Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Why Educating Our Patients is a Professional Responsibility and NOT About Guilt October 11, 2009

Filed under: Ramblings — NursingBirth @ 12:43 AM
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Yesterday I wrote a very long response to a comment left on my blog regarding a post I wrote entitled New Study Hypothesizes Bottle-Feeding Simulates Child Loss Increasing a Mother’s Risk for PP Depression

 

I woke up this morning and read all of the comments left on that blog post.  I wanted to take this opportunity to thank everyone who wrote in with support and encouragement!   You all keep me blogging.  Although I have many issues with a couple of responses, overall they were positive and well written.  Thank you! 

 

I have read FearlessFormulaFeeder’s response on my blog and on her own.  I truly don’t think I could write anything better to respond than this article emailed to me by one of my readers:

 

<tongue in cheek> Confessions of a proud breastfeeding zealot </tongue in cheek> by Katie Allison Granju

 

I make a conscious effort every day as both a nurse, an activist, an everyday woman, and a blogger to never use guilt based techniques to support any certain “way” when it comes to choices in labor, childbirth, and breastfeeding.  That does not mean that some choices do not carry more risks than others.  Not all choices are equal in their efficacy or safety.  This is a fact.  I also know some people do use guilt, either intentionally or subconsciously, to influence their peers or patients; Even nurses, doctors and lactation specialists are sometimes at fault for this!  And it’s not just breastfeeding supporters that sometimes use guilt; both sides are guilty of using GUILT to further their cause.  However I am NOT one of those people and I feel that my past posts on controversial topics speak for themselves.  I certainly have a strong opinion but I never (until FearlessFormulaFeeder came along)  have been accused of making other mothers feel “bad” after providing sound, well researched, evidenced based information to my readers.

 

I promise you that I will continue to educate myself regularly on the newest research and practice evidenced-based nursing.  Furthermore I will continue to ask my patients appropriate questions at appropriate times in order to assess their knowledge base, background, and learning needs with the aim of providing them with age appropriate, culturally competent information and care to assure that any decision that they make is an informed one.   In fact, it is my professional responsibility to do so. 

 

As a nurse I am so much more than an executor of orders.  I am an advocate, a caregiver, a leader, a listener, a teacher.  Since I do not personally subscribe to the philosophy that women should be guilted or bullied into making certain decisions I will not take responsibility for any other person who does choose to act in that manner.  I am only responsible for my own actions.  Likewise, if providing evidenced-based information, including the risks and benefits of a particular choice in a sensitive way at some point causes a person to feel guilty about one thing or another, it will not stop me from providing that information.  This includes reporting and commenting on the latest research. 

 

In my own practice as a nurse I often ask people the question, “Do you feel that you have received enough information on the risks and benefits of ______ to make an informed decision?”  (I have to ask about things like plans for pain medication/epidural, plans for VBAC/repeat cesarean, plans for breast/bottle feeding during my admission or triage interviews).  If a patient answers “YES“, I then ask, “Do you have any questions for me or your doctor/midwife?”  If a patient answers “NO” I ask more questions to find out what they still have questions about.  I have found this line of questioning to be the most efficacious when talking to many mothers/couples since the feedback I have received is that it is a non-threatening/non-judgemental way to open the dialogue between patient and nurse.  And boy have I stumbled upon some moms that have been given some misinformation! 

 

Here’s an example of an actual conversation I had with a patient once.  This mom was a 21 year old single white female with a long-term boyfriend.  She worked as a nurse’s aide, her boyfriend as a UPS carrier.  They had family in the area but lived together in an apartment in the city.  She was pregnant with her first baby and was being admitted for an induction for post-dates:

 

Me:  “Are you planning on breast or bottle feeding?”  [**see addendum below**]

 

Mom: “Bottle.”

 

Me: Do you feel that you have received enough information on the risks and benefits of bottle feeding to make an informed decision?”  [**see comments section**]

 

Mom: Well yeah, because I have to go back to work after 6 weeks so I can’t breastfeed.

 

Me:  “Many mothers feel overwhelmed about the fact that they have to go back to work very soon after having their baby.  However, some mothers don’t realize that any length of time that they breastfeed their baby is absolutely wonderful and even breastfeeding for the 6 weeks that you are home from work can provide you and your baby with many benefits.  Especially since the first milk you make, called colostrum, is filled with so many great antibodies that help your new little one stay healthy and grow during those very important first few weeks. 

 

Mom:  “I didn’t realize that you could breastfeed for only 6 weeks!  I thought if you were going to breastfeed you had to breastfeed for like a year!”

 

Me:  Some moms start breastfeeding without a set goal of how long they are going to breastfeed and just take it one day at a time.  Some mothers will stop breastfeeding before they reach 6 weeks.  Others will breastfeed up until they have to go back to work.  And others are lucky enough to work something out before they have to go back to work so that they continue to breastfeed even after they return to work.  The great news is that no matter how long or short of a time you breastfeed for, your baby will benefit from having your milk to help him grow and stay healthy!!  If I brought you some information in about breastfeeding would you be interested in learning more about it?

 

Mom:  Yeah!  That would be great!  Thanks!!

 

I had the priviledge of being a part of this mom’s birth and was honored to assist her in getting her son to latch on for the first time.  She breastfed her son throughout her hospital stay and did leave the hospital without supplementing with any formula.  Unfortunately I do not know what happened to her once she got home.  She could have had troubles and switched to formula, she could have successfully breastfed for her six weeks, or she could still be breastfeeding her 8 month old!  (This is one bummer about being an L&D nurse with no ability to follow up on patients.)  But I do feel that she learned quite a bit from our conversation during her admission interview and from the information I provided to her that she read during her induction and I am proud that I was part of the reason she decided to give breastfeeding a try. 

 

**Addendum**  After a great comment left by Lonely Midwife on 10/11/09 I have decided to make a change in my practice.  Instead of asking “Are you planning to breast or bottle feed?” she has suggested I ask “How are you planning to feed your baby?” as it is a more open-ended question with less chance of being perceived as judgemental.  I really like that and have decided to adopt that question into my practice.  This is also much more like the question I already ask about pain management in labor since during my admission interview with patients I ask “Tell me about your plans for pain management during labor” instead of the more common question “Are you planning on having an epidural or using IV pain medication for your labor?”  Thank you to Lonely Midwife for opening my eyes to some hidden judgement in my admission interview. 

 

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My point is that the “mommy wars” are out there.  I certainly am not looking forward to them when I one day become a mother and often speak out against them.  But I personally have made a conscious decision as a nurse to not use guilt based techniques to influence or educate my patients.  I use facts and regardless of my own personal beliefs, I provide both the risks and benefits of any choice or option when counseling patients.  And because I do that I do not and will not take any responsibility for another person’s guilt even thought it is true that I feel badly that a person might feel that guilt.  After all, guilt is a cognitive or an emotional experience that occurs when a person realizes or believes – whether justified or not – that he or she has violated a moral standard, and is personally responsible for that violation. 

 

Fellow blogger Stork Stories has shared with me some very important wisdom that she has learned over her very impressive career as a labor & delivery nurse and lactation consultant fro 35 years.  I would like to share her wisdom with you all.  THIS (NOT guilt based persuasion) is MY philosophy on breastfeeding education.  I couldn’t have said it better myself and I thank Stork Stories for sharing!

 

* It is inappropriate for a health care professional to indicate to a mother directly or indirectly that formula feeding and breastfeeding are equal. Human breast milk is the superior food for human infants. Properly prepared infant formula is an acceptable substitute for those who cannot or choose not to breastfeed.

* The first approach is probably the number one factor in gaining a mother’s interest in what you have to say.

* The education process to a mother needs to be in small doses, sensitive to her unique learning abilities, her cultural beliefs and practices and most importantly, her choices and individual breastfeeding goals.

* With that in mind, try to provide her with the information she needs to make her decision.

* Never overestimate a mother’s desire to breastfeed her infant.

* Never underestimate a mother’s desire to breastfeed her infant.

* Listen to the mother; help her define her true desires and goals.

* Many times, the first question she asks may not be what she really wants to ask.

* The mother’s individual breastfeeding goals, how she defines them, how important they are to her and how she relates them to her actual breastfeeding experience all help define how she measures success.

* Support the mother, support the mother, and support the mother.

 

 

I’ve said my peace.

 

~NursingBirth

 

The conversation continues over at Stork Stories with her post:  **ROAR** on Breastfeeding Guilt 

Please check it out!!

