Tuesday, August 17, 2010

Eight years ago today...

Eight years ago my first son was born. It was the single most life-altering event in my life: I became a mother, but I also became scarred and took the first step on my journey toward birth activism. I almost never share my c-section birth story. It is incomplete, it makes me cry (not in a good way), it doesn't even get to the good part: hearing my son's first cry and hearing the OB announce that he is a boy. But here it is:

Little Vincente, you are everything I could have asked for. My love for you is total and complete, and I know without a doubt I would lay down my life for you. Your every breath, every yawn, every cry, is a joy to me. When I see you smile, my heart could burst from the love I feel for you. This is your birth story.

I found out I was pregnant on December 1, 2001. Your dad was out picking up wings at Woody’s when I took the pregnancy test, and when I saw that it was positive, I was so happy I jumped around the bedroom for a while. I think your dad was a little surprised, but he was happy, too. The pregnancy was easy. I didn’t have morning sickness, didn’t have weird cravings, didn’t gain too much weight (even though I did get HUGE). Feeling you kicking and squirming inside me was one of the most incredible sensations I’ve ever had. I remember the first time you got the hiccups, and also how when you’d get them right before you were born I could watch my belly jump a little with each one. Toward the end we realized you were going to be a big baby, and also that you were stubborn and didn’t want to come out. Induction was scheduled for August 15, a week past your due date.

Your father and I had gone to birth classes and were planning on having a natural, intervention-free birth. Since I didn’t go into labor naturally, we knew we were going to have to modify that plan somewhat, but were still hoping to have an essentially natural birth. The night of the 15th, we went to the hospital and checked ourselves in. The nurses started cervical ripening at about 11 p.m., and within a couple hours I was starting to feel some mild contractions. Labor! I thought. By the morning of the 16th, I was established in a pretty good contraction pattern, and my doctor broke my water. That picked the contractions up even more, and the labor nurse said we might not have to start pitocin as long as I was making progress. My mom showed up with Gary, and both of them came into the labor room—this was after I had said I didn’t want anyone in the labor room except your father and my mom. The labor nurse helped out by having me get into the Jacuzzi for a while, and wow was that wonderful. Unfortunately it also seemed to slow down my contractions, and when I got back to the room we had to start pitocin. Once the drip was started, I had to be hooked up to the monitors all the time, so I was restricted to the area right around my bed. That wasn’t too bad at first. Contractions were just starting to get painful, but since I could still change position and move around I was able to deal with it pretty well. Then the downward spiral began. Your heart rate started dropping after contractions, which concerned the hospital staff (and us, too). I had stopped making progress, so the pitocin had to be increased, which made your heart rate drop even more. By about 2:00 Saturday afternoon, the only position you would tolerate was me lying on my left side. Since I was stuck in bed, I couldn’t do anything for myself to help control the pain. I was tired and scared and frustrated and hurting, and I felt kind of alone. The birth wasn’t going like I had hoped, and I still wasn’t any closer to actually giving birth. It seemed like an awful lot of pain for no progress, and I was questioning my resolve to go drug-free. At some point your dad’s mom and your uncle Carlos came into the room, and I found myself thinking “Good lord, could you just keep everybody the f*** out of here???” My mom and Gary left to get lunch, and it was shortly after that I hit the lowest point in my labor. Your father was watching football, eating potato chips, while I lay in bed behind him, hurting and wishing he would come hold my hand or touch my face or just look at me and tell me I was doing good (even though I felt like I was a total failure at that point). Of course I didn’t say anything. Then mom and Gary got back with lunch, and your dad got up and walked out of the room without so much as a backward glance in my direction. After about 30 seconds in the room, alone, I started crying and totally lost the last of my ability to deal with the pain of the contractions. My mom came back to sit with me while your dad ate his lunch (I wasn’t allowed to eat or drink through this whole ordeal), and she and the nurses both kept asking me why I was crying. I couldn’t tell them it was because I wanted my husband to comfort me. I don’t know why I couldn’t tell them that, but I just couldn’t. So I said it was part pain, part concern for the baby, and part disappointment that the labor was going so horribly. All of that was true, but all of it still wouldn’t have been as bad if I had had the support I wanted….. Anyway, sometime after lunch your dad and I kicked his mom out of the room so we could talk about whether I should get an epidural. We decided that since I couldn’t get out of bed or change positions to try to deal with the pain and help the labor along, it didn’t make sense for me to be in so much pain. The next time the nurse came in, I asked for the consent form, and after going to the bathroom one last time I signed it. After that, my contractions intensified again. I was still crying, and now I started puking my guts out, too. God, it was horrible. Mom and Tomas held the stupid kidney bowls for me, and I fruitlessly clutched the side rails of the bed, trying so hard not to lose the last little bit of control I had over myself. Oh, how I hated it. The anesthesiologist finally got to me, and your dad held me as the needle went into my back. Within minutes, there was no more pain and I felt like a different person. As much as I had wanted to avoid the epidural, I was so glad to have it. Your heart rate was still dropping, though, and now I had developed a fever, too. We had internal monitors, IV antibiotics, constant checks, catheter…. Pretty near every possible intervention. And still, I was no closer to giving birth.

