Monday, October 31, 2011

I Am a Homebirth Advocate and This is Why

This week I received a comment about looking for homebirth blogs, as I seem to be geared towards those planning a hospital birth.  It's true, the last several posts have been geared towards alerting the hospital birthers about certain practices/policies to be aware of.  I certainly don't want to be known as a Bradley birth blogger though!  Statistically, up until this last year, 25% of my students have birthed in the hospital.  Over the last year, it has gradually flip-flopped to 75% are out of the hospital.  This is what happens when a birth center makes your class required for their clients though! 

I have birthed two babies in the hospital and two at home.  I believe that a woman will birth "best" where she is most comfortable -- physically, and more importantly, emotionally.

Over the years, the normal progression for people that take my class has been this:

Baby #1:  Switch from an OB to a CNM, remaining in the hospital (just in case).

Baby #2:  Switch from a CNM to a CPM and birth in a freestanding birth center.

Baby #3:  Birth baby at home with a CPM and wish they had done that from the very beginning!

I decided to go through the homebirth blog posts I have written over the last three years and link to them this week.  Enjoy!

I found so many other posts that were related to homebirth -- dozens when it was mentioned -- but these are probably the ones that homebirth is the main focus.  Still aggravated after all these years that "homebirth" is flagged as not being a word.

Romy's Birth Story from Ceci Jane on Vimeo.

This video of my co-chapter leader for TCBN, Shannon, about sums up the beauty of homebirth. Ceci is another TCBN chapter leader and she did this amazing video. Shannon had an incredible team of women there, all hand-picked. Her husband was incredibly touched by the love and support they received as they welcomed their new baby into their family. It is evident on everyone's face this was a glorious homebirth. I am so lucky to work with such talented people. If you haven't seen this video yet, grab your tissues. Then go read all these homebirth posts I've written over the years!

Monday, October 24, 2011

Pushed into Supine Pushing Positions

When I was thinking about getting pregnant with my second baby, I visited my OB, Dr. Brian Wolsey, that "delivered" my first baby.  I had been gathering lots of information and knew I would do things differently with the second baby.  One of the questions I asked him was how he felt about me pushing in a different position besides flat on my back.  He got down on the floor (in his very nice clothes), and on one knee, contorted his body, and while looking and reaching up, said, "Well, it's kind of hard to catch a baby in this position."  He was more concerned with his comfort than mine when it came to pushing my baby out.

I never returned to his office.  

This is an important question to ask your care provider. The answer should be a respectful "Let's see how you feel when it comes time to push.  The benefits to using gravity and an upright position are ...    An example of when you might not want to use gravity is ..."

I've had a number of people return to class saying things like, "My doctor said I can hang from the rafters for all he cares" or "I can squat on the floor like I'm in the jungle!"  They seem happy with these responses, but in reality, your doctor is making fun of you.  He thinks its undignified and foolish.

If I am an OB -- or even a Certified Nurse Midwife -- working in a hospital, chances are, approximately 90% of the births I attend is with an epidural.  The mom is mostly on her back.  Like it or not, this is how I get used to catching babies.  This is what I am comfortable with.  Even to have a mom on hands and knees, well, this looks different to me, and I am not as comfortable with this situation.  I will find a way to get this mom on her back.  I will give her lots of excuses that sound really good, such as, "The baby is caught on the pubic bone and I need you to lean back."

If a woman is left alone to choose her birthing position, very often she will use gravity in some form or another.  Rarely will she lay flat on her back to push her baby out.  Squatting, for example, is known to widen the pelvis up to 30%.  Many OBs will not suggest a mom get up and squat, but instead, will cut an episiotomy to get the baby out quicker.  Or worse, perform a c-section because her hips were "too small."

I simply wanted to let women know that what position you birth your baby in is your choice.  This seems common sense, right?  I routinely hear women talk about their doctor wanting them in a certain position when it comes time to push.  Pushing while flat on her back can cause more problems that it fixes.  The only person benefiting from this position is the OB. 

When you ask your care provider this important question, listen for silly answers that are really meant to make fun of you.  Listen for responses that put his/her comfort above your own.  The good answers are the ones that inform and respect you and your comfort.  Follow what your body is telling you to do.  Don't let them push you around when it comes to pushing your baby out!  

Monday, October 17, 2011

It's Just an IV -- What's the Big Deal?

I posed a question on my Facebook page this weekend asking if an IV was required at your place of birth.  As expected, the majority of those birthing in the hospital said yes.  I recently had an IV when I went for a colonoscopy, and I must admit, I did not like it.  My number one complaint is that feeling of cold fluid running through my veins.  Not a fan. 

What about for labor though?  Should an IV be a part of a normal labor?  The hospitals think so.

Let's face it -- nearly everyone who finds themselves on the Labor & Delivery floor will have an epidural.  Or an induction.  Likely both.  Before an epidural is placed, a mom will receive a couple of bags of IV fluid.  Epidurals are notorious for causing the blood pressure to drop, so these fluids are necessary.  Here's why they want you to have an IV when you walk through the door:  The minute you say you want an epidural, they can give it to you.  Otherwise, they have to wait for these IV fluids to be administered.  They believe that you will eventually beg for the epidural, no matter how many times you say that you want an unmedicated birth.  I hate to sound paranoid - or make others paranoid - but the truth is quite ugly when we talk about IVs.  You will very likely have other things running through an IV besides saline water, with pitocin at the top of that list.  Even if you don't have pitocin during the labor, you will assuredly have it after your baby is born to "aid" in the delivery of the placenta.  If you have an IV, you won't even know pitocin was added.  They simply do not ask your permission. 

Antibiotics are often added to an IV.  This is given, typically, under three scenarios: 

1) Mom develops a fever.  This could be due to infection, but epidurals cause fevers in many women.  Since we aren't sure either way, antibiotics are administered.
2) Water is broken so antibiotics are given routinely, you know, just in case she might develop a fever.  (Can you hear my eye roll?)   

3) Mom tested positive at 36 weeks for Group B Strep and antibiotics are standard procedure.  This post is not a post about GBS, but suffice to say, antibiotics are very necessary if the baby actually acquires GBS on the way out of the birth canal, but only 2 out of 1000 babies that are born to GBS-positive mothers will be affected.   One-third of women will test positive, so that is a lot of women receiving antibiotics -- just in case.   I have strong feelings about antibiotics from my own personal experiences, but you may not care one way or another.  Maybe you feel that it is better to be safe than sorry.  It's a decision each parent needs to make for themselves.

Is an IV ever necessary in labor?  In short, yes.  A woman in labor should be eating and drinking plenty of water.  Water is crucial in helping the uterus work effectively.  Without it, the uterus can become "irritable," often making an IV necessary.  Under these conditions, she'll often experience contractions close together and intense, but only lasting about 30 seconds.  An IV might help her stay hydrated and therefore causing more effective contractions.  If a mom can't keep fluids down, she might also require an IV.  As with all interventions, there is a time and place for everything.  IVs should not, however, be a routine part of a normal labor. 

 It seems that many moms end up consenting to a hep-lock, which is an open vein.  If they need to give you an IV quickly, they won't have to "fumble" to find a vein.  To quote one of my Facebook readers, "They said it was in case there was an emergency and I started to bleed out.   I said "If you're telling me if there isn't anyone here that can save me in an emergency if I dont have an IV line in already then I need to leave because I don't feel safe." They laughed, said good point and left me alone."  The hospital group I refer to in the Fort Worth area, the UNT Health Nurse-Midwives, have not required even a hep-lock for my students unless there was a medical reason to do so.  

One more thing I found extremely interesting about IV use in labor.  This can have a negative effect on breastfeeding.  Mellanie Sheppard, IBCLC, explained this at a Tarrant County Birth Network meeting one evening:  When a woman has IV fluids, she becomes swollen and puffy until the extra fluid has time to leave her body.  This can include extra fluid in the breast.  A woman who didn't think she had flat nipples before now may have a problem with the baby latching properly.  She might be started on a nipple shield and thus started down a road that could have been prevented by simply avoiding the IV in the first place.  

