Archive for the ‘Birth Controversies’ Category

The Best of Both Worlds

One of the most common questions I’ve heard posed by those who oppose home birth is this:

“Which is more important to you- the birth experience? Or the baby?”

It implies that mothers who choose home birth are irresponsible. That they care more for low lighting, eating and drinking, and romantic photographs of labor than having the possibility and convenience of immediate medical care. That they are making the choice to birth at home as a trade-off- “Well, I understand my baby might die, but I really like my house better than that cold, sterile room.”

Of course those women who chose home birth cringe at the accusation. We love our babies just as much as those who chose the hospital. And home birth moms cry out that it’s not just the experience that draws them to home birth-it’s also the medical advantages that home birth offers.  It’s the lowered risk of hospital-based infections, the probability of faster, easier labor, the less likelihood of unnecessary interventions that can cause even more problems. They challenge the idea that the hospital is the safer place to be for low-risk mothers.

And both sides pull out studies. Both sides pull out horror stories or anecdotal evidence to support their own position. It seems that either you risk a life or you compromise your healthy, calm labor experience.

But I challenge you all.

My question is, why can’t you have both a beautiful and safe birth experience in either setting?

Why can’t home birth midwifery be legalized in all 50 states so that it wouldn’t fly under the radar, creating unqualified providers and dangerous birth settings?

Why can’t there be standardized training for those legal home birth midwives so that all mothers can get the safest care available?

Why couldn’t there be traveling OR units for cesareans at home in a true emergency, as one birth blogger suggested?

Why not require OB’s to have more training and experience with completely natural births? How about having to witness some home births before beginning practice?

Why not allow a mother to have a “home birth in the hospital?” All it would require is to allow a mother to labor freely under midwifery care, just as she would at home- only just down the hall from OB’s & the OR as needed.

Why can’t OBs provide the quality and continuity of care that mothers love when hiring a midwife- longer appointments, a holistic view of woman’s health, having the same doctor from prenatals to birth to postpartum care?

Why do money and legalities rule our health care decisions?

Why doesn’t the minority have the same opportunity to birth naturally and safely, just as women have the opportunity to birth with pain medication and/or in a more medicalized environment?

And why can’t these things change?

I know many of my hopes are only far off dreams… things that seem impossible now. But in reality, why not?  Why can’t we live in a world where we can have the option of more natural and peaceful hospital births, or the opportunity for a qualified home birth care provider for every woman who wants one?

Most of these ideas aren’t even on the horizon yet. But hey, a girl can dream, can’t she?

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Eleven Ways to Avoid the CPD Diagnoses

Cephalopelvic disproportion is commonly diagnosed, but women who have had the label slapped on have later birthed subsequent babies (sometimes larger!) vaginally without a problem. CPD has been noted as one of the most common and most controversial reasons for a c-section, and the general consensus (among birth professionals and crunchy birth bloggers alike) is that in most cases the diagnoses is incorrect. (It could just as easily be called “failure to progress”-or as I prefer to call it, “failure to be patient.”-an equally unsatisfying reason for a C-section in many cases…) If you missed it and would like to read more, check out The Problem with the CPD Diagnoses.

So, how can you avoid getting stuck with the CPD label? Try going through this checklist before determining that your pelvis is too small or that your baby is too big. Remember that some of these suggestions are pointed at the fact that the CPD diagnoses is often given to women who don’t birth quickly enough by your caregiver’s standards. (e.g., Your baby isn’t coming? He must just not be fitting through.)

1) Allow the mother as much freedom of movement as possible.

The more the mother can move about, the more room she creates for her baby to wiggle and move downward through her pelvis. Think of it like fitting a key into a tight lock- sometimes it gets jammed, but if you wiggle it this way and that, then it will fit in just fine. Many times getting up and walking around, moving your hips, or simply shifting positions can allow baby the extra room he needs to fit through.

2) Allow pain management drugs to wear off a bit.

Sometimes mothers who are on an epidural cannot feel enough to push their babies out. If they allow the medication to wear off just enough that they begin to get some sensation again, they may be able to connect to their pushing muscles to feel enough to continue on to a vaginal birth. The mother is not to blame if she cannot feel to push; rather, she should be aware of this possibility and consider asking for more time to birth vaginally, provided that she and the baby are doing fine.

