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Entries in birth activism (3)

Thursday
Apr142011

Lorell Bentley

A woman I adore. We have a lot lot lot in common and you'll see a lot more of her in the future.

Wednesday
Mar162011

Guest Post: Molly Remer on Hospital Routines

What to Expect When You Go to the Hospital for a Natural Childbirth

By Molly Remer, MSW, ICCE, CCCE

There is a fairly “normal” course of events for women having a natural birth in a hospital setting. In order to be truly prepared to give birth in the hospital, it is important to be prepared for “what to expect” there and to know how to deal with hospital procedures. All hospital procedures/routines can be refused, but this requires being informed, being strong, and really paying attention to what is happening. I hope this list of “what to expect” with help you talk with your medical care provider in advance about hospital routines and your own personal choices, as well as help prevent unpleasant surprises upon actually showing up in the birthing room. This list is modified from material found in the book Woman-Centered Pregnancy and Birth. I am not saying that is how your specific hospital operates, but that many American hospitals function in this manner.

  • Expect to have at least some separation from the person who brought you to the hospital, whether this separation is due to filling out admission paperwork, parking the car, giving a urine sample, being examined in triage, etc.
  • Expect to remove all your clothing and put on a hospital gown that ties in the back.
  • Expect to have staff talk over you, not to you, and to have many different people walk into your room whenever they want without your permission and without introducing themselves.
  • Expect to have your cervix examined by a nurse upon admission and approximately every hour thereafter. Sometimes you may have multiple vaginal exams per hour by more than one person.
  • Expect to have an IV inserted into your arm, or at minimum a saline lock (sometimes called a Hep lock).
  • Expect to be denied food and drink (at best, expect clear liquids or ice).
  • Expect to give a urine sample and perhaps a blood sample.
  • Expect to have an ID bracelet attached to your arm.
  • Expect to have to sign a consent form for birth and for application of a fetal monitor that states that your doctor will be responsible for making the decisions about your care (not you).
  • Expect to have a fetal heart rate monitor attached around your belly—two round discs on straps that will often stay with you continuously until you give birth (or, at best, for 15 minutes out of each hour of your labor).
  • Expect to have your water manually broken at about 4 centimeters (or at least, strongly suggested that you allow it to be broken). After this point, expect to be encouraged to have an electrode screwed into the baby’s scalp to measure the heartbeat and a tube placed in your uterus to measure your contractions.
  • Expect to be offered pain medications repeatedly.
  • Expect to receive Pitocin at some point during your labor–”to speed things up.”
  • Expect to be encouraged (or even ordered) to remain in your bed through much of labor, especially pushing.
  • Expect to either have your legs put in stirrups or held at a 90 degree angle at the hips.
  • Expect to be told you are not pushing correctly.
  • Expect to hold your baby on your chest for a few minutes, before it is taken away to be dried, warmed, and checked over.
  • Expect the baby to have antibiotic eye ointment put into its eyes (without telling you first).
  • Expect to have your baby suctioned repeatedly.
  • Expect to be given a shot of Pitocin to make your uterus contract and deliver the placenta.
  • Expect not to be shown the placenta.
  • Expect your baby to be given a vitamin K injection.

I think it is important to note that what you can expect is often different than what you deserve and that what you can expect often reduces or eliminates your chances of getting what you deserve. In my classes, I’ve made a conscious decision to present what women deserve in birth and though I also talk about what they can expect and how to work with that, I think sometimes they are left surprised that what they actually experience in the hospital. At minimum, what you deserve are Six Healthy Birth Practices (as articulated by Lamaze):

  1. Let Labor Begin on Its Own
  2. Walk, Move Around, and Change Positions Throughout Labor
  3. Bring a Loved One, Friend, or Doula for Continuous Support
  4. Avoid Interventions That Are Not Medically Necessary
  5. Avoid Giving Birth on the Back and Follow the Body’s Urges to Push
  6. Keep Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding

As an example of what I mean about what you can expect clashing with what you deserve, consider the second healthy birth practice “Walk, Move Around, and Change Positions Throughout Labor”—monitoring and IVs directly conflict with the smooth implementation of a practice based on freedom of movement throughout labor.