Last week I wrote about various policies that contribute to the high c-section rates and neglectfully left routine IVs off that list.  It should have been there.  Drink your water.  Talk to your care providers.  If you are choosing to birth in the hospital, search out the care providers who practice evidence-based maternity care.  You will likely have to concede on some issues, but choose your "battles" carefully and thoughtfully.   

Monday, October 10, 2011

Hospital Policies that Encourage these Outrageous C-Section Rates

Over the years, I have narrowed down the hospital policies that are the biggest problem for moms who want to have an unmedicated birth.  Short and sweet!  Here are your red flags:

1)  The use of continuous Electronic Fetal Monitoring (EFM).  I wrote about this one last week.  This chains mom to the bed.  She's not moving around, helping her baby figure his/her way out.  This policy is applied in nearly all hospital births.  It's very convenient for the nurses, but not for the mom.  Evidence indicates that it is not safer for the baby and the c-section rates rise when EFM is used.  Check with your hospital and your care provider.  If your care provider "approves" intermittent monitoring, make sure that gets written in your chart.  (Just a heads up -- while this improves your chances of not having EFM, it is not a guarantee.)

2)  If your water breaks, you are in bed for the duration of your labor.  They claim this is for your benefit, saving you from a c-section, as the umbilical cord could suddenly slip out, endangering the baby, making a c-section necessary.  The chances of this actually occurring are about .3% of all births.  How can you prevent this from occurring?  Don't let anyone break your water!  This is more likely to happen if the baby is high in the pelvis.  If your baby is low, this is not really a risk.  Also, if this is going to occur, it usually happens when the water breaks. 

A couple other things worth noting that may or may not seem obvious:  You will be on a time clock once your water breaks (find out what that means at your place of birth - usually 12-24 hours), so you really want to do things that encourage the baby to come.  Laying in bed on a monitor doesn't really do that!  Pitocin is usually started after water breaks.  Evidence just doesn't make a lot of sense with this policy.  They say that they are trying to prevent you from having a c-section, but by keeping you in bed, that is exactly where you are headed!

3)  Vaginal Exams every two hours.  The reason women are given vaginal exams are because they have epidurals and can't feel when they are ready to push.  A woman who isn't numb doesn't need to be told how dilated she is or when to push.  Failure to Progress is the 2nd most common reason women have c-sections (2nd to already having had a previous c-section).  So let's add this up:  She's in bed, on a fetal monitor, having vaginal exams every two hours.  She's not moving or using gravity. I know of a hospital midwifery group that hardly ever does vaginal exams, unless there is a medical reason to do so.  This is how it should be.  Many women will stay at a certain number of dilation for many hours and then suddenly dilate in a short amount of time.  Labor is not all about the dilation of the cervix!  Vaginal exams are directly related to the dreaded time clock. 

4)  Does your hospital employ midwives?  This is a big deal.  If there are not midwives at your hospital, only the medical model of care is practiced.  This is the only model the OBs use and the only model the nurses see.  The midwifery model of care views labor and birth as a normal process.  The medical model views childbirth as a medical emergency waiting to happen. They believe that medicine and technology improve the safety and process of birth.  

5)  Does your hospital have a no-VBAC policy?  Then they don't trust birth and they don't read the evidence.

Finally, don't ignore the red flags.   I could go on and on about policies that the majority of hospitals have that are problems for a natural birth mama.  Follow your gut.  There are great places to have your baby.  Seek them out.  Hopefully this list will be helpful on your journey.  Don't be a victim!  Like I always say, as long as your baby is still inside, you have options.  This is your birth.  Choose a birth place that respects your wishes and shows reverence towards your special day.

Monday, October 3, 2011

Electronic Fetal Monitoring -- Is it really saving babies?

 As Tim McGraw's biggest fan, I subscribe to a number of Country news emails and Facebook groups.  I skip over most of it, but sometimes I'll see something that catches my eye that is not even related to Tim.  As you can imagine, it usually has to do with someone having a baby.

A couple of weeks ago it came across my News Feed that Jewel was showing off her new baby.  She lives in this area of Texas, about an hour from me, and because we have about a 50% c-section rate, I was very curious how things turned out for her.  (I had heard that she had desired a "natural birth.") 