3) Try alternate pushing positions.

This goes back to #1. Getting off your back and getting in the position you feel most comfortable in can help your baby to find a little more room to fit through. For example, squatting opens the pelvis up to 30% more than in other positions.  (Check out this video for a discussion on walking and squatting for labor and pushing, and this video to hear suggestions for alternate pushing positions.) Upright pushing positions can also give you the advantage of gravity, and more pushing force. Both of these can aid in getting your baby out more easily.

4) Encourage your baby to be in optimal fetal positioning.

What position is your baby in? Do you know that it can make a big difference in how easily he makes his way out? For example, a baby that is in the occiput posterior position (crown of his head facing your tailbone) has a much more difficult time fitting through the pelvis (though most will turn if given a chance). The baby’s rotation to fit through your pelvis is just as normal a part of labor as your dilation is. Check out Spinning Babies for more information on how to decipher your baby’s position and to encourage a great one for labor and birth. This can be done during pregnancy or even during labor. (Here’s a great article specifically on CPD.)

5) Consider chiropractic care in pregnancy.

“Some women report that chiropractic care throughout and between pregnancies is helpful in avoiding CPD. Look for a chiropractor who has experience working with childbearing women and utilizes in-utero constraint techniques.” –ICAN on CPD.

6) Keep your energy up during labor.

Rest. Eat. Drink. Try not to wear yourself out. The uterus is a muscle- and just like any other muscle, it can get tired and give out if worked too hard. Keeping your energy up can help your uterus (and you!) to have the strength to birth vaginally.

7) Avoid an induction if possible.

If you and the baby are both healthy, try to avoid early or routine inductions. (Remember, even ACOG states that a pregnancy isn’t considered postterm until 42 weeks.) Your risk of cesarean is significantly increased in an induced labor. What might contribute to a “CPD” cesarean caused by induction? One factor is that you are less likely to dilate as quickly or effectively in an induced labor.  Another is that you are more likely to need pain medication when induced, which in turn creates less mobility for the mother (remember #1-3?) and also tends to slow labor. (That’s not even mentioning the emergency C-sections due to increased risks to babies from inductions, but that’s off topic…)

8) Keep a calm birth environment.

If women are allowed a calm, peaceful environment where they feel comfortable and at ease, it is quite possible that they will dilate more quickly. Adrenaline suppresses oxytocin, so being nervous can quite literally slow your labor progress (& sometimes stall it out!).

9) Hire a doula.

Doulas can help suggest ways to encourage your baby to move into a better position for birth, to make pushing more effective, and to generally help speed and ease your labor. The various techniques a doula brings to your birth are invaluable for many reasons, but can also help you to avoid a “case” of CPD.

10) Listen to your body.

This might sound strange to some, but you should pay attention to how your body is feeling throughout labor. Extreme discomfort is often a signal that something needs to change. If you feel like you can hardly bear a certain position, try a different one that works for you! In the process, you may help your progress and facilitate baby’s descent.

11) Be patient.

If you and the baby are both healthy, a slow labor or long pushing phase doesn’t necessarily mean anything is wrong. It took 3.5 hours of pushing for my son to decide to turn from his posterior to anterior positioning and make his exit. Yes, it was difficult. Yes, it was exhausting. And I do admit to thinking to myself, “So what’s wrong with a c-section?” There was a period where I myself didn’t believe that he would actually come.

Most of the time labor doesn’t bring immediate results. It is long, sweaty, hard work, and all you can do is ride it out and wait for each contraction and each challenge to pass. Patience doesn’t guarantee a perfect birth, but oftentimes patience can save you from jumping the gun and trying to “fix” something that wasn’t broken in the first place. Sometimes what seems like a baby not fitting through the pelvis is actually a case of the baby simply taking longer to make his way down through the pelvis and birth canal.

