Babies Behaving Badly

There are certain phrases that, every time you hear them, they make the hair on the back of your neck stand up on end. For some, it's "you're going to need a root canal procedure", for others it's "while we were changing your oil, we noticed a problem...". For me, it's "if your baby behaves".

If your baby behaves, we'll let you go ahead and deliver vaginally.
If your baby behaves, we will let you get off the monitor and walk around.
If your baby behaves, you can get in the birthing tub.

Let's forget for a minute how ridiculous a concept it is that an unborn child would "misbehave". It is just as ridiculous as the concept that a newborn baby, or any baby for that matter, would misbehave.

Birth is an active, interactive and dynamic process. It is not simply a matter of an object (the baby) being pushed through an opening (the birth canal). There are complex physiological, chemical and psychological processes involved in normal birth that we (health professionals, physicians, researches, midwives) don't even fully understand yet. When women are monitored continuously during birth through Electronic Fetal Monitoring, the baby's physiological responses to the processes of labor, active processes for both mother and baby, are picked up by the technology and converted into waveforms on a piece of paper. This technology has been repeatedly shown through clinical research to bring NO IMPROVEMENT to outcomes (maternal and fetal well-being, absence of birth-related brain injury, and mortality rates for both mother and baby). What it does provide is a minute-by-minute record of every heartbeat the baby experiences throughout labor if someone is sued by someone else after the birth occurs. That's it. That's the role that continuous electronic fetal monitoring plays in a normal vaginal birth that is not altered by intervention. I do not know a physician who would not admit this. It is not a secret.

When you start adding interventions to the mix, which you are likely to do if you are having a baby in the hospital, the monitoring technology plays an additional role. It watches how your baby reacts to the interventions (as most babies do because the intervention represents a change in the normal process in which the baby is designed to participate) so that attendants can remedy issues with additional interventions.
Your blood pressure drops from an epidural and your baby receives less oxygen, causing a change in heartrate pattern. You get supplemental oxygen and more I.V. fluid.
Your baby's cord appears to be compressed by the weight of his body after your membranes are artificially ruptured at 4cm's, you are told to turn over to the other side.
Your baby's heartbeat slows with stronger-than-natural contractions as a result of Pitocin admministration, your dose is titrated.

Of course, this monitoring technology draws a picture as opposed to opening a window. We don't REALLY know how your baby is doing, but we have some clues offered by the technology. The technology, like many things done to women under the medical model of childbirth and unlike MOST (non-obstetrical)healthcare technologies, was actually widely applied before much research was done on its accuracy, safety and efficacy. As a result, the guidelines for interpretation of the printouts have evolved over the past couple of decades and some practitioners have failed to keep up with the new standards. This means that the person reading your fetal monitoring strip and making decisions about your care has as much influence on what happens to you during your labor as what your baby does or does not "do" during your labor.

And Im explaining all of this so that, hopefully, you will understand what bothers me so much about the phrase "if your baby behaves".

Most of this is not adequately explained to most of the women who undergo this type of monitoring during their labor. I would venture to say that in many cases, none of it is explained. The fact that we can't make a diagnosis based on the strip. The fact that the technology has not been shown to improve outcomes. The fact that the processes represented on the strip are not fully understood. The fact that the only thing we can say based on a strip is that we are or are not reassured about the status of your baby.

Now, I know my readers are of above-average intelligence, but really, did anything I just said in the above four sentences befuddle and confuse you? Were you able to appreciate the meaning of the words I just put together to convey a concept?
Granted, you are probably not reading this while in labor anticipating the birth of your baby and your entire life changing in the course of about a day.
But, still. You understood me, right?
So, why then, is it that instead of explaining to women, say, when they are pregnant and NOT in labor, the way that this technology works, its strengths, shortcomings and implications, we instead approach adult women and their adult partners and utter the words "Your baby is not behaving. Do as I say now." or "Your baby is not behaving. We are going to have to do a cesarean."

Even without taking into account the well-documented shortcomings of the technology being relied upon, even without taking into account the desire to not get sued as a motivator, even taking into account all the reasons, founded or not, fact-based or fear-based, that women undergo continuous fetal monitoring during hospital labors, the crux of my issue with this phraseology is that it offers a glimpse into the crux of one of the biggest problems with the medical model of childbirth as it is routinely applied to low-risk, normal pregnancies.

That problem is that it does not respect the basic rights of women.

If you walked into the ICU to find your mother or your father intubated and on a ventilator and asked the physician or nurse "What happened?" and they replied to you "He was not behaving so we had to apply these interventions", would you be satisfied with this answer? Would you say "Okay, doctor, whatever you think is best."? If you took your newborn to the emergency room for signs of dehydration and you were told "She is not behaving, she needs I.V. fluid." would the conversation stop there?

It's almost laughable, isn't it?

And yet this is the kind of information women are given about their babies during labor.
"The baby does not like the pitocin. She is not behaving."
"Your baby doesn't like when you lay on the left side. Turn over."
"The baby is just not cooperating with your induction. You tried, but you are going to need a c-section."
Laughable? Or insulting?
Laughable? Or misogynistic?
Laughable? Or failure to gain informed consent?
Laughable? Or denial of the right to self-determination and refusal of treatment?

Every time Ive heard this phrase uttered, I have waