Tuesday, March 31, 2015

"F*** it All!"

Woke up about 4 am and saw the beautiful moon.
Woke up about 4 am and saw the beautiful moon. (Photo credit: Wikipedia)
Yep, that's how I woke up feeling this morning in regards to this journey to becoming a midwife. I've felt that way a whole lot over the past year, and for the most part I've kept it silent. My old wounds from my own traumatic births are so triggered that studying is a struggle, and there seem to be no opportunities to actually put anything I've learned to any kind of use. I thought after all my formal training there would be doula clients and midwives to assist, but no. It's a nightmare. I'm standing in my underwear (figuratively) with everyone staring at me waiting to see what I'll do next. As much as I want to run and hide, I'm only able to move very slowly towards some unknown.

Then I woke up. No, I'm not where I want to be. Yes, it sucks. But it's not about me. It's not about my personal struggle to become something useful to myself, my family, or my world. This is being human. This is knowing the struggle inherent in every birth. This is giving when there is no more to give. The moment of wanting to give up. There are so many of these sacred moments, not only at the end of an unmedicated birth, but before the cesarean that mom and her doula wish wasn't happening. No smooth waters. We're going to find every crack in this boat until you're soaking wet. And then comes your trial by fire. I smile. I've been here before. I dump some coffee into a sour stomach and prepare to pull an all nighter.

Maybe no one needs what I'm able to offer today. That doesn't make my calling a mistake. As much as I would love to have only good memories of my children's births and to gift every pregnant mama with the joy I know is possible when birth is held sacred and moms treated with the respect due them, my place tonight is beside my textbooks. This is not what I want to give my calling. Somehow, I expected a nice/neat balance of coursework and clinical work and a sort of comfortable float towards my goal. Now, I'm laughing.

Tomorrow, I'll be a different person, and the next day, and the next day... Who knows where I may end up? It doesn't matter because I can love where I am right now.   

Wednesday, February 26, 2014

Checking in on the homebirth debate

070909 Chani at the Homebirth Rights Rally
070909 Chani at the Homebirth Rights Rally (Photo credit: Nico Nelson)
"Homebirth is dangerous!" "Homebirth is safe!" This argument has become a big angry throwing match using a bunch of muddy statistics. The anti-homebirthers slam right into our deepest fears with neonatal death statistics. Homebirth advocates throw back the pain and anguish of maternal injuries and deaths. Sadly, it has come down to pitting the mother against her unborn child.

Statistics can be argued indefinitely, but what if we focus on those things that are known to be true and NOT a matter of debate.

-Hospital birth is always an option when wanted or needed. Homebirth isn't an all or nothing proposition.
-IVs, medications, surgery, and other medical procedures are never completely risk free. If the risk of the intervention is greater than the benefit then you're simply creating risk that would otherwise not exist.
-A majority of babies will be born healthy no matter where birth takes place. Only a few rare emergencies will cause serious problems.
- The cesarean section rate in the United States is too high and can be reduced without compromising safety.
-If mom suffers baby suffers. A mother's physical and mental health is closely tied to that of her child's before and after birth. Extreme stress during pregnancy (arguing with a doctor or nurse over testing and birth plans would count) is bad. Arguing during labor is even worse. A mother traumatized by rough treatment during birth is going to be less able to give the constant care a newborn needs.

If that isn't enough for you, consider this instead of arguing whether or not homebirth is safe: How can hospitals say that they are the best place to have a baby due to their ability to quickly respond in an emergency, but in the same breath say that they are not equipped to handle VBAC because they can't respond quickly enough in an emergency?

Why are we even debating this in a country with such a "good maternity care system"?
Deadly delivery: The maternal health care crisis in the USA

One of the best journal articles I have found about the debate
Mother Beware: Perilous Scholarly and News Media Discourse around Homebirth
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Thursday, December 12, 2013

Fetal Personhood Is a Violation of Human Rights

Human embryo at six weeks gestational age
Human embryo at six weeks gestational age (Photo credit: Wikipedia)

Fetal personhood doesn't just affect women who choose abortion. It is a threat to all pregnant women because it puts their bodies at the mercy of medical and legal interpretation. It is based on the overwhelmingly false assumption that a pregnant woman will not make the best decisions for her unborn child. A woman and her fetus are in it together for however long the pregnancy lasts. Putting the rights of a fetus in the hands of anyone other than the pregnant woman can only serve to cause needless pain. To illustrate this point, I will share two very difficult private moments in my life that could have been made far more painful by fetal personhood.