So, how do you work with or around these routine expectations and your desire for a natural birth?

  • Go through the above list of “what to expect” and make a decision about how to handle each one on a case by case—you may choose to actively refuse something, you may be okay with accepting certain procedures or routines, and you can develop a coping plan for how specifically to work with any particular issue.
  • Take independent childbirth classes and learn a variety of techniques and pain coping practices so that your “toolbox” for working with labor is well stocked.
  • Hire a doula, or bring a knowledgeable, helpful, experienced friend with you. It can help to have a strong advocate with you (this may or may not be a role your husband or partner is willing to take on).
  • Another tactic is to “never ask permission to do what you want, but to go ahead and do it unless the hospital staff actively stops you.” (An example of this is of getting up and walking around during labor)
  • Many people, if they can find no other way to get around a dangerous or unpleasant hospital policy, unobtrusively ignore it—a good example of this is with regard to eating and drinking during labor. Restricting birthing women to ice chips or clear liquids is not evidence-based care. Bring light foods and drinks and quietly partake as you please.
  • Leave the hospital early, rather than remaining the full length of stay post-birth. This can minimize separation from baby and other routines you may wish to avoid.
  • When you get the hospital, ask to have a nurse who likes natural birth couples. My experience is that there are some nurses like this in every hospital—she’ll want you for a patient and you’ll want her, ask who she is! If possible, ask your doctor, hospital staff, or office staff who the nurses are who like natural birth—then you’ll have names to ask for in advance.
  • Put a sign at eye level on the outside of your door saying, “I would like a natural birth. Please do not offer pain medications.” (It is much easier to get on with your birth if you don’t have someone popping in to ask when you’re “ready for your epidural!” every 20 minutes.)
  • Once in labor, stay home for a long time. Do not go to the hospital too early—the more labor you work through at home, the less interference you are likely to run into. When I say “a long time,” I mean that you’ve been having contractions for several hours, that they require your full attention, that you are no longer talking and laughing in between them, that you are using “coping measures” to work with them (like rocking, or swaying, or moaning, or humming), and that you feel like “it’s time” to go in.
  • Use the hospital bed as a tool, not as a place to lie down (see my How to Use a Hospital Bed without Lying Down handout)
  • If you feel like you “need a break” in the hospital, retreat to the bathroom. People tend to leave us alone in the bathroom and if you feel like you need some time to focus and regroup, you may find it there. Also, we know how to relax our muscles when sitting on the toilet, so spending some time there can actually help baby descend.
  • Use the “broken record” technique—if asked to lie down for monitoring, say “I prefer to remain sitting” and continue to reinforce that preference without elaborating or “arguing.”
  • During monitoring DO NOT lie down! Sit on the edge of the bed, sit on a birth ball near the bed, sit in a rocking chair or regular chair near the bed, kneel on the bed and rotate your hip during the monitoring—you can still be monitored while in an upright position (as long as you are located very close to the bed).
  • Bring a birth ball with you and use it—sit near the bed if you need to (can have an IV, be monitored, etc. while still sitting upright on the ball). Birth balls have many great uses for an active, comfortable birth!
  • When any type of routine intervention is suggested (or assumed) during pregnancy or labor, remember to use your “BRAIN”—ask about the Benefits, the Risks, the Alternatives, check in with your Intuition, what would happen if you did Nothing/or Now Decide.
  • Along those same lines, if an intervention is aggressively promoted while in the birth room, but it is not an emergency (let’s say a “long labor” and augmentation with Pitocin is suggested, you and baby are fine and you feel okay with labor proceeding as it is, knowing that use of Pitocin raises your chances of having further interventions, more painful contractions, or a cesarean), you can ask “Can you guarantee that this will not harm my baby? Can I have in writing that this intervention will not hurt my baby? Please show me the evidence behind this recommendation.”

