Two more strikes against Cesarian deliveries

1. Premature babies delivered by Cesarian section are at an elevated risk for asthma.

2. Cesarean delivery does not diminish the risk of postpartum depression (which some doctors had previously thought).

Correction (but not Concession)

I think I need to correct my facts in last week’s post about early epidurals. As I read more about the study, it appears I flipped the results. The epidural was more effective, faster acting, etc. than the other option.

Nonetheless I still take issue with the study. First, it was performed by an anesthesiologist. Might this person have an interest in making epidurals more readily available?
Second, the particular epidural used in the study is NOT what most of us think of when we think “epidural.” Seven paragraphs from the end of the NYT article on the story, it quotes Dr. Laura E. Riley, director of labor and delivery at Massachusetts General Hospital. Here’s an excerpt from the article:

"[The doctors in the study] do a very intricate kind of analgesia," Riley said, referring to the combined spinal and epidural technique. "I don't know that many places that can do it."
The findings may not apply to other patients who have standard epidurals without the spinal component or epidurals that use different drugs from the ones in the study.
"It may just pertain to this group of patients," Riley said. "It's not clear that this is really generalizable."

This distinction has not been made clear in the headlines running in newspapers across the country urging women to get their epidural early in labor.

Somewhat relatedly, it appears some anesthesiologists are concerned about administering epidurals to women with tattoos in the area where the needle gets inserted. If you're debating getting a tattoo above your sacrum and want epidural relief in childbirth, you may want to hold off a while!

Desecrating my Temple on Primetime

I had a great conversation yesterday with a friend I hadn’t seen in a while. I was telling her about my doula work and found myself talking about (and simultaneously realizing for the first time) the degree to which birth is the closest approximation of spirituality I have in my life.

Then a few hours later I found myself watching Discovery Health’s Birth Day Live! and getting sucked into nearly ninety minutes of unplanned T.V. watching. My reaction to the show went from delight at stumbling across LIVE BIRTHS on T.V. to shame at my persistent voyeurism in watching families shuttled through the show’s smashmouth football style production to anger, ultimately, at the complete lack of disregard the show had for birth. If birth is my religion, this show was pure sacrilege.

I finally turned it off when one of the “sideline” reporters was interviewing a mother in between pushing contractions. At one point the reporter said to the nurse, “I see [the mother] is trembling a lot and I remember that from my own births” – at which point a camera zoomed in on the pale face of this mother who was indeed shaking as most women do in transition or pushing – “why is that?”

The nurse said, “Well some people say it’s from the epidural, but I think it’s just birth.”

Reporter: “You mean the trauma of it?”

Nurse: “yes.”

Can I litinize all the things wrong with this? A nurse that presumably hasn’t seen natural birth to know that you shake even when you haven’t had an epidural. The reporter assigning the label “trauma” to a birth without asking the woman actually experiencing it. The conversation ABOUT the mother as if she’s not even in the room. The presumption that a side conversation about the physiology of labor should upstage this family’s real time labor.

Earlier in the show they were in the room of a woman in early pushing and they invited in all the nurses about to come on at shift change so they could show some of the important, caring faces that are an important part of birth. There were at least 10 nurses in the room, laughing at the reporter’s jokes and smiling prettily while in the foreground the mother was grabbing behind her knees and bearing down. Honestly!

In the time I watched, there were 7 births. Five were Cesarean and two were vaginal. They interviewed one couple on their way in for a Cesarean. Their doctor said “Well she’s been pushing for an hour and her baby won’t come down. It’s at plus one [station] and hasn’t made any progress. It’s too high up to do a vacuum extraction, so a Cesarean is the best option.”

The reporter turned to the mother and said, “Now you’re pretty disappointed about this turn of events. Can you tell me why that is?” The mother said she was really hoping to have a vaginal birth but that she trusted the doctor. Her husband said almost the same thing verbatim. It was almost like they’d been brainwashed. Trust the doctor. Trust the doctor.

