Common Sense Labor Practices - the Walsh argument

It looks like I’ll be finished reading Denis Walsh’s Evidence-based Care in Normal Labour and Birthing soon. I’ve really enjoyed it.

One thing I really like about this book is the underlying theme of using common sense to return to normal labor and birth. The author seems to come back to this idea at least once in each chapter, but I think it is best displayed in the argument surrounding the following topic: Movement in Labor and Birth.

Why is it that we seem to need randomized clinical trials to show us that moving and using gravity in upright positions would be good for birthing?

I was really struck when I was reading about this concept. Well, duh. Of course, even those promoting natural birth do forget about this. We try and try to prove that this works, but why is that we must prove something so common sense? Are we that far away from good birthing practices?

Quite simply: Yes. [insert a number of choice words]

As a culture, we have truly become a nation that absolutely relies on medical intervention. It’s pervasive. We go to the doctor with flu symptoms and find ourselves getting chest x-rays, bloodwork, and antibiotics (Let’s not forget that the flu is a virus. Antibiotics are for bacterial infections, not viruses). Our child gets a bad bump on the soccer field, and he’s in the ER for a CT scan (see this article).

Recently, we took my son to the doctor (not our pediatrician), for a suspected ear infection. Fortunately, he didn’t have one, but the doctor offered us a prescription for something just in case. When I declined, he replied that was fine, and that he offered because some people feel unsatisfied if they come to the doctor and don’t get something, even if nothing is wrong.

Novel idea, I know, but if you’re not sick, you don’t need something.

And this is much of what Walsh is arguing. If not sick, which pregnancy and labor should never be considered pathologies, then why are we doing randomized clinical trials to prove that natural labor needs natural things? (The same argument can then made against IVs, routine AROM, monitoring…)

I’m not making a new argument of course. I’m simply reiterating what many are already saying.

Pregnancy, labor and birth are normal the vast majority of the time. They require normal, common sense things. If they cease being so, then we’ll call for something else. Don’t do anything just to say that you’ve done something.

Preventing ALL Death and Injury?

I’m currently reading Denis Walsh’s Evidence-based Care for Normal Labour and Birth. In my reading this week, I was struck by the chapter called “Fetal Heart Monitoring in Labour.” I understand that fetal heart monitoring is not proven beneficial, though it continues to be in widespread practice. I was familiar with much of the information presented, but the following reference caught me off guard.

Walsh discusses a number of studies and reviews throughout the book, and in this particular case, the review being discussed brings up one (of many) possibly disadvantages for continuous electronic fetal monitoring. Walsh quotes directly, as will I, the following: “[it] shifts staff focus and resources away from the mother and may encourage a belief that all perinatal mortality and neurological injury can be prevented.” (Reference below).

Can I just stop and say “WOW”?

Of course, it makes perfect sense. This attitude is pervasive in western culture. All death should be prevented until natural causes in old age. All other death is negligent and/or preventable by future technologies.

Again, WOW.

I come from this culture of course, and I struggle constantly with the idea. Late last year, my dad was diagnosed with prostate cancer. His prognosis was very good: he was (and is) in excellent health, and it was caught very early. He had surgery and has thus far done well without any other treatment.

My mother, of course, panicked with this diagnosis. Current research suggested to her that even with surgery and complete removal of the tumor, it only extended my dad’s life expectancy ten years. She was distraught.

Let’s put the above in perspective. This year, my dad will be 66. Ten years is 76. My dad (due to good health) probably had a previous life expectancy of 80.

Was surgery helpful? Certainly. Would my dad have died sooner without it? Yes, probably. He has a genetic risk for prostate cancer, so his cancer was likely vigorous. Does he have cancer now? Nope, not as far as we can tell.

Should my mom still be concerned about his life expectancy? Nope, not in my opinion. He will die eventually anyway.

That’s heartless sounding of course, but it’s true. Some of us will die from cancer. If we cure cancer, it’s likely some will die of other causes, beyond the “natural.”

My point is, as a culture, we are terrified of death. We string ourselves out at the end of life, struggling for each breath in some sterile hospital, without being allowed to die in dignity and grace surrounded by family and friends at home.

Unfortunately, birth is no different. Birth is a symbolic act of life beginning in another (though I would argue the life began long before, it just needed constant care in a different environment before birth). It is logical that once life begins, it will certainly eventually end. And as much as we would like to, many times we cannot prevent it, not should we.

I do not believe there will ever be a time when NO women and NO babies die in childbirth. That would be like saying there will never be any more SIDS or miscarriages. As tragic as these things are, they happen. They are a part of the life cycle.

Therefore, we need (as much as possible considering the culture we’ve been raised in) to attempt to lose this idea of preventing all perinatal mortality and injury. It will likely never happen. Our focus should be on healthy normal childbirth so we can recognize when it goes astray. When it goes astray from normal, we should focus on doing what we can, WITHOUT CAUSING FURTHER INJURY OR HARM to either the baby or the mother. After that, we should focus on supporting and counseling the family through a difficult life event.