It has been almost 8 years since I failed to finish Vince’s birth story, and in many ways I have forgotten how painful the experience was. Over the course of the night, my labor complications continued. Though I was at least somewhat able to rest after getting the epidural, my fever continued to be nonresponsive, Vince’s heart rate continued to be problematic, and I never dilated fully. After reaching a point where there was “just a lip” of cervix left, I swelled back down to 9 cm and at that point my OB said we should go in for a c-section. Vince was born at quarter to three on Saturday morning, big and healthy. I remember hearing his first cry, and crying myself. After the c-section, I spent the better part of a year unable to forgive myself for “failing” at labor and delivery.

Thursday, July 29, 2010

Are all cesareans necessary?

In a blog titled "The Myth of The Unnecessary Cesarean" Dr. Nicholoas Fogelson argues that while many cesareans may be preventable, it is impossible to truly call any specific c-section "unnecessary" because we don't know what would have happened had the surgery not been performed. There's some excellent discussion in the comments (and I can't tell you how great it was to see the doctor coming back and responding!), I posted the topic for discussion on BabyCenter's VBAC board, and the discussion has continued on other blogs as well. As you might imagine, many who feel strongly about the cesarean epidemic are taking Dr. Fogelson to task, saying he's missing the point and sometimes suggesting he is no different from any other scalpel-happy OB.

I beg to differ.

Don't get me wrong. I understand the necessity of questioning the reasons behind an unwanted cesarean. I understand needing to look back and find failure in the system that put you in the OR rather than finding failure in your body. I spent literally years trying to pin down how I really felt about my own c-section, and after almost 8 years I still have not been able to finish writing my birth story because by the time I've read what I do have written I'm an emotional wreck and just can't face it. And yet... when I read the responses to Dr. Fogelson's article, what strikes me is the defensiveness, the aggressiveness, the instinct to attack over a single turn of phrase rather than consider that perhaps we are trying to acheive the same goal with different words.

Words are powerful, and the way we talk about birth is important. I've been taken to task for using the word "normal" in my blog title, we talk about how discouraging it can be when we're told we'll be "allowed" to have a "trial" of labor, and I've even seen heated debates about whether or not a cesarean should rightly be called a birth at all. While the perspective offered by this OB may raise our hackles, I think it can be helpful if we sometimes lower our defenses and agree to speak the same language when we're talking about birthing options and outcomes.

Tuesday, July 6, 2010

Mainstreaming Midwifery- are OBs the answer?

I've been reading a little bit lately about the suspension, reinstatement, and subsequent resignation of a popular SoCal OB, Dr. Biter. There's an entire group dedicated to his saga, and I really enjoyed a blog The Navelgazing Midwife wrote about the situation. I don't know enough about the details to address Dr. Biter's situation directly, but it did get me thinking about how we view the hospital experience from a patient perspective vs our expectations of our providers in the same setting. I've seen OBs like Dr. Biter referred to as "a midwife in OB's clothing" and that concept brought me back to something I've been intending to write more about: the mainstreaming of the midwifery model of care.