I mean, you have to trust your doctor. But they weren’t saying “This is the decision we made in consultation with our doctor and we believe it is in the baby’s best interest.” They said we don’t want to do this but we trust the doctor. Very different dynamic.

Finally, at one Cesarean birth the reporter was talking remotely with the doctor, who’d been miked. She said, “I understand there have been some complications with this mother. She’s hypoglycemic?” The doctor said, “Yes, but that’s probably because she hasn’t been allowed to eat or drink anything all day. She’ll be o.k. We’re giving her everything she needs through her I.V.”

I think I should just stop now.
Did anyone see this? Were you repulsed?

At least I could have been at a birth...

What excuse to I have for missing last night's The Simpsons, in which Patty came out of the closet and got married to her girlfriend by Homer? Only that I was cutting my dear spouse's hair.

The 8-9 p.m. Sunday night block is pretty much the only time each week that I make an effort to watch television. The one-two punch of Simpsons and Arrested Development can not be beat.
But it had been 3 weeks since dear spouse first pleaded with me to cut his hear. And by last week I had begun referring to it as a pompadour. So.

I have been in a lather for weeks over the PBS decision not to air the "Sugartime" episode of Postcards from Buster because it included a lesbian-parented family. My blood pressure has risen just now from thinking about this censorship.

If an antidote to my rage at the homophobic agenda exists, it doesn't necessarily come from prominent proponents of anti-gay policies having to confront their own children's coming out. Instead, it is probably best delivered by the writers of The Simpsons. I'm half-way through Planet Simpson, a deconstruction of the Simpsons through American pop- and consumer-culture lenses, and getting more respect for the show with each page.

To miss their take on same sex marriage -- and their broadcasting of it during prime time -- is a loss I can hardly bear.

Postpartum Doulas and Geriatric Care Nurses

The two may become synonymous in Ann Arbor if a plan rumored to be under consideration by a local nursing home comes to fruition.

Glacier Hills, a large senior care facility in town, is apparently considering having some of its visiting nurses undergo postpartum doula training. That way they can have one pool of nurses provided two revenue streams.

Without knowing the Glacier Hills visiting nurses, I reserve commenting on whether or not they might have the "doula heart" that is such a vital ingredient in successful doula care. I suspect, however, they have not felt called to serve families in the childbearing year the way most doulas have.

The good news is that the Center for the Childbearing Year, which already runs an award-winning volunteer birth doula program, is looking into beating Glacier Hills to the punch.

Godspeed ye bona fide doulas, godspeed.

A-ha!

I saw a headline in the Boston Herald today that read "Numbing News: Early Epidural Not Too Risky." The article goes on to say that a study published in the New England Journal of Medicine "found that giving a low-dose epidural early in labor won't increase the risk of a Caesarean section and may shorten labor."

Really?

You can read the full text of the study here and an abstract here.

The study was comparing early pain relief (before 4 cm dilation) in the form of intrathecal injection of fentanyl against systemic hydromorphone (epidural). It was NOT comparing epidural against NO epidural.

Moreover, in the abstract, the study found that although there was no significant difference in Cesarean rates between the two groups (intrathecal or epidural), there were these significant differences:

• The median time from the initiation of analgesia to complete dilatation was significantly shorter after intrathecal analgesia than after systemic analgesia (295 minutes vs. 385 minutes, P<0.001)
• The median time to vaginal delivery was significantly shorter after intrathecal analgesia than after systemic analgesia (398 minutes vs. 479 minutes, P<0.001)
• Pain scores after the first intervention were significantly lower after intrathecal analgesia than after systemic analgesia (2 vs. 6 on a 0-to-10 scale, P<0.001)

Most importantly:

• The incidence of one-minute Apgar scores below 7 was significantly higher after systemic analgesia (24.0 percent vs. 16.7 percent, P=0.01).

Correct me if I'm wrong, but what I interpret this article to say is that although there is no significant difference in Cesarean rates between women with early injection pain relief or early epidural pain relief, there IS a bias in the immediacy and degree of relief, in the time to complete dilation and to delivery, AND in the baby's first health assessment...ALL AGAINST THE EPIDURAL!

