Friday, June 25, 2010

Doctor's Birth Plans and Doula Bans: Think it's not happening in your area?

This is a bit of a "round-up", but I couldn't let the hot (read: infuriating) items that have been circulating in our circles the last few days go without mention - especially since this very issue was brought home to me yesterday in a client meeting, live and local and in-our-faces.

Before I get to yesterday's incident, here's a little background from a while back.

Once upon a time (last November), this sign prohibiting Bradley Method and/or "doulah"-assisted births from a practice in Utah was shared on The Unnecesarean, and everyone had a semi-good time roasting it in appalled mockery:

This came on the heels of one OB's disclosure to his patient, who fortunately took it for what it was and RAN FOR THE HILLS, as of October. Excerpts:

* Home delivery, underwater delivery, and delivery in a dark room is not allowed.

* I do not accept birth plans. Many birth plans conflict with approved modern obstetrical techniques and guidelines. I follow the guidelines of the American College of Obstetrics and Gynecology which is the organization responsible for setting the standard of care in the United States. Certain organizations, under the guise of “Natural Birth” promote practices that are outdated and unsafe. You should notify me immediately, if you are enrolled in courses that encourage a specific birth plan. Conflicts should be resolved long before we approach your due date. Please note that I do not accept the Bradley Birth Plan. You may ask my office staff for our list of recommended childbirth classes.

* Doulas and labor coaches are allowed and will be treated like other visitors. However, like other visitors, they may be asked to leave if their presence or recommendations hinder my ability to monitor your labor or your baby’s well-being.

* IV access during labor is mandatory. Even though labor usually progresses well, not too infrequently, emergencies arise suddenly, necessitating an emergency c-section. The precious few minutes wasted trying to start an IV in an emergency may be crucial to your and your baby’s well being.

* Continuous monitoring of your baby’s heart rate during the active phase (usually when your cervix is dilated 4cm) is mandatory. This may be done using external belts or if not adequate, by using internal monitors at my discretion. This is the only way I can be sure that your baby is tolerating every contraction. Labor positions that hinder my ability to continuously monitor your baby’s heart rate are not allowed.

* Rupture of membranes may become helpful or necessary during your labor. The decision as whether and when to perform this procedure is made at my discretion.

* Epidural anesthesia is optional and available at all times. The most recent scientific data suggest that epidurals are safe and do not interfere with labor in anyway even if administered very early in labor.

* I perform all vaginal deliveries on a standard labor and delivery bed. Your legs will be positioned in the standard delivery stirrups. This is the most comfortable position for you. It also provides maximum space in your pelvis, minimizing the risk of trauma to you and your baby during delivery.

Amazing. Trust me, it goes on and on, I just had to crop it for length.

So just the other day, this letter from an Ohio practice came to light, courtesy of Birthing Beautiful Ideas. Same crap, different zip code:

The team at Kingsdale Gynecologic Associates is so pleased that you are expecting. We look forward to helping you enjoy your pregnancy and hope to provide a meaningful and safe birthing experience.

Because of concerns for increased risk to you or your baby, the doctors at KGA have made a thoughtful, unanimous decision not to allow doulas to participate in the birthing process. It has been our experience that they may serve to create a state of confusion and tension in the delivery room, which may compromise our ability to provide the safest delivery situation possible for you and your baby.

Again, with safety in mind, we have created a Kingsdale Birth Plan (which can be viewed in the obstetric packet provided at your initial visit), outlining the philosophy of our doctors with regard to labor and delivery. It is our opinion that other birth plans are unnecessary. We feel that our many years of obstetric experience in a setting of modern day challenges (larger babies, more difficult deliveries) enable us to provide sound judgment with regard to each woman’s particular needs during her course of labor.

Thank you for your understanding in our hopes of facilitating a safe pregnancy and birth process.

Patient’s signature


She goes on to post a revised version of this letter (make sure to check it out, it says everything I would have said and more), and then, the next day, shared a copy of the actual "Kingsdale birth plan" this practice offers. Click over to read it itself in all its chocolately paternalistic glory.

To top it all off, The Feminist Breeder had JUST posted this unknowingly prescient piece the extremely revealing chart found in Marsden Wagner's book "Born in the USA", exposing the downright contempt many (of course not all) OBs have for patients who dare to think for themselves.
It both precipitated and underscored the garbage from the Kingsdale practice that hit the net the following day.

