Mothering the mother in ALL circumstances: doulas and cesareans

I recently had the opportunity to do a consultation with a mother who is considering hiring a doula for her medically necessary scheduled C-section. Being me, I fear that I might have barraged her with a garrulous deluge of overinformation, but the interest was definitely there, and a good connection was made. Hopefully she'll be able to process what we talked about in her own time, along with the folder full of printouts I gave her.

So, what ARE the advantages of having a doula present at a cesarean, especially a planned one? As I wrote in the previous post on cesareans and birth plans, isn't the whole idea to use them (plans and doulas) to avoid having cesareans in the first place?

Yes and no. It's true that a woman seeking a natural or minimally interventive childbirth is doing herself a great favor by seeking out doula support. But A) There are, of course, rare times when complications can arise, even in a well-supported normal birth, and a cesarean truly is a lifesaving situation. Should the doula pack her bags and take off at that point? Of course not. She probably will not be allowed in the OR if the father is present, but there are other ways she can continue to be of great service, as I'll discuss in a moment.

And B) On a broader note, doulas are there to enhance ALL birth experiences for all women, and priority one is to support mom's own choices, helping her to achieve her own goals. The mission statement for doulas is often summarized as, simply, "mothering the mother". Yes, of course we do everything we can, within reason and within mom's parameters, to help her avoid a cesarean if she doesn't want one (and most women hiring doulas obviously don't), but we are not just vaginal-exit-only cheerleaders. This seems more obviously logical if the need for a c-section arises out of a spontaneous labor, but though it's rarer, there's no reason a doula would not be valuable, in some different ways as well as some very much identical ways.

So, then, what are some of the specific things a doula can provide to a mother having a cesarean? Let's say for the sake of argument that this needs to be a scheduled event (though much of it applies regardless). I would say there are three primary advantages to having a doula in this situation.

First of all, a doula can help the mother develop a birth plan that makes the absolute most out of the situation. The choices will have to be approved by the doctor and hospital, of course, but as I wrote in my post on c-section birth plans, there are actually a multitude of choices to be made. Some of those choices may be brought up by your doctor, but many others may not - they might even be new to him or her, and there are good doctors out there who are willing to try new things and learn and grow in their practice. Check out that post for a detailed discussion of the options available. The same doula can educate the parents about the whole overall process as well, if their doctor isn't able to take as much time explaining things as they'd like.

Secondly, it is a truth that more babies born via cesarean may have to spend some time in the NICU. Should that happen, typically the father will go with the baby - leaving mom alone and unsupported. The delivery of the baby, once everyone is prepped and ready, only takes a few minutes (5-15, depending on circumstances), but putting mom back together again takes significantly longer, generally 45 minutes to an hour, and that's assuming there are no complications. This can be a very difficult time for mom if her baby has been taken away, and having the doula step in for emotional support and companionship can make a huge difference.

The third major advantage is helping to get breastfeeding established. This is more challenging for moms in terms of positioning, even for experienced mothers with existing children, and can be particularly confounding for a first-time mom who is learning to nurse for the first time. Milk can also take a bit longer to come in (remember, though, 3 to 5 days is perfectly normal), and sometimes cesarean babies can be sleepy due to medication. If the baby is having to stay in the NICU, a doula can help mom to get pumping right away, establishing her supply and providing the baby with the best possible nourishment for him or her. All of these extra challenges are much easier to face with doula support.

Now, there are definitely some L&D nurses who are very good with breastfeeding, but, it must be said, there are sadly some who are not. Many a breastfeeding relationship has been sabotaged by hospital practices, even with an uncomplicated vaginal birth. And even the nurses who are good can be in short supply if you happen to be there on a particularly busy day. Same goes for actual lactation consultants. Some hospitals have them, but availability (and quality, too) can be limited.

Those, as I said, are the big ones. There are a lot of other little things that a doula can help with along the way - guiding both mom and dad through the admissions process; helping mom relax during the prep for surgery, including the epidural or spinal (a big fear for a lot of women); taking pictures as much as is desired and possible; keeping communication going between parents if they are separated by a NICU stay, and keeping mom up-to-date on baby's status; establishing skin-to-skin contact as soon as possible, which can be difficult if mom is having trouble with uncontrollable shaking from the anesthesia; running interference with relatives if needed, even running errands for the parents.