The Boston Herald article says the study's findings "could lead to hundreds of thousands more early epidurals in mothers-to-be each year." Great! That's 7,300 more babies with Apgar scores below 7 than if the mothers had had intrathecal injections (and how many more than if the mothers had been supported in an effort to birth without pain relief?).

Better than Grandmaw’s Feather Bed

This month, for the first time in my entire life, I was looking forward to my period. I was nearly giddy with anticipation. Why? Two good reasons. First, a few days’ relief from my fibrocystic breast pain. Second, the opportunity to try out my reusable cloth pads!

Now that “Aunt Kathy” has come and gone and I’m in the post-event let-down period not unlike the weeks after Christmas, I thought I’d cheer myself by offering a few reactions to the pads. [Spouse: you probably want to stop reading now, if you have even made it this far.]

For my first go ‘round I opted for the strategy I recommend to parents contemplating the use of cloth diapers: order one or two from several different sources to see which you like best BEFORE buying a two-week supply. For my part, I bought Lunapads and Gladrags.

Both are in delicious flannel. That is exciting right there. I am a fool for flannel. I have flannel sheets and flannel pajamas and even though it makes it difficult to turn around in bed I use them at the same time. And the Gladrags were in this sweet calico print that almost made me want to cuddle them like stuffed animals instead of snap them into my panties.

I was prepared to prefer the Lunapads. Not only do they have a great web site, they use a removable liner system that allows you to keep the pad in place. This seemed more practical for being at work, and more economical, since the liners are much cheaper than a whole Gladrags pad. And the Gladrags were huge. They reminded me of the maxiest of maxi pads I wore back in the days when my mother bought my period supplies. More life raft than a sanitary napkin.

But in the wearing, Gladrags came out on top. The Lunapads liners were difficult to keep in place. They got wrinkled, which made them uncomfortable. By comparison, the Gladrags’ size and softness was so soothing, so gentle. Almost as good as a trip to the spa.

Which is close to a vacation as I’ll get for the next few months!

Preventing pre-term labor

It was announced last week that researchers believe they have come up with a profile of the metabolic by-products in amniotic fluid that can flag women who will go into preterm labor. This means there could be a test to predict who's at risk for it. Though I wonder whether, if it's an amniotic fluid test, there isn't a risk of starting preterm labor through whatever process is used to collect the fluid. I'm guessing that it would not be a routine test, but rather one that is used selectively on women who have had preterm labor before.

Preterm birth (meaning before the 37th week gestation) occurs in about 12% of U.S. births.

Philosophy 101

I saw this article about a woman who guarantees to have babies sleeping through the night by nine and a half weeks.

Nine and a half weeks?!! Are these babies breast fed?

Baby sleep -- where, how and with whom -- is such a hot-button issue among parents that it truly can lead to arguments and bad feelings among lifetime friends. The co-sleepers are enthusiastic about the benefits of sharing their bed with their baby (or toddler, or children). The Ferberizers proudly proclaim their children will go to sleep anywhere, with anyone putting them to bed.

Whether you find yourself enjoying the pleasures of waking up next to your children every morning or delighting in a parents' night out without your six-month-old, you probably find yourself thanking one of "the names" in parenting philosophies. Dr. Sears, Dr. Brazelton, Dr. Spock...the list goes on.

Many parents are now seeking out parenting philosophies before their babies arrive. They feel pressure to know whether they'll be natural families or Bible-based practitioners.

The parenting style I'm most suspicious of is what I'll call "It worked for you." Its most vocal proponents are grandparents and inlaws. They have good ideas. But they also can forcefully insist on dogmatic adherence to the ways that worked for them. Their "We did it with you and look how you turned out" presumes they actually KNOW how you turned out -- and that the factors they use as determinants are the ones you, too, value.

I think a sampling of several sources, cut with a heavy dose of self-forgiveness, and a what-the-heck openness to things that seem a little too "out there" is what has worked best for me.

