Feeds:
Posts
Comments

Posts Tagged ‘C-Section’

Control Photo

This is a quick reflection on how birth is about “the unexpected” and about how important it is that women be in control of decision-making in birth precisely BECAUSE so much in birth is unexpected.

I think there is nothing worse than expecting one thing, having something entirely different happen, and feeling like the decisions were not in my control. Yet, this is what happens in birth across America every day.

We all have some vision in our mind of how our “perfect birth” will go. And I have yet to meet the woman who achieved her vision 100%, although I’ve definitely met a lot of women who are happy with their experiences. I’m always amazed at how even women with seemingly perfect births can obsess about the things that did not go right! (That’s a post for another day, because, come on! Let’s start talking about what went RIGHT at our births!) But this post is not about those seemingly “perfect” births.

It’s about the births in which we’ve planned really well, we’ve hired just the right support team, we’ve done everything we can to ensure that our vision has the best chance to succeed…

and then the baby decides to turn her head sideways or come out foot-first

or there is a flood/tornado/hurricane/outbreak of SARS (that last one happened to friends of mine who gave birth in Toronto!)

or our midwife is sick

or our blood pressure gets dangerously high during labor

or whatever….

And we have to improvise. We have to make decisions that we wish we didn’t have to make. We accept interventions because we know they are the right thing to do in the moment, but we also know that we researched and planned for HOURS and WEEKS and MONTHS to try to avoid them.

It’s just so important that women have as much decision-making control (and support) in birth because when these scenarios arise we will feel so differently about them when WE said, “Yes, it’s time for that intervention” than when we felt like it “happened to us.” Our healing for the days, weeks, and months after the birth will hinge in many ways on whether we feel like we had no choice or whether we chose.

We may be sad and angry that we did not have the perfect birth we envisioned, but we will not feel tricked, disempowered, or trampled upon. We can be sad and angry and also, simultaneously, grateful and empowered. These do not have to be mutually exclusive.

Advertisements

Read Full Post »

ID-10020876

“I can’t afford a doula,” said a pregnant woman to me recently who was only a few weeks away from giving birth. “And, anyway, my husband is going to be there.” We chatted a while about the kind of birth she was envisioning. This was her first baby. She had a strong desire to avoid a cesarean and to give birth without drugs. She really didn’t want a “huge needle” in her spine.

This mother had clearly done her research and knew that many of the interventions that are so common in American childbirth are unnecessary. She had a lot of statistics at the tip of her tongue and we discussed many of them. I could tell she was determined to beat the odds, even though when you think about these odds, you probably would not bet against them in Vegas!

Eighty-three percent of American women receive pharmaceutical drugs for pain during labor (despite polls that show that most women say they would prefer NOT to do so). Ninety-one percent of American women lie on their backs or just a bit propped up when they are pushing out their babies. Forty-seven percent have bladder catheters during labor (which means they are NOT walking around). The list of interventions goes on and on. (These statistics come from the study “Listening to Mothers III.)

When I asked her how she thought she would avoid these common interventions, she said, “Well, I’m informed. I’ve done my homework.” She imagined herself just saying “no” to these interventions during labor.

This is when I asked whether she’d considered hiring a doula and she told me she couldn’t afford one. I asked how much the doulas she interviewed cost. She had not interviewed any doulas, but she’d “heard” that they cost $1,000.

In my town, only the most experienced doulas charge $1,000 as birth doulas and the real going rate is somewhere between $350-700. So her data on this point was inaccurate. But this woman’s tone indicated that this line of inquiry was closed. She was just not open to the idea of hiring a doula in these last weeks before giving birth and I could tell that continuing that conversation was not an option.

But if she had been open to the conversation, this is what I would have said to her:

It’s possible that you will have the kind of labor that never gets really hard. You might pay $1,000 and realize at the end of the day that you and your partner could have handled that birth without any outside help at all. It does happen. I have met such women before.

It’s possible that you will have the most amazing labor and delivery nurse who reads your birth plan and gives you a lot of labor coaching because she is a strong believer in natural birth. Even at the moment when you say, “I can’t do this anymore. Get me an epidural!”, this nurse will say back to you, “You’re doing great. Just focus on this contraction.” And you will focus on this contraction and the next one and after a few minutes that feeling like you can’t do it anymore fades away and you start to feel the urge to push. This also happens. I have met such women before.

