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. 

Traumatic Birth – or why some women may prefer cesarean birth

Lately, I’ve found myself wondering why some women feel cesarean birth is better than vaginal birth. It’s been something I questioned before I was pregnant and was particularly confusing when I was confronted with my own cesarean.

For me, I always wanted a natural, med-free, intervention-free birth. It was devastating for me to be confronted with a cesarean. The recovery was particularly difficult, and the couple of times I “overdid it” really were painful and debilitating.

I’m looking at future pregnancies with fear, as complications during pregnancy are more common after cesarean – placental issues, tubal pregnancies, secondary infertility. The VBAC fight was never one I wanted to be faced with, but here I am.

So how could someone be not just satisfied, but even pleased, with this? I’m slowly beginning to understand.

Recently, I read an article about post traumatic stress disorder following birth; it’s on the rise. As a medical system, we need to acknowledge that in an age where 1 in 10 women suffer from postpartum depression, much less PTSD, that it is apparently not about “just a healthy baby.”

Women need to have the opportunity to mourn the births they have lost. The ideal birth, whatever it is for that particular woman, needs to be acknowledged, and if at all possible, pursued. For me – I lost my first birth to major abdominal surgery. For some, it’s losing the ideal of pain management when a planned epidural doesn’t work, or just being able to go into labor before the pressure of induction begins.

Many women see the cesarean as what saved them – whether it did or not. Maybe it saved them from another traumatic induction lasting 48 hours or more. Maybe it was a way of attempting to control the unknown. Maybe the recovery temporarily saved them from additional childcare and household responsibilities.

As a birth professional, I’ll be honest that I’m a little biased about the solution. But fortunately there are studies and guidelines to back me up. (I’ll list them at the end.)

Childbirth education should be expanded, encouraged, and absolutely available to all. It needs to involved couples working through both their fears and expectations. It must involve current research about normal labor processes and when interventions are medically necessary as opposed to simply routine. It should provide an opportunity for couples to build relationships with others in the childbearing year, expanding their network of support.

Doula care needs to be covered by Medicaid and private insurance. Having a labor doula can decrease the need for cesarean by up to 50%. Postpartum doulas can fill the role once done by the extended family – helping the new family adjust with each child added to the family.

Midwifery care should be more widely available, particularly in rural areas where OB presence is minimal. Low-risk women should be seen first by midwives and referred to OBs as necessary.

Women with negative birth experience should report these to their care providers with the intent that questions are answered and care is altered. It wasn’t too long ago that women and families decided it was unacceptable for fathers to be in the waiting room during the birth of their own children, or that women shouldn’t be forced to undergo “Twilight Sleep” and not be mentally and emotionally present at their own birthing.

It should be no different now that we refuse to accept the parts of the system that make us uncomfortable and that are not supported by rigorous research. What we’re comfortable with may be different woman to woman – med-free, highly managed, etc – but it’s time for individualized care again.

No woman should have to feel that major abdominal surgery was an easier and more acceptable solution that the birth route her body was made and designed for.


Studies and Resources:
Expecting Trouble – written by an obstetrician who feels 80-90% of women should have midwifery prenatal care and at least 70-80% should deliver with a midwife.

The Doula Book – numerous studies about the benefits of a doula – from childbirth satisfaction to birth outcomes.

Healthy People 2020 Guidelines - reduce cesareans, among many others

Post Traumatic Stress Disorder After Childbirth - particularly look at Ten Questions to Ask

Traumatic Birth News Article

Why do doctors even use due dates?

Probably the most common method of calculating a due date is to use the “last menstrual period” or LMP. Once a woman finds out she is pregnant, an OB or midwife simply asks when the first day of her previous period was. This becomes day 1 of the pregnancy; day 240 is her estimated due date or EDD. (Of course, they have handy wheel for this calculation.)

The biggest problem with using the LMP is the wide variance of cycle norms for women. LMP due date calculation depends absolutely entirely on every woman having a 28-day cycle and ovulating on day 14 of that cycle, without fail, every single cycle of her life.

Please, stop laughing. They do this.

Yes, there are many doctors and midwives who very much believe this method is accurate, or at least simple. It’s certainly a convenient method and it has an air of mathematical certainty.