A few years ago, I was treated for hyperthyroidism caused by autoimmunity. I didn't do so well on the medication so I didn't refill the prescription and was still trying to consider my treatment options. Unexpectedly, I turned up pregnant. I had had negative experiences with both the endocrinologist and nurse midwife I had most recently seen so I didn't know who to call for thyroid testing and treatment. I wasn't even ready to tell my husband the news when the gush of blood and tiny barely distinguishable fetus came a few days later. I cried and cried along with my husband. I blamed myself. If only my thyroid levels had been closer to normal, maybe the miscarriage wouldn't have happened (of course there's no way to say for sure that that was the reason for the loss).

 The point is I went against doctor's orders and lost a pregnancy. Under fetal personhood laws that could have easily been construed as a crime resulting in jail time and a criminal record. Think that's a far fetched notion? Just read the news.
Mississippi Could Soon Jail Women for Stillbirths, Miscarriages
Women Jailed for Miscarriages in El Salvador

The other situation was when I was in labor with my third child and having a very ugly argument with the nurse-midwife. My water broke during early labor and progress towards birth was going slow. After having suffered two traumatic (and unnecessary) pitocin augmented labors, I refused to allow pitocin, which would have restricted me to bed with IV and continuous monitor hooked up which meant no way to handle stronger contractions and the calm natural birth I was working so hard for would be gone. The nurse midwife said my baby would be born septic and die. I still refused. (Ultimately I left that hospital, but still didn't have the birth I was going for because I was given cytotec, which is also sometimes used in medical abortions. There never was any hint of infection.)

What if the nurse-midwife and staff obstetrician (who I never saw) could have gotten a legal order to protect my unborn baby by whatever means necessary? Would I have been chained to the bed? Would they have sedated me or simply let me scream in terror? Would they have rushed me to the operating room for needless major surgery? Think that would never happen. Again, read the news.

Woman Ordered by State to Submit to Hospital Confinement, Cesarean
Forced Pregnancy, Forced C-Sections

Still wondering?
Pregnant Woman Suffers. You Won't Believe Who's to Blame.
Your Body, Your Decisions – This Means You, Moms!
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Wednesday, October 2, 2013

What you should never have to expect when you're expecting: Cytotec/ Misoprostal

diclofenac sodium - misoprostol
diclofenac sodium - misoprostol (Photo credit: farlukar)
So your doctor says he's using cytotec to induce labor, or your CNM comes in your hospital room with a jagged pill piece to speed things up after you vehemently refused pitocin. From one mom to another, please don't do it. Here's why:

Cytotec works as a prostiglandin to induce labor contractions and is relatively fast, effective, and inexpensive.
Cytotec is not FDA approved for any purpose other than treatment of ulcers, and is specifically contradicted by the manufacturer for use in pregnant women.

Reality Check:
Popular (My colleagues and I use this drug all the time.) and safe (This drug has scientific studies proving that it does more good than harm.) are two very different things. Cytotec frequently causes uterine hyperstimulation. It can lead to uterine rupture or a rare amniotic fluid embolism or even neonatal brain damage. After lawsuits involving tragedies related to cytotec use, it is generally no longer used in VBAC situations because of the high risk of uterine rupture.

What is the risk of uterine rupture when using cytotec in someone (like me) who has not ever had a c-section? I was shocked to find out that nobody really knows for sure if the risk is that much lower. Just because your care provider has not witnessed a serious complication doesn't mean it couldn't happen to you. The scary reality is that once cytotec is given it can't be stopped. You can be given another medicine to slow down contractions, but this is rarely done.

I was lucky. My baby was born quickly before the cytotec induced nightmarish pain caused a complete uterine rupture, but I did have the warning signs of a small uterine tear starting. It is so absolutely unnecessary to take that chance. If you absolutely cannot avoid induction, consider alternatives such as the foley balloon catheter or even cervadil.
American Journal of Obstetrics & Gynacology: A randomized trial of preinduction cervical ripening: dinoprostone vaginal insert versus double-balloon catheter 
If all else fails, pitocin is still safer so long as you make sure it is turned off at the first sign of uterine hyperstimulation (once again this is defined as more than 5 contractions in 10 minutes or less than 1 minute between contractions).  

Need more evidence?
Consortium for the Evidence-based practice of Obstetrics: Information on the off Label use of ulcer drug Cytotec / misoprostal to induce labor

Need even more evidence? Read Born in the USA
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Monday, September 30, 2013

What You Shouldn't Have to Expect When You're Expecting 1: Pit to Distress

chemical structure of oxytocin with labeled am...
chemical structure of oxytocin with labeled amino acids (Photo credit: Wikipedia)
So you're expecting a baby and for whatever reason your care provider has chosen to give you pitocin/synthetic oxytocin to start or speed up labor.

This medication goes through an IV so it can be carefully controlled. The goal is to have 3 moderately strong contractions during a 10 minute period of time. More than 5 contractions in 10 minutes or less than 1 minute of complete uterine relaxation between contractions constitutes a serious adverse reaction and should automatically result in pitocin being stopped. It may be okay to have it restarted at a lower dose if patient and care provider agree to do so.