It’s possible that your midwife will maintain a calm and protective aura in your room and never let you know that there is a resident just down the hallway who is watching your baby’s heart rate monitor and suggesting all kinds of interventions. This happens. I have watched it happen in hospitals in my town.

It’s possible you will be able to speak calmly and rationally throughout your labor. It’s possible that you will be able to interact with your hospital staff very rationally and weigh pros and cons of interventions on the spot. It’s possible that when the obstetrician says something like, “I’m a bit worried about your baby and I’d like to get some more information. I’m going to break your bag of waters and put in this internal monitor,” you will be able to say, before the next contraction hits you, “Oh, thank you so much for your concern. Is my baby in real danger right now? Could you tell me the pros and cons of this procedure?” And the obstetrician will patiently wait at your bedside while you handle an intense contraction that lasts a minute and a half. When you’re back to yourself, the doctor will touch your arm gently and explain the particular situation with your baby (who is not in imminent danger) and the pros and cons of breaking your water and using an internal monitor. Except that the explanation will be interrupted by four more contractions. But you have the best obstetrician in town, who will patiently wait through all of these contractions. You will be able to ask specific questions about parts you don’t understand. You will ask about alternative ideas. And you will be the kind of woman who is still able, after all this, to say politely, “No, thank you. After considering your explanation, I don’t want to do this right now. Let’s wait a little while longer.” It’s possible.

Although I want to tell you that I have not really met more than a handful of women who can do this during an active, strong labor.

This is where women who want natural births without unnecessary interventions often end up “giving in” and later regretting it. They are deep in the physical work of labor and they can’t really (and shouldn’t really!) concentrate on logical conversations. All the intellectual information we have gathered during pregnancy really does us almost no good when we are in labor because we are not really able to access much of our intellectual knowledge during labor. It’s much easier to say, “Yes,” during labor than it is to articulately say, “No, thank you.”

We imagine ourselves as our everyday Self in labor. Our everyday Self may be a strong, educated, and even opinionated person who is able to advocate for herself. But our Labor Self is a different self. Our Labor Self is strong and educated in a very different way, in a sensual, physical way. Labor Selves rarely articulate themselves well in full sentences and well-considered arguments.

You don’t pay $1,000 (or, more often, $500) for the labors that are easy and that you could manage without help. You pay $1,000 (or, more often, $500) for the possible times that having a doula changes the game.

So, if we are playing the Vegas odds, let me tell you that while it’s possible you will have that easy kind of labor in which your doula is really unnecessary, the odds on it are not very good. Maybe 3 in a 100. But the chances that a doula has something to offer you in labor that turns out to be important? Well, those odds are worth betting on. I’m going to put that at about 89 out of 100 or even higher.

In case she is needed, what will she be needed for?

Maybe for fifteen hours of squeezing your hips because when she squeezes your hips during a contraction, the pain changes from unmanageable to just manageable. But.only.if.she.squeezes.your.hips.EVERY.TIME.

Maybe she will help you walk around the hallways when your labor seems “stalled” at six centimeters and the hospital staff say it is time to think about a cesarean for “failure to progress” and it turns out that getting moving helps your labor a lot and you are eternally grateful for your doula’s insistence on walking before agreeing to the cesarean.

Or back to our scenario of “rational decision-making” during labor. It might feel like you paid $1,000 for her to whisper to you, after the doctor explains the pros and cons of the intervention, “I know you’ve heard what this doctor has said. Do you want a minute to discuss this with your partner?” And you nod your head. The doctor leaves the room and your partner is able to ask you, without a lot of eyes and ears around, “I know how important doing this naturally is to you. Do you want me to tell them we don’t want to do this and we want to wait a few hours?” And you can nod your head. You don’t have to say any words. You have a team that knows what you want, a team that knows how to create a situation in which you are likely to get it, and that does not expect you to talk rationally.

Let’s be honest that most women in America will not pay even one penny for this kind of support. Around 94% of American women, in fact. Maybe for these women paying $1,000 (or $500!) is not worth it for these “moments.” They are happy enough to go along with the routines of the hospital and have the kind of birth that the hospital staff guides them toward. If their labor is medicated and no one suggests anything “hippie” like walking around or using a shower to manage labor pain, if they end up with an unnecessary cesarean, they are pretty OK with it. They choose the route of “going with the flow” and that route works well for them.