 

Why It’s Not Irresponsible to Research the Hazards of Formula Feeding October 9, 2009

Filed under: Ramblings — NursingBirth @ 1:48 PM
Tags: , ,

 

Submitted on 2009/10/05 at 11:23pm

In response to: New Study Hypothesizes Bottle-Feeding Simulates Child Loss Increasing a Mother’s Risk for PP Depression

 

 

Dear NursingBirth,

 

As so often happens with interpretation of breastfeeding studies, you are ignoring the fact that this study was observational. Yes, certain factors were controlled for; however, since it wasn’t a case where they took 100 women with postpartum depression (PPD) and forced half to breastfeed and half to formula feed, you have to look at the results with some perspective. One could easily take the opposite interpretation and say that the guilt inflicted on formula feeding women in our society (and by studies like these) can exacerbate PPD. It certainly did for me, and for many women I have interviewed for a book I am working on.

 

I am certainly not anti-breastfeeding; I think it is a wonderful thing. But there are cases where formula feeding is the best – or only – choice, and implying that formula feeding can cause PPD is just plain irresponsible, in my opinion. The LAST thing women struggling with PPD need is pressure to do anything. If they want to breastfeed, then great; however, it is often far more useful to get on antidepressant medications, which are not universally recommended for lactating women. There have been studies saying that the long-term effects on babies who’ve been exposed to antidepressants in breast milk are negligible, but as my own pediatrician said, “none have proven this without a doubt.”  If nursing is going to keep a woman from taking needed medication, then I do not think it is a healthy thing for baby or mother.

 

Just another opinion….

 

~Suzanne

fearlessformulafeeder.blogspot.com

 

 

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Dear Suzanne,

 

Thank you for commenting.  I appreciate all comments left on my blog, both assenting and dissenting, as long as they are not ad hominem attacks.  I also see that you are a new blogger and would like to welcome you to the world of blogging!  If you are anything like me, you will both love it and hate it!  I don’t know how long you have been following my blog but I invite you to take a look at one of my past blog entries entitled My Philosophy: Birth, Breastfeeding, and Advocacy.  Here is an excerpt:

 

“I believe that pregnancy, birth, and the postpartum period are milestone events in the continuum of life that profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.

 

 I believe that breastfeeding provides the optimum nourishment for newborns and infants which does NOT mean that I am not grateful for the advancements in artificial milk for those mothers and infants who truly require it.”

 

 

Now that you know a little more about me, I’d like to respond to your comment.  I will number the points for ease in reading:

 

#1  You write, “As so often happens with interpretation of breastfeeding studies, you are ignoring the fact that this study was observational.”  I fail to see how I am ignoring the fact that this study was observational.  For one, I posted a direct link to the original study in which the authors discuss the method of their study.  The authors write:

 

“We recently completed a study of over 50 mothers recruited through local pediatric offices at 4–6 weeks postpartum.  Consistent with previous reports, we found that those who [formula] fed their babies scored significantly higher on the Edinburgh Postnatal Depression Scale than those engaged in breastfeeding. The increased risk of depression among mothers who relied on [formula] feeding held true even after we controlled for such things as age, education, income, and the mother’s relationship with her current partner.”

 

No where in there do they claim that the study is a randomized controlled trial, often regarded as the gold standard for research as it is considered to obtain the highest level of evidence.  However not all research questions can ETHICALLY be answered with a randomized controlled trial.  You wrote:

 

“Yes, certain factors were controlled for; however, since it wasn’t a case where they took 100 women with postpartum depression (PPD) and forced half to breastfeed and half to formula feed, you have to look at the results with some perspective.”

 

 

The fact of the matter is Suzanne that that type of study is completely unethical in this situation and therefore completely implausible and therefore it is unfair to suggest that this is a flaw in the author’s study.  It is certainly a limitation but not a flaw.  This is a problem that is realized the by research community, that is, that you can’t always randomly assign patients/subjects/participants to a certain cohort because you, for example, cannot force someone to breastfeed or someone else to bottle feed.  Or force some to have a vaginal delivery and someone else a cesarean section.  Or force someone to have a hospital birth and someone else a home birth  Or force someone to smoke cigarettes and someone else not to smoke cigarettes.  For this reason observational studies may address these problems to some degree and might therefore be the best way to answer research questions that cannot ethically be answered with a randomized controlled trial.  The bottom line:  It is careless of you to dismiss the implications of this study just because it is not a randomly controlled trial. 

 

I also wrote about how this study was observational in nature in my post:

 

“The paper’s authors (who work in the Department of Psychology at the University of Albany/ State University of New York, Albany) recently completed a study of over 50 mothers recruited through local pediatric offices at their 4-6 weeks postpartum visit and evaluated them using the Edinburgh Postnatal Depression scale.”

 

Seems like transparent writing to me!  I fail to see how I was “ignoring” anything.

 

[Side note: I am truly interested in learning more about your educational and professional background as I feel that you may lack experience in reading healthcare research if simply for the fact that you continue to misuse words like “cause.”  Being that this study is a Level II observational study without randomization the authors by definition and design cannot (and DO NOT) claim or imply that formula feeding CAUSES anything!  They can only imply that formula feeding might be a risk factor for PPD, which is exactly what they do.  Being a “risk factor” for something and “causing” something are not one in the same.  For example Human Immunodeficiency Virus (HIV) causes AIDS.  Having unprotected sex with multiple partners and sharing dirty needles are both risk factors for acquiring HIV and hence developing AIDS.  Having unprotected sex with multiple partners and sharing dirty needles do not cause AIDS.  See the difference?

 

Proving true causation is very very difficult (and for some questions, theoretically impossible) and requires multiple studies at different levels of evidence that can be duplicated with different populations by different researchers at different times.  One book that I found helpful to learn more about research was Nursing Research: Methods, Critical Appraisal, and Utilization by Geri LoBiondo-Wood and Judith Haber.  I had to read it for a class I took in nursing school.  Even if you are not a nurse I still think it can be a great learning tool for you, or anyone, who is interested.]

 

 

#2 You write:

 

“You have to look at the results with some perspective. One could easily take the opposite interpretation and say that the guilt inflicted on formula feeding women in our society (and by studies like these) can exacerbate PPD.”

 

First off, I do not deny that feelings of guilt regarding a variety of things can exacerbate PPD.  Secondly I do believe that the authors are interpreting the results of their study with “perspective.”  In fact their conclusion at the end of the article is written as follows:

 

“Bottle feeding practices and hospital procedures that simulate child loss may increase the risk of postpartum depression and fall within a growing number of medical issues that could benefit from an evolutionary perspective.”  [Emphasis mine]

 

In addition, in my blog post on the study my conclusions are as follows:

 

            “This is a fascinating article to me for a variety of reasons.  First off, it is written by psychologists, not health care professionals and hence, takes a look at this very important topic from a completely different perspective.  Second, it is a study/analysis that focuses “not on the advantages of breastfeeding per se, but rather on the negative psychological consequences of the decision not to breastfeed.”  Thirdly, for mothers who cannot breastfeed (as related to the health of the baby or mother for example) or choose not to breastfeed, this article shows us how important it is as health care professionals to assess these mothers thoroughly for signs and symptoms of postpartum depression as well as to educate these mothers and their loved ones about their potentially increased risk for postpartum depression so that they can obtain help and/or counseling if their “baby blues” turn into something more serious.

 

Sounds like a whole lot of “perspective” to me!!  NO WHERE in either the study or my blog post did the authors or I ever make any claim that the results of this study are completely definitive or that formula feeding your child will most definitely cause you to suffer from postpartum depression.  In fact the perspective the authors are taking is an evolutionary one.  As any good study does this one raises more questions than it provides answers to and it opens the door to thinking about breastfeeding from the perspective of evolutionary medicine, or human history.

 

To deny the existence of the complex cocktail of hormones involved in labor, birth, and breastfeeding as well as their importance is something that mainstream medicine has been doing for decades.  This study does not make judgment calls on women who either cannot or choose not to breastfeed and neither do I.  But it is foolish to not at least take into consideration that we, as human beings, are indeed MAMMALS and by design are intended to nurse our young and if we do not or cannot, that we and our offspring as mammals might suffer some consequences.