Here's what I want to know: When women flock to OBs who support birth as a natural physiological process, why are they doing that? I've read that OBs whose practices are similar to the way midwives practice are often incredibly overbooked and women wait hours for their appointments. I've seen and heard members of the birth community rave about Dr. So-and-So who truly supports his patients, has fabulous bedside manner, and should be at the top of everyone's list when they are looking for a provider. I've listened to other moms talk about the kind of care they wish they'd received from their OBs, and even though that care sounds an awful lot like midwifery, most women- even the lowest-risk women- absolutely believe they require an OB's care to have a safe pregnancy.

What would maternity care look like if low-risk women were directed to midwifery care instead of being shoehorned into the only "good" OB practice available? What if those OBs worked with large midwifery groups, where low-risk women received care from midwives, secure in the knowledge that they'd have an incredible OB backing them up if they did become high-risk? What would it take to see true partnership between OBs and midwives in the US- similar to what seems to be the norm in many other countries? I understand that the relationship between obstetrics and midwifery in the US is complex (to say the least), but there clearly are OBs who are willing to buck the system. Could they be the answer to increasing midwifery care for low-risk women? Or is it unrealistic to expect any OB to tell a woman she's low-risk and doesn't need obstetric care for her pregnancy?

I don't have the answers to these questions but they are asked honestly. Women seem to want the kind of care midwives offer, but they want that care from an OB. Up next in my musings: why don't midwives have the kind of instinctive trust and respect we give OBs?

Sunday, June 13, 2010

Kegels, Fat Obstetrics, and Fear Factor

I just realized I haven't posted here in almost a month. A MONTH!! I've been diligently working on a post continuing my "mainstraming midwifery" thought process but I keep getting sidetracked. So, a couple random thoughts on recent things I've read:

Are you going to stop doing your Kegels? Apparently the concept that kegels don't work has been around for a while- a quick Google search turned up all kinds of information on how unnecessary and ineffective they are. I wonder, though, if we're tossing the baby with the bathwater? Even if Kegels are not the whole answer, comments I've seen are generally in the vein of "Great! I didn't like them anyway and now I can stop doing them!" Is doing nothing really going to be better than doing something? I'm not a physiologist. I don't know much at all about exercise and muscle-building, but I do know everything I've read about getting in shape suggests that balance is critical. I also believe that Kegels helped me personally, though I never did hundreds a day and I was doing a lot more than just Kegels. I'm going to be watching to see if any more information comes out about this, and in the meantime, I'll keep Kegeling like I always have.

The Navelgazing Midwife wrote a great blog about Fat Obstetrics. I was clinically obese prior to (and during) my first pregnancy, and no one ever said a word about the potential impact it had on complications. Even outside of pregnancy, I had only one care provider tell me my weight might be affecting me negatively. That was a company RN who was doing my annual physical; she told me my high blood pressure (consistently in the 140/90 range) could be due to my weight, and that if I made some simple changes (she suggested walking a mile a day) I could see big improvements in my health. I blew her off- my labs were fine, high blood pressure ran in my family, and I was healthy. Well, except for my recurrent rectal abscesses, which are typically seen in obese middle-aged men, but my doctor said that's just one of those things that happens. Nothing I could do about it, except get through my pregnancy and then have surgery to correct it. After my pregnancy, I decided to make a concerted effort to lose weight, and over the course of 7 years I lost about 50 pounds. I'm (barely) in normal weight range, my blood pressure is normal, and I never did have to have surgery for an abscess because they never came back. Okay, okay, I know anecdotes aren't that statistically useful, but I can tell you that I went from "healthy" to seeing big improvements in my health. I don't judge women who are still struggling with weight because I know it is a struggle, but I don't like the message that we're all medically the same regardless of our weight. Big women deserve respectful, quality care-- but quality care has to include an honest discussion about the impact our weight can have on our health even if we appear healthy. I think Barbara really nailed the issue in her post, and I highly recommend reading it!

Where does Fear Factor come in? Everywhere. I feel like everything I've read lately has been based on Fear. Fear of offending, fear of intervention, fear of losing control, fear of having too much control, fear of failure. Is it possible that we, collectively, are trying to circumvent the necessary processes of overcoming our fears? We seem to look for an easy answer- no more Kegels! Fat is Healthy!- wanting to find utopia without having to slog through the messy realities of change. And this brings me back to the post I'm trying to write about midwifery care and whether or not it's realistic for an OB who supports physiologic birth to work in a hospital setting. That will be coming soon!