Let me be perfectly clear. True CPD, though rare, does exist. If you are one of those women who actually does have it, do not blame yourself. You are not at fault. We live in a broken world, and not everything always works as it should. These suggestions are meant to be tools for you to try to help avoid the CPD diagnoses. You are doing everything you can to do the best for your baby and yourself, and in the case of a truly necessary cesarean, you are absolutely doing the best thing for your family by going through with it.

So now you have some tools to take with you to labor. Suspected big baby? Previous CPD diagnoses? Don’t be afraid. Give it a shot. You can try to birth this baby vaginally, and many of you will go on to do so.

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The Problem with the CPD Diagnoses

There’s no way that head was fitting through vaginally!

No wonder you needed a c-section, your baby was so big!

Don’t worry honey, it’s not your fault. Your pelvis is just way too small.

The diagnoses for the cesarean?

Cephalopelvic Disproportion (CPD)
1. a condition in which the fetal head is too large to traverse the maternal pelvis. (MediLexicon)

Either the baby is too big, or the woman’s pelvis is too small, or a combination of both, they say. However, CPD seems to be one  of the most common and the most controversial reasons for a c-section. I personally have known many women who were told that their babies couldn’t fit through their pelvis. Many choose to have an elective cesarean afterwards; others go on to birth subsequent (and sometimes larger) babies vaginally.

So, outside of the labor room, what are people (birth advocates and medical journals alike) really saying about CPD?

“Cephalopelvic disproportion (CPD) occurs when a baby’s head or body is too large to fit through the mother’s pelvis. It is believed that true CPD is rare, but many cases of “failure to progress” during labor are given a diagnosis of CPD. When an accurate diagnosis of CPD has been made, the safest type of delivery for mother and baby is a cesarean.” – American Pregnancy Association (APA).

“Cephalopelvic disproportion is rare. According to the American College of Nurse Midwives(ACNM), CPD occurs in 1 out of 250 pregnancies. If you have been diagnosed with CPD, it does not mean that you will have this problem in future deliveries. According to a study published by the American Journal of Public Health, more than 65 % of women who had been diagnosed with CPD in earlier pregnancies, were able to deliver vaginally in subsequent pregnancies.” APA

“When a diagnosis of CPD has been made, many people still believe that this constitutes a reason for elective repeat caesarean section in future pregnancies, despite the wealth of evidence to the contrary. Indeed, there have been many documented cases where women have been diagnosed as having CPD and then gone on to deliver vaginally a larger infant than the one that was delivered surgically.” –Belly Belly

“In one study, 68% of women diagnosed after labor with “absolute CPD” still went on to have a vaginal birth. However, in extremely rare cases, true absolute CPD does exist, usually in the context of severe malnutrition or a permanent injury.” International Cesarean Awareness Network (ICAN) (1).

“A trial of labor is reasonable in women whose previous cesarean was for dystocia in the second stage of labor. In this series, patients who underwent a trial of labor after a previous cesarean for dystocia in the second stage had 75.2% (95% confidence interval 69.5, 81.0) chance of achieving vaginal delivery.Obstetrics & Gynecology (2) (Note that dystocia is associated with a long labor, and is often associated with the CPD diagnoses.)

A woman’s pelvis is flexible and is made to open during birth. When there is interference with the birth process (induction before baby is ready, mother’s movement is restricted, etc.), the pelvis is not able to open to its maximum. The baby’s head molds (changes shape) during labor and delivery in order to fit through the pelvis. Neither the pelvis nor the baby’s head are fixed in one position; both expand and shift as labor progresses. A birthing woman’s pelvis is most likely to expand freely and accommodate the baby when the following conditions are present:

The birth takes place when the baby is ready and when natural birth hormones are present.The laboring woman moves freely to her comfort level.Adequate time is allowed for the molding of the baby’s head.” –ICAN

(All bold print mine.)

All of this is not to say that true CPD doesn’t exist, nor that all cesareans for CPD are bad. But there is sufficient evidence available that should make one rightly question the commonness of the CPD diagnoses. Could it really be that so many women’s bodies are not able to function properly in stretching and opening for a baby? Or that babies are that much bigger today than they were many years ago (say, back in 1970 when we only had a 5% c-section rate?) Or that a women’s pelvises could actually get that much smaller in the past 40 years?