I realize that some of these strategies may seem unnecessarily “defensive” and even possibly antagonistic—I wanted to offer a “buffet” of possibilities. Take what works for you and leave the rest! Great births are definitely possible, in any setting, and there are lots of things you can do to help make a great birth a reality.

Finally, and most importantly, “birth is not a time in a woman’s life when she should have to FIGHT for anything,” so if you find that you feel you are preparing yourself for “hospital self-defense” I encourage you to explore your options in birth places and care providers, rather than preparing for a “battle” and hoping for the best. If you feel like you are going to have to fight for your rights in birth, STRONGLY consider the implications of birthing in that setting. Also, as The Pink Kit says, “hope is not a plan”—so if you find yourself saying “I hope I can get what I want” it is time to take another, serious look at your plans and choices for your baby’s birth.

 Side bar: Here are additional suggestions of actions to take prior to hospital admission….

  • Choose your doctor carefully—don’t wait for “the next birth” to find a compatible caregiver. Don’t dismiss uneasiness with your present care provider. As Pam England says, “ask questions before your chile is roasted.” A key point is to pick a provider whose words and actions match (i.e. You ask, “how often do you do episiotomies?” The response, “only when necessary”—if “necessary” actually means 90% of the time, it is time to find a different doctor!). Also, if you don’t want surgery, don’t go to a surgeon (that perhaps means finding a family physician who attends births, rather than an OB, or, an OB with a low cesarean rate).
  • If there are multiple hospitals in your area, choose the one with the lowest cesarean rate (not the one with the nicest wallpaper or nicest postpartum meal). Hospitals—even those in the same town—vary widely on their policies and the things they “allow” (i.e. amount of separation of mother and baby following birth, guidelines on eating during labor, etc.)
  • Work on clear and assertive communication with your doctor and reinforce your preferences often—don’t just mention something once and assume s/he will remember. If you create a birth plan, have the doctor sign it and put it in your chart (then it is more like “doctor’s orders” than “wishes”). Do be aware that needing to do this indicates a certain lack of trust that may mean you are birthing in the wrong setting for you! Birth is not a time in a woman’s life when she should have to fight for anything! You deserve quality care that is based on your unique needs, your unique birthing, and your unique baby! Do not let a birth plan be a substitute for good communication.
  • Discuss in advance the type of nursing care you would like and request that your doctor put any modifications to the normal routines in your chart as “Doctor’s Orders” (if your doctor is unwilling to do so, seek a new medical care provider!)
  • Cultivate a climate of confidence in your life.
  • Use affirmations to help cultivate a positive, joyful, welcoming attitude.
  • Read good books and cultivate confidence and trust in your body, your baby, your inherent birth wisdom.
  • Take a good independent birth class (not a hospital based class).
  • Have your partner read a book like The Birth Partner, or Fathers at Birth, and practice the things in the book together. I frequently remind couples in my classes that “coping skills work best when they are integrated into your daily lives, not ‘dusted off’ for use during labor.”
  • Practice prenatal yoga—I love the Lamaze “Yoga for Your Pregnancy” DVD—specifically the short, 5-minute, “birthing room yoga” segment. I teach it to all of my birth class participants.
  • Learn relaxation techniques that you can use no matter what. I have a preference for active birth and movement based coping strategies, but relaxation and breath-based strategies cannot be taken away from you no matter what happens. The book Birthing from Within has lots of great breath-awareness strategies. I also have several good relaxation handouts and practice exercises that I am happy to email to people who would like them.
  • Before birth, research and ask questions when things are suggested to you (an example, having an NST [non-stress test] or gestational diabetes testing). A good place to review the evidence behind common forms of care during pregnancy, labor, and birth is at Childbirth Connection, where they have the full text of the book A Guide to Effective Care in Pregnancy and Childbirth available for free download (this contains a summary of all the research behind common forms of care during pregnancy, labor, and birth and whether the evidence supports or does not support those forms of care).
  • Ask for the blanket consent forms in advance and modify/initial them as needed—this way you are truly giving “informed consent,” not hurriedly signing anything and everything that is put in front of you because you are focused on birthing instead of signing.
  • If all your friends have to share is horror stories about how terrible birth was, don’t do what they did.
  • Look at ways in which you might be sabotaging yourself—ask yourself hard and honest questions (i.e. if you greatest fear is having a cesarean, why are you going to a doctor with a 50% cesarean rate? “Can’t switch doctors, etc.” are often excuses or easy ways out if you start to dig below the surface of your own beliefs. A great book to help you explore these kinds of beliefs and questions is Mother’s Intention: How Belief Shapes Birth by Kim Wildner. You might not always want to hear the answers, but it is a good idea to ask yourself difficult questions!
  • Believe you can do it and believe that you and your baby both deserve a beautiful, empowering, positive birth! 