Your Child's Chubby -- FYI

An e-mail notice just came in from my younger son's day care, the subject of which was what you see in the heading to this post. I thought, "Well I know we can only put him in overalls or elastic waist pants, but isn't CHUBBY a little harsh?"

Then I noticed it was to ALL the parents, so I thought maybe they were having a parents' information night on toddler weight control. Again -- not striking me as an appropriate concern for two-year-olds.

Then I read the body of the message and re-read the subject. A-ha! I was wrong. Cubby. My Child's Cubby, for my information, has been moved.

Now I don't have to reply "Well at LEAST he doesn't smell like patchouli oil!"

Rushing the Placenta

Again, from "Listen to Me Good," an example of how granny midwives handled things:

"Now a whole lot of places you go to, the afterbirth didn't come right on behind. ... Sometimes the afterbirth takes twelve or thirteen hours to come loose. If you going to pull and jerk on it, you're going to leave some in there. That's going to cause a problem. If you just give it time, you work with it after the baby come. If it don't come-a-loose, leave it alone. If they are tense, they need to go to sleep and relax. That makes the afterbirth come loose. Let her stretch her feet out or turn on her side or whatever she wants to do. ... I've had them hang on all night, but by the next day, it turned loose."

This from a woman who never lost a mother in nearly 3000 home births.

So why is it hospital birth attendants get itchy if it takes more than 20 minutes to detach?

Depression and the Pregnant Woman

A few months ago I read a very interesting book. It was called Love Works Like This, by Lauren Slater. Slater is a woman who did not want children, who takes several medications for her depression, and who has been institutionalized because of her mental illness. The book is about her struggle to incorporate “mother” into her identity and to prepare for the life changes of a baby in the face of her illness.

It was an unsettling read. Slater is unconventional in her failure to be charmed by any of the sweetness of motherhood or pregnancy. She steadfastly requires that others – her spouse and a nanny – assume primary caregiving responsibilities for the baby. She decides she’ll “be the dad.”

And yet I cherish the book for giving voice to the taboo feelings toward motherhood that so many women think at one time or another. There are those thoughts that we have and then think “Does that make me a bad mother?” Slater, a psychologist, doesn’t worry about those moral labels. She’s more preoccupied with the question “Can I survive this.”

The first part of her book is about her struggle to go off her medication when she finds out she is pregnant. Because there is little research into the effects of antidepressants on fetal development and newborn complications, mothers have little guidance on how best to balance their mental health needs with their baby’s safety.

Last week a study that looked at WHO data concluded that infants born to women on SSRIs showed withdrawal symptoms and therefore “SSRIs, especially paroxetine, should be cautiously managed in the treatment of pregnant women with a psychiatric disorder.” An article summarizing the study and placing in context for prenatal care appeared in last week’s New York Times.

Some Good Reading

First, for a nice birth story, check out today's post on Sage Femme.

Second, if you haven't read "Listen to Me Good: The Life Story of an Alabama Midwife," you should. This is the biography/autobiography of Margaret Charles Smith, who died in December.

A few passages I have particularly enjoyed:

• In talking about spirituality among midwives, Linda Janet Holmes, co-author, writes, "Midwives...said that they could 'count on God to get to the birth before they did,' 'to be the doctor' and to show them signs before complications occurred."



• Later, Ms. Smith talks about supporting women at births:

"You are sitting there to do what you can for her, rub her or put something under her back, trying to rest her back some. That's what you are there for, talk to her. If you like tea, you can make them some hot tea, and that will pick them pains up. Then you can rub the stomach and make the pains start back...

"Sometime they want to get up, and I'd help them up. Walk around in the room. Walk a pain off than get back in the bed. A lof of people get a kick out of walking. Go into different rooms and sit in different chairs, or get down on their knees -- anywhere they think they can get ease. But there's no ease for birth till it's over with. It's good to walk, but you'll have to stop sometime. You can pretty much do what you want till you get down to the nitty-gritty.

"...You just make the best out of it you can, talking kind, giving kind words and rubbing her hands. That means a lot. That means all of it. Kindness whipped the devil. Kind words, that's right, and belief."

