Empowering Birth Blog

Thoughts on blogging

This blog is a bit off topic but has been on my mind ever since the bruhaha on the neighborhood moms mail group to which I belong.  The scandal began when I posted this post on my local mail group and a mom who seemingly interpreted this post as an attack against epidural-users slammed me publicly on the site.  I had mixed feelings about starting a blog.  I was afraid of trolls and wasn't sure if I wanted to deal with people leaving attack comments on my blog.  I didn't want my posts being mis-interpreted. My good friend and fellow blogger helped me get over my fear (I need to toughen up, I know!) but lately I've been thinking a lot about virtual communities and the hostility and miscommunication they often engender.

I was reading the bloggers code of conduct, and wishing that all virtual communities would make some attempt at following these rules, specifically this one: We won't say anything online that we wouldn't say in person.  Interestingly enough the proposal of this code of ethics drew waves of protests from parts of the blogging community. The virtual group I visit most frequently is not just a virtual group, we are all parents and live in the same neighborhood.  And yet our group has a hard time following the bloggers code of conduct, particularly the suggestion not to say anything online that we wouldn't say in person.  What is it about the online medium that provokes us to respond with rapid-fire remarks, often not policing our content, misinterpreting another's words without first asking the author for clarification or emailing off-line?  Members of my virtual community often have little excuse for their attacks.  Many times the attackers know the posters and an email off-line would be the better approach (again, the suggested path via the bloggers code of conduct).  Certainly I have learned much from the discourse of my virtual/real community, primarily, to reflect carefully on what I post (a good lesson for me who has been too quick to post in the past).  On the web, however, it is much easier to misinterpret another person's blog.  We don't know that person and, unless we have been diligently following their blog, it is hard to understand the context within which they write. We might have missed a previous post that might be critical to understanding a future post.

I felt that Navelgazing Midiwife, whom I love, misinterpreted my post "Why Are Moms so Threatened" on her recent blog entry.   This post was a direct response to the attack I received in my online community to the post Doctors have much to learn from Midwives when it comes to induction, which was inspired by the difference between how the midwives handled the mom I was working with who was past her due date and how the doctors of neighborhood moms had handled the "problem" of a mom going past 40 weeks.  On the one hand (with the midwives), there was a wait and see scenario that didn't involve talk of induction until the mom was 41 weeks (and induction was not a given until 42 weeks) on the other hand the doctors mentioned the moms might have a big baby because they were past their due date and, in one case, told the mom horror stories of shoulder dystocia when the mom questioned the need to induce.  Navelgazing's midwife's post on my entries seem to suggest that I believe all babies must fit through the pelvis (I most certainly don't, although the percentage that won't is small indeed) and completely misunderstood my use of the term "big baby" (perhaps I should be more clear about my use of the term, I will clarify this in my post).  The lesson is, I suppose, that I need to be more clear in my posts and to remember there is a lot of background information that my readers don't have and that I sometimes assume they have.  But for the record, and for my readers, I would like to clear up some of the misinterpretations of my posts.

Navelgazing midwife asks me to respond to the following scenario:

"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."

My response "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" shocks Navelgazing Midwife.  Her response "Blinking, I wondered why she couldn’t develop a relationship with her client that fostered a belief in each other… one where if the midwife said, “There isn’t forward progress. We need to go in,” the client would say, “Let’s go.” One where no one is angry with anyone else."

The scenario described by Navelgazing Midwife is of course the ideal.  There is a reason I spoke of the scenario where the mom is angry at the midwife rather then one in which the midwife is trusted.  Here is the background information I did not supply: my midwife is currently under attack by two moms who are very angry with her care of them (yes, you can definitely argue she should not have taken them on and I understand Navelgazing's midwife fear of certain clients after my midwife's experience), so that is what is on my mind at the moment.  On another day/moment I might have given a different answer. 

As an aside, while I believe that you must fully trust your caregiver, the trust must be earned and moms must honestly assess whether or not they can trust their current care provider/practice to fully support your birth choices (the glaring example being docs who "say" they support VBACs but have a successful VBAC rate around 1%).  It isn't easy to question your caregiver, I know, I was there. While I am usually very good a pursuing what I want, when pregnant with my second, it was a friend who said "Kat, I am hearing you say you want a VBAC but the actions of your care providers and your desires for the birth suggest you will have a hard time having a VBAC in a hospital."  I switched to a CPM at about 7 months thanks to a friend who gently but persistently encouraged me to listen to my heart/follow my instincts.  And that is what I hope to encourage moms to do, not to give their trust blindly to a caregiver (who because of the large practices in the area, will probably not even attend their birth) but to seek out information, follow their heart, and find a caregiver/practice who will support them.