The story goes that she was doing Hypnobirthing -- no details available.  Could have been self-study or CDs, maybe a class.  So I assume that desiring a "natural birth" really did mean an unmedicated birth, not just a vaginal birth.

The article went on to describe how violent the Braxton-Hicks contractions were and put the baby at risk.  Yadda, yadda, yadda... she had an emergency c-section that miraculously saved her baby.

The singer, who studies hypnobirthing, was eager to have a natural birth, but things didn’t work out as planned. When Jewel started having early Braxton Hicks contractions, Kase’s heart rate dropped. She admits, “I feel lucky to be pregnant in the modern age where they could actually tell he wasn’t well during those contractions.”  

In the end, Jewel says her scheduled birth plan wasn’t what was important to the young family. “We felt thankful that we had good doctors and a good hospital nearby, and that everything was OK,” she says. “I’m so lucky that we have a healthy baby boy. That’s all I cared about.”

I can't help but think this poor reporter got his terms mixed up about the contractions, and there's little information to go on from there.

Regardless, how many women have had c-sections that truly believe they were necessary -- that their baby would have died without the surgery?  Countless.  The year the Electronic Fetal Monitor was introduced, we went from a 5% c-section rate to 23%.  Studies have shown time and again that a baby who is truly in distress will be picked up with intermittent monitoring.  (Side note:  "intermittent" means different things to different care providers.  It may mean during and between a couple of contractions per hour, or 20 minutes per hour.  Find out what intermittent means at your place of birth.)

One of the problems with the continuous monitoring is the lack of communication between the birth team and the parents.  Mom is monitored from down the hall, and when a nurse does walk in, she tends to look at the monitor and not the laboring woman.  Another problem is obvious:  mom can't move around and help her baby out.  The baby is left to figure it out on his/her own. 

Problem number 3:  Any time a mom receives drugs of any kind, she'll be put on a monitor to be sure the baby is handling it OK.  This can mean hours and hours of a baby being exposed to ultrasound.  That's what Electronic Fetal Monitoring is -- ultrasound.  I've written posts on the risks of ultrasound in the past.  Click here and here and here.  You need to decide how comfortable you are with this intervention.

Problem number 4:  The biggest problem of all is simply that they have to do something with the results of the readout.  Take a baby that has a cord around the neck, for example.  This baby will have decels of the heart rate on the printout.  They aren't sure why the baby's heart rate is dropping, but better safe than sorry, right?  Lawsuit alarms start going off and a c-section is performed.  The baby is fine (Jewel's baby looked great!), but there is this perception -- or defense mechanism -- that thank goodness the c-section was performed and saved the baby. 

Was the baby ever in trouble?

We'll never know.  But now, because it's so hard to find a VBAC-friendly doctor, we've put this mom on a c-section path for all her children -- unless of course she becomes informed of her VBAC options.  As an OB, this is exactly where I want her.  Easier for me and twice as much money.  Few women will question the c-section because it makes her look like a bad mom.  She trusts her doctor.   It's easier to believe that the surgery saved the baby.

Another side note:  The cord around the baby's neck occurs in about one in three births.  When a c-section is performed where the cord is around the neck, the OB often makes a big deal about it, making the parents feel like this was very dangerous.  It's not.  The OB or midwife, after the head is out, will simply lift it over the baby's head.  It could be wrapped around the neck several times!  The most I've seen from one of my student's was 4 times!  Had she stayed with her original hospital and OB -- who required continuous monitoring -- she assuredly would have had a c-section.  Instead, she had a fabulous water birth with CNMs at a different hospital.

So, I feel bad for Jewel.  Maybe her baby really was in distress, but I suspect that the doctor didn't want such a public birth taking a chance at going sour.  Given the high c-section rate in our area, perhaps he was less comfortable with (unmedicated) vaginal birth than cesarean birth.  He knew he could perform a mean c-section and spin it like he saved the baby.  Again, just me speculating.  I do believe that she was likely another victim of our broken maternity system and doesn't even realize it.  While I always advocate for women being informed of their choices in childbirth, sometimes ignorance is probably quite blissful.