Mystery Solved!

How often in life do you get the opportunity to have one of your outstanding life questions answered? Don't you just figure you're going to have to wait until you get to heaven?

Well let me tell you about heaven on earth: patchouli oil.

Not that patchouli oil is heaven on earth. It is the anwer to one of my lifelong questions, question being "What IS that smell?"

When one moves in the "alternative" community as we doulas often do, one sometimes comes across a new (O.K. , new if you grew up in a small midwest town) idea such as smudging or totems. For my part, I have enjoyed this expansion of my world view.

I have not, however, enjoyed a certain odor that some doulas and clients share. The origin of this odor has puzzled me since I first noticed it on several law school classmates. At first I thought it was maybe a gender neutral designer cologne. Well, actually, at first I thought it was B.O. But it was nothing like most B.O. I knew, so then I suspected it was a fragrance of sorts.

But I never felt comfortable saying to someone, "By the way, what is that smell you always have?" So I've suffered in silence.

Then last week my sister's boyfriend and I were waiting for her in an Aveda spa of all places, when he says "Wanna smell what a Grateful Dead concert is like?" and pulls one of the essential oil bottles off the shelf. I practically shrieked with joy when I inhaled that elusive pungent draft.

Now I'm wondering if I will ever get to see images of a live Giant Squid.

WHO's Next (Talkin' 'Bout My Generation)

I have been checking regularly and finally the World Health Organization has posted an update on the six pregnant women around the globe. They had their babies. Don't tarry! Go read about them. The various birth stories and conditions are amazing. Interestingly, the only Cesarean birth was to the woman in England.

On the local front, I'm impressed by my current doula client's changing attitudes toward birth. She is a medical professional who has a lot of contact with new mothers and newborns. I assumed she would have absorbed a lot of information about birth from the setting she works in. And yet she was surprised by a lot of what she learned in her Lamaze classes and has been reading some of the books (Birthing from Within, Mind Over Labor, Natural Childbirth the Bradley Way) that I loaned her.

In two months' time she has gone from saying "I want an epidural as soon as they'll let me get one" to "I'd like to try to go without medication." She said she'd simply never known before that there were any reasons to avoid an epidural. But of course she had obvious reasons to want to avoid pain.

All of which is to say, the role of eduation is so so so so important. Mothers want to do what's best for their babies. When given complete and accurate information, many of them elect to try a harder, but safer route.

Woman Centered Abortion

A friend sent me a link to this article about a new sneaky technique from the pro-life dominion: as part of "abortion counseling," women are given an ultrasound to see if their fetus is even viable. When women see the pulsing heart on the screen their decision to abort is swayed.

While some would argue this simply confronts women the reality and the gravity of what they are doing when they elect to terminate a pregnancy, I think it is taking an unfair emotional advantage of women.

Indeed, the reason many women end up with an unwanted pregnancy is that they let the emotional strength of intimacy and passion temporarily move them into a carpe dium mindset. (I am here putting a decidedly positive spin on the situation; this is assuming the women had sex willingly.)

Some time later, far removed from the moment of emotional unaccountability, they find out they're pregnant. After a more rational, long-sighted assessment of the situation, they decide to abort the pregnancy.

To then lure these women back into an emotional trap under false pretenses is truly a betrayal.

Conversely, it is a similar disservice to women to provide outpatient abortion services without also addressing each patient's complex social, emotional, psychological and physical issues before and after the procedure. I am not familiar with the full protocol at someplace like a Michigan Planned Parenthood clinic, but their website mentions only "pregnancy options" counseling, not anything about conseling postpartum.

It would be so nice if we could remove the abortion issue from the moral sphere and put it solely in the reproductive one. Each woman and each unwanted pregnancy could be approached on an individual basis. Women would be given unbiased and accurate information, devoid of moral context. They would be counseled through whatever decision they made and given post-decision counseling, because whether they are aborting a fetus or foregoing their non-pregnant life, they will experience loss. For some women the loss will be mild and fleeting, for others profound and prolonged. Frances Kissling, leader of Catholics for a Free Choice, got grief for exporing these and other gray areas of abortion in her Winter 2004-2005 Conscience editorial.

