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December 16, 2007

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EnjoyBirth

This is a question that I don't know the answer too. All I can think of is that they see doctors as God's who are all knowing and all powerful and to question them is wrong?

I actually once read an article in readers digest
http://www.rd.com/content/prevent-medical-errors/
which shows how even doctors are intimidated by other doctors. They are not immune from it.

I think it is also that moms are scared of childbirth and they see their OBs as someone to save them?

Carey

I just wanted to let you know that I really appreciate you doing the research and trying to help mom's be better informed about birth.

anonymous

Kat, I just wanted to thank you for continuing to disseminate evidenced-based information to women, even in the face of repeated criticism. It is such a shame that this type of information isn't provided by the "experts". Keep up the good work!

Navelgazing Midwife

So, I'm going to play Midwife Devil's Advocate.

You're the midwife and you have a woman pushing for a couple of hours and you do a vaginal exam, having the woman push through two or three contractions... you don't feel any forward movement. What do you say? "Great! Things are progressing nicely!" Do you not say anything at all? Or do you look at mom and tell her there is no progress and you should probably think of the next course of action.

There is NO WAY to never say to a woman, "I think something isn't right... it doesn't feel like the head is coming down." You do enough births, you learn, for a fact, that SOME BABIES DON'T FIT! It might be a fluke of positioning, but the baby just won't get through the pelvis alive unless a cesarean is done.

I think that too many post-cesarean moms are angry at the situation that occurred when there *really* wasn't any other course but surgery.

How does a care provider cope with this situation?

How will YOU work it out inside your head and heart as YOU have to tell a woman the baby isn't fitting?

Kat

I agree that sometimes the baby just won't fit and know that in the future a mom might be mad at me because of a hospital transfer I felt was necessary but which disrupted the moms plans for homebirth. I've been thinking a lot about control lately and how we "natural" birthing types can be as guilty of it as the medical community. While we might not always like to admit it, the reality is that of course some babies don't fit.

I believe that my cesarean birth, however, was a different story. When there was a bit of tachycardia, my midwife ask that I exit the birthing pool and move to the hospital bed where I was placed under continuous fetal monitoring. I lost my freedom of movement and was semi-reclined on my back, tethered to the bed. After a few strong contractions where the monitor lost the heart-rate (possibly due to shifting position of the baby?), the midwife panicked rolled me over to my side, and called the doctor. It was the point that the doctor entered the scene that things really began to change. My husband and I sensed conflict between the midwife who felt I could deliver vaginally and the doctor who was certain I couldn't (and of course all this was discussed in front of me and, being conditioned to trust the expert, I couldn't help but side slightly with the doctor). Instead of the baby and my body leading labor with my midwife observing, the doctor was closely managing the labor. There was a lot of fear in the air and I was no longer handling the labor as well. Given the concern about the heart-rate, the doctor ordered that I be hooked up to an internal monitor and was forced to push for over two hours, using the hold your breath and count to ten method which can't have been very good for baby. I was instructed to push with every contraction and I remember begging for a rest but soldiering on when the instruction
"PUSH" was delivered. After over two hours of pushing I was told that if I wanted the guarantee of a healthy baby, I should have a cesarean, and my doctor seemed annoyed I had been allowed to labor as long as I did (my midwife kept asking for more time).

Since my cesarean birth I have attended many births, including my own VBAC. At many points in my and other homebirth labors, I noted the difference between the management of my care during the first birth and how the other moms/my VBAC labor was managed, and felt that it was those differences that resulted in my cesarean. Interestingly enough I think there was some stress /disagreement between the doctors and the midwives at the hospital because shortly after my cesarean birth, the hospital kicked out the midwifery practice for monetary reasons and because the doctors wanted to focus on high-risk obstetrics (http://findarticles.com/p/articles/mi_qn4155/is_20030903/ai_n12515768).

When I was doing research as preparation for my VBAC, I actually called the hospital where I delivered, talked to the head labor and delivery nurse, and asked her to review my chart and comment on whether or not I was a good VBAC candidate. She expressed the belief that my cesarean was due to the fact that I was exhausted and the doctor felt I was unable to push the baby out. I should add that I had had nothing to eat since noon and had a difficult labor (very strong and long contractions very close together for most of the labor). By the time the cesarean was performed, I had not eaten or drunk anything besides ice chips for 15 hours. The nurse declared I was an excellent candidate for VBAC.

Would love to hear your thoughts on my story. Thanks for commenting!

Navelgazing Midwife

Before commenting on your story, I want to let you know I posted a piece piggy-backing off your post. It isn't pleasant, so be prepared. No personal offense meant, but some serious encouragement to *think hard* about what you say and to whom.