But hold on here, are you even allowed to have a doula in the operating room? In some cases, no. If the need for one arises during labor, it's true that it is very unlikely that a second support person will be allowed, though the doula can be standing by should dad have a hard time with the procedure or become ill or pass out - rare, but it does happen. (The other advantages of doula support still remain.) But if it is a scheduled cesarean, it is possible that special arrangements can be made in advance. As doula Rachel Wickersham explains:

Though it is possible your caregiver may initially be resistant to the idea of a doula in surgery with you and your partner, you may be able to convince him or her of the possible benefits to you - especially if you work with a doula who attended at least a few. And this may not be as far fetched as it may seem. I know of at least one practice in which there are doulas who specialize in cesarean.

I came across one mother's story of how invaluable her doula Shelly was for her own cesarean birth at Fort Wayne Doula Network. After attempts to turn Alison's breech baby via external version were unsuccessful, the family reluctantly decided to proceed with a C-section.

Shelly was very sympathetic and reassuring to us both. Mostly without words. Which we appreciated. She and Doug left the room while they prepped me for surgery. When they came back we made sure Shelly had her camera. Although we cried through the c-section a little it was very exciting too.

From the moment they got the baby's little bottom out Shelly started snapping pictures and showing them to me so I felt more a part of what was going on instead of so disconnected. It was great to have Doug and Shelly there so one person could be with me and one with the baby at all times until I joined him in the recovery room. She also unlatched my arm to touch the baby better after my pitiful attempts to stroke his little head while restrained for the surgery.


Shelly was intregal in getting me nursing the baby within 40 minutes of birth (not bad for a c-section!) She continued "nursing" Doug back to health a little bit by getting him what he needed and also helping out so he could get to the post partem room to rest for a bit. I was wheeled to my room with my sweet baby latched on and nursing like a pro!

Once we were settled in our room for a little bit Shelly asked if it would be ok timing for her to slip out for a bite to eat and to develop the pictures. When she returned she had an album of all the pictures she'd taken. I cried as I flipped through them... I would continue flipping through them MANY times over the next few weeks until I had memorized them so it actually felt like my memories instead of the actual memories I had of trying so hard to see everything and be a part of it while my baby was so far away at the little bassinet as they measured and treated him (the whole time he's just wailing for Mama)

I can't describe how much it meant having Shelly there. I am trying to in this email, and I tried to when I wrote her a thank you note after coming home from the hospital. But she was much more than a doula to me that day. She was a mother figure that I so needed. She filled that role when I needed it most. She was concerned for me and excited for me and I felt as if I'd always known her. She was truly the only advocate I really felt I had that day with me. My midwife was not able to be there during the c-section, and Doug was still kind of coming around and trying to get to feeling better himself. It was a very emotional day- but thanks to Shelly and her support the deliriously joyful emotions outweighed the negative. I had a happy, healthy (Big) boy and was well cared for with my medical needs.

Shelly helped give me memories by taking pictures of what I otherwise would not have seen. I can't tell you the value of that. It's priceless. I wonder if a doula isn't maybe even more needed w/ a c-section than a normal labor/birth- for the emotional side of it anyway. Even though it's such a shorter period of time. I guess everyone's experience is different. Shelly helped make the overtones of the day very happy. I just don't know how many different ways I can say it.

Two other great pieces I've found online do a great job of explaining the value of doulas with C-sections: Doula for a Cesarean Birth, by Robin Elise Weiss and the aforementioned "Is it worth hiring a doula if I'm going to have a C-section? by Rachel Wickersham.

Did a doula help you during your C-section? Have you been a doula at cesarean births? Please share your stories!

"The first thing I'm going to tell you is that your daughter is beautiful and perfect."

In lieu of my usual Weekend Movie offering, today I absolutely must share with you the birth story of Nella Cordelia. Be warned, this is pretty heartwrenching - but also incredibly heartwarming in the end. This mother is amazingly honest, raw, eloquent, and fierce. And anyone reading this can tell that she is the perfect mother for little Nella, with the perfect family and group of friends to come along on the journey.

Make sure you have tissues handy. I was mostly holding it together until she wrote: "Love me. Love me. I'm not what you expected, but oh, please love me."

Welcome to Holland, Kelle. Welcome to Holland.

Ready, Set, Suck: On breastfeeding marketing & Medela's WHO violations

It came to my attention not too long ago that Medela, probably the largest manufacturer of breastfeeding-related products, might be less than squeaky clean in terms of their compliance with the very important WHO Code regarding marketing of formula, bottles, and other breast & breastmilk replacing products. But I managed to coast along in denial for a while longer, having had Medela products play such a huge role in my daughter's long and exhausting road to the breast.