It’s something to think about… and maybe even something worth questioning.

Have you ever been faced with the CPD diagnoses? Do you think it was given rightly? Why or why not?

Check back in next time for a post on how to try to prevent the CPD diagnoses during your birth.

(1) Impey L, O’Herlihy C. First delivery after cesarean delivery for strictly defined cephalopelvic disproportion. Obstet Gynecol 1998 Nov;92(5):799-803.

(2) Bujold, Emmanuel MD; Gauthier, Robert J. MD. Should we allow a Trial of Labor After a Previous Cesarean for Dystocia in the Second Stage of Labor? Obstetrics & Gynecology 2001 Oct; 98(4):652-655.

Quotes from The Trenches

As a passionate birth advocate, I occasionally begin to wonder if I’m completely crazy. If a lot of the medical profession disagrees with us nutty doulas, then should we even be opening our mouths? Have we gone off the deep end?

I am grateful to receive continuing confirmation from the medical world that what I advocate for is indeed evidence-based, and that I am not obnoxious or ridiculous (at least not because of my beliefs about birth!). Here are some real quotes from nurses and doctors at births I have attended that have brought me great encouragement.

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“We used to turn up Pitocin very quickly, but now we’ve learned that it takes time for the body to adjust to its effects and so we do it much more slowly now.” -OB to mother.

“We break the water far too much these days. There’s no real advantage to it.” -Nurse to me.

“There are two schools of thought about the episiotomy, but most of the evidence does show that it’s better to risk tearing than it is to be cut.” -Nurse to mother.

“You can eat or drink whatever you want during labor if I’m there.” -OB to mother, during a prenatal visit.

“That’s exactly how a birth should go.” -Non-natural friendly OB to mother after witnessing an unmedicated, calm VBAC.

“You can tell your baby was unmedicated because she’s so much healthier [e.g., more alert, less weight loss, no jaundice, better nurser].” -Baby nurse to mother after a drug-free birth.

“I  hate to say it, but a lot of things do happen because of time, not because of medical reasons. I’m not nervous about it taking a while, but who knows what the OB’s schedule is? ” -Nurse during a mother’s labor.

“Studies show that most cesareans happen at shift change. It’s true.” -Nurse to me after a birth.

“A vaginal breech birth can be safe if it’s done under the right circumstances. And you want an older OB who knows how to do it. Most of the younger ones are too nervous to try it.” -Nurse during a discussion about normal birth.

“I would never have my baby there [at our local hospital]. I see what they do there, and it’s crazy. Next time I’m pregnant I’m having my baby at home.” -OB nurse to my husband at a middle school career day.

“Tell your story. So many women wouldn’t even know how to advocate for themselves or their birth. It’s so important that women hear what you did to achieve this.” – Nurse to VBAC mother who negotiated with her OB many times. For example, she fought to buy more time at the end of her pregnancy to avoid a scheduled repeat c-section, to gain freedom of movement, permission to consume clear fluid foods, to keep her membranes intact to avoid a time clock, etc., etc. She stood up for her rights gracefully and respectfully. I believe this is what led her OB to work so well with her, despite his initial resistance. In the end, it was a perfect balance of the family respecting medical opinion and the OB respecting the mother’s desires.

These are just a few examples of quotes I’ve heard that show me I am not alone in my desire for evidence-based birth practices. And it also shows that change is happening, right in my own backyard! I am so grateful for these wonderful hospital staff members who are also striving to change the face of over-medicalized birth as we know it. It may not be quick, and it may not be easy, but one mother, one doula, one nurse, one OB, one midwife at a time, change is happening. Birth is beginning to be seen more and more as a normal event that should be supported, not forced, interrupted, or “rescued.” Keep up the great work- always with passion, gentleness, and self-control.

Pain Vs. Suffering in Labor

Here is Penny Simkin lending us some great insight on pain vs. suffering in labor. What do you think about her points? Anything you disagree with? Agree with wholeheartedly? Enjoy.

I Do Not Consent: A Sequel

I wrote a post almost a year ago now entitled “I Do Not Consent,” and I noticed it was getting a lot of traffic (for my blog, anyway!) the past few days. As I reread the post, I felt as though it needed to address some additional issues in order to give a complete picture of my views. Some comments I received also confirmed this need.  I feel that further exploration of the topic of non-consent is an important pursuit.

If you haven’t read the original post, you can go ahead and read it here first so that we’re on the same page before continuing. Okay, here we go…

1) Non-consent is a serious decision.

I did say this in my original blog, However, it appeared as though some readers missed it, so I quote: “I will say… that this phrase should probably not be taken lightly. Weigh your caregiver’s experience against your own intuition. Is your baby still ok? Are you still ok?  Find out whether the caregiver is recommending a procedure out of medical necessity, or because of convenience or a hospital policy.”

I am not– I repeat- I am not recommending anyone deny a procedure that is truly medically necessary for themselves or their baby. This is utter foolishness. I am also not recommending that you go into the hospital (or at your home) throwing this phrase around at the drop of a hat. This probably will not be helpful to your cause. This leads me to my next point…

2) Communication is key!

I am not much for fighting during a birth. I am not suggesting that you argue with your care provider. Keep an open line of communication with your doctor or midwife before and during the birth. Ask for things politely. Discuss your preferences first. If you come to a disagreement, then you can can implement my suggestion from my previous post:

“You can always say, ‘Wait. I do not consent yet.’ Go on to ask these four questions:

1) Is this an emergency? (If no, move on.)

2) What are the benefits of this procedure?

3) What are the risks of this procedure?

4) What happens if we do nothing?”

If you disagree with a procedure, talk through your options with the doctor or midwife (provided that #1 is answered with a no). Goodness, you could even compromise if you’re both comfortable with it! Even non-consent to an unnecessary procedure, however, doesn’t have to be rude.

3) Consider your relationship with your care provider early on.

Please do not go into a birthing situation planning on being “up-in-arms” about everything. If you think all OBs are surgical monsters who don’t know how to let a woman labor, then why did you sign up for their care? If you think your home birth midwife is full of fluff and incompetent, why are you paying her to attend your birth?

In most cases (with some well-acknowledged exceptions), you chose your care provider. Don’t plan on not trusting them from the start. If every appointment you are thinking how much your midwife makes you mad or uncomfortable, then you should switch providers.

As one reader commented, “You should never discount your providers education, training and experience. There are times during birth when a caregiver must make life and death decisions and may not have time to offer a 30 min. consult on the pro’s/con’s of their decisions. I am not saying that there will be an emergency in every situation, however, If you do not trust your provider and their judgement to do what is best for you and your baby, you should find a different one! Yes, be well informed. Ask lots of questions PRIOR to the birthing room when there is time to go over all the nuts and buts of why things are done a certain way – but waiting to be informed until you are in the middle of your birth is…well, negligent on your part.”

Ideally, you should choose a  provider who respects your preferences as much as is possible, AND whose  expertise and training you can respect in situations that you are unsure of. However, less-than ideal situations sometimes can come up in the company of an on-call doctor, or a nurse, or with the midwife’s assistant (or what have you!), no matter how well-prepared you are.  In this case, non-consent should still be considered a reasonable option.

4) Don’t leave the hospital in the middle of a c-section.

Yes, I know I’m being silly. When I wrote in my original post that it’s never too late to switch care providers or birth sites, I guess there was an actual limit to that. Pushing and surgery are probably cutting it pretty close. However, I have heard of many women who have requested new providers, left their home birth, or traveled to a different hospital in order to find the respect, courteousness, and medical sensibility they lacked in the first place.

4) Women need to have the option of non-consent.

Women still need to have the option of non-consent. Why?

  • Because sometimes there really are flat-out medically unnecessary procedures being performed out of habit, preference, liability, or policy. I’m not saying it’s happening all the time or that this is the primary motivation for most care providers. I’m just saying it happens sometimes, and it shouldn’t.
  • Because even for the most well-prepared mom, unpleasant surprises can arise during labor. Sometimes its from an on-call staff member that she just didn’t have time to talk to before the birth.
  • Because sometimes there are situations that are just plain assault. Like the mother whose doctor cut an episiotomy “just to teach her a lesson.” Or the two doctors who ripped a mothers perineum with their hands when she asked them not to cut her. Or the midwife who emotionally abuses her patient by scolding her for not handling pain. No woman should have to feel that she should sit through something like this for the sake of being a “good patient.” If we don’t allow women the right to stand up for themselves at this point, then when will we?