 

Second, as far as your “One could easily take the opposite interpretation and say that the guilt inflicted on formula feeding women in our society (and by studies like these) can exacerbate PPD” comment, you are incorrect.  In theory someone might be able to make the opposite interpretation but YOU cannot make such an interpretation (and neither can I) since YOU (nor I) have access to the study’s data and the authors did not elaborate on what else besides age, education, income, and the mother’s relationship with her current partner they controlled for.  They could have controlled for other emotions the mothers were feeling…no one but the authors know… and perhaps not controlling for “guilt” is another limitation of their study.  But neither YOU (nor I) can take such a leap without access to a more thorough description of the method (which was not provided by the authors) or the raw data itself.  If you feel there might be another explanation other than the author’s explanation for the results, it would take another study to test your hypothesis.  You cannot derive a conclusion from a study about a hypothesis that you didn’t test for.  That’s research 101.

 

Thirdly, you comment that “studies like these” will exacerbate a formula feeding mother’s PPD reveals your lack of respect for research in general.  The studies on depression that have been carried out over many decades have led to a better understanding about the disease and better care for people who suffer from the disease.  Don’t mothers who suffer from PPD deserve the same? 

 

 

#3  You write,

 

“I am certainly not anti-breastfeeding; I think it is a wonderful thing. But there are cases where formula feeding is the best – or only – choice, and implying that formula feeding can cause PPD is just plain irresponsible, in my opinion.”

 

I ask you Suzanne, why are you so afraid of the possible evolutionary and biological connection between the early cessation of lactation and neonatal loss?  The authors of the study write,

“The present paper focuses on the decision people make to unwittingly depart from one of the defining features of mammalian evolution: to [formula] feed rather than breastfeed their infants. For 99.9% of human evolutionary history the decision not to breastfeed would have been tantamount to committing infanticide. The technology that lead to [formula] feeding as a substitute for the breast (e.g., bottles, rubber nipples, formula) has only become available within the last 100 years.

 

Opting not to breastfeed precludes and/or brings all of the processes involved in lactation to a halt. For most of human evolution the absence or early cessation of breastfeeding would have been occasioned by the miscarriage, loss, or death of a child. We contend, therefore, that at the level of her basic biology a mother’s decision to [formula] feed unknowingly simulates child loss. The death of a child is a well documented trigger for profound parental grief and depression, and evidence shows that mothers tend to be more affected than fathers. Suarez and Gallup theorize that depression as a response to the death of a child may be an adaptive mechanism that functions to (1) punish instances of inappropriate parenting or neglect, and (2) trigger social and psychological support from close friends and relatives during the particularly difficult period following the loss of an infant. Because [formula] feeding simulates child loss at a physiological level it may also play an important role in postpartum depression.”  [Emphasis mine]

 

I ask you Suzanne, what do you find so objectionable about those paragraphs?  What do you find so objectionable about my own conclusions?  What do you find so objectionable about the possibility that formula feeding (and not using your breasts for breastfeeding) could be a risk factor for developing PPD simply for the fact that there are levels of HORMONES involved in breastfeeding that are not being released when you formula feed!!!  For goodness sake it’s BIOLOGY! 

 

Biology Fact #1: When an infant suckles at the breast as during breastfeeding, the pituitary gland releases both prolactin and oxytocin in the mother. 

 

Biology Fact #2: Prolactin is a hormone also known as the “motherhood hormone” that stimulates development of the breast during pregnancy, controls the production of milk, is responsible for nest building in animals, and triggers aggressively defensive behavior in lactating females.

 

Biology Fact #3: Oxytocin is a lactogenic hormone also known as the “hormone of love,” is released during suckling, labor, birth, sexual intercourse, and while sharing a meal with others and is responsible for uterine contractions, male and female orgasm, the ejection of milk from the milk producing sacks in the breast, and feelings of calmness and bonding during childbirth and breastfeeding.

 

Biology Fact #4: If a mother does not breastfeed, prolactin levels usually reach non-pregnant levels by 7 days postpartum.  Mothers who exclusively breastfeed have higher oxytocin levels over time than do women who supplement with formula or exclusively formula feed.  When a mother supplements with formula or exclusively formula feeds her infant, prolactin levels decline markedly and fall even further over time, and oxytocin levels remain depressed and do not climb. 

 

Biology Bottom Line:  Mothers who exclusively breastfeed experience levels of hormones that mothers who supplement with formula or exclusively formula feed do not.

 

(References: Breastfeeding and Human Lactation by Jan Riordan & Birth and Breastfeeding by Michel Odent)

 

What is so objectionable about taking a further look into these hormones and their potential link to PPD?!  What is so objectionable about educating gestating and new mothers about the benefits of breastfeeding the potential hazards of formula feeding so that they can make a truly INFORMED decision about whether to breast or bottle feed?  And if in the end these mothers choose to bottle feed, as health care providers, what is wrong with being more aware of the potential increased risk these mothers have to developing PPD, just as we would be more aware of the increased risk of developing PPD with mothers who have experienced a loss or with mothers who have a history of depression.  It’s called being a RESPONSIBLE HEALTH CARE PROVIDER and therefore I reject your claim that this study and by default my blog post are irresponsible!

 

#4    As far as your statements about the use of antidepressant medications during lactation, I believe that just as with the use of antidepressant medications during pregnancy, every mother should be counseled by her health care provider on a case-by-case basis where the risks are weighed against the benefits for both the mother and fetus/baby.  I personally am not an expert in the use of antidepressant medications in pregnancy or lactation but I understand that there is an important debate regarding this issue that I have to learn more about. 

 

In conclusion I am excited about all of the breastfeeding research that is out there, both past, present and future!  And as far as your position as a “fearless formula feeder,” one point that I agree with you on is that mothers (and fathers) have to STOP the guilt trips and senseless competition.  But unlike some other choices, I feel like the “to breastfeed or formula feed as a choice” question is not one that should be taken lightly (and I am not talking about the mothers or babies that cannot breastfeed for other reasons besides choice). 

 

The more research that is done on breastfeeding the more we are learning that breastfeeding should no longer be considered “just nice” or “better” or “best” and formula feeding should no longer be considered “good enough”.  The “choice” to breastfed should not be on par with the decision on what new car to buy [“Well the Lexus minivan is better but the Chrysler minivan is good enough].  Breastfeeding is NORMAL and more and more research is showing that formula feeding puts your baby AT RISK.  If the benefits outweigh the risks when it comes to formula feeding for you or your baby then so be it.  If not, but you still choose to formula feed, my only concern as a healthcare provider is that your choice is based on INFORED CONSENT and NOT misinformation, pressure from family or friends, untruths, or lack of support or resources.  There are too may women out there who want to breastfeed but lack the support from family, friends, nurses and even doctors as well as lack the resources, and/or knowledge to do so.  I am sorry but the cause of those women needs more attention which does not mean that I condone the “guilting” or judging of women who choose not to (and certainly not towards women or babies that cannot) breastfeed.  

 

I dream of a world where ALL mothers who are willing and able to breastfeed get the support and encouragement and resources they need to do so!  And I work everyday to make my dream a reality.

 

Sincerely,

NursingBirth

 

 

P.S.  I encourage you to read a couple of my past blog posts:

            My (Aggravated) Response to “Ban the Breast Pump”  and Why The Today Show Hurts America (or, Battling The Case Against Breastfeeding)

 

Natural VBAC Hospital Birth: One Reader’s Empowering Experience September 3, 2009

Dear NursingBirth,

  

I wanted to share with you my birth story.  I thought since I did an all natural VBAC, it might be something you would want to share.  Thanks for the posts.  YOUR blog helped me get though my second birth! Your stories of inspiration that you have are amazing, and just your general  tone.  The fact that there are nurses out there like you made me have the confidence to trust the nurse with me, but also not be totally trustworthy. It helped me realize that I am the final decision maker.

 

In preparing for my VBAC I read your Injustice in Maternity Care Series and your story “I Needed to Know My Body Could Do It!”: A VBAC Story over and over.  I also read Active Birth by Janet Balaskas which I think helped me a lot, and with our first daughter (my c-section) we took Bradley classes so we both thought we were so prepared.  This time I had my mom, a friend and my husband as my birth team and we took control, which reading about it from your point of view gave me the courage to do so!!!


Thanks for all you do!  I love the blog!

 

Sincerely,

Katie C.

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Dear Katie C.,

 

I would LOVE to reprint it and am honored that you would even send it to me!  Thank you for reading and THANK YOU for being such an awesome and empowered woman and mother!!  It is women like you that are an inspiration to ME!