Finally, Navelgazing Midwife writes "In ignorance, for there is no other way to say it but this, Kat says that whenever a doctor or midwife speaks about induction because the baby is getting large, that that is a threat."  I feel that I must have miscommunicated here.  In the post in question, I was referring to the phenomenon I have observed lately of doctors routinely offering induction as a way of preventing the complications, such as shoulder dystocia, associated with truly big babies. I wrote:

"When an "expert" declares you need to induce because you are going to have a big baby he/she is making a threat, not a suggestion.  The threat is, if you don't induce, your baby will "be too big" and you may "tear", "baby may get stuck," etc. (this is what the doctors say to their clients, in reality there is nothing wrong with having a big baby). " 

I am referring specifically to doctors who suggest that induction is the solution to the big baby "problem," something that Henci Goer has found to be false.  If there was an error in my post, it was that I could have eliminated the phrase, "there is nothing wrong with having a big baby."  I didn't mean to imply that there aren't complications associated with a big baby but rather to send mom the message that their pelvises are indeed ample and in most cases, their baby will indeed fit (see Pelvises I have known and Loved*).  I think it completely unnecessary to scare clients with the threat of having a big baby and wrote rather passionately on the subject because I've heard too many stories lately from moms who have felt pressure to induce in order to avoid a "big baby." None-the-less, so as not to imply that I think ALL babies will fit (is anything ever absolute?), I updated my post to read "induction will not reduce the complications associated with a big baby" and included a link to an article by Henci Goer on the subject. 

I was encouraged that at the last birth I attended, the midwives made no mention of a big baby, even though we all thought that was exactly what we were going to have.  There was a point in the pushing phase where the midwives seemed to be a bit concerned about the shoulders but thankfully all went well.

Thanks Navelgazing Midwife for encouraging a lot of reflection.  I will try to be more clear in my posts and be careful of assuming background information.  Please ask me for clarifications readers when/where they are needed. I am a student and have much to learn. And thanks to my kids who were very, very patient as I was blogging today.  I owe you EXTRA quality time tomorrow!  You really are wonderful little beings.

•Thanks to Pregnancy Birth and Babies for leading me to this article.

More thoughts on Induction and GBS testing

In the spirit of furthering the dialogue, I wanted to share the below email sent by a midwife who tried to comment on my site but for some reason was unable to do so. 

I have attempted to subscribe to the Blogs and add my comments to you publication, no joy my computer will not link in.  might be telling me something!
Any way, if you think this is relevant perhaps you could add it?
1.  Induction of Labour:  There has been, is and will be great controversies  over this in the Uk.  Many of us remember the days of 'non' IOL, and 'Unexplained Stillbirths' over 42 weeks.  20-15 years ago, a long time for some people, but not in the history of childbirth.  we, the Health Proffesionals in the UK extended the length of pregnancy 42, 43, 44,+ weeks.  Partly do to 'people power'.  After increased fetal and maternal deaths, larger centres screened women over 41 weeks and found that in a majority of women over 42 weeks pregnant fetal compromise and maternal risk factors increased.
many UK facilities did not have the technology to enable them to offer indepth screening. (and still don't, we have referral centres, perhaps many miles away from home).
The general concensus was to offer IOL at 42 weeks, this recently has been altered by NICE (government body) to 41-42 week in un complicated pregnacies.
As some one who has seen different IOL practises over 40 years, I am aprehensive once the pregnancy reaches 42 weeks, for the health of mother and baby.  There is always the exception but I have seen too many sad parents who 'did their own thing and waited'.
2.  GBS, perhaps for a different aspect of Group B Strep visitors to the Blog/empowering................
would like to visit a UK parent lead web site........... www.gbss.co.uk   or www.gbss.com It will tel you how parents whose babies have died of GBS or have become ill through GBS feel about 'testing'.  You are fortunate in the USA at least if you know the mother is a carrier you have a choice whether to have antibiotics in labour and what to watch for in the baby up until 3 + months. gbss has motivated change and prevention in the UK.  Without their energy and committment more babies would be at risk and families suffering.
3.  being radical, I feel ALL pregnant women and their partner, if present, should be tested for any infection that could harm the baby.