So, with all this buzzing in my head, I went to meet with a really wonderful young mother and prospective practice labor support client. She's very interested in having doula support, as there's not a lot of other support in her life, and has several pressing reasons of her own that she'd like to pursue a natural birth if at all possible. Hasn't read a whole lot yet but is very eager for information (I lent her "Your Best Birth" to start with) and is starting a childbirth ed course next week. All sounds good, right?

Well, she's also slowly figuring out that she may have to change care providers, as they recently informed her that she is allowed to use one of two pre-approved specific doulas - anyone else would be prohibited. I would have been more stunned if I hadn't just read and re-read all of the above, but as it was, I just had to sigh and shake my head.

If I were one of the two approved doulas, I wouldn't know whether to be flattered or appalled. (I'm not at all insulted at not being included, as I literally haven't even gotten started attending births in the area yet.) Frankly, I'm leaning towards appalled. I'd want to know WHY I was kosher and others weren't - was it because I was most likely to go with the hospital ride and not make waves? It's also possible that some other doulas had been too confrontational, perhaps, and gone beyond our scope of practice. Could it be a combination of the two?

Regardless of the reasoning, I'd so frustrated by all of this. It seems like we've been making progress with educating the public about doulas, and improving doula training, and increasing access - but then, what good does it do if more and more OB practices are issuing official kiboshes on us when it comes time to actually go into action? The bottom line probably does fall to the consumer.

Readers who are appalled at the Aspen Women's Health Center, the Kingsdale Gynecologic Associates, the doctor in Texas, and the group practice here in Erie - don't assume it's not also happening in your own backyard. We advocates can blog about this stuff until we're blue in the fingers, and we will and do, but it really comes down to the individual women themselves. Mothers who care about their births (no matter what their own goals are), have to stop patronizing care providers like this, and let them know why.

P.S. This was one of my entries for the Unnecesarean's Photoshop contest:

P.P.S. But wait! There's more! The Feminist Breeder and I basically simulposted today, and in her latest, she shares YET ANOTHER doctor-generated mandatory "birth plan", this time from the Chicago area practice WomanCarePC. I can't even be buggered to quote it here - click on over to read, it's exactly what, by the end of this post, you'd expect. But I will quote TFB herself, echoing my sentiment on using our power as consumers:

We all want to believe that it’s just angry women making hostile accusations toward well-meaning OBs and hospitals. Calm down honey, it’s all in your head. However, it’s pretty hard to ignore when the obstetricians are the ones sending out their patriarchal beliefs in writing, and then asking pregnant women to sign it.

There is a solution. Fire them. Take back your body. Refuse to be treated as a wombpod. Let them know that we ARE consumers in this process, and if they won’t treat us with respect, then by golly we’ll get our birth attendants elsewhere, thankyouverymuch.


In medical billing courses, you’ll learn about the birth process.

Friday, June 18, 2010

Fire & Rescue

Here's what we're talking about.

You're on the second floor of a burning building. Fire completely blocks the door of the room you're in. Your only chance of surviving is by jumping out the window, despite risk of some injury. Of course you're going to jump. This is absolutely a lifesaving action.

Bruises or a sprain are a probability, a broken bone is quite possible. Other major injuries are a lower risk, but still real. Once in a great while you could even be killed by jumping out the window, but the chances are very low, and it's absolutely worth the odds and the healing time to recover from the fall. After all, staying inside the house means facing certain death. THANK GOD we have the option to jump.

Now take the fire out of the picture. The house is perfectly fine.

Is jumping out the window still an equal choice to going down the stairs and walking out the front door?

It happens almost every time the cesarean epidemic is discussed these days. The most recent skirmish that I know of, which motivated this post, was, relatively speaking, a very minor one (a site rating blogs was discussing our mighty friend The Feminist Breeder). Sometimes the conversations go on for days, comments numbering into the hundreds. No matter the specific conversation, whether it's a story on how significantly the risks increase with multiple c-sections, or the possibility of increased likelihood of various lifelong problems for children born surgically, or simply talking about ways to avoid it, someone - and often multiple someones - posts defensively about their own cesarean experience, pointing out how it saved their life, their baby's life, or the live of a loved one or a loved one's baby. In many cases this is clearly coming from an emotional place, often quite a raw one, and very understandably so.