 

I just love everything about your birth story!!  First off, CONGRATULATIONS on your VBAC and on the birth of your daughter!!  What a wonderful time for you and your family!  It also must be really nice to NOT have to recover from major abdominal surgery and take care of a newborn and 3 year old!  Second, one HUGE pat on the back to you for choosing to go back home during your initial trip to the hospital when you were found to be 2 centimeters.  That took A LOT of courage and trust in your body and your abilities, especially since the on-call doctor was pressuring you to stay.   And I completely agree with you; choosing to labor at home until you were more “active” most definitely had a significant impact on your successful unmedicated VBAC.  Thirdly, KUDOS to you for being an active participant in your birth!!  It no doubt helped your labor progress to be upright and moving during your labor!  I am so proud of you!!  While it’s true that no one can really “plan” their birth, you did everything you absolutely could to stack the cards in your favor!!  Yay!  Yay!  Yay!!!

 

Thank you again for reading and sharing!

 

All My Best,

NursingBirth

 

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Katie C’s VBAC Birth Story

College Station, TX

 

Starting on Friday, May 22, I started having very mild but consistent contractions at 5 minutes apart at lunch time.  The rest of the day they came and went, some getting farther apart but stronger slowly as the day went on.  I also had a lot of brownish and pinkish spotting.  Figured that maybe I was in very early labor.  Did my usually stuff that day and went to bed about 9:00pm, just in case this was it. Saturday morning I woke up about 1:00am with contractions strong enough that I couldn’t sleep.  I got up and ate some peanut butter toast and drank a bunch of water and tried to go back to sleep.  Contractions were about 7 minutes apart but stronger and enough so that I was having a hard time sleeping.  Likely because I was excited.  Got up and took a bath but that didn’t help.  Tried to go back to sleep.  Got up and ate 2 huge bowls of apple cinnamon cheerios.  Finally fell back asleep about 4:30 am.  Woke up at 7am and was just very tired.  Contractions were completely bearable but figured that we were starting (maybe) and so I had Madison go to Jaxson’s (and George and Amie) house for a few hours while my mom and I stayed home to see if anything would progress.

 

Lamaze International's Tips for a Normal Birth #5:  Eat and drink as your body tells you to. Drinking plenty of fluids during labor will keep you from getting dehydrated and give you energy.

Lamaze International's Tips for a Normal Birth #5: Eat and drink as your body tells you to. Drinking plenty of fluids during labor will keep you from getting dehydrated and give you energy.

 

As the day went on they got stronger but not really closer.  I called L&D and she said 3-5 minutes apart, not able to talk through them, so I just figured I would wait.  Wasn’t ready to go to the hospital yet anyway.  I called Meredith (a friend), who was working about 2 hours away, to let her know that she might have to come back that night. We decided that she would come back that night instead of waiting for a call at 2:00 am and have to drive then.

 

Lamaze International's Tips for a Normal Birth #6: Think carefully about who you want to give you support during labor and birth. Consider hiring a doula or other professional labor support person to give you, your partner, and any other support person who's with you, continuous emotional and physical support.

Lamaze International's Tips for a Normal Birth #6: Think carefully about who you want to give you support during labor and birth. Consider hiring a doula or other professional labor support person to give you, your partner, and any other support person who's with you, continuous emotional and physical support.

 

My back started hurting and I called another friend of mine who does massage. She wanted me to come to her studio, but I really didn’t want to leave the house, so I decided to stay home. Rob called his mom and went to meet her and take Madison to her house so that we wouldn’t have here with us. By the time Rob got back, about 6:30pm, contractions were 5 minutes apart and getting stronger. I could still talk and walk, but it took effort. I called Meredith back and she said she was on her way to my house. At 7:30pm I started to panic.  The contractions seemed very strong to me, I was concentrating on them and they were consistently 5 minutes apart, so we decided to head to the hospital.  I called Meredith and told her to meet us there.  Once I got there, my contractions stopped pretty much, likely due to my nerves.  They got me into a room and set and checked me and I was 2cm and 80% effaced.  I was devastated!  I told them I wanted to go home.  The doctor on call was leery of that since I was a VBAC and they said they would really like me to stay but I refused and we packed up and came home.  (In hind site, this was the reason it all worked out!! Best Decision!!!)

 

 

I went to bed disappointed and tired, since I had been contracting for nearly 30 hours at this point and I just wanted to either be in labor or not.  I ate a snack and went to bed.  At about 3:00am I was woken by very strong contractions, 7 minutes apart, strong enough that I would flip to hands and knees in bed and rock and moan through them. Rob decided I was in labor, though I was still not sure!  LOL!  I started just sleeping in between them.  (Must have been some natural coping mechanism, since I did it until about 6:30 am!)  We started timing for real at 7:00am.  Meredith came over and she helped my mom.  My mom would time the start to start and Meredith would time the duration. They were about 5 minutes apart with about 30 seconds of what I would call pain.  The actual contraction would last about a min or longer.

 

 

As the morning went on, I could no longer do anything during the contractions except hang onto Rob and moan.  Contractions got stronger and longer.  They were 4-5 minutes apart, and lasting (pain) about 70 seconds.  During one contraction while I was hanging on to Rob I had a huge rushing feeling, almost like a pushing sensation (or so I thought) so I just said, “We have to go NOW!” We packed up and went up to the hospital.  I had 4 contractions in the car, which were the hardest ones!  [At that point I preferred to be standing during them, since sitting or lying down was excruciating.] We got back to the hospital and I was moaning and hanging on Rob and everyone in the ER was looking at me funny.  It made me laugh.  They probably all thought I was crazy!  

 

 

I went back up to L&D and they put me in the same room and got me all set up again.  The nurse said, “We were waiting for you!” I was so nervous that I would only be 3 centimeters and they wouldn’t let me go!  She checked me (about 11:00am) and I was 6cm, fully effaced!!!  I cried when she told me, I was so happy!!  Rob, Mom and Meredith clapped!  LOL!  They told me I had to stay.  I said that was fine!  They put me on the monitors and said I would be able to get off of them, but then the Dr. on call said “NO!” so I was worried I would be stuck in bed.  The nurse said, “You can move as much as you want, so long as the cord is long enough,” so I got out of bed and stood next to it for most of the day.  We said I didn’t want to be checked again except by the doctor or if they thought I was complete (i.e. pushing) so when the doctor got there at 1:00pm she checked me and I was a stretch 8!! I was still concerned that it wasn’t going to happen, but everyone else was excited.

 

Lamaze International's Tip #4 for a Normal Birth: Plan to move around freely during labor. You'll be more comfortable, your labor will progress more quickly, and your baby will move through the birth canal more easily if you stay upright and respond to the pain of your labor by changing positions. Try rocking, straddling a chair, lunging, walking and slow dancing.

Lamaze International's Tip #4 for a Normal Birth: Plan to move around freely during labor. You'll be more comfortable, your labor will progress more quickly, and your baby will move through the birth canal more easily if you stay upright and respond to the pain of your labor by changing positions. Try rocking, straddling a chair, lunging, walking and slow dancing.

 

Transition for me was the second hardest thing I have ever done.  I refused pitocin (which they really didn’t push since I was a VBAC) and did not let them break my water. I stayed at a 9 centimeters for almost 3 hours, then at 9 ½ centimeters for a while until I begged them to stretch my cervix!!  LOL!  I was on the bed with the back raised on my hands and knees and suddenly had a contraction that felt better when I kinda of pushed at it. My mom went to get the nurse and she tried to check me like that but said I really needed to lie down.  I said I didn’t want to push lying down and she said, “Sweetie you can push however you want, but I need to make darn sure you are complete so you don’t swell.” I knew that was true so I got down and she checked me and then had the doctor come in and doctor said, “I’d call that complete!” I was so freaking happy! However I was also exhausted and once I was lying down, though I was hurting, I just couldn’t get back up again.  They broke my water sometime in there.  [I think it was earlier when I was at a 9 ½ centimeters but I can’t remember.]

 

 

The first few pushes I really thought I was doing it but I think the contractions were just not strong enough.  I actually asked the doctor how far down Hana had to be to use the vacuum!  I was exhausted!  The doctor said that she wasn’t going to use the vacuum, so I was just going to have to push!  I started pushing about 4:45 pm.  She would come down (once I finally figured out just how freaking hard you have to push!!) and then scoot back in.  They explained to me that a little bit of pitocin would help to bring the contractions a little closer together, so I would be more effective in pushing, since I was having over a minute between them and Hana would just scoot back in.  I finally agreed to it at about 5:45pm.  The started it at about 6pm.  The doctor suggested a pudendal block, in case I needed an episiotomy (which while I wanted a natural tear, I wasn’t against at that point and I never thought I would come through it with no tear or cut).  I even got a mirror to see my progress, and knew right then that something was going to have to give! I made them put the mirror away!