Perhaps we sometimes overlook that the baby IS the innocence in 'Happy Families'!

                                     Yours Truly
                                    Anni Plummer.  midwife.

Re Anni's thoughts on GBS testing, my post on the subject suggests that the decision to test or not (in the absence of risk factors) is not as clear as it might seem.  Certainly testing seems warranted when risk factors are present.  When they are not, it is my opinion that whether or not to test should be the mom's decision.  I worry about the long-term consequences of the over-use of antibiotics.  Too often the solution can lead to a bigger problem.

In response to Anni's comments on induction, my biggest concern is with routine induction as well as how induction is often handled.  For example, induction appointments in my area are regularly made at the 40 week visit and the date is often picked in favor of the hospital's/doctor's schedule.  For example, the induction will be scheduled earlier to avoid a weekend or holiday induction.  I certainly do not believe that all moms should be allowed to go past 42 weeks but that care providers should assess baby and mom, perhaps scheduling a biophysical profile if warranted, and if signs are good, then care provider and mom should sit back, relax, and await labor.  Myles Textbook for midwives notes that perinatal mortality "is lowest at 40 weeks, and increases after 42 weeks, but that risk reduces with the use of modern methods of fetal monitoring.  Where the perinatal mortality and morbidity in post-term pregnancy are increased, this may be a result of labour or birth rather than antenatal events."1

As I understand it, some moms have longer gestation periods and induction is not warranted, for other moms, baby really is post-date and would fare better outside the womb rather then in.  And of course there is the problem of determining whether or not a baby really is post-date given that most moms don't know when they conceived and that Naegele's rule doesn't take into account the variations in calendar months etc. etc. etc.

1 Diane M. Fraser and Margaret A. Cooper, Myles Textbook for Midwives (London: Churchill Livingstone, 2003)532. 

Why are moms so threatened?*

So I posted yesterday's blog post on my neighborhood news group and it warranted a strong attack from a fellow mom.  Perhaps I should have added the below blurb at the top of my post.  This blurb is from a post on a pregnancy/birth blog about big babies**.

(this is not meant as medical advice, this is to remind moms everywhere that you have rights.... choose to use them!  Trust your body!  Choose care givers who trust your body!  Make educated decisions.  Care providers give you information... you have to decipher it and choose how to use it, ask questions, get answers you are satisfied with, if you aren't satisfied remember it is never to late to change to a new care provider or you can choose to just say NO!.) (http://www.pregnancybirthandbabies.com/Big_baby.htm)

I thought the above information was self-evident but I guess it isn't.  Why do moms feel so threatened when I provide them with information?  Why is a public attack necessary?  I know there are many more attacks around the corner given the line of work that I have chosen but I do not relish the thought.  What is wrong with helping women trust their bodies?  If women would rather not read my posts, they can delete them in their in box or choose not to visit my site.  My post was prompted by the sad reality that more and more women have been reaching out to me in my neighborhood informing me that their doctors bring up induction and the big baby worry.  In my mind, that is a threat.  When an "expert" declares you need to induce because you are going to have a big baby he/she is making a threat, not a suggestion.  The threat is, if you don't induce, your baby will "be too big" and you may "tear", "baby may get stuck," etc. (this is what the doctors say to their clients, in reality induction will not reduce complications associated with a big baby).  Moms are going to believe the doctor/expert.  You may have nagging doubts but in the end most moms seem to choose induction because "if the doctor is telling me I should be induced, I probably need to be induced."  My goal is to provide more information so that moms are encouraged to question their care rather than blindly accept the opinion of an expert.