Now for the very disturbing reality check:
Pit to Distress

An overstimulated uterus is very common with pitocin yet extremely uncommon with natural labor primarily because the body produces natural oxytocin in short bursts and synthetic oxytocin is run through a continuous IV. Just like any other medication, people react differently. Many people (my hand waving furiously) will experience contractions without relaxation and/or contractions that are way too hard and way too fast.

To be absolutely sure the uterus experiences the much needed relaxation phase during labor, simply place a hand on the abdomen and if it remains hard instead of going completely soft after contracting it is an abnormal and very dangerous situation. Equally concerning is if there are more 5 contractions in 10 minutes and/or less than 1 minute between contractions. If this situation goes unchecked, not only will mother be in distress from unimaginable pain not associated with normal childbirth, but the unborn child will be robbed of oxygen and can become quickly distressed. Continuous monitoring may not give an accurate picture of the contraction pattern and might even miss warnings of fetal distress.

Where is the doctor? Probably not even at the hospital. Doctors and even some nurse midwives are only trained in treating the birth of a child as a medical condition, not in how to wait for nature to do its job.
What about the nurses? Don't they have orders to stop the medication in case of adverse reaction? Not necessarily. They have likely not been trained in what to expect in normal childbirth. If they do know this is abnormal, they may still be ordered to continue the pitocin.

It is up to you to demand evidence based care prior to being given any medication, and if things go wrong be prepared to demand that the medication be discontinued if you react abnormally.

Need resources to make an informed decision?
Evidence Based Birth articles for induction and augmentation

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Tuesday, September 3, 2013

Braless Confessons

Barbie Basics
Barbie Basics (Photo credit: dog.happy.art)
Yes, I did run errands this morning. No, I am not wearing a bra.

One of my earliest memories was of playing dress up with my older sister. She padded her new bra for me and everything and I paraded out of the bedroom. I remember my father's deep voice yelling my sister's full name (middle and all!) "Get your bra off your sister!" People sure get ruffled over who's wearing the "right" underwear.

I've never found bras natural or comfortable. Many people say that any discomfort in a bra just means you are wearing the wrong size, which is most likely true, but only part of the story. Bras may actually be unhealthy (Bra Free!)  .

 Maybe you can't say that bras cause breast cancer (I personally believe it's more complex than that), but there may be enough research to say that they reduce lymphatic flow through the breast tissue, which cannot be good.

Some say that it's impractical for all but the smallest breasts. I think not. I've been through most of the usual spectrum of bra sizes, from the pre-kids A cup to a D cup when breastfeeding my youngest child. My normal settled size is not extremely perky. Because I'm smaller my chest looks bigger than average. 

Yes, without a bra they move around more, and I have less cleavage. I don't have an issue with nipples showing, but I do wear a camisole or tank top. You don't necessarily have to throw all your bras away. Sometimes, you may want the illusion they create. Just don't wear them all day, every day. Go for a weekend day or go out to a movie without one (and notice how nobody notices). Work up to grocery shopping and other public bralessness.

Will bras go the way of the daily corset tied so tight that broken ribs were a real possibility? I don't know, but I hope so!
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Monday, August 26, 2013

Why I don't tell hospital birthers to "go in pushing"

IMGP1260 (Photo credit: Nico Nelson)
Yes, you should try to labor at home as long as possible before going to the hospital. But before trying to use that as your technique to have an intervention free birth (especially for those facing opposition to a VBAC), you need to recognize the inherent variability of the birth process and how hospitals may respond to it.

Good luck calculating exactly when you will be ready to push your baby into the world. If you can do that, be sure to account for traffic, unless you would rather enjoy the first stage of labor in the hospital parking lot. For a fair share of women, the second stage of labor, where they are actually pushing, doesn't last as long as a drive to the hospital. Yes, a fair number of women do get to the hospital just as they are ready to push, but it's not fair to count yourself among them except in hindsight.

Going to the hospital early in labor is just part of our natural instinct to get settled and feel safe before labor is too advanced to move. It's natural to want support and reassurance that the baby is doing well. The problem is when the hospital isn't willing to just let you wait it out. Unfortunately it doesn't matter when you arrive, you can be subject to unwanted and unnecessary intervention without informed consent, up to and including surgery.

The better option is to plan for the birth you want as early in your pregnancy as possible (or even before), and if you meet with hostility change care providers and/or birth location. Keep trying to find what you want and it's never too late to change your mind. You do not need full blown arguments during any part of your labor. In that situation, the person who's not in labor has the upper hand. No matter how it turns out, having to do battle while trying to birth a baby will color the experience. Yes, women who are actively and successfully pushing out a healthy baby can still get wheeled into the operating room against their wishes.
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