Their high quality, extremely efficient Advanced Pump in Style double electric breast pump was what got Lily fed, period, for the first 5 months of her life, while my LC and I worked at various strategies to get her to latch. Using the SNS was an important step we needed to take along the way (though I ultimately found the Lact-Aid to be superior), as were their nipple shields. And primarily because I became emotionally invested in them, I also purchased accessories like their breastmilk storage bags, breast shells to help draw out flat or inverted nipples (and to air-dry them if sore or healing), their travel wipes for the pump, and the microwave steam cleaning bags. It’s convenient when the pump you’re using fits with the bottles you want to use, when replacement attachments are readily available, and when you feel like there’s a consistent quality there that you can trust. I completely understand that kind of brand loyalty.

Because I was such a loyal customer, it was all the more stinging to read this post by PhD in Parenting last week, full of serious truthiness as it is. I won't rehash the entire thing here, as she has done such a good job already, as did the above much earlier post from Hoyden About Town - do go check them out for yourself. Suffice it to say that not only has Medela flipped the bird at the code, marketing bottles in violation, they're now making matters even worse with this sly, underhanded "Medela Mom Mavens" campaign.

I can understand, to a degree, that it's a tricky line to walk at times. Having some of these products available, like the ones my daughter and I benefited from during our insane nursing saga, is important. They should be available to moms who need them, and easily so. I am thankful that when I needed a different size nipple shield, I was able to run out to the local big box baby store (more on that in a sec) and pick one up. I'm thankful that replacement attachments for the pump were similarly conveniently available. I am thankful that the moment it seemed like my situation might call for an SNS, my LC was able to hand me one immediately. Such breastfeeding support products can make a HUGE difference in breastfeeding success when there are complications. As Annie at PhD in Parenting says:

I don’t want to be overly critical of Medela. I think the company does a great job promoting and facilitating breastfeeding. Most of the information on its website is wonderful. Most of its products are of the highest quality. I have been nothing but happy with my Medela products. However, I do think that some of their current actions to promote their bottles are inappropriate. It would not be difficult for Medela to continue to promote breastfeeding and sell its bottles without promoting them. However, it has chosen to ignore the WHO Code and push more bottle imagery and bottle messaging on moms (more on why bottle imagery and messaging is hurtful here). The result is that Medela is directly pushing bottles on moms and also doing so indirectly via the Medela Mavens and others who might pick up on the message about how breastfeeding ties you down, so you really need a pump and bottles so you can get your hair done.

To be clear, on a sliding scale this is not even close to Enfamil or Nestle or other formula companies. Not even close. But I would argue, and others do argue, that any violation of the WHO Code weakens its potential impact. We cannot say “it’s okay because you are Medela,” but then slap Nestle on the hand for everything it does wrong.

Lines have been crossed, not only in the clearer terms of promoting their "breastmilk bottles", but in the more nebulous grey area of promoting products over breastfeeding. I've been mulling all this over for a few days, and trying to find a way to put that thought into words, and then I went to the big box baby store yesterday, a trip that was disappointing on two levels.

I was there to drop off some flyers for the upcoming doula training I'm sponsoring, as well as some business cards. The last few times I was there (hey, pickin's are slim in this town), probably 2 months ago or so, there was a small table behind the registry area where local birth and baby-related services could leave their materials. There was never a lot, but there was a brochure for an independent childbirth class, cards for a breastfeeding support group, a small calendar of mom's playgroup activities, that kind of thing.

When I walked in yesterday, the table was empty. I asked an employee whether it had moved, or if there was another area to post about things like childbirth classes - a community message board, perhaps. She told me that no, they had decided to not allow outside materials any longer. Disappointment #1, in terms of small businesses and independent agencies. But hey, she said, they have some classes of their own! She pointed out the board below:

Here's a closer look:

A "Breastfeeding 101" workshop, sponsored by You Know Who! A basics of breastfeeding class whose description begins with "Ready, set, pump!"

If that doesn't make their priorities clear, I don't know what will. Believe me, I know firsthand that a pump is sometimes absolutely essential. And certainly it is for mothers who work outside the home. Hallelujah for them, seriously. But a breastfeeding class that focuses first and foremost on pumping? The rest of the description: "Get the scoop on breastfeeding and all the great products sure to make it easy to feed baby naturally." I mean, it's not that I was surprised to see a live, in-person infomercial for Medela products disguised as a breastfeeding "class". Especially not at a big box store (with similar classes in car seats, sponsored by Graco, and the like). I'm not so naive. Just very, very disappointed.

So, like many other lactivist moms out there, I can no longer in good conscience continue to promote Medela products. So what to recommend in its place? Makes Mom Happy has an excellent and thorough post on the matter, which starts out bemoaning the same state of affairs and then goes on to explain the Hygeia and Ameda pumps, both of which sound great - in addition to being WHO compliant, and proudly so, unlike some people, they are also closed system pumps, much preferable to Medela's open systems (don't worry, she explains it all).