In my first birth, when the doctor asked me if I was ready to have a cesarean, she did so after several comments along the lines of "you aren't bringing the baby down,"  "you aren't going to be able to birth this baby vaginally" etc.  I remember her placing her hand inside my vagina while I was pushing and her comments about the ineffectiveness of my pushing (those types of comments certainly don't help a mom push!!!).  Of course I consented to the cesarean.  Though the question was disguised as a choice, neither I nor my husband felt that we had been given a choice.  A doctor told me I couldn't birth my baby vaginally, I didn't know enough about birth to question her statement, so I agreed to go ahead and have a cesarean.  For at least a year after the birth I made a story up to myself about how I HAD to have a cesarean, that it was an emergency cesarean (it wasn't an emergency, I was given a "choice," after the doctor left the room the midwife offered that I could have the baby vaginally, though she couldn't "guarantee the condition of the baby" but after the strongly given opinion of the doctor, I couldn't really hear the midwife).  If you had suggested that perhaps my cesarean was unnecessary during that first year, I probably would have felt threatened, I may not have been ready to "hear" what you were trying to say, but I would like to think that I would not have attacked the messenger.

* I wrote a follow-up/clarification of this post entitled Thoughts On Blogging.

**Please note, I am not trying to imply that complications are not associated with big babies, I am well aware that there are, but rather that the oft proposed solution, induction, is not the answer.  I think it would be much more useful for care providers to tell their clients that their pelvises are ample and that most women will have no problem birthing a big baby.

Doctors have much to learn from Midwives when it comes to Induction

Too many moms have approached me about their doctor threatening induction lately.  I am currently supporting a mom who is past her "due date" and I have been struck at the difference in the management of her care (she is birthing at a birth center with midwives).  Instead of making comments about a big baby, the midwives affirm that all is well with mom and baby (more on the midwives' protocols follows below).  So here are more thoughts on the management of induction.

1. Best case scenario, induction shouldn't even be discussed unless there is a problem with health of baby/mom (in other words, if baby would fare better outside of the womb rather then in).  I would love to see more  doctors/midwives patiently wait for baby to come.

2. Since scenario number one isn't really an option in most areas of the U.S. unless you are having a home birth with a Certified Professional Midwife (and I am all for that!), here is a typical way induction is handled at a local birth center.  I think it is a good balance between waiting for baby to come and acknowledging the reality that birth centers are backed up by hospitals that have strict induction protocols that must be followed if they are to continue having hospital back-up.  I wonder why more OBs can't have a similar induction protocol....

• Around 41 weeks the midwives talk to mom about ways mom might get labor going (lots of walking, sex, spicy foods, evening primrose to soften the cervix, etc.)
• At 41 weeks and three days, they encourage mom to really work on the things that help get labor going (see above) often adding castor oil into the mix and your membranes can be stripped as well.
• At 41 weeks and 5 days, the midwives are obliged to discuss aggressive induction.  This might mean a foley bulb or breaking the bag of waters.  If your cervix is hard and not effaced, you will probably be scheduled for a hospital induction which means pitocin etc..  The reality is that baby needs to be delivered by 42 weeks in order to keep in good standing with the hospital.
• Generally NO VAGINAL EXAMS unless mom requests or to determine if cervix is ripe enough to do a birth center induction (close to 41 weeks and 5 days). 
• Bio-physical profiles and non-stress tests will be ordered as needed to ascertain that baby is doing well (and to prove to induction-happy hospital that baby is indeed doing just fine).

The above scenario is NOT how many doctors I know (or the doctors moms tell me about) handle induction.  At 40 weeks (instead of 41 weeks) they schedule your induction (which will usually happen by 41 weeks, 41 and a half if you are very lucky) and may use the threat of a big baby to silence the mom's questions.  End of story.  This is NOT the way to do things.  You and your baby deserve better.  Induction can increase  your cesarean risk by 50%-250% (Henci Goer)!  Please read this article on induction if you would like to know more: http://hencigoer.com/articles/elective_induction/.  And on the big baby note, please read this: http://parenting.ivillage.com/pregnancy/plabor/0,,8nbq-p,00.html.  Studies show that inducing big babies DOES NOT, repeat DOES NOT reduce cesarean, shoulder dystocia or birth injury (the complications associated with big babies, although many of these complications arise from birthing a big baby on your back with an epidural).  If you are having a big baby and want to reduce your risk, make sure you don't get an epidural, stay mobile, and be certain that your care-provider is comfortable delivering babies when mom is in an all fours position.

Moms who are being threatened with induction, my heart goes out to you, this is the LAST thing you need when you are about to have a baby, but have faith, your body knows how to give birth, your baby will come, and your body CAN birth a big baby, much depends on staying mobile and finding a good position.