I would never argue the validity of someone's else's birth, and there is NO doubt that cesareans are lifesaving miracles when they are necessary. No doubt whatsoever. And I believe I can safely say that I speak for the vast majority of birth advocate types on this. I am so thankful that cesareans exist - they truly are a wonder of modern medicine, and we are lucky to live in an age where they are available. Sometimes it gets tiresome to have to preface any discussion of cesareans with this lengthy disclaimer, though, as genuinely as I mean it (and I do really mean it).

Once and for all (maybe): It is the unnecessary ones we are talking about. We know that houses do sometimes catch fire. And we know that sometimes it happens even when the house had been at low risk of catching fire, even when precautions are taken. It is when the house is NOT on fire, and a combination of factors pushes women - and their babies - to jump out the window anyway.

I realize that this analogy is a simplification (as all analogies do eventually break down). A house being on fire is a pretty absolute, concrete situation, whereas the reasons for cesarean are definitely a judgment call much of the time. But there is a core truth there, as well as other ways to stretch the metaphor.

A la: A toaster catching fire CAN, in fact, lead to the house catching on fire, which could then lead to jumping out the window. But does it then follow that as soon as we smell smoking bread, we should jump out the window? I would submit that we try to put out the toaster fire itself first, and further point out ways to avoid the toaster catching on fire in the first place. And we should also give thanks that modern technology has made jumping out the window safer than ever, if the fire department has assembled and is holding a good quality safety net*.

I could go on like this for way too long -but you catch my drift. So once again, when we ("we" being rather broadly defined here) discuss our myriad concerns about the growing cesarean epidemic, we are not denying the truly life-threatening situations that have indeed saved many lives, or criticizing the mothers in those life-threatening situations, or suggesting that she would be a better mother/woman/human if she had refused the lifesaving cesarean. We just don't want other mothers to be pushed out the window for no good reason.

* Thoroughly off-topic aside: one of my best friends was a firefighter and paramedic, working for a time on a campus-based volunteer service. Once year the batch of new trainees was learning how to hold a safety net, and was having some trouble organizing their group to do so effectively. One rookie piped up, "Well, can't we just lay it on the ground?"

Saturday, June 12, 2010

Weekend Movie - Black Family: A Doula Story

Wow. This isn't available to embed, alas, but trust me. This is worth clicking through.

Take an hour. You won't regret it. (Thanks to Blacktating for sharing this!)

Wednesday, June 9, 2010

S2S as the Standard That Should Be

I wrote a two-parter a while back on cesareans, not (for once) on how to avoid them or about the epidemic in its societal context, but instead about how, if one did become necessary, to make the absolute best of the situation. One post focused on birth plans, and the other on a doula's role when birth becomes surgical. Check them out if you haven't read them - I won't rehash here, but suffice it to say that there is MUCH that can be improved on, for both mother and child.

Needless to say, I was thrilled to see this post by veteran OB Nurse 35 Years, on one of the most potent factors: S2S - Skin to Skin Contact Minutes After C/S in the OR. YES. (And she links to the same excellent breastfeeding video I just shared, hooray!) Skin to skin is vital, whenever an emergency doesn't preclude it, due to so many things, like its positive effect on breastfeeding initiation, regulates temperature, reduces crying, the fact that it functions, itself, as an analgesic for healthy babes, and the simple profundity of, yes, bonding. Check her bad self out:
Why is it so hard for the doctors and nurses to get on board? Most of them understand the word “bonding”. But what many don’t realize is that it took a long time for the actual concept to take hold, to allow “time” for bonding to occur. It sounds silly but many times if the baby and mother are still together after 2 hours…the nurses call that “extended bonding”. I have been doing this for over 35 years now and the changes from the 70′s to now are fascinating and frustrating at the same time. To understand the process of change, we have to sometimes remember where we’ve been.