I want to also say that it is very apparent that your own birth experiences have colored your view of birth and the broad strokes sweep over all the other women with whom you are in contact. This isn't uncommon, but if you are going to be any good to your doula clients (or midwifery clients in the future), you'll need to outgrow this myopic viewpoint of everyone being The Enemy.

(I really am trying to say this lovingly and kindly, but it's hard to impart such important and *loud* beliefs and thoughts in a comment. I hope you will "see" me sitting with you over a cup of tea, my sharing many years of experience so you won't have to struggle through the painful experiences I did.)

It's easy playing Monday Morning Quarterback. It's easy for someone to listen to your story and second-guess everything. It's also fairly easy to read through your chart (which are notoriously inaccurate) and think that things should have been done differently. In most cases, women "should" try for a VBAC. What else would the nurse say?

But, in the moment of your birth experience, if everything is as you say (and I don't have your chart and we haven't talked beyond this post and your comments), there can be interpretation that your cesarean was absolutely warranted.

Tachy babies can be terrifying. Babies' heart rates that are above 170-180 can plummet down to zero in a split second. Did you know that? Sure, being in the tub can cause mom to be too hot and the baby's heart rate to go up... which is why you were taken out of the tub... to make sure it was the heat and not fetal distress or an infection. Your verbage of being "tethered" to the bed demonstrates your misunderstanding of how important it can be to HEAR that baby when tachychardia is occuring.

You complain about not having eaten, yet you know that that is part of the hospital experience. "You buy the hospital ticket, you go for the hospital ride."

It *does* suck when the doctor and midwife have conflict, but that is more common than not and there isn't much to do about it. Don't BE in the hospital where that conflict can occur and that's a start.

You speak about pushing for 2 hours and there not being any forward progress and the doctor AND midwife feeling the safety of the baby was important. If you were so tired that the doctor didn't think you had any more in you (and ONLY YOU know the truth to that statement and I *highly* encourage you to be honest with yourself about your feelings IN THAT MOMENT), your baby wasn't far behind. Babies are only as strong as their mothers.

I understand you wanted a rest - and perhaps a rest would have helped. Maybe not. Maybe when you rested, all contractions could have stopped and you would have needed more augmentation and it might have seriously compromised your baby. (See the "what-if's"?) Who's to know? How can a doctor gauge that? Wouldn't it be a wise thing for a doctor to do surgery on mom when the baby is still doing well? When the mom can be somewhat conscious for the surgery? The more exhausted the mom, the more dangerous the surgery is for both "patients."

But, again, you were in the hospital and hospitals just don't allow resting during second stage. It's part of the reality of hospital birthing. Anyone who reports differently is rare indeed.

I'm really sorry you had a hard time with your first birth, but, being philisophical from my vantage point, look how much you learned from it! You learned so much that you did things differently the second time. You became a doula. You help others not make the same blind choices you feel you made the first time. (I believe your choices were right on, but that's my belief just reading your story.) It's amazing what we learn with our kids, isn't it?

Broaden your vision of how birth can be for others... that it isn't just like yours was... allow women to have their births unfold, their stories to be written as they are happening and witness it all with a respect that *sometimes* we all need help. Whether a hand, a loving hug or a scalpel... sometimes we all need help.

Claire, Midwife

Just because you are in hospital does not mean that you eschew your human right to eat and drink. Just because you are in hospital does not mean that someone has the right to force you to lie on your back on a bed and be coerced into doing valsalva pushing (which we know is not only totally ineffective as it's contractions that do the work, not holding your breath!) but also is more damaging to babies. This has nothing to do with 'being in hospital', it has to do with the care system and those who attend births and their practice, which I would argue is outdated.

If a choice was given then it wasn't an emergency caesarean. If no effort to use optimal fetal positioning, hydration of the mother etc was used then there was poor management of the case. What women need is midwives and doctors who understand physiology and who work with it, not against it- then it's a lot easier to trust people when women really DO need help, becuase you're knowing they have no hidden agenda...