Molly Remer, MSW, ICCE, CCCE is a certified birth educator, writer, and activist. She is a professor of Human Services, an LLL Leader, and editor of the Friends of Missouri Midwives newsletter. She has two wonderful sons, Lann (7) and Zander (4) and Alaina (2 months). She blogs about birth at Talk Birth, midwifery at Citizens for Midwifery, and miscarriage at Footprints on My Heart.

Friday
May232008

Random Stuff

1. My Tristan's band (he's the road manager), Ryan Bingham (and the Dead Horses), is on Late Night with Conan TONIGHT (scroll down to Friday's schedule to see Ryan's mention!). Please DVR it! Bands are usually on at the very, very end, so make sure your DVR is set for over the actual end time.

Ryan's band was also mentioned here when Reese Witherspoon and Jake Gyllenhaal attended a cocktail party for the band! How cool is that? They are touring at the moment, so I don't yet know if Tris was there.

2. Student Midwife - UK is gone. Her teachers found her blog and she was very scared about what she was going to do. Even though many of us encouraged her to keep writing, she is gone. I hope she comes back - even if totally privately - so we can continue reading her thoughts and experiences. Sad. Very, very sad.

It's really so hard, this blog stuff. At least for anyone that has a thought that might not be in the mainstream. So many of us birth bloggers turn our heads sideways to look at things through many different angles, exposing our considerations and concerns... and observations... and if someone isn't fond of what we say or if they feel they know better, they can skewer us. It isn't fun sometimes, but for most of us, writing is as vital as breathing and we take the smacks and slaps as a matter of course... yet we stand tall and firm. It's really sad when one of our own succumbs to the challenges... the pain. I do understand, but wish it wasn't so hard for everyone.

3. Kneelingwoman wrote one of the most amazing pieces I have ever read in a blog. Now that she has left midwifery behind, she is free to avoid much of what I mention above. There has to be something said for a lack of censorship. I look forward to that day.

In the Beginning, There Was Woman - Affirmation for My Sisters says so many important things, I beg of you to read the entire piece.

In part, she says:

- "Prior to the 1950's, it was highly unusual for mothers to spend the kind of time and attention now lavished on children and yet, for all the 'attachment parenting' going on in the last 20 years; the level of behavioral, emotional and social dysfunction in children has skyrocketed and more young women and mothers are on anti-depressant and anti-anxiety medications than at any time in the last two generations! The last time an entire demographic of mothers were, in large numbers, being prescribed psychiatric medications was back in the late 50's and 60's -- remember 'Mother's Little Helper?'

The idea that 'bonding' and 'attachment' are delicate, sensitive arrangements that happen only in ideal circumstances, or only with great difficulty if anything imposes on those precious, irreplaceable few hours after birth is nonsense."