I took a look at Big Box Baby Store's pumps to see if they had either of the above. Nope. They had one Lansinoh electric pump, and one Evenflo hand pump, and the rest was, of course, all Medela, all the time. So, it's frustrating. Medela is no doubt the most widely available. You can go see them for yourself, talk to a salesperson, and take one home the same day. Ordering things online is less appealing and even prohibitive for some people. But I have to recommend doing so nonetheless, at least until/unless Medela does a serious 180 (and I would be thrilled if they did). If you're lucky enough to live in an area with smaller businesses that might sell alternative pumps directly, then hooray (for that among other reasons).

What about some of the other products, though? Smaller ticket, yes, maybe not as big a deal to the company, but still. I can make a few recommendations. For the best storage bags: I always liked Lansinoh's. And I honestly would recommend the Lact-Aid over the SNS even if Medela was behaving ethically - same basic concept, but the difference in user-friendliness is HUGE, and again I must point out that Lily would NOT be nursing today were it not for the Lact-Aid - along with the brilliance of my LC of course. But I digress: As for nipple shields, that's one where I'm stumped. Breast shells as well - I know that for drawing out inverted nipples, Supple Cups are now available, and reputed to be very good, but for helping to air-dry sore or wounded nipples, I'm not familiar with an alternate brand. Lactation pros, moms with nursing challenge experience, do you have any ideas? Please chime in.

I close with the following from the Hoyden About Town piece, on the insidiousness of Medela's current marketing:

[Medela's commercial states:] “When you choose to breastfeed, you’re doing what’s best for your baby. When you choose Medela breastfeeding products, you’re doing what’s best for you both.”

Medela is saying, directly, that breastfeeding is not best for women. It might be ok for babies, sure, because they get the breastmilk, but Medela is telling us loud and clear that pumping is better for mothers than breastfeeding is. No qualifications, no circumstances; just “pumping and bottle-feeding is best for women”, with a side serve of “and it’s just as good for babies”.

This isn’t just a WHO Code violation; it’s not true. And it’s a lie fed by all of our dysfunctional societal issues around breasts and breastfeeding and public feeding and mother-child attachment and women and the workplace. It’s fed by the huge pile of myths about how easy pumping is, and about how bottled stored breastmilk is just as good, and about how it’s vital to schedule feeds and “see how much babies are taking”, and about how babies don’t know when they’re hungry or thirsty or full or in need of comfort. The problem is, it isn’t just fed by those dysfunctions, it’s feeding back into them, reinforcing them.

These sorts of advertisements are part of the huge coercive societal mechanism denying support for mothers and children, part of the capitalist machine preventing women from being able to afford time with new babies, and keeping them being good little workers and consumers. I think it’s no coincidence that two countries with no moves towards a full legislative implementation of the Code, the USA and Australia, are also the only two industrialised countries in the world without mandatory paid maternity leave.

Words mean stuff. Marketing is powerful. Advertising works.

And it makes a whoooole lot of money.

Weekend Movie: Taking on nonconsensual exams by med students

After finding out yesterday about the abhorrent practice of medical students performing pelvic exams on patients under general anesthesia without their consent, I MUST feature this documentary, Check out "At Your Cervix" (not to be confused by the fabulous eponymous blog).

"The documentary 'At Your Cervix' explores the connection between the way medical and nursing students are taught pelvic exams and the reality that most women experience them as painful and disempowering.

'At Your Cervix' breaks the silence around the unethical methods used by medical and nursing schools to teach students how to perform pelvic exams; the most egregious being on unconsenting, anaesthetized women."

The original article: Time to end pelvic exams done without consent

Other blog posts on this outrageous practice, besides the one from Unnecesarean at the top of this post:

PhD in Parenting (from whom I got others): Canadian women are livid, and rightfully so
Sassymonkey: Not without my consent
Three Seven: I think I might throw up
Bad Moms Club: Bad Moms don’t Like Non-Consensual Nether-Probing
Living My Social Work: “Implied” Consent
Coffee with Julie: A pelvic exam without my consent?
Chaos Theory: Does the Canadian Medical Association Support the use of Roofies too?

Pissed off? Sign the petition from Her Bad Mother.

C-section Birth Plan: An Oxymoron? (Not even.)

Birth Plans. Normally, they're a collection of things to do or not do in order to give birth the way you prefer, and a major component of that for most women is avoiding a c-section. Same goes for a doula, right? In addition to helping create a birth that is as close to your ideals as possible, moms choosing to birth in hospital settings hire doulas to get their best chance at avoiding a cesarean.