One last note on induction....

I know I have been on an induction kick lately but it has been on my mind and I was up all night at a birth so no energy to write a new post....  So here we go....

In the Listening to Mothers II Survey, four out of ten (41%) of moms surveyed indicated that their caregiver tried to induce their labor.1  That is outrageous!  Unless mom and/or baby are not thriving there is absolutely no reason to be induced.  If you choose induction, please be aware that your risk of having a cesarean may double.  Lately I have had too many moms call me after an induction and share that they ended up having a cesarean.  It makes me angry that doctors scare mom/dad into an induction.  One mom told me that she had received two different opinions.  One doctor scared her into having an induction, the other one said baby was fine, not to worry.  Being an older mom with a concerned husband, the mom opted for induction and the story ended with a cesarean birth. 

Moms, if your doctor wants to induce, they should prove to you that an induction is warranted.  If there are no obvious reasons (true pre-eclampsia being a good reason to induce, for example) ask them to do a bio-physical profile.   If all looks good, for heaven's sake, please don't get induced.

Reflecting back on today's birth, it was another reminder why so many moms are induced.  When nature is left to take its course, birth can take a very very long time.  Hospitals don't have the staff/resources to let moms labor away for a couple of days.  They would rather mom come in and "get a little help," even if that "help" is a direct route to cesarean delivery.  Thankfully this empowered mom let baby come when baby was ready, and oh was it worth it!  Story to come later....

1 Eugene R. Declerq et. al. "Listening to Mothers II, Report of the Second National U.S. Survey of Women's Childbearing Experiences." Childbirth Connection, October 2006. http://www.childbirthconnection.org/article.asp?ClickedLink=205&ck=10068&area=2.

Considering Induction? Make sure you know your Bishop Score

A lot of moms considering induction are not familiar with the Bishop score.  (Umm, excuse me, will someone please tell me why doctors don't thoroughly discuss the Bishop score with their patients and the STRONG likely hood of a failed induction if the score is low.)

The elements that make up the Bishop score are determined by a vaginal exam.  It is generally believed that with a score less than nine, induction is likely to be unsuccessful so make sure you ask your doctor what happens when induction fails.  All of the failed induction stories I have heard lately have ended in a cesarean.  If I wanted to avoid a cesarean, I would make sure my Bishop score was super high!

Bishop score

Parameter\Score	0	1	2	3
Position (of uterus)	Posterior	Intermediate	Anterior	-
Consistency (of cervix)	Firm	Intermediate	Soft	-
Effacement (shortening/thinning of cervix)	0-30%	40-50%	60-70%	80%
Dilation	<1 cm	1-2 cm	2-4 cm	>4 cm
Fetal station	-3	-2	-1, 0	+1, +2

Be VERY Sure about your Due Date

Midwives call due dates estimated due dates and treat them as such.  It isn't always easy to calculate your due date.  We learn in sex ed that we have 28 day cycles and ovulate on day 14.  Right?  I tried to conceive for a year.  I tried every trick in the book. One day we had sex outside the "appropriate window" of time to conceive, and I became pregnant.  After looking back at my charts and temperatures, I realized I ovulate around day 19-21, not day 14.  No wonder it took us a year to get pregnant! 

And why is this so critical?  Because if your real due date is later then the due date calculated by your doctor, chances are you will end up with a premature baby.  At least in this part of the country you will.  I don't know about what things are like in your city but here, as you get close to your due date, doctors start talking about induction, and as you go past it, doctors ask you to get out your palm pilot and make room in your schedule for that special day.  Repeat after me, I DO NOT NEED TO BE INDUCED IF BABY AND I ARE FINE.  If your doctor is pushy (remember, he too learned about the 28 day cycle, I tried for a whole year using the wrong information and I consider myself a rather well-informed person, so he might need some help) ask him to do a bio-physical profile in order to assure your doctor (and you) that baby is fine.  Beg for the bio-physical profile if necessary and if everything comes out ok and your doctor still wants to induce, please refuse.  I have heard of too many inductions ending in cesareans.  Birth can be beautiful, amazing,empowering.  Starting labor off with an unnecessary induction can make it very hard to have an empowering birth.