But if you are the kind of woman like the one I met at the park the other day, the kind of woman who has done her homework and knows the statistics, who wants to beat the hospital intervention childbirth odds, then I would roll my dice with a doula. Every time.

photo by Salvatore Vuono

If you want to read more about ‘Listening to Mothers III” you can find a report here:http://transform.childbirthconnection.org/wp-content/uploads/2013/06/LTM-III_Pregnancy-and-Birth.pdf

Read Full Post »

 

Brazil ImageBrazil has a cesarean rate that is, depending on the year, the highest in the world. Their rivals include Taiwan and China, but not the United States. Here we hover around the 33% mark, but in Brazil about half of all babies are born by surgery and in some urban, private hospitals the rates are in 70-90% range.

To put this in perspective, if we took a 20% cesarean rate as “normal” (and I do not think that is normal!) as a 2010 World Health Organization report did, several million Brazilian women are having unnecessary cesareans every year. That report calculated a world-wide excess of 6.2 million cesareans annually and half of those are in China and Brazil.

(http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf, p. 8).

Why is the cesarean rate in Brazil so high?

If you ask Americans, they tend to blame Brazilian women.  Almost invariably, the first ideas we Americans have are about how the WOMEN must want more cesareans, how the women must be more used to surgeries (since they have so many more plastic surgeries than American women), how the women must be more concerned with keeping their vaginas tight and beautiful, how the women must not be willing to undergo labor.

But when I ask Brazilians in the United States, they tell me the same things that American women tell me. They say things like, “My doctor told me I didn’t have enough amniotic fluid” or “My baby was too big to be born vaginally” or “My baby was in distress.” In other words, Brazilian women understand their own cesareans as medically-necessary, even though statistically it can’t be true for most of them. (The same phenomenon occurs in the United States, I find.)

A 2014 article in the Atlantic confirms this. That article concluded that the medical system is not set up to support laboring women who are aiming for vaginal births (much less unmedicated vaginal births!). In hospitals where 70% or more of births are by cesarean, women who aim for vaginal birth are nuisances to the schedules of doctors and nurses. And it is a self-fulfilling prophecy that doctors and nurses who are skilled at cesarean birth become less and less skilled at managing natural labors.

All of this adds up to a fascinating cultural picture that I am eager to learn more about. So I am headed to Brazil at the end of May for a two-week crash course in all things birth in Brazil. I will be in Florianapolis with Ana Paula Markel, doula trainer extraordinaire, and in Belo Horizonte with my Portuguese teacher, who has promised to introduce me to young women and their families who are in the thick of this childbearing conundrum.

I’m so excited! If you are Brazilian, Brazilian-American, or an American who has given birth in Brazil, I want your stories!

Here are two articles if you’re interested in more.

http://www.theatlantic.com/health/archive/2014/04/why-most-brazilian-women-get-c-sections/360589/

http://www.pri.org/stories/2014-05-14/brazil-half-all-mothers-have-c-sections-whether-they-want-it-or-not

Read Full Post »

So, I wish I wrote this about the cesarean rate. And I wish I made all the great graphics to go with it. But, even though I didn’t write it myself, I’m in love with this piece. It’s really helpful for answering the question I get all the time, “So, why do you think the cesarean rate is so high?” I can talk, talk, talk about all the reasons, but this piece just quickly runs through the reasons and more importantly gets to WHAT WE CAN DO actually.

Let’s get to it!

http://www.toprntobsn.com/bringing-birth-back/

Read Full Post »

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?

Read Full Post »

Wide variation in C-Section rates: to those of us in the natural birth world this is NO surprise.

Here’s my suggestion: rather than try to “route out” the doctors who are doing too many C-Sections, let’s study the doctors with the ten percent rate of C-Sections and find out what they are doing differently. What are they doing RIGHT that could be copied by other doctors? Just slapping the hands of doctors doesn’t help. We need to point them in the right direction. Let’s focus on the best practices, not the worst.

http://www.boston.com/news/local/massachusetts/articles/2011/05/17/state_study_finds_wide_variation_in_c_section_rates_at_hospitals/

Read Full Post »