 

 

I started pushing 5-6 times per contraction and the doctor had been with me the whole time.  She had them break the bed and get all the stuff ready and I asked “Is she coming out this way?” and the doctor laughed and said, “I’m not doing a c-section today!” She asked me also if I wanted to feel Hana’s head, but I just couldn’t bear the thought for some reason.  I kept pushing and finally she said, “Ok, this next one you’re going to have your baby!” and so I hauled back and pushed harder than I thought possible and her head popped out and I kept pushing (oops!!) and Hana was born Sunday May 24th at 6:28pm!!!  It was the most amazing thing in my life and no doubt pushing was the hardest thing in the world.

 

Lamaze International's Tips for a Normal Birth #10: Keep your baby with you after birth. Skin-to-skin contact keeps your baby warm and helps to regulate your baby's heartbeat and breathing. Keeping the baby with you in your room helps you to get to know your baby, respond to your baby's early feeding cues and get breastfeeding off to a good start.

Lamaze International's Tips for a Normal Birth #10: Keep your baby with you after birth. Skin-to-skin contact keeps your baby warm and helps to regulate your baby's heartbeat and breathing. Keeping the baby with you in your room helps you to get to know your baby, respond to your baby's early feeding cues and get breastfeeding off to a good start.

 

They gave her to me and after a few minutes (she was breathing but a little blue still) they took her over to rub her and clean her up some.  I was shaking so bad at that point that Rob had to hold her. I ended up with a 4th degree tear… not from her head, but her shoulder popped out when I pushed and the doctor wasn’t expecting it, and so that’s that.  But it isn’t so bad!  She stitched me up, and while it is sore, it beats the hell out of a c-section! Right after she was born I said, “I had a baby out of my vagina!” much to the amusement of the nurses and pretty much everyone in the room! But I can’t tell you just how amazing it was for me. I had been waiting 3 years for that.  And now I have it!  Hana was given back to me and she latched on right away and nursed like a champ for 15 minutes on each side (I was STILL being sewn up!) and finally Rob and Hana went off to the nursery.  To our surprise (and the doctor’s too) she was 8lbs 1 oz, 19 inches long.

 

Happy Birthday Hana!!!!

Happy Birthday Hana!!!!

 

 

I am recovering very well and almost feel like new!!

 

For more information on Vaginal Birth After Cesarean (VBAC) check out the International Cesarean Awareness Network's website at http://www.ican-online.org/

For more information on Vaginal Birth After Cesarean (VBAC) check out the International Cesarean Awareness Network's website at http://www.ican-online.org/

 

New Study Hypothesizes Bottle-Feeding Simulates Child Loss Increasing a Mother’s Risk for PP Depression September 1, 2009

A new study entitled “Bottle feeding simulates child loss: Postpartum depression and evolutionary medicine” published in the journal Medical Hypotheses suggests that bottle-feeding (with formula) and hospital practices/procedures that lead to intermittent separation between mothers and infants during the immediate postpartum period simulate (speaking in terms of evolutionary medicine) child loss and therefore increase a mother’s risk for postpartum depression.

 

The authors write, “For most of human evolution the absence or early cessation of breastfeeding would have been occasioned by the micarriage, loss, or death of a child.  We contend, therefore, that at the level of her basic biology a mother’s decision to bottle feed [with formula] unknowingly simulates child loss.  Consistent with this analysis, there is growing evidence that bottlefeeding is a significant risk factor for postpartum depression.”

 

The paper’s authors (who work in the Department of Psychology at the University of Albany/ State University of New York, Albany) recently completed a study of over 50 mothers recruited through local pediatric offices at their 4-6 weeks postpartum visit and evaluated them using the Edinburgh Postnatal Depression scale.  They found that those who bottle fed their babies scored significantly higher on the scale than those who breastfed, even after they controlled for things such as age, education, income, and the mother’s relationship with her current partner.

 

The paper also cites four other studies that link bottle feeding [with formula] to an increased risk of postpartum depression and/or breastfeeding’s ability to decrease one’s risk for postpartum depression.

 

This is a fascinating article to me for a variety of reasons.  First off, it is written by psychologists, not health care professionals and hence, takes a look at this very important topic from a completely different perspective.

 

Second, it is a study/analysis that focuses “not on the advantages of breastfeeding per se, but rather on the negative psychological consequences of the decision not to breastfeed.”

 

Thirdly, for mothers who cannot breastfeed (as related to the health of the baby or mother for example) or choose not to breastfeed, this article shows us how important it is as health care professionals to assess these mothers thorougly for signs and symptoms of postpartum depression as well as to educate these mothers and their loved ones about their potentially increased risk for postpartum depression so that they can obtain help and/or counseling if their “baby blues” turn into something more serious.

 

Forth, it is just yet another reason for me to continue to learn as much as I can about breastfeeding so that I can properly educate all my moms about the benefits of breastfeeding and the hazards of formula feeding.  I look forward to future reserach on this topic.

 

After all, babies were BORN to BREASTFEED and if a mother and baby are healthy enough to do so it is important for all mothers to know that babies DESERVE breast milk and DESERVE to be breastfed!   I dream of a world where ALL mothers who are willing and able to breastfeed get the support and encouragement and resources they need to do so!

 

A Little Bit of Laughter :) May 16, 2009

Filed under: Just For Fun — NursingBirth @ 9:25 AM
Tags: , , ,

My grandmother who has access to the Internet at her job (she’s still working full time at 75 years old!!) always fills my Inbox with silly chain emails.  I feel bad not reading them (because she will often ask me about a particular one!) so instead of deleting them, I usually skim them over, just in case I am “quizzed” later!  Yesterday however she sent me a doozy and I wanted to share it with all of you.  A bit of a “mental health break” to start your weekend off right!  Enjoy!

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Kids Say The Darndest Things!!

 

As I was nursing my baby, my cousin’s six-year-old daughter, Krissy, came into the room.  Never having seen anyone breast feed before, she was intrigued and full of all kinds of questions about what I was doing.  After mulling over my answers, she remarked, “My mom has some of those, but I don’t think she knows how to use them.”

 

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 On the way back from a Cub Scout meeting, my grandson asked my son the question. “Dad, I know that babies come from mommies’ tummies, but how do they get there in the first place?” he asked innocently.  After my son hemmed and hawed awhile, my grandson finally spoke up in disgust.  “You don’t have to make something up, Dad.  It’s OK if you don’t know the answer!”

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Have a great weekend!

 

My Philosophy: Birth, Breastfeeding, and Advocacy April 25, 2009

 

I am honored, humbled, and excited to report that just a few days ago my blog had over 1,500 hits in just one day.  I was floored when I saw the number and almost choked on my Cheerios J!  When I started this blog in February I was feeling lost, frustrated, burnt out, defeated, and disempowered regarding my role in the current maternity care system in America.  The day I wrote my very first post, NursingBirth is BORN!, was only one week after I almost up and quit my job after I had witnessed a very traumatic assault and battery against a woman I was caring for as her obstetrician performed a pudendal block against her will as she and her husband were screaming for him to stop. 

 

(Side Note: This is one situation that I still have not been able to bring myself to write about.  The fact is that assault & battery on patients in health care happen DOES happen and it was the first time I had ever witnessed such an event.  I cried for days, ran the story over and over and over again in my head, wondering what I could have done differently, wishing I had the courage to throw myself over her to physically prevent him from violating her, instead of just saying “Stop!”.  I am getting pretty choked up even thinking about it so for now, I will have to continue to process that event and hopefully one day, I will be able to write about it.)

 

My intention for this blog was simple…if I could reach one mother, just one, who might stumble upon my blog and be inspired to learn more about labor, childbirth, and birth options, to realize that she has options and rights regarding her experiences and her body, I would then feel triumphant.  I had convinced myself that for months or maybe even years the readers of my blog would probably only be my husband and sister-in-law J.  I conceded to using this blog as just catharsis and a way to process my experiences.  What I never imagined was that more than just a few people would ever read, never mind enjoy and keep reading, this blog!

 

So MANY THANKS are owed to all of my readers, who have turned out to not only be moms, but grandmothers, nurses, doctors, doulas, childbirth educators, midwives, and other people in the birth advocacy community.  THANK YOU, for reading!  Thank you to those who find themselves sharing many of my interests and beliefs!!  I love networking with all of you and learning more every day about how to better serve childbearing families.  And thank you to those of you who not only disagree with me but tell me about it too!!  You keep me thinking and on my toes.  Great things come out of great discussions and a discussion isn’t quite as interesting if everyone has the same opinion. 