I wrote about Medical Science vs Natural Childbirth a year ago because I feel history IS important to help us move forward. Often it is about control… but many times nurses and doctors are simply task oriented/ focused and not patient centered. They want to complete all their procedures and charting and move on to the next task. I understand this, there is always a lot to do and document. I work there too! The environment provided to us, the health-care workers, is one in which regulations are abundant and staffing is not always optimal. Flexibility is needed. I know there is a way. This culture just has to change. And it happens in small little doses.

SO–> Skin to Skin immediately after a C/S? I have been told by coworkers, doctors and anesthesia:

“It’s impossible, “

“It can’t be done”

“There’s not enough room”

“This patient (the mom) is in the middle of major surgery!”

“The baby needs to be under the warmer, it’s too cold in the OR.”

Really? Seriously? Watch Me………
And she then goes on to describe various barriers in the OR and how she has learned to cope with them. She closes with a final scenario, with a potent moral to the story:
The baby was crying and pink when born and without thinking about it, the doctor, nurses and myself had him on the baby unit drying him. Mom went panicky! “Give him to me, give him to me! He has to be ON me! You just took him OUT of me, now he HAS TO BE ON ME!” She was literally trying to sit up. Anesthesia was drawing up meds for her (that was his answer). I said “OK here he comes!”. So I didn’t ask anyone’s permission this time….. just held that naked baby in one hand, snapped open her gown with the other and helped him move in. I asked for a warm blanket and looked up to see the other nurse and doctor staring at me. I said “Seriously… she’s exactly right, he does belong ON her!” Anesthesia saw the immediate transformation of his frantic patient to one with calm maternal bliss, admiration and cooing. He was then helpful to let her other hand out. This little boy stayed with mom, breastfed before he was 15 min old and went to the PACU with mom. She was so incredibly happy. I never got to see her after that since it was near the end of my shift and I wasn’t on shift the next few days. I saw that she exclusively breastfed in the hospital and without complication went home on day 3. At least part of her birth experience went according to plan!

If she hadn’t have been so vocal about what she wanted, so adamant… she would not have experienced what she did.


Right on. Keep fighting for this, OB Nurse! We all know cesareans ARE sometimes necessary. There is no question about that - and thank God we have that available to us. But there is no reason that immediate skin to skin contact, and no routine separation of mother and baby, should not be THE standard of practice in all cases except when medically necessary. Make it happen indeed.

Saturday, June 5, 2010

Weekend Movie: Fabulous instructional breastfeeding video!

RAVE. I was impressed with every single thing I saw in this preview/condensed version of Breast is Best (yes, it falls into the trap of the Breast is Best language conundrum, but I can forgive it here). I can't wait to see the entire thing - I'm definitely ordering if for my resource library.

Things I'm especially tickled about:

*The fact that this opens with a demonstrations of immediate skin-to-skin contact even with a cesarean, continuing on into no separation during the recovery period unless medically necessary (and in that instance, emphasizes how dad steps in as the skin-to-skin provider). I'm curious to know whether this is more common in Sweden, where this was filmed. I cannot understand why this is not the default in every case, as long as, again, there's no medical reason for either mom or baby to break away from it.

*They explain how cosleeping and breastfeeding both work together biologically and help to get mom more rest, and point out how to do so safely in very simple terms.

*There's a great short demonstration of achieving a good latch, complete with slow motion breakdown. I love that they show the PROCESS of baby learning - and eventually getting it, with patience from mom. (I would have liked a liiiiiiiiitle more explanation of asymmetrical latch, but I am nigh impossible to please completely).

*They even address tongue-tie, however briefly, which I was thrilled to see (even though they only show one type, an anterior one). They even show how the tongue is "clipped" - a simple procedure called a frenectomy (without which Lily would never have nursed). I think including this would be very reassuring and normalizing to concerned parents.

All this, and it's not even the full video! I can't wait to see the rest. If you're involved with birth or breastfeeding professionally, from any angle (childbirth ed, birth or postpartum doula, lactation consultant, midwife, anything), this could be an essential tool for your resource library.

Thursday, June 3, 2010

Fatal Distraction

Hot weather is here - time to be more mindful than ever as parents. I know we always strive to be anyway, but when it comes to kids in cars, nothing could be more important. I've seen this story shared elsewhere, and thought it so important that I should pass it on, too.

I'm linking to a blog that links the actual article, both because I like what she has to say about it AND because it gives you one more chance to rethink it if you change your mind about reading it. Because seriously, this is as gut-wrenching as it gets.

THIS article, this heartbreaking destroying story of so many parent’s grief and guilt, this tragic tale of loss and forgetfulness, is worth every single minute it will take you to read it from beginning to end. And do not skip from one point to the next. No, all these stories deserve to be heard and all these cautionary tales need to be told.

It’s coming up on that time of year again. It was in the 80’s here today. It’s so easy to sit here and say, “I would NEVER forget my baby in the car,” but judgement doesn’t make you immune to accidents and temporary lapses in memory.
And that's key. NONE of us is a careless parent, by a long shot, and yet all of us have forgotten our car keys or lost our wallets or left the water running - because that's a human thing to do. And the way our brains organize information, it is possible for even the most loving, present, conscientious parent to have a lapse, as we multi-task our way through life. As the article explains:
"Memory is a machine," he says, "and it is not flawless. Our conscious mind prioritizes things by importance, but on a cellular level, our memory does not. If you're capable of forgetting your cellphone, you are potentially capable of forgetting your child."

Diamond says that in situations involving familiar, routine motor skills, the human animal presses the basal ganglia into service as a sort of auxiliary autopilot. When our prefrontal cortex and hippocampus are planning our day on the way to work, the ignorant but efficient basal ganglia is operating the car; that's why you'll sometimes find yourself having driven from point A to point B without a clear recollection of the route you took, the turns you made or the scenery you saw.

"The quality of prior parental care seems to be irrelevant," he said. "The important factors that keep showing up involve a combination of stress, emotion, lack of sleep and change in routine, where the basal ganglia is trying to do what it's supposed to do, and the conscious mind is too weakened to resist. What happens is that the memory circuits in a vulnerable hippocampus literally get overwritten, like with a computer program. Unless the memory circuit is rebooted -- such as if the child cries, or, you know, if the wife mentions the child in the back -- it can entirely disappear."
Be careful, mamas, hell, be paranoid, even, IMO. One friend of mine commenting on the article said she always puts her purse in the back seat, so she can't help but look back there - I think that's a great idea that I'll be implementing immediately - and yet, is even that enough? Look at all the variables that aligned in the final story the author shares, Lyn Balfour. What if that ONE DAY, I decided to run in somewhere without it because my cell is at home and I can just put my keys in my pocket? I know the entire point is that sometimes it happens no matter how many safeguards we put in place - which is why I feel a little cruel in even sharing this with you. But the importance won out.

It's funny, because after seeing Babies recently, I was left with the amused feeling that JEEZ, we Western and highly industrialized parents need to chill the heck out already, after watching the Namibian and Mongolian babies frolick freely with goats and drink out of streams and the like, not to mention the scene where the mother of freshly swaddled Bayar hops on the back of a motorbike, holding him in her arms. No Graco travel system installed by certified technician necessary. I chuckled a little wryly at our dogmatism (though I would never say safety is not something to take very seriously) and was feeling a bit more "free-range". After reading Fatal Distraction, which deservedly won a Pulitzer Prize. I feel ready to amp up the parental OCD.

We think it could never happen to us . . . and so did the parents to whom it happened. I wish them whatever peace they can find.

Tuesday, June 1, 2010

This just in, from the "Ya think?" department

MSNBC reported yesterday that, and this is the directly-quoted headline: "Induced labor may boost rate of early births".
In the new study, researchers used U.S. government vital statistics to show that labor inductions increased from 14 percent of full-term singleton births in 1992, to 27 percent in 2003.

Moreover, those same years saw an increase in the proportion of births at the earlier end of full-term pregnancy. In 2003, 30 percent of births occurred during the 37th or 38th week, versus 19 percent in 1992. And just over 60 percent of full-term births occurred before the 40th week — up from 42 percent in 1992.

The findings suggest that the rising rate of induced labor is a "likely cause" of the earlier births, the researchers report in the American Journal of Obstetrics & Gynecology.

That's what they "suggest", huh? Worthy points are then made regarding the increased risks for babies born in the earliest window of what is considered 'term', but really, guys.

Next up: "Rising cesarean rates seem to be connected to the the increasing number of babies born by cesarean, study shows". And from our weather center, "Blueness of sky leads many to believe sky is blue."