Kat

I don't consider myself an angry VBAC mom. I am very grateful for my cesarean because without it, I would never be on the path that I am on, and I cannot express the gratitude I feel for the journey that lead me here.
The somewhat defensive nature of this post came as a result of the fact that I was aggressively attacked by a mom on a neighborhood listserv. Many many moms came to my defense but I was left saddened (yes, I am a bit too sensitive!) and the attack led to the above post. Navelgazing midwife has a good point, moms do need to trust their caregivers, but trust must be earned. Does a 10 minute prenatal visit (standard in hospitals) warrant absolute trust? Shouldn't the mom be educated, ask questions, and search to find the provider that will help her have a better birth?
The problem with blogging is there is so much background information that is often missing, it is easy to take a post out of context, and there are SO many points of view. You could argue that by choosing a hospital, I agreed to their policies of not eating and drinking (but how many of us doulas sneak food in :-)), you could argue that I should not have been surprised by the conflict between the doctors and nurses, that I should have been at home in the first place, but making the leap to homebirth for a first birth can be hard. I am trying to help moms question their caregivers when their gut encourages them to do so so that birth is better in hospitals and at home. The moms in my neighborhood who reached out to me about big babies had "theoretical" big babies. In other words, going past 40 weeks equals big baby. One mom had a repeat ultrasound at my suggestion and the result was the discovery that the baby wasn't big at all, and she avoided induction. Another mom decided to say no the induction for the baby who was supposed to be 10 pounds and had a 6 pound baby. I should add that I live in the DC area, many of our hospitals have cesarean section rates close to 40%, our OB practices are large so there is often little chance to build a trusting relationship with a caregiver, and malpractice is a big problem (there is the joke that everyone in DC is either a lawyer, a recovering lawyer, or in law school). Which again leads me to the problem of blogging, with the attempt to be somewhat anonymously there is so much background information that is missing and it is harder to understand the community that influences the writer.
The main reason I switched to a homebirth for my VBAC is that I knew I could trust my provider. That is such a good feeling, a feeling all moms deserve but that not all moms have. My urge, that moms learn more about birth, that they interview their providers, not about their political parties, smile, but about whether or not they will have continuous fetal monitoring and who is responsible for that decision (etc. etc.). It is usually the system, not the doctors/midwives that are failing our moms. It is important for moms to understand that too or there won't be change, perhaps I haven't written enough about that part of the problem...
And finally, for the record, Khady's heart-rate did not go over 180, but you are right, it is very hard to figure out what happened after the fact. My understanding of the story needed to be that IF something had gone wrong with the first birth, it had been the system and NOT my body. Given different circumstances, it very well might have been my body. If I am transferred to the hospital for a cesarean with this pregnancy, I will have the luxury of knowing that the cesarean was indeed necessary, which of course brings us back to the importance of trusting your provider.
Please excuse the rambling nature of my reply. So many thoughts and I have a sick Fen on my lap, but wanted to get a few of them out there. Stay tuned for more thoughts on tomorrow's post.

Kat

I should add that beautiful hospital VBACs are very possible, the problem is that in the DC area, they just aren't very probable. Click here for the VBAC rates in Northern VA:http://icanofnova.org/articles/Cesarean_Rates.

Navelgazing Midwife

Claire,

You are right! It shouldn't be that way. But, if women want it to be a different way, then they *have* to find a provider (nee, a PRACTICE) that agrees with them in order to bypass "hospital policy."

I'm totally with you. I work HARD to help women have the best experience possible - and that includes what you and I would consider "normal" birthing, even in the hospital. If you haven't seen my montage yet of two natural births in the hospital, you can go see them here:

http://tinyurl.com/29n6rx

In my walk, I work hard to demonstrate to hospital personnel how it SHOULD be by being a support person for those that have to birth in the hospital for a variety of reasons. It's rare that the nurse in our room isn't transformed by my client's strength and power during her birth. If the hospital staff never sees anything different, they don't know that anything different is possible.

I do understand, Claire. And work right next to you to make things different.

Agatha

Kat, I think the real story behind your story (so to speak) is here when you write:

"...being conditioned to trust the expert, I couldn't help but side slightly with the doctor). "

So, when you were in labour, you saw your doctor as the 'expert' - & there is nothing wrong with that, but you sound like you feel in retrospect that you could have birthed that baby vaginally, & that you should have gone with your instincts. We'll never know how that could have turned out...

It's very interesting reading indeed!

Kat

Agatha,
I think you are definitely right and IF I had had a doula, things might have been very different (I am now a certified doula and very pro-doula) but I wouldn't change the current path I am on for anything and I probably wouldn't be on this path if not for that cesarean.
Thanks for your comment! A fellow student midwife finished her studies in the UK and is now in the U.S. figuring out how to practice here (CNM or CPM). According to her, it seems like people tend to be much more trusting of birth over your way.
Kat

Agatha

How fabulous that you know someone who is doing that - where can I get in touch with this woman?? That's pretty much my plan... once I qualify, IF I qualify!

I think the only reason that women here are so trusting of their bodies & births is because midwifery-led care is 'the norm' here - is is what women aspire to. But we have always had that really, at least in living memory. I think the US can change it's attitude towards birth - but it'll take a minimum of 3 generations.

I think things in the US are much more medicalised... have a friend in WI who was telling me about her antenatal appointments & told me she had a VE at EVERY appointment. WHY??? I attend births where a woman has never had one & never will... but i'm still just a 1st year, I mean, i've yet to catch a baby from a woman with an epidural, i've yet to get involved with a physiological 3rd stage!

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