 

THANK YOU!  THANK YOU!  THANK YOU!

 

With all of that being said I feel that it is time to share a bit more about my personal philosophy regarding birth, breastfeeding, and advocacy.  Of course my opinions do shine through in my writing (after all, it is my blog J) but with all of this “success” (haha, take that with a grain of salt please J) I have found that many people are beginning to label me with thoughts, feelings, and beliefs that I do not hold.  Contrary to what some readers have implied, my goal in writing this blog was not to push my own agenda or to bully women into believing everything I do.  (For example, one mom linked to a lighthearted post on my blog entitled Top Ten Things Women Say/Do During Labor on a popular baby website and wrote something to the effect of “Beware of the rest of her posts because she is pretty hippy-crunchy.”  Another person commented that my blog was something to avoid because I was a “crunchier than thou/more natural than thou natural birth Nazi.”)  Please note that I am NOT writing about these comments to start a flame war, nor did they hurt my feelings (I work in L&D after all, I have a pretty tough skin!  Haha!)

 

However, I did feel compelled to outline what my personal philosophy is so my intentions are clearer in future posts and since it is my blog that is exactly what I am going to do!  I feel that it is better for me to “fill in the holes” rather than have readers “guess” at where I am coming from.  That being said, I DO NOT expect everyone in the world to share the same philosophy.  The beliefs I have written below are meant to be provocative, that is, I am not trying to hide or sugar coat anything to make it have universal appeal.  Also, although I strongly believe in these statements, I can also understand the other side of the story.  For example, although I am a supporter and advocate of spontaneous, un-medicated labor and birth as well as VBACs, I do not condemn any woman for getting an epidural, taking pain medication, or scheduling a repeat cesarean.  I know there are some people out there that would, but I do not feel that way.  In reality more so than anything else, it’s not the epidural, pain medication, or repeat cesarean that bothers me; instead, it’s the women who request these things but have never even researched their safety or risks.  Like author Henci Goer, one of my goals in writing this blog is to never hear another women ever say, “But I didn’t know that was an option” or “I never would have agreed if I had known that could happen.”  You wouldn’t believe me if I told you how often I actually hear women speak these exact words because I hear it ALL THE TIME.  Also, I would like to point out that this is not a completely exhaustive list.  Regardless, here it is!!

 

(Note: Many of these statements are taken or adapted from the following resources)

v     Childbirth Connection’s Rights of Childbearing Women

v     BirthNetwork National’s Mission & Philosophy

v     Coalition for Improving Maternity Services’ Mother-Friendly Childbirth Initiative (MFCI)

 

My Personal and Professional Birth, Breastfeeding, and Advocacy Philosophy

 

Pregnancy, Birth, & Breastfeeding

1)     I believe that pregnancy and birth are normal, healthy processes and should not be treated as illness or disease.

2)     I believe women and babies have the inherent wisdom necessary for birth.

3)     I believe that pregnancy, birth, and the postpartum period are milestone events in the continuum of life that profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.

4)     I believe that breastfeeding provides the optimum nourishment for newborns and infants which does NOT mean that I am not grateful for the advancements in artificial milk for those mothers and infants who truly require it.

5)     I believe that every woman has the right to virtually uninterrupted contact with her newborn from the moment of birth, as long as she and her baby are healthy and do not need care that requires separation.

6)     I believe that for the majority of women, VBAC (or vaginal birth after cesarean) is a safe option that should be available to all women in all birth settings who safely qualify.

 

The Obstetric vs. Midwifery Model of Care

7)     I believe that uncomplicated, healthy pregnancies far outnumber pregnancies that have complications and hence, the technology and techniques utilized to maintain the safety of mother and baby in high risk pregnancies should not be automatically or routinely applied to low risk pregnancies.

8.)     I believe that the current maternity and newborn practices in the United States that contribute to high costs and inferior outcomes include the inappropriate application of technology and routine procedures that are not based on scientific evidence.

9)     I believe that although you cannot make blanket generalizations about the model of care that a birth attendant follows just by their credentials, typically speaking I believe OBGYNs tend to follow an obstetrics model of care while midwives tend to follow a midwifery model of care based on the very nature of their education.  After all, obstetricians are surgical specialists trained in the pathology of pregnancy and women’s reproductive organs.

10) I believe that per the very nature, philosophy, and experiences of medical education/obstetrical residency and midwifery education/apprenticeship, midwives should be the only health care providers attending normal, healthy, uncomplicated labors & births while obstetricians should be called to consult or transfer care to if and only if a problem or complication out of the scope of midwifery practice arises.

11) I believe that women need access to professional midwives whose educational and credentialing process provides them with expertise in out-of-hospital birth as well as hospital-based and clinical care that extends beyond the childbearing cycle.

12) I believe that midwives can obtain quality education and experience in a variety of ways and programs, including certified nurse midwifery and direct-entry midwifery. 

13) I believe that integrity of the mother-child relationship as well as the safety of our mothers and babies is compromised by the pervasive over-medicalized, obstetrics model of maternity care in this country.

 

Interventions & Natural Birth

14) I believe that research supports the reality that both a mother’s body as well as her baby will initiate the beginning of labor when the baby is ready to be born and that women should not have their labor induced for any elective reason unless the health of the woman or baby is found to be in immediate danger if the pregnancy is allowed to continue. 

15) I believe that empowering and safe births can and do take place in a variety of settings including birth centers, hospitals, and homes.

16) I believe that every woman should have the opportunity to give birth as she wishes in an environment in which she feels nurtured and secure and her emotional well-being, privacy, and personal preferences are respected, whether that be in a hospital, birthing center, or at home.

17) I believe the research supports that a minimal to no intervention, medication free, spontaneous vaginal delivery is the safest birthing option for the vast majority of both mothers and babies.

18) I believe that the obstetrical model of maternity care plus a pervasive American cultural phenomenon that teaches women to fear childbirth, doubt their innate ability and power to give birth, and be ashamed of their bodies and their sexuality is responsible for many women opting relinquish all control over their birth experiences to others and consent to unnecessary interventions that seem to provide a way to escape.

19) I believe that every woman has the right to create her own birth plan and that her birth attendants and labor companions have the responsibility to assist her in making it a reality as best and safely as they can.  I also understand that for some women, their birth plan does not include a medication or intervention free labor and childbirth and I support this as long as the women has been provided with informed consent, including all the risks and benefits of her requests.

 

Autonomy & Empowerment

20) I believe women are entitled to complete, accurate, and up-to-date information that is supported by evidenced based research on their full range of options, including all procedures, drugs, and tests suggested for use during for pregnancy, birth, post-partum and breastfeeding.

21) I believe that women have a right to make health care decisions for themselves and their babies and that this right includes informed consent as well as informed refusal.

22) I believe that interventions (i.e. many standard medical tests, procedures, technologies, and drugs including narcotic medications for pain relief in labor, epidurals, labor inductions, primary & repeat cesarean sections) should not be applied routinely during pregnancy, birth, or the postpartum period and in my opinion should be avoided in the absence of specific indications and true necessity for their use.

23) I believe that said interventions have life saving potential and are necessary in certain circumstances (which I am entirely grateful for) but are often abused and misused.

24) I believe that maternity care practice should not be based on the needs of the caregiver or provider, but solely on the needs of the mother and child.

25) I believe that every woman has the right to health care before, during and after pregnancy and childbirth.

26) I can admit that (probably related to my educational background, experiences, and values) I am not entirely comfortable with the “free-birth” or “unassisted childbirth” movement but I can also admit that I know little to nothing about the movement and I am open-minded to learning more.

27) I believe that every woman has the right to receive continuous social, emotional and physical support during labor and birth from a caregiver who has been trained in labor support and I believe that the current obstetrical education in this country does not train physicians to provide labor support.

28) I believe that every women has the right to have how ever many supportive labor companions and birth attendants of her choice (as she deems necessary) attend her labor and birth, has the right to change her mind at any time, and has the right to decline the care or presence of any unnecessary personnel during her labor and birth.

 

In closing, I am NOT anti-obstetrician, anti-hospital, anti-intervention, anti-induction, anti-epidural, anti-pain medication, or anti-cesarean.  Quite the contrary I am PRO the appropriate use of such interventions when they are necessary to support the health and safety of the mother-baby unit and facilitate a safe and empowering (hopefully vaginal) birth.  I have found my passion in assisting women and families during the intrapartum period and my number one goal in my job is to support, facilitate, and encourage a natural-as-possible, empowering, and safe birth experience, however that may be, for all those involved.