Reference: Alfirevic, Z., Devane, D. and Gyte, G. (2006) Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, Issue 3.

Baby fever and putting it off...

I have baby fever. It’s unfortunate that right now we can’t have another, so I’m going to lament and have myself a pity party.

As some may know, in January I decided to apply to nursing school with a local two-year R.N. program. Nursing had been in the back of my mind as an eventual pathway to midwifery, but I hadn’t truly considered it for awhile. The decision to apply was very much spur-of-the-moment, and to be honest I can’t remember all the reasons my husband and I considered when we made the decision I should apply. A primary concern of course was financial stability: we’ve struggled our entire married life, and I was not going to reenter full-time public school teaching unless I had to. (We did consider it, and I’m thankful my husband said he’d rather we struggle a way longer than put me through that). My husband is also going for nursing, though he’s not starting the program this fall with me. We felt that since I have a bachelor’s degree, I would get through the nursing program faster than he would. Then I’d be able to do a three day a week/full-time thing while he finished up the program himself. Three days a week would give me enough time home that I would still feel like a full-time mommy, at least as much as I am now working part-time and going to school part-time.

Of course, going to school full-time and then trying to find a job is really difficult pregnant and/or with a new baby. Not impossible, but…

I’ve considered the fact that I could probably take time off from the nursing program. Legally, I’m allowed a semester off (R.N. programs have some special requirements due to accreditation), though I’ve been told by the program director that I’m not allowed any time off. I could fight him on it, but I wonder if it’s worth it. I don’t want any difficulties going through, and I want to be finished and move on with my life. I also get his perspective; they’ve had a lot of concerns about the program’s accreditation with people not passing/dropping out. Rumor has it that of the latest class in the hospital partnership, only about half are making it to next semester. That’s got to be nerve-wracking as a program director to be staring accreditation worries in the face.

Also, I think about what I’m going to be looking at with my next birth. We want a large family, and I’ve already had one cesarean. I don’t want to have another and I’m really considering my options to ensure a VBAC this time. Out-of-hospital birth certainly seems to be the best option, but is it an option for me with my medical history? If I’m risked out of midwifery services, do I “free-birth?” (probably not, but it’s been on the table). How do I manage a hospital VBAC fight while struggling with clinicals? (and a family?)

Apart from the next birth, what about the next postpartum: I want to do everything I can to have a healthy postpartum transition this time around. Fewer stressors would equal reduced risk for me developing postpartum depression again. I was switching from working full-time to mothering full-time at the last birth, so being settled and having less life change is ideal.

Having a great start breastfeeding is also key in my mind: not being able to get out to find the help we needed was a huge factor in our failure to continue breastfeeding. Little man needed specialized care, and that simply did not get met. I would like to not battle with returning to school and pumping; arguing to pump at work seems to be a much easier battle.

So yeah, we’ve decided to avoid for the time being. Neither of us is very happy about it. We both have baby fever to the extreme, and the little man is not very little anymore. He’s talking now, and it’s really obvious that he’s a BOY rather than a little baby. It’s hard also when I consider that by the time I’m done with school, he’ll be almost FOUR. We had hoped to get them close together, so it’s a bit of a blow for us. Of course, we know that conception is not controlled by us, so I guess we’ll see if anything else comes up.

Until then, I’m burying myself in my birth studies, focusing on being the best nursing student, mothering my little man, and being a wife to my fabulous husband. These next two years (or so) better fly by.

Thoughts on the birth battle

Recently I have been becoming more and more disgusted watching the arguments in the birthing world. I'm sad part of me is less "green" about it all, because I certainly like the hopeful, optimistic me. 

Part of this stems from my entering nursing school (well almost - I'll know by April if I'm accepted) in an effort to continue down my path to helping birthing women while trying to support my family. I feel like a spy in my classes with nursing majors, like I'm trying to figure out how the brain works to so blindly trust the medical model at the expense of common sense, mamas, babies, and families.

My conclusion: In many ways we're all guilty of the same blindness.

Both sides of the birth war use the same methods of guilt and anger, the same self-righteous attitude. 

Before I get hate mail, let me be clear that I am certainly on the homebirth, breastfeeding, unassisted if you want it side. 

But we're not free from the negatives - the failure to see some options as appealing to others even we will feel they're dangerous (so hard!). And to be honest, I don't know what we do about it - if anything.

It is absolutely true that we often make women feel guilty for not breastfeeding.

Mothers should feel guilty about not breastfeeding - just as they should feel guilty about giving a child a Coca-cola and a donut instead of milk and a banana.

But how do we prevent that guilt from turning into defensive rationalization and inability/refusal to change? How do we communicate with love, empathy, and understanding?