Addressing the "informed decision making" and "holistic" approaches to pregnancy would serve women much better than giving them Christian-sponsored ultrasounds or escorts to abortion clinics.

My Patron Saint of Pregnancy (and Birth Support Dream Team Member #2)

I read somewhere that there are 3 things you should never discuss with other people because no matter how fascinating they are to you, they are boring to anyone else. Those three things are: your vacations, your children and your dreams.

That said, let me tell you about the dream I had last week. Actually, the only detail I need to mention is that it prominently featered Tommy Lee Jones. (It was G rated in case you were wondering).

His guest appearance was of sharp interest to me because previously Tommy Lee Jones has only visited me – and these instances number in the high single digits – when I was pregnant. He was so reliable that by my third pregnancy, I rarely went more than two months without a Tommy Lee Jones dream.

Thus it was quite a scare to have him show up unexpectedly. I am quite certain I am not pregnant (please oh please) but thought I would use this as an opportunity to introduce you to my patron saint. There actually is a real Patron Saint of Expectant Mothers, but I doubt he is anywhere near as studly.

Let Me Tell You About My Fibrocystic Breasts!!

Why, why, why, why, WHY can’t caregivers spell things out for us laypeople? Is it so hard to share the name of a health condition or explain how symptoms relate to a disease?

A recent example: Roughly a year ago I began having tenderness in my left breast. I watched it for a few months and noticed that though it was always present at some level, it was much improved in the days after my period. I mentioned this to my doctor. He did a breast exam and said he felt nothing to be concerned about, but referred me for a mammogram to be safe.

At the breast clinic they did a thorough manual exam. The woman doing it said she could definitely feel “some nodularity.” My heart rate shot up. “What does that mean?” I asked. “Oh, it could be anything. It’s probably just the way you are. Let’s do the mammogram and the radiologist can tell you for sure.”

[Aside: Malcolm Gladwell, one of my favorite contributors to The New Yorker, wrote a great piece about the fallibility of mammograms that makes me take any imaging report with a grain of salt.]

After the mammogram and the nauseating, awkward minutes sitting in that waiting room with all the other women in matching green hospital tops, some of whom may be there for routine mammograms, others who may be about to get some terrifying news, others who are about to have their day made – but you DON’T KNOW WHO IS WHO and so you stare at your crappy magazine with intense concentration…

…the woman called my name and took me back into the room and said everything looked fine. She handed me a piece of paper that said I should get another mammogram in 5 years and headed for the door. “So, about the pain?” I said. “It’s just you,” she replied.

Um. O.K.

So the symptoms have persisted pretty much the same as they were when I made my enlightening trip to the breast center.

Then last night I’m on-line looking up information about Evening Primrose Oil because I want to blog about its efficacy in cervical ripening. Only in one piece “breast pain” catches my eye and nearby are the words “fibrocystic breasts.” Really?

I surf around. It becomes abundantly clear that fibrocystic breasts explains (at least part of ) what is going on with me. I have fibrocystic breasts. Can I say that again, please? I have fibrocystic breasts. It’s not “just me.” It’s a whole lot of women. It’s very common between 30-50 years of age (I’m 35) and it almost always resolves with menopause.

So why was this label never given to me? It would have allowed me to learn more about this condition. I like to understand what is happening with my body. I think most people do.

A similar thing happened with my hyperemesis. For three years I thought I had just been cursed with uniquely bad morning sickness. I mean, I was cursed with bad morning sickness. But it turns out it is a medical condition. It has diagnostic parameters. Web sites exist to help you try to treat it. You can tell your freaked out family that your state is something known to medicine.

Anyone who works around or has been through pregnancy sees this happen all the time. “The baby is a little tachycardic.” “If you pass a clot bigger than a quarter call us.” “You have ketones in your urine.” What does this mean? Please tell us. We name our babies; why shouldn’t we be able to name our maladies?