Unfortunately for them (and us), very few women fit into this category of 28 day cyclers. There are women who seem to have short cycles – less than 28 days. Chances are that these women also ovulate earlier in their cycle, throwing off LMP due date calculation for them. There are women, like myself, who have long cycles and ovulate later than day 14. Personally, I average about 35 days per cycle, and usually ovulate somewhere around day 21. (Side note – if you want to learn about an FDA approved aid to conception that will help you learn your personal cycle norms, check out the fertility awareness method – not to be confused with the rhythm method.)
Then of course there are those of us who have no earthy idea when our LMP was. Maybe we have irregular cycles – 28 days then 45 then 24 then… Maybe we were breastfeeding or otherwise newly postpartum and our usual “regularity” hadn’t yet returned. For those of us with no idea, there is the ultrasound method of determining EDD.

When the doctor asked me my LMP, I told him I didn’t know. Actually it was October 30 (I know because I had one of the worst periods of my life and took two days off work sick as a dog, unable to get out of bed longer than the time it took to clean up every few hours.) I had been using the fertility awareness method and not only did I know my LMP, but I also knew our conception date – the only possible one within a week before my estimated ovulation date. All other “baby-dancing” days were well outside the possibility of fertility. Calculating my EDD based on what I knew about my cycle, I arrived at August 12.

Of course, my OB didn’t know any of this. He didn’t believe charting had any value. When I told him that I didn’t my LMP, he simply scheduled a dating ultrasound early first trimester. Dating ultrasounds require that an ultrasound technician measure different parts of the baby and compare those to established growth charts. Throughout pregnancy, these measurements can vary by at little as millimeters; you can guess how important it is that your ultrasound tech be a really good one.

Our early ultrasound measured my son to be due August 15, a due date that wasn’t humanly possible with the conception date we had. But a later due date is always better than an early one.

Some OBs don’t stop at that early ultrasound or LMP for determining EDD. They continue to change the EDD throughout the pregnancy based on further ultrasounds (and sometimes fundal height, but that’s a whole ‘nother ball game).

Ladies (and gents!), don’t let this happen to you! It is error and is not based on science in the least to continue to change the EDD.

Ultrasound dating, as I have mentioned, depends on technician skill as well as these growth charts. What we tend to forget is that 50% on a growth chart does not mean normal or perfect. It simply means that your child is larger than 49/50% of children, and smaller than 49/50%. 80% means you have a larger than average child, but not necessarily than anything is wrong, just as 30% or even 10% simply means you have a petite child. (The worry stems from not staying around your percentile as you age or suddenly increasing or decreasing as you age.)
At 32 weeks gestation, my son measured around 4 lbs 2 oz, or 80% and up on the growth chart. However, the ultrasound equipment registered this not at 80% for 32 weeks, but at 34 weeks gestation.

Fortunately, my OB didn’t change my EDD based on this late pregnancy ultrasound. I know women who have been in this situation though and did have their EDD changed. Their OBs didn’t account for the possibility their child would be larger (or smaller) than average.

Having a due date change can be a serious problem. Normal pregnancy, as by ACOG definition, can last from 38-42 weeks. Yes 42 weeks. However, in practice, due dates are set in the middle of this range at 40 weeks. You can still have a normal pregnancy and go past your “due date”; OBs’ own organization admits this.

Most women though aren’t “allowed” to do go past their EDD. Once they begin to approach their EDD, even if this was moved from a later estimate, the induction talk may begin. Women are more often than ever finding themselves against going into labor on their own before 40 weeks or facing induction at 40 weeks. (The number of inductions in the US has doubled since 1992.)

My suggestion: A due month (and arguing with your doctor if necessary). I plan on using the due month with my next pregnancy. The due month is a simple concept (I didn’t come up with it and I’m not sure who did). It’s based on that ACOG definition of normal pregnancy – 38 to 42 weeks. A four week period – your due month. For my son, my due date was August 12. I should have just said that he was coming “sometime in August.”

Believe me, using this method, even just with family and friends, is beneficial. Towards the end of a pregnancy, well-meaning family and friends begin to ask how long the doctor is going to “let you go.” As the EDD approaches, the questions change. “Isn’t he going to induce you?” “What’s happening? Is something wrong?”

Save yourself a wee-bit of anxiety (as much as possible at least) and give them just a ball-park, a taste.

“Oh, Junior? He’s coming when he’s ready, sometime end of April or mid-May. No worries.”