Tuesday, May 25, 2010

Shouldn't it be about more than just pushing out a baby?

I'm not going to link to the birth stories I'm about to discuss because I want to respect the feelings of these moms. They are happy because they achieved something that seemed impossible: they VBACed! They VBACed against the odds- with an unsupportive doctor, or after being told they had to induce to avoid a big baby. They VBACed triumphantly: a big fat I-told-you-so to the establishment that told them they couldn't. They should be on a good strong high for a good long time- they deserve it, they DID IT, they proved they are capable.

And yet, my heart wrenches reading their stories. A woman told she had to induce because her baby was getting too big, a doctor who cuts an episiotomy that extends into a 3rd degree tear and significant internal damage, a mom whose blood pressure crashes and who passes out due to blood loss. Another woman with an unsupportive OB who tells her she better push her baby out in 10 minutes or she'll be cut open again- amazingly, mom is able to do it, but not without sustaining a 3rd-degree laceration in the process. Someone else whose epidural dose is upped right before she starts pushing, another 3rd degree tear.

Reading all these stories so recently, a part of me wonders if this is really better than the alternative RCS. Are OBs punishing women who choose VBAC, women who "force" the doctors to be on the L&D floor waiting for them to deliver, who increase the potential for a malpractice suit? Is there a subconscious bias encouraging OBs to think "She wanted to VBAC a huge baby, this is what she gets" as the scissors slice through the mother's perineum? (by the way, that baby was barely over 8 pounds...) Or, even scarier, is there a conscious thought process on the OB's part: "I told this woman I don't like vaginal births, period, so if she can't push this baby out in the time it would take me to get the OR prepped, I'm cutting her."

Or were these OBs going to be awful no matter what? Are these the OBs who talk about their dinner plans while performing RCS, completely forgetting that the mother and father are there for the birth of their baby? Would these doctors have asked the mothers to get their tubes tied as they were lying there on the operating table? Would they have lied, telling the mothers they were moments away from rupture, so they could add to their own perception of themselves as saviors?

Though I will never regret encouraging women to choose VBAC and pursue it even when the odds are stacked against them, my heart aches because the women whose stories I've read this week deserved so much more. They deserved support, respect, encouragement, so much more than the simple triumph of pushing their babies out. A long time ago I read a line about how our goal in promoting VBAC needs to be more than simply having babies come out of vaginas. These birth stories really brought that home for me, and made me realize once again the scope of what birth activists are up against.

Saturday, May 15, 2010

Prove me wrong!

Over the past few years, I've been trying to track down a source for a statistic that I am fairly sure doesn't exist. More and more frequently I am hearing from women who've been told the risk of uterine rupture in VBAC is the same as the risk of uterine rupture for a first-time mom, or for an induced first-time mom.

Listen, I am all about putting the risk of rupture into perspective, but just as I hate it when the risks of cesareans are understated or misrepresented, I can't tolerate the same thing from my own camp. Every single source I have been able to find shows rupture risk in VBAC many times higher than risk with an unscarred uterus, regardless of parity, induction of labor, etc. I can not find a single reference in literature to a study showing a 1/2% to 1% risk of rupture in a non-VBAC labor. All I find are dead ends, and data confirming that a uterine scar is the single biggest risk factor for rupture.

I've asked multiple people in multiple forums for a source substantiating this claim, and no one has ever been able to provide one. So I figured I'd ask here too: does anyone have a source that will prove me wrong?

Tuesday, May 11, 2010

Happy birthday to me!

About this time 37 years ago my mom was in labor with me. It was a Friday, and I was 10 days "late." Nobody had talked to her about induction, or how big I was going to be, or how dangerous it was to be pregnant for so long. Awesome, right? She was also required to have an epidural, be shaved, and have an episiotomy. Not so awesome.

I think it's interesting to contrast my own birth experiences with my mom's. So many things are better today, but many things are worse as well. Even as we have demanded- and to a certain extent received- the right to make our own decisions in the delivery room, we have stopped viewing pregnancy and birth as a normal and natural part of a woman's life.

Hopefully when my daughter is having her children, she'll get the best of both worlds.