- "Over the last 20 years, the 'natural parenting' movement that grew out of Midwifery has had the bewildering side effect of polarizing women against women and mothers against mothers. There is a definite generational divide, in my readership, between women older than 45 who may have opted for 'midwifery' attended birth in home or hospital/birth center, and who happily breastfed but who, for the most part, worked outside the home in some capacity, possibly homeschooled but in a very open, communitarian way; helping their children establish learning and social experiences across a broad spectrum of neighborhood and society. They maintained very active and diverse contacts within their respective communities and families.

The women who are 35 and under who are making the same basic parenting choices but seem, in large numbers, to have embraced a kind of moral and emotional zealotry that is essentially fundamentalist! There is a strict code for 'good mothering' that holds that homebirth, attended or unattended with the 'supermother' edge given to those who birth unassisted, extended breastfeeding, co sleeping, no separation of mother and baby for any reason at any time well into toddlerhood, and homeschooling that is far more isolationist, in terms of the broader culture, than what we embraced back in the late 80's and early 90's. The kids seem to spend most days alone, at home, with mom and the social contacts are limited largely to planned activities with other homeschooling families. There seem to be more issues with extended family over these choices and I think it may be because of what looks like a kind of 'separatist' nature to the lifestyle choices, as opposed to the more 'community' oriented goals of the earlier decades."

- "What I am finding increasingly disturbing is the viciousness of the attacks! The name calling! I honestly thought that once people were past, say, High School, the labeling and negating of someone by verbally assaulting them or questioning everything from their character to their sanity, just kind of went by the wayside but, on many of the blogs and forums; there is a veritable tsunami of ugly and cruel taunting, slurs and character assassination."

- "Robotically conforming to a predigested, limited palette of parenting choices out of fear of rejection by the same, computer-generated non-relationships permeating the ether is a form of self-neglecting and self-hate that no mother should model for her children; even if they are sitting on her lap breastfeeding while she does it!"

I have written before about the polarization in midwifery, how there isn't room to be realistic and hopeful at the same time... how you are either a gung-ho every-woman-can-birth-naturally proponent or you are (or I am!) a med-wife who sees trouble at every turn. I am baffled by the myopic views of many of my peers and it really doesn't help any of our clients to ignore the realm of possibilities, expected and unexpected, in birth. But, there is a midwife for everyone, even the most idealistic of us.

It's refreshing to hear another midwife speak of the curious behavior of women who profess to want their children to grow up utilizing the wide range of choices in the world, but only expect the "right" choices out of their friends and families. And surely, their children, too. I admit I am of the ilk that squirms and feels anxious thinking my own children might circumcise their sons, who might only nurse for a few months or who might put their babies in a crib in another room, but I have to trust that they will do what is right for their families - and know that I have instilled in them the importance of a baby's feelings and needs in infancy. I have to trust that I gave them everything I could (information, encouragement, knowledge, belief, etc.) while they grew up and now, releasing them, they will translate my "words" into their lives.

Why is it so hard to do that with those around us?

I used to be such a hard-ass about breastfeeding. Thinking I was sooooo progressive and understanding, when I was a La Leche League leader, I really was quite judgemental and, probably, not the kindest counselor a woman would come to. Back then, I really believed every woman could nurse - if she just tried hard enough. Women who couldn't weren't as committed as others (me!). Never mind the systemic yeast (that we didn't really know about back then), PCOS (which we didn't know about back then), thyroid issues (that none of us ever seemed to know about or remember), the bleeding and cracked nipples, the incorrect sucks, the influence of family and friends or inner issues that might seriously affect the nursing relationship; every woman could nurse.

In time, I worked with different cultures, mainly migrant Hispanics, and learned that it was a mark of affluence to bottlefeed - trying to get them to nurse was distasteful at best. They wanted to be Americans - and bottlefeeding came with that distinction.