 

Thanks for reading.

 

 

The “All That Matters” Phenomenon: Grieving the Loss of a Vaginal Birth April 24, 2009

The other day I had the privilege of taking care of a couple who was in labor with their first baby.  Denise, a G1P0 at 41 weeks and 3 days, broke her water at 1:00am with contraction starting about 8-10 minutes apart at 4:30am.  She and her boyfriend, Ralph, labored at home until about 8:00am when the contractions were coming about every 3-5 minutes apart.  When she arrived to the hospital at 8:30am, a resident’s vaginal exam revealed that she was 3cm/50%effaced/-3 station!!  Since she was a young healthy woman (her health history only comprised of PCOS, or polycystic ovarian syndrome) and had had an uncomplicated, normal, healthy pregnancy, she was “allowed” to ambulate in the halls all morning but required to stay on continuous telemetry monitoring and not allowed to labor in the tub per her physician’s direct order. 

 

(Side Note:  This particular physician, Dr. O, is an older physician who is part of a group that is well known for aggressive labor management.  They induce almost all of their patients for one reason or another, often once they hit 39 weeks, and if a patient is not already ruptured once they get to the hospital, they will artificially break their patients’ water regardless of dilatation.  That’s right, I have personally refused to give them an amniohook when a patient is only 1 or 2 centimeters and they sneak in the room without me and break her water anyway!  One time, Dr. U (another doctor in that group) ruptured a patient who was still in triage!  They are notorious for setting up “post dates” inductions at 40 weeks and 1 day and although they advertise that they attend VBACs, their statistics show something quite different: Almost NO “successful” VBAC vaginal deliveries and a cesarean rate that is at least 40%.  Myself and many other nurses have bombarded them with research and position statements from a variety of sources, including their OWN association (American College of Obstetricians and Gynecologists, or ACOG)) that states intermittent auscultation is the standard of care for low risk, uncomplicated pregnancies, but they refuse to listen.  So Denise’s situation is unfortunately not uncommon.  To be honest, I am surprised they “let” her get past 41 weeks!  I think they view it as a slap in the face to attend any delivery after 40 weeks!)  

 

When I came on at 3:00pm, Denise was in the middle of getting an epidural.  Turns out that at 12:30pm, Dr. O’s vaginal exam revealed that the patient was “only” (his words) 4cm/80%/-3 so he ordered pitocin augmentation and the pit was started at 1:00pm.  Although the patient had originally told the nurse it was her plan to labor without an epidural, pitocin lead to stronger, longer, and closer contractions which lead to the patient requesting one.  And an epidural was granted.  For the next 3 hours I was instructed to continue to turn up the pitocin to obtain 5 contractions in 10 minutes.  I titrated appropriately until I obtained moderate to strong contractions (per my palpation) every 2-3 minutes, where the baby was still looking good on the monitor.  I changed the patient’s position every 30 minutes: right side, sitting up high, left side, sitting up high, etc. in hopes that I would help the baby makes his way down the birth canal and not get “stuck” in any acynclitic position. (According to the patient, she was complaining of severe back pain the last few hours so I was concerned about an occiput posterior baby.  So since Denise could no longer move herself to help move the baby, I was doing the moving for her!) 

 

At 7:00pm Denise was feeling a lot of rectal pressure, so much that she was breathing through it (even though the epidural was still effective at taking away her back and abdominal pain).  We all were very excited!!  Since Denise was only feeling rectal pressure during contractions I told her it would be best to wait until she was feeling rectal pressure at all times, with our without a contraction, before we called the doctor.  Well Dr. O must have had ESP because he came into the room to perform a vaginal exam.  His exam revealed that Denise was 4cm/100%/ -1 station!  The patient was a bit disappointed that she was still only “4cm” but I assured her that he was completely thinned out and that she had brought the baby down a whole bunch!  However, Dr. O had a different take on it, “You are still only 4cm, he said, “And if you don’t make any significant progress within the next hour we will have to talk about a change in the plan.”  (Could he have BEEN any more vague?!)  And then he turned around and walked out.  “What does he mean by change of plan?” Denise asked me.  “Well I’m not sure,” I said back, “let me go find out.” 

 

The fact of the matter is that I knew exactly what Dr. O meant….he meant that he was going to do a c-section.  But I didn’t want to tell her that for two reasons, 1) it is NOT my responsibility to tell a patient that someone else is going to perform a cesarean section on them, it’s the SURGEON’S responsibility, and 2) I hate even talking about the possibility of a cesarean section when someone is in the middle of labor because it is like you are telling the patient you are already “giving up” on them.  Of course I understand that some cesareans are necessary, but I know that if I was in her position and someone gave me a “cesarean ultimatum” during labor, I would feel like people were giving up on me!  I mean here she is, basically being given a one hour ultimatum, and because of the limitations of the epidural it is not even like she can “do” something to play an active role:  she can’t walk around or get in the tub, we’ve already got her hooked up to pitocin and an epidural, we’ve already tried the position changes, her water is already broken, and I am pretty sure she doesn’t know magic.  So here I am feeling like my hands are tied, but trying to stay positive and encouraging so that the patient does not feel upset, passive, defeated, or worried.  Because those emotions do NOT facilitate labor, and in fact, those emotions can actually release hormones in your body that directly work AGAINST labor. 

 

So I walked out to the desk to find Dr. O but he had already left.  (I don’t think he went very far, maybe into another patient’s room, but nonetheless, he was no where to be found.)  I felt an obligation to tell Denise something so I went back into to the room and said this:

 

Me: “Denise, I think Dr. O is with another patient right now but once I find him, if you would like, I can ask him to come back in to answer any questions you might have.”

 

Denise:  “Yeah, I would like him to come back in because I don’t want a c-section.”  (starting to get a bit teary eyed)  “I mean, is that what he meant by change of plan?  Can they give me any other medicine to help with my contractions?”

 

Me:  “Well I don’t know what he meant exactly but he could have meant he would like to try an IUPC which stands for intrauterine pressure catheter.  It is a thin tube that lies beside the baby’s face and actually measures in millimeters of mercury how strong your contractions are.  If I have an IUPC, I might be able to go up on the pitocin if the contractions aren’t “strong enough.”  Right now the external monitor only tells me when they are coming and when I feel your belly it is all subjective.  Unfortunately there isn’t any other medicine we can give you to help “speed up” labor besides pitocin.  He could also have meant a cesarean.  But we won’t know until we talk to him.”

 

Denise: (almost in a scared tone)  “But I don’t want a c-section!  I want to push my baby out!  Oh I don’t want a c-section!” 

 

Me:  (feeling like I wish I could help but don’t know how)  “Well let’s talk about what you can do.  If Dr. O comes in to check you, you have the right to refuse his vaginal exam and request more time.  You also have the right to ask him about all of your options, if there are any, besides a cesarean.  You have the right to ask him his reasons for why he thinks a cesarean is necessary.  You have the right to hear all that information and then take as much time as you need to decide what you would like to do.  If you need some alone time with Ralph or if you need to call your mom or any other family members you have that right.  I just want you to know that if you and Dr. O decide together that a cesarean is the best option, it will NOT be an emergency and therefore you can take as much time as you need to prepare.  The baby is not in distress and in fact, has looked beautiful on the monitor all day.   If you both decide that a cesarean is the right course of action, I promise I will go over everything to expect with you, I will make sure anesthesia sees you before you get to the OR so you can ask them any questions, and barring any other emergency, I will be with you the entire time, from the moment I wheel you in to the OR, to the moment I wheel you out of the recovery room.  I’ll help you breastfeed as soon as possible.  I will stay with you the whole time…”

 

At this point I was starting to get a bit emotional and realized I was rambling so I excused myself and went out to the desk.  I just knew in my heart what was going to happen and I was deeply saddened by it.  And don’t get me wrong, I am not trying to be overly dramatic but I just knew that when she broke her water at 1:00am and came to the hospital at 3cm, she was not expecting to end up with a cesarean. 

 

Well exactly one hour later Dr. O came back into the room to do a vaginal exam.  I turned towards Denise and I said, “Is that okay with you, Denise?” and she said “Yes.  According to Dr. O, Denise was still the same and had made no “progress.”  Dr. O, while standing at the foot of the bed, looked up at Denise and said “Well Denise, we’ve run out of options here.  If we continue to keep you on pitocin eventually the baby is going to run out of gas and crash.  Uteruses can only take so much and your uterus is going to get thinner and thinner and will be at risk of rupturing if we continue like this.  You have essentially been 4cm for 7 hours and for a primip, you need to progress at least one centimeter an hour.  We need to do a cesarean and as soon as I tell the charge nurse we’ll get going on it.”

