emergency AND a beautiful birth.

I do not even entirely blame this doctor. We have created a medical education system that penalizes many doctors if they try to be well-rounded, emotionally-intelligent, full human beings. Probably, if this doctor experienced a major obstacle in her personal life in her first year as an intern, she was not going to be given empathy, kind words, time off to relax and rejuvenate, understanding, etc. She probably faced a spoken or unspoken expectation to tough it out. What we reap as a culture, we will sow.

In Russia, there was certainly a divide between doctors and patients. But in one area, I watched with amazement at how quickly the barriers fell down. That was in the area of pharmaceutical treatment. Diagnosing was the purview of the physician; but treatment was often a mutually-negotiated conversation that occurred between equals. Why is that? Well, most of the doctors and patients shared a common, deep knowledge of herbs. Everyone at my birth hospital seemed to share a tacit understanding that herbs were the preferred method of treatment, if possible, and pharmaceutical drugs (like antibiotics, painkillers, etc.) were only a second option.

The entire culture expects urban Russians to spend time gardening and foraging in forests (for mushrooms, herbs, etc.) as a normal part of life. It’s the best way to spend a summer weekend in Russia! That ubiquitous hobby has a strong impact on the way that doctors and patients interact in the maternity ward. Many Americans hear me talk about this and immediately jump to attack the Russian medical system. I know there are problems there (as there are here), but my experience was in a beautiful, well-run birth hospital with intelligent, capable doctors, midwives, and nurses that boasts excellent outcomes. And, in this one arena at least, there was a model for doctors and patients being able to discuss treatment options as equals.

Those consent forms, I think, are supposed to remind patients that they share in a joint responsibility with their caregivers for their own healing. Perhaps they also remind physicians that interventions are never risk-free. But in the end I believe that real conversations between two real people are the best protection: from lawsuits, from errors, from decisions we later regret. Legal documents are a mere shadow of that human connection.

Here’s the blog post:

Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit. We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed. Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.


As usual, I discussed what we could expect to gain from the hysterectomy. There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better. Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.
We also discussed the risks. “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery. You could get a communicable disease from a blood transfusion. You could develop a wound infection or abscess, which sometimes is easy to treat and other times quite complicated. Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures. Anything damaged can be fixed at the time by myself or a consultant. There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury. If this occurs you might need further surgery, antibiotics, or hospitalization. Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”
At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons. I am well trained to do this surgery and will do my absolute best for you.” I answered her questions, the consent is signed, and we had our pre-op.

While this consent process is quite standard, it just seems a little ridiculous to me. Its a bit like asking your neighbor bring your son home from school, and having her say “we may get hit by another car, I might run a red light, we may run out of gas on a train track, there might be a meteor that hits the car and kills us all…. but don’t worry I am a good driver and your son will be fine.”
The fundamental reason we do these consents is that we believe that in some way they will protect us in a lawsuit if something bad happens. For example, let’s say somehow I transect a ureter in my patient’s hysterectomy, I can say “See – I said this was a risk of the surgery… it wasn’t my fault!”
But isn’t that a bit ridiculous? Is telling somebody that something bad could happen actually a defense if that bad thing does happen? In some cases a problem is truly random, such as the development of a pelvic abscess after a hysterectomy, but in other cases it is not. There is almost no situation in which I could cause a ureteral injury and have it not be a surgical error. If it happens, I did it – and it was a mistake. Ureters are damaged in about 1% of hysterectomies, but its not like they magically get injured in 1% of cases. In 1% of cases the surgeon makes an error.
When I was a resident I worked with one attending that thought along these lines as well, and had a very different consent process.
“We are doing X surgery because of X. I’m a good surgeon, and think I can do this surgery without a problem. You need to sign this paper or the hospital won’t let me operate. I think it will go well, but anything can happen, and if it does and you think its my fault you can still sue me.”
This all seemed very glib the first time I heard it, but I have to say I have always had a lot of respect for that attending’s honesty. He was telling it like it really was, even though it wasn’t necessarily the smoothest way to go about it. He was indeed a very good surgeon. His partners thought he was a bit nuts, though.
The trouble with the standard consent process is that it doesn’t deal with the real issue; errors do occur, and physicians cannot be perfect. By naming error-driven events as statistical occurrences, the process supports an expectation that surgeons will never make errors, and thus the corollary that any surgical error is a de facto breach of physician’s fiduciary duty.
Every time I do a standard consent process, I think about doing it differently. Perhaps something like this:
“We are doing X surgery because of X problem. I am well trained to do this surgery, and think I can give you a great chance at an good outcome. Your surgery is something I know I can do well, but I cannot guarantee that you will not have a problem. I can only guarantee that when I do your surgery I will be well rested and that my team and I will do our best.
Sometimes when bad things happen during or after surgery it is a random event. There are certain things we can do to reduce these events, and we will do those things. Another kind problem can be because a member of my team or I makes a technical error. While I do my best to operate perfectly, it is possible that I could make a mistake. I have occasionally done so in the past, and will no doubt do so again in the future. As I have always learned a great deal from these rare mistakes, I hope to think I will never make the same error twice. Fortunately, almost every error is recoverable, and I know how to make those recoveries. If we have a problem, I will be there to fix that problem and help you through whatever recovery is necessary. I will explain the problem to you, and if I know, I will explain how it happened.
(now sign this paper or the hospital won’t let me operate )”
I often wonder if the common legalese consent process we go through actually protects us. Ultimately, we are bound to meet the goal of “The Standard of Care”, and we don’t get to define that standard on our consent form. Lawyers love to say that this standard is readily viewable in any textbook, but in reality its pretty grey. The exact definition changes from state to state, but usually is defined as what another reasonably practicing physician of similar training and situation would have done in the same situation. Fortunately, reasonably practicing physicians of similar training and situation also make mistakes from time to time, and usually lawyers and juries recognize that. As long as one recognizes the mistake and does the right thing from there forward, usually one has a reasonable defense.
So let’s just say that up front. We are well trained, and we do our best. If we screw up, we’ll let you know that, and we’ll fix it. Now sign here.

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