The Mexican migrant women (and many other Hispanic cultures) who breastfeed also used bottles from day one, usually with te de manzanilla (chamomile tea) to help keep colic at bay. I remember trying, in vain, to get them to quit the tea, but pretty quickly realized my ethnocentric manipulations and shut up about it.

But what about nipple confusion? Weren't they going to cause nipple confusion by nursing and using bottles? Especially introducing bottles so darned early? Well, apparently, Hispanic babies don't get nipple confusion. That seems to be an Anglo problem. Why would that be? Expectations is my belief. If there isn't such a thing as nipple confusion, it doesn't happen. If we fret over the baby's sucking changing with the introduction of an artificial nipple, then maybe that is why they get wiggy about it.

I also began seeing women who'd been sexually abused who couldn't/wouldn't nurse - it was horrid to them. How could I begin to argue with that? I suppose I could have haughtily suggested they get mental health help, but most of them already had. I realized that, sometimes, the most empowering thing some women can do is to schedule a cesarean or bottlefeed their babies. Humbling for me, to say the least.

I've softened over the years. If women choose to have a Gestational Diabetes Screen, I help her do it in a comfortable way. If she chooses to have three sonos in her pregnancy, it's her thing. If she wants a 4-D, so what? If a woman considers an amniocentesis, my counseling style is much more relaxed than it used to be. If it makes her feel safer in her pregnancy, why not? If a woman chooses to have an epidural in the middle of her labor (and I can't think of a single case of that happening [yet] with me), so what? Why would I consider making her feel guilty about it. I'm not in her body! I'm glad to be a sounding board to disappointment afterwards, but would also really encourage acceptance of what was and an understanding of body dynamics (the baby included) and situational experiences. There is nothing gained in a woman feeling guilty/bad/sad about choices made with intelligence and feeling at anytime during pregnancy, birth or postpartum.

When it comes to health issues, that's a different story. I am particular in not taking women who smoke, who eat like crap and won't change or who participate in behaviors that can hurt her heart, body or mind without a plan to eliminate them. While it might seem like judgement calls, I am being hired to oversee the health, safety and life of two human beings and I can only do that with full participation, spiritually and physically, from the client who hires me.

Not nursing can have an affect on the child; I had one myself. But, with the many artificial milk alternatives available today - and the (expensive) alternative of obtaining breastmilk - I am not nearly as vociferous as I once was about women who choose not to nurse. I haven't had a midwifery client yet who didn't want to nurse - and would certainly explain the safety factors of nursing for the mom (often overlooked in the breastfeeding discussions) - but if she really didn't want to nurse, I'd be okay with that.

For me, the softening has come with maturity and time. I admire midwives who go with the flow (and there are plenty of them!). Some, however, are so tight in their dogma (including issues like physical autonomy, prenatal and postpartum tests, "normal" behaviors, etc.) they find delight in bashing women who have other ideas of what might work for them. It's so much sweeter to see midwives embrace the whole woman and her family instead of picking her apart, piece by piece.

See how many thoughts Kneelingwoman brings forth? Read her piece and then formulate your own thoughts about what she has to say.

4. On the heels of accepting women for where they are, comes an exhibit I would love to see come to America. The Exhibit on Multicultural Childbirth Rituals sounds absolutely fascinating! I know that, for me, the more I learn, the more I see I don't know. About loads of topics, including birth in different cultures.

5. ACNM is releasing the newest version of Life-Saving Skills Manual for Midwives in the fall. The manual is geared towards midwives in areas where supplies are extremely limited and, as a pocket-sized book, will be a great addition to any midwife's birth bag.

6. Possible Biological Explanation for C-Section-linked Allergies and Asthma Found - Yet another reason to shy away from unnecessary cesareans.

7. A 12 Pound Vaginal Birth! - Yeah, some shoulder issues, too. The midwife must have had her eyes bugging out as that baby was born.

That's it for the news of the moment.

Head off and read!

And don't forget to DVR or watch Conan tonight!