So why would you even want to think about cesareans during your pregnancy, when you're focusing on visualizing your birth as positively as you can? And why would you bother with a birth plan if you know you're having one? Once the plan changes to surgery, whether it's in the heat of labor or in advance, isn't the whole raison d'etre for birth plans and informed choices out the window? Isn't it basically all the same?

Not at all. There are absolutely choices you can still make, choices that can make a huge difference in the experience for both your baby and yourself.

Hypothetical Reader: But I don't have any indication for a scheduled c-section, and no reason to think that I will be more likely to have an emergency arise during labor than any other low-risk mom. I want a natural birth if possible, or at least a low-intervention one. Are you saying I should write a backup cesarean plan? And doesn't thinking about this stuff risk manifesting it?

I remember all too well when I was facing the very real possibility of a cesarean, and a scheduled one at that - the very antithesis of the home birth that I had been planning and yearning for. Over the course of my pregnancy, my placenta moved from complete to partial to marginal, to finally, finally just over 2 centimeters (the minimum required to be in the clear for a vaginal exit) away from the os, at my 34 week ultrasound.

That whole story is a post unto itself, again, but I want to talk today about how I dealt with the possibility. Or rather, how I DIDN'T deal with it. Because I was intensely focused on doing visualization to help my placenta move upwards, I deliberately avoided reading anything at all about cesareans. I'm a pretty voracious reader, especially when it comes to this subject, and I read quite a few pregnancy books. But I confess to you all now, right here in virtual public, that I skipped right over everything that had to to with cesareans. I covered my ears and sang "Mary had a little lamb . . . (at home in her birth pooooool)".

Yes, it's true that I was able to dodge this bullet by the skin of my teeth, but in hindsight, I think this kind of willful denial was really not the best thing to do. Now, I'm not talking about turning it into a fixation that becomes a self-fulfilling prophecy, investing your energy into fear and anxiety. And as I said, I can relate. I understand not wanting to think about it too much. But I have read enough birth stories now where the mothers, in their admirable preparation for a natural or low-intervention birth, wind up heading into surgery for one reason or another, having absolutely no idea what was in store for them.

So to go back to our Hypothetical Reader, on the first question, "Are you saying I should write a formal backup cesarean plan?" No, not quite going this far (unless you have reason to schedule one, in which case, definitely yes; keep reading below), necessarily, but it is worth taking a deep breath, looking over some information on cesareans, and thinking about what your preferences would be if this were to arise. Perhaps write them down based on the examples to follow, if writing works for you. Take a few minutes to talk to your partner, doula, and anyone else on your birth team about these wishes. Confront it calmly, and then put it away. On the second question, "Doesn't thinking about this stuff risk manifesting it?" Again, this isn't about fixating on it and creating a self-fulfilling prophecy, this is acknowledging it and letting it go. Again, confronting it calmly, and then putting it away.

I want to share with you some really eye-opening and helpful information I've culled so far on the matter, most notably from Morgan of Adventures in Diapering and Beyond. (By the way, in case it's not already clear, let's assume for the purpose of this post that we're talking about necessary cesareans, both scheduled and unscheduled. You all know how I feel about unnecessary ones, and there's much to be said on them. But not today. Today we're talking about the ones that really do save lives.) First, Morgan herself gives a great explanation for using a birth plan for a cesarean here. An excerpt:

Why bother with a birth plan if you're having a c-section because you don't really have any say in what happens, right? Wrong. Even when you are expecting a c-section, there are still choices that you can make during and/or after the birth. Knowing what your options are can help you feel more a part of the birth experience rather than just an observer. While researching your choices, you will become better informed on what your doctor and hospital's expectations are and what you can/cannot do in a hospital setting.

Morgan provides a comprehensive collection of posts on c-section information, from questions to ask, what to pack, recovering from surgery, and a good visual guide for what to expect. She even shares a video of one of her own births. If yours needs to be scheduled, I would pore over every single link she provides. For those who aren't planning a cesarean but want to take my advice re: confronting it briefly but thoughtfully, her example of a c-section birth plan is a must. I'm going to quote extensively here, to illustrate just how many choices there really are, but all credit goes to her:

During Surgery:

*Catheter put in AFTER spinal (this is standard procedure at many hospitals)
*Volume down on heart monitor beeping
*Husband will photograph c-section
*One of the staff members from my dr.'s office will video tape Baby's birth

*I'm allergic to (x drug). Please make sure I am not given this drug.

*Warm blankets during surgery
*No sedatives after birth. I want to remember my Baby's first day of life.
*Please reinforce my uterus and use dissolvable stitches for closing me up [Note from Dou-la-la: I would recommend making sure that your doctor uses a double suture, as this increases likelihood of a safe VBAC.]

Baby:

*Please hold baby up for me to see as soon as Baby's born
*Husband to announce Baby's gender (or maybe not announce gender at all and allow me to see for myself)
*Keep cord long for Hubby to cut
*No Eye Gel, No Hep. B vaccine. I will sign the waiver ahead of time.
*Please bring Baby close to me during measuring & weighing.

*If Baby is doing well medically, please bring Baby to me as soon as she is suctioned, weighed, and measured. Please do not worry about cleaning her up much before bringing her to me.

*I would like to hold Baby while Baby is being foot printed, getting bracelets on, and while the paperwork is being filled out.

Recovery:

*Once back in our room to recover and been checked as stable, we would like to be alone with Baby to nurse.
*We would like to keep Baby with us at all times. If Baby must go to NICU due to medical reasons, my Husband will follow.
*If someone arrives to visit, please check with my husband or I as to whether we are up for company before allowing them in our room.
*Delay Baby's bath until the evening after Baby is born rather than bathing Baby right after birth.
*I am willing to be up and walking as soon as possible so I can get leg compressors off sooner
*I would like my Catheter out early the morning after surgery
*Baby will sleep with me in the hospital bed. While I am sleeping, there will be another adult in the room with Baby and I.
*I will be nursing on demand and whenever Baby is fussy to help stimulate my milk to come in and to soothe Baby.

Excellent, right? I think she has done a wonderful thing in providing all this information. make sure to also check out her post on Things I Wish I Had Known Before My 1st C-Section. It has lots of firsthand information about possible side effects, descriptions of some of the strange sensations and hospital protocols you MUST be aware of if you want to avoid them (like taking baby to the nursery while you recover). Morgan, my hat is off to you.

I also want to address some possibilities that may be outside the realm of most OB's experience, but if you have a really good one, they might very well be willing to try something new. If you poke around in the birth spheres on the internet as much as I do, you may have run across the term "gentle cesarean". Dr. Nick Fisk in the UK has been a proponent of this approach, pointing out that "while couples having normal deliveries have been given more and more opportunities to be fully involved in childbirth, very little has been done to see how we could make the experience more meaningful for those having caesareans."

The scent of lavender fills the air and classical music is playing quietly. On the bed, Jax Martin-Betts, 42, is calm, focused and in control. With the birth of her second child just minutes away, the midwife, Jenny Smith, is giving her a massage. Her husband, Teady McErlean, is whispering words of encouragement: just a tiny bit longer, and our baby will be in our arms!

It could be a natural birth at any maternity unit in Britain, but we are in an operating theatre at Queen Charlotte's and Chelsea hospital in west London, and the birth we are about to witness sounds a contradiction in terms: a "natural" caesarean section.

Jax has been on the theatre table for half an hour, and the obstetrician, Professor Nick Fisk, has almost completed the incisions through her abdominal wall and into her uterus. "OK, the baby is about to be born," he says. "Let's prop you up so you can see him coming out."

Smith removes the blue drape between Jax's head and her belly, and the head of the bed is lifted to give Jax a clear view. Fisk cuts into the amniotic sac and a fountain of fluid rises into the air before he rummages around to locate the baby's head. In a few seconds it comes into view, covered with the milky-white vernix that has protected it in the womb. For the next few moments, the atmosphere in the theatre is electric: Jax and Teady gasp in wonder at their new son, who is now looking around, although his lower body and legs are still inside his mother's uterus.

The "gentle cesarean" tried to make the environment more soothing and slows the pace of the entire process down, making the baby's entrance more gradual and thus, hopefully, more peaceful. It may even help in squeezing the lungs out, the way vaginal birth normally functions, and one of the distinct disadvantages of surgical birth for the newborn's respiratory function. The parents can see the birth if they wish, rather than being walled off by drapes, and the baby is given immediately to the mother, instead of whisking him or her away just because of protocols/habits.

This may or may be your cup of English Breakfast, so the specifics are up to you and your doctor, but if a necessary elective cesarean is required, you could think about incorporating some or all of this into your birth. I encourage you read the whole article - you might want to consider printing it and bringing it in to your doctor to discuss it.

In a similar spirit, Radical Doula featured a story on what was termed an "assisted cesarean", where the mother was able to catch her own baby! Check out this image:


A far cry from the usual image we see of someone holding the baby next to the face of the mom, who is strapped motionless to the table, unable to touch her baby. Radical Doula raises a very important point here, commenting, "But is this just an attempt to make an entirely medicalized process seem more mother-friendly? Luckily both the mother and doctor in this situation don’t want this procedure to encourage c-sections:"

But women should not consider assisted caesareans ahead of vaginal birth. “I still think a vaginal birth is the best way to birth your baby,” Ms Chapman says. “I don’t want women to choose to have a caesarean because of this,” [Dr. Gunnell] says. “We need to be very clear that this is not a good alternative to a vaginal birth; the caesarean section rate is very high . . . "But for those of us who don't necessarily have that opportunity [for a vaginal birth], this is a way of making an intervention experience a better experience.”

The original article also acknowledges that this certainly isn't going to appeal to everyone. Many women would shudder at the thought of seeing their own incision, for one thing. But if you look at the picture above and think this is a pretty amazing thing under the circumstances, why not at least ask your doctor? It's worth a shot. Even if he doesn't go for it, hey, maybe your other preferences won't seem like such a big deal anymore, by comparison. A nice bargaining chip, at the very least.

One final thought from Dr. Michel Odent. He was asked for his thoughts on how to make the best of the situation if a cesarean is inevitable, and he makes a case for allowing labor to begin on its own (hey, one of the Healthy Birth Practices, even if the context is a bit different) even if the end result is known.

Q: We now find ourselves preparing for a cesarean birth. We are wondering what things would be helpful to keep in mind/plan for/request in order to have the gentlest birth possible considering the circumstances.

A: The best way to deviate as little as possible from the physiological model of birth would be that the medical team is comfortable with the principle of an elective in-labor cesarean. In other words, the medical team would accept to wait until the day when you are in labor to perform an "in-labor non-emergency cesarean." This way it is a guarantee that the baby will have given a signal indicating that his or her lungs are mature. We know today that the baby participates in the initiation of labor. Furthermore, during labor contractions, the baby is exposed to hormones that make more complete the maturation of his or her lungs. This is why, as all pediatricians know, there is an increased risk of respiratory problems during the days following a cesarean performed before labor starts.

I think that's a pretty strong case, whenever the situation allows for it. Logistics would have to be managed, especially in terms of making sure your own doctor is available, or that his or her partners are also on board with whatever your plans are, but the effort is likely to be well worth it.

All efforts to reduce cesarean rates aside (and you know I'm all about that), a cesarean birth is still a birth, and is worth all the TLC you can possibly give to it, for both mom and babe. It IS possible to make it a healthier, less traumatic, and gentler experience. They both deserve it.

*****

Hypothetical Reader: Wait, isn't one character glaringly absent from this whole picture? What about having . . . a doula?

Indeed, what ABOUT having a doula? This will be addressed in a future post - for which I am soliciting stories from readers who have had cesareans with doulas. Please tell me your story!

Top photo by Arif Tanju Korkmaz.

Weekend Movie: A Walk to Beautiful

I had the opportunity to watch an incredibly moving and important documentary this week. "A Walk to Beautiful" tells the stories of several women in Ethiopia suffering from obstetric fistulas, caused by prolonged, obstructed labor that goes without treatment, their babies having died in the womb. The women (and young girls, too) are rendered permanently incontinent without medical care, and as such, become outcasts from their societies and even their own families.

Up to 5% of all pregnant women in the world develop fistulas, with a high incidence in places like developing countries in Africa where malnutrition is a root cause. Malnourishment causes insufficient skeletal growth, and thus the pelvises of many women truly are too small to safely deliver vaginally. This is true cephalopelvic disproportion, not the Big Baby Bull that is so often sold to women in our own American culture.

Here's the trailer:



Of course, watching this, I felt gratitude for living in a country and socioeconomic status where I have both quality midwifery for healthy, normal births with access to modern medical care for a complicated labor, should complications arise, and further for having grown up with more than enough nutrition to prevent stunted skeletal growth in the first place. But even more than that, I felt suddenly profoundly aware of another advantage I have that I take for granted every single day, one example of which I am exercising right now: the combination of information and connection to others.

The women in this video have been existing in emotional isolation, and sometimes near or complete literal physical isolation as well. They sometimes had no idea that there was a name for what had happened to them, or that it happened to other women, too. Literacy is an issue in itself, but even for those that are literate, information sources are scarce to say the least. They don't have an ICAN Facebook page. They don't have a bookshelf overflowing with empowering pregnancy books. They don't attend webinars. They can't watch "The Business of Being Born". They don't have a blog and a Google Reader full of birth-related material. They don't Tweet. (I certainly mean no disrespect to any of these things, participating in every one of those things listed myself.)

The Fistula Foundation, featured here in the film, provides not only treatment for afflicted women, but a safe haven. I was deeply affected watching these women, having been shunned and shamed for so many years (some from their early teens on, or younger), finally finding kindred spirits, finally a place of comfort and acceptance, a place to talk about their experiences. They are given not only care but caring company, for the first time since their unbelievably traumatic births. The camera captured some of the clinic's patients talking together about their stories, and I got the feeling that this may have been the first time they had ever been able to speak so freely about what had happened to them - and to someone who could really understand.

You can watch the full version below, and I hope that you do, but it's well worth purchasing the DVD to support the cause, or, if you watch online, consider making a donation to the Fistula Foundation, the organization behind this wonderful cause.

Being "With Woman"

I've been working on a post about cesarean birth plans as well as how doulas fit into a picture that includes a cesarean, but I just can't concentrate on it. I'm too distracted thinking about a laboring friend of mine. Forgive me if this post is rambling and unfocused and more emotional than usual.

Obviously, I am pro-midwifery as a matter of principle, of course, and the ones I have met and encountered personally have all been wonderful, but I realize that this still does not mean all midwives are wonderful, deeply ethical, and compassionate people. There are bad apples in every profession. And unfortunately, I think my friend got one of them.

She has been coping with really difficult prodromal labor for a few weeks now. Her midwife is dropping her from care as of midnight CST, as she hit 42 weeks today. Now, this much is understandable, as regulations in the states that license midwifery require this. If she wants to keep her license, her hands are tied. I completely and totally get that. But this midwife is also refusing to shift into a supportive role, as is standard among home birth midwives upon transfer of care. This blows my mind.

Usually, when transfer of care happens, midwives will shift into a doula-like role (with the exception of the 11 illegal states, and my friend is not in one of them). This is true whether the transfer happens in active labor or whether care has to change hands prior to onset of labor. *I* was facing a scheduled section for a good chunk of my pregnancy, and my midwives didn't bail on me; in fact, they made it crystal clear that they would continue to be my allies throughout the whole process. Nancy literally said, "We're not just going to abandon you!" The explained all the things they could do to help me through the process (holding the baby to my chest if I was shaking too badly from the anesthesia, helping me get started nursing, running interference, helping dad deal, and so on) and make the absolute best of the situation if it came to that.

This woman actually said, point blank, "I'm a midwife, not a doula." I call serious Code Mec on this.

But let's back up a little more. This entire two weeks that my friend was coping with prodromal difficulty, the midwife somehow missed the fact that the baby is POSTERIOR. (For those who don't know, a posterior baby is in a bad position, causing slow progress and back pain for the mother.) This was discovered today by her apprentice (not the midwife, who never came over to see her at all today, this day being the last that she had a chance to deliver at home). My friend had gone the castor oil route yesterday, and things seemed to be picking up for a while - her water even broke (clear fluid, too, which is great). But then things slowed down again. Lo and behold, the apprentice immediately ascertains that she's posterior. So of course she's not progressing well, the head isn't engaged and pressing down on the cervix. How the HELL did the midwife miss this?

There ARE things you can do to turn a posterior baby, and I was talking to her about some of them . . . but these things (and also other measures that are no longer feasible, like chiropractic care) would have been much more helpful TWO WEEKS AGO, when her midwife SHOULD HAVE PALPATED THIS! I guarantee you the baby didn't just flip into posterior yesterday. So the midwife could have done something about it anytime within the last two weeks, but now, wouldn't you think she'd try to work with mom just this little bit longer, to try and help, and give it one last good shot (especially with ruptured membranes), to help with positioning, exercises, work with a rebozo, whatever? Keep an eye on mom's temperature and blood pressure and baby's heart tones (all of which are currently just fine)? Especially since she herself contributed to the situation by not picking up on an easily-identified malposition? And further, then recommended castor oil without verifying fetal postion first?

Nope.

"I'm a midwife, not a doula." Are you even kidding me? Lady, let me remind you that the translation of midwife is simply "with woman". It does not mean "Almighty Birthing Empress Who Must Be In Charge, Or Else Might As Well Not Even Show". It just means being with her. I don't see how this can't evolve with the mother according to her needs, within the very definition of the word. Once again, it is completely standard for midwives to assume a supportive role upon transfer of care.

This is what happens when access to midwives is so limited - this woman is the only game in town for home births, so she can practice as uncaringly and, in my opinion, unethically as she wants.

Can you tell I'm pissed? I considered not posting this, as it's very emotional and personal, but if I'm going to be critical of many doctors and so many standard obstetric practices, it wouldn't be honest of me to not express this, too. So here's proof that I can dish it out to more than just OBs.

Okay, calming down, now that this is out of my system (sorta), I am focusing on sending my friend good energy over the miles. Please send some energy or prayers or whatever you do her way. Be "with" this woman in whatever way you can.