 

At this point Denise burst into tears, “OH GOD, BUT I DON’T WANT TO HAVE A C-SECTION!  I WANTED TO PUSH HIM OUT!  I WANTED TO PUSH HIM OUT!   I REALLY THOUGHT I COULD DO IT!  I WANTED TO DO IT!  I WANTED TO PUSH MY BABY OUT!”  Ralph gave her a big hug and I kept squeezing her hand trying to bit my lip so that I didn’t start to cry myself.  She was sobbing.  And then Dr. O said “Listen, Denise, there is no reason to get like this.  I mean, when you came to the hospital this morning I also had 4 other patients that came in around the same time.  Everyone else has already delivered…you’re the only one left.  And some women even came in with cervixes more closed than yours.  You see, the baby just isn’t coming down enough in the birth canal to dilate your cervix, and it’s just a failure to progress.  It’s just failure to progress that’s all.”  Then he turned to me and said “As soon as I tell the charge nurse we’re going to go.  So then I said, “Well I am not at all ready to go yet.  And I think she deserves a minute to come to terms with all of this, Dr. O.  She deserves some time to make her decision and call her family.  And then Dr. O looked straight at me, baffled, said “Whatever” and then stormed out slamming he door behind him. 

 

I threw myself onto Denise and have her the biggest hug I could.  I whispered over and over in her ear, “You are NOT a failure Denise, I know you wanted to push him out.  I know you did.  You have done so much work today and you never gave up.  You are a strong woman, Denise, you did not fail and your body did not fail.  NOBODY is a failure here.  It’s okay to cry.  It’s okay to cry, Denise.  Please know you did so much for your baby and you never gave up.  You are a strong woman…”

 

I stayed there for about 10 minutes with her and Ralph, letting her cry.  When she calmed down a bit I encouraged her to take her time to talk with Ralph and call her mother or family if she needed too.  I told her that I needed to get some things ready and that I was going to give them some privacy.

 

So by this point I was pretty upset.  For one, I think the way Dr. O went about the whole thing was so cold and insensitive.  Um hello, do you think telling a patient that “everyone else” has already delivered is going to make them feel better!?  Because in my opinion, it just stresses the insane notion that her body is in someway a “failure.”    I could mull over and over and over again in my head everything that surrounded this whole situation and I have almost made myself sick over wondering if this was really a necessary cesarean for “true” arrest of descent/dilatation.  But regardless, I feel like he completely took Denise and Ralph out of the whole process and it should have been handled better.  Second, Dr. O did NOT go over the risks and benefits of the cesarean with them, claiming later that the residents “review that” on admission (which, by the way, they don’t…they just have everyone sign a consent for “vaginal delivery possible cesarean section”).  Third, Dr. O did not at all go over other options besides cesarean, and even if he thought the safest course of action was a cesarean at that point in time (which I am not disputing), he didn’t even say anything like “and our other options, X, Y, & Z, are not the best course to take because of A, B, C, so it is in my professional opinion that the safest course of action is to perform a cesarean section.  But please take your time to talk it over.”).  I have seen other doctors do this before.  Even in situation where everyone agrees that a cesarean is absolutely necessary, it is still the patients right to make the final decision.  And finally, he didn’t even give them a chance to talk it through and when I asked for “some time” he got pissed. 

 

So I walked out to the desk to get my paperwork ready and Dr. O was writing a note in her chart:

 

Dr. O:  (sarcastically and not even looking up from what he was writing)  “So when do you think you’ll be ready to go?”

 

Me:  (frustrated)  “It’s not about me being ready, it’s about Denise and Ralph being ready!  I think it is more than just a courtesy to allow them some time to come to terms with this new development.  They have a RIGHT to some time, Dr. O.  This isn’t an emergency.  The baby has looked great on the monitor all day and I shut the pitocin off.”

 

Dr. O:  (frustrated)  “I don’t know why you are fighting me on this!” 

 

Me:  (increasingly frustrated) “I’m not fighting you on ANYTHING Dr. O, but you have to understand, she is devastated that she is going to have a cesarean.  We owe it to her to let her calm down and not wheel her down the hall as a sobbing mess!  Her whole family lives in a different state, including her mother, and I think that it isn’t too much for her to ask for some time to call her family before she goes in for MAJOR ABDOMINAL SURGERY!” 

 

And then he said it….he said that phrase that breaks my heart every time I hear it…

 

Dr. O: “She’ll forget all about it when she is holding a baby in her arms.”

 

This phrase comes in many forms but every one says the same thing, “All that matters is that you get a baby out of this deal… and your experience, your experience doesn’t matter.”

 

Kristen, a doula, graduate student, mom, and author of the blog Birthing Beautiful Ideas wrote an amazingly insightful and moving must read post entitled, “Scars That Run Deep: ‘All That Matters’ After A Cesarean” that explores this very topic. 

 

Kristen writes:

 

“You have a healthy baby.  That’s what matters.”

 

Mothers who express sadness, anger, or disappointment after undergoing a cesarean section often hear these words uttered by (presumably) well-meaning family, friends, and health care workers.  In fact, these words seem to be one of the most common responses that people give upon hearing that a mother has had a cesarean.  I presume this is because it can be jarring to witness the juxtaposition of the joy and wonder of a newborn life and the mother’s grief over her baby’s entrance into the world.  And so, particularly in a culture that does not have a well-developed ritual for expressing and experiencing grief, people try to fill up the mother’s “empty grief jar” with an elixir of “healthy baby joy.”  But, as we all know, grief and joy don’t work like that.

 

Kristen goes on to write about why having a healthy baby isn’t “all that matters” after a cesarean, the concept of mourning the loss of a vaginal birth, and why a mother’s birth experience IS part of “what matters” regarding the entire childbirth experience.  Kristen also outlines step by step details about what a mother experiences when she undergoes a cesarean, from the minute the wheel her into the operating room to the first time she gets to hold her baby to caring for a newborn after major surgery.  Kristen writes,

 

In addition, the de-valuing of the mother’s birth experience–a de-valuing implied by the “healthy baby line”–undermines the significance of one of the most transformative days of a mother’s life.  For on the same day that her baby is born, she is “born” as a mother.  And if this dual-birth is marked by passivity and separation, then it is no wonder that the mother grieves her birth experience.  That having her healthy, miraculous, wonderful baby is not all that matters to her.

 

In fact, her sadness is partially a result of being separated from her healthy, miraculous, wonderful baby during the first few moments and even hours of that baby’s life.  And it can be the result of a feeling that her body is “broken,” “unable” to bring her child into the world on its own.  And it can be the result of a feeling that her body might not even “know” how to work properly to bring a child into the world.  And it can be the result of feeling as if she has disappointed not only herself but also her partner and/or other friends and family.  And it can be the result of the sheer difficulty of recovering from major abdominal surgery and simultaneously caring for a newborn baby, two of the most physically and emotionally demanding experiences that any person will ever undergo.

 

In other words, her sadness and her grief are understandable.  They are normal.

 

Please check out Kristen’s post in it’s entirety on her blog.  The excerpts I have provided here are only a small piece of this very eye opening composition.

 

In the end Denise gave birth to her 9lb 8oz baby boy, Rayne Nicolais, by cesarean section at 9:01pm.  Baby Rayne was found to be in an occiput posterior position and still very high in the pelvis when he was born.  I had the opportunity to stay with Denise, Ralph, and Baby Rayne for the entire experience and with the help of a ton of pillows, Denise breastfeed Rayne skin to skin in a football hold for an entire hour and 15 minutes in the recovery room.  And boy was he a vigorous breast feeder!! 

 

Although all in all, there was a positive outcome to Denise’s birth experience, I do wish that for Denise and Ralph, things could have turned out differently.  I wish that Denise could have PUSHED her baby out like she so desired and worked so hard for.  And of course I am grateful that at the end of the day Baby Rayne was a happy, healthy, chubby, bouncing baby boy.  In the recovery room where Denise really held her baby boy for the first time, she welled up, looked at her boyfriend and said, “I think I am falling in love all over again!”  It was so beautiful!  As a nurse, experiences like this solidify what I feel in my whole being is true about pregnancy and childbirth; That the journey is as important as the destination. 

 

In closing I would like to leave you with one of my favorite quotes…

 

“It’s not just the making of babies, but the making of mothers that midwives see as the miracle of birth.” ~ Barbara Katz Rothman.

 

 
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