I think we have to start with these assumptions - we do not know all the reasons a mother may choose to do "X" and she is not at the same place we are.

The second assumption, to me, is the hardest and the most important. We can talk until we're blue in the face about the risks of not breastfeeding (which as a note is proven more effective than presenting it as the benefits of breastfeeding - study) but without long-term cultural change we are not going to get there with everyone.

I hate this.

The idealist in me wishes I could help everyone, save every mama and baby from a bad birth, but I can't. No one can. We can try our damnedest and then we just have to hope. Things may not change now, but down the road these seeds may sprout and bloom. We just have to keep planting and watering and weeding. 

Breastfeeding Misinformation begins with Doctors and Nurses

As some of you may know, I have recently gone back to school. I've applied to a local RN Associate Degree program and am working on related coursework. One of my courses this semester is Nutrition and Diet Therapy, and as part of the course requirements, we're presenting group projects. Yes, pregnancy nutrition was taken by the time I got to sign up, but I managed to snag breastfeeding.

I started by scanning my textbook (which is required as we're primarily presenting the text information and supplying research to compliment). I came across this gem: "The adjustments [of breastfeeding comfortably] are easier if supplemental formula feedings are not introduced until breastfeeding is well established, after at least 3 to 4 weeks. Then it is fine if a supplemental bottle or two of infant formula per day is needed." [Contemporary Nutrition: A Functional Approach]

I had a few choice words and then set out to find the research to disprove it. I'm presenting that here.

First - The statement goes directly against current breastfeeding recommendations. WHO states that "exclusive breastfeeding is recommended up to 6 months of age, with continued breastfeeding with appropriate complementary foods up to two years of age or beyond" (Citation) American Academy of Pediatrics goes this far: Supplements (water, glucose water, formula, and other fluids) should not be given to breastfeeding newborn infants unless ordered by a physician when a medical indication exists.” and “Pediatricians and other health care professionals should recommend human milk for all infants in whom breastfeeding is not specifically contraindicated and provide parents with complete, current information on the benefits and techniques of breastfeeding to ensure that their feeding decision is a fully informed one.  When direct breastfeeding is not possible, expressed human milk should be provided." (Citation) Healthy People 2020 Targets are exclusively breastfeeding through 3 months - 46.2% and exclusively through 6 months - 25.5% (Citation)

Second: Formula Supplementation has been linked to early breastfeeding cessation: “Partial breast-feeding (supplementing more than one bottle of formula per day, measured at 1 month postpartum) was associated with shorter breast-feeding duration. This latter effect was minimized by frequent nursing (seven or more times per day), despite formula supplementation.” (citation) 

And finally: “Clinicians who recommended formula supplementation or who do not think their advice about how long to breastfeed is very important may be sending signals that exclusive breastfeeding is not something that mothers should value highly. In addition, our results indicate that many clinicians do not feel confident in their skills to support breastfeeding and may have limited time to address the issue during preventive visits. As for mothers, experiencing problems with the infant latching on or sucking seems to be a risk factor for not exclusively breastfeeding.” (Citation - I found the full article through Ebscohost and cannot link it directly. You can comment/email me for the file and I will be happy to supply it.)

I'm excited to use the information I've found to disprove such a fallacy and educate other nurses. Let's hope they listen...

How do you know when to go to the hospital/birth center in labor? An observation.

Last night as I was waiting in the ER with my dad (minor surgical complication; he's fine), I observed the strangest thing - three women entered and were directed to the OB admission area. The strange part - none appeared to be in active labor. One in particular (only 37 weeks) sat for at least 10 minutes nearby without even a peep or a squirm. The other two (both 38 weeks) talked with nurses easily, filled out admission paperwork, and climbed into wheelchairs.

The thought in my head - Why are they here yet?!

In pregnancy, among the labor and delivery horror stories, I also often heard about the women who went in too early - "Oh don't worry, I got sent home 'x' times before they kept me."

Did no one bother to tell them that they can (and should) stay at home as long as possible?

I tell women (even those planning an epidural) that in normal labor, you should look for 4-1-1 before heading in. This helps reduce the interventions you may "need" and gets you to the hospital at the point when labor is more likely to keep going rather than stall. Getting to the hospital earlier may even get you there at a point when you can't yet have an epidural (depending on your hospital and anesthesiologist).

With 4-1-1, contractions are about 4 minutes apart, last about 1 minute each, and have been doing so for about 1 hour.


Disclaimer #1: Follow 4-1-1 unless you have another reason to go to the hospital ASAP - bleeding, foul smell with vaginal leaking, feeling something through the cervix/vagina, if you feel that labor is going too quickly, or if you are not yet 38 weeks. I'm not a doctor and don't pretend to be one :)

Disclaimer #2: Don't go to the hospital at all if you can help it! Find a good midwife and birthing center or a good homebirth midwife if you're low-risk in pregnancy. It's not just a "fad"; it's good medicine.