I felt that expansion and clarification of “I Do Not Consent” was necessary, especially if you are not a regular reader who understands my broader views on birth and providers. I hope that my list of “qualifiers” wasn’t too long, and I hope that it was clear. Please feel free to ask questions/give input in the comment section. I’ll summarize with a reply I wrote to a commenter on my original post. Thanks for reading, as always. 🙂

“Birth should ideally be a partnership between birthing mother and caregiver. Only when the mother is being coerced or attacked for non-medical reasons should refusal be resorted to. I am sorry this didn’t come across more clearly in [my original] article… I don’t want to encourage recklessness. But I do firmly stand behind the protection of a woman’s intelligence and dignity during birth, and that means that she has to still have her rights in the birthing room.”

*Not to be taken as medical advice.

EFM vs. Intermittent Listening: A Sometimes Senseless Debate

What type of monitoring should be used during labor and birth? Many will defend one type of monitoring over another. Here are the options:

  • Continuous External Fetal Monitoring (EFM)– The belts around the belly you so often see. One belt picks up the baby’s heart rate, one belt picks up contractions.
  • Intermittent EFM– The above method can be performed intermittently by simply disconnecting the belts periodically, assuming the baby is doing well.
  • Continuous Internal Monitoring– In this method, a tiny electrode is screwed in the baby’s scalp to read his heart rate. This method is much more accurate, but also somewhat more invasive since the amniotic sac has to be broken.
  • Intermittent Listening– Your care provider listens at intervals via a Doppler or fetoscope. Yes, mom has stop periodically to have someone listen to her baby, but its probably more comfortable than having belts tightened around the belly.

Today, I would like to look at only two of these options- continuous EFM vs. intermittent listening of any sort. (I will not address internal monitoring because it is generally considered to be more accurate, and is likely remain continuous throughout the duration of its use.) Some say that continuous EFM is more likely to catch a possible problem with the baby earlier than intermittent monitoring, and some say that EFM really only catches more reasons to perform a cesarean and avoid a potential lawsuit. Some insist that intermittent listening is just as safe as continuous EFM, some insist that a mother who desires intermittent listening is putting her baby at serious risk. I will not jump on the debate bandwagon today. Why? Because…

The method of monitoring chosen during labor and birth is only accurate to the extent that it is used correctly.

I cannot vouch for every single birth out there, but I will say that in my experience, it is extremely common for the baby to slip off the monitors. I cannot tell you how many times a nurse would come in, adjust the monitors, find the baby, walk out, and not five minutes later the baby would be off again (sometimes even from a mother simply shifting her weight, or from an active baby visiting the other side of the womb). Sometimes it would be thirty minutes to an hour until we would see the nurse return to adjust the monitors again. Suddenly, continuous EFM is no longer so continuous. Furthermore, in a busy hospital, nurses simply do not have the time to keep coming to adjust the belts or to listen themselves for a few minutes with a handheld Doppler. This is not a value judgement on nurses or hospitals- it’s simply the nature of the birth setting.

On the other hand, intermittent listening by an attentive care provider in any setting, if used correctly, may provide just as accurate information or even more accurate than the neglected EFM belts. Of course, it is extremely important that the care provider doing the listening is skilled at discerning differences in heart rates and knows well the trouble signs to look for. Plus, they have to listen frequently enough to detect signs of distress before they become an emergency. If these conditions are not met, then intermittent listening can of course fail.

My point is not to avoid choosing a specific type of monitoring over another, as certain types of births do call for more consistent monitoring than others. My point is that the issue simply cannot be debated when the methods of listening are so often used incorrectly. Once care providers make sure that continuous EFM really is continuous, and that the intermittent methods being used are done correctly and at appropriate frequency, then you can go ahead and debate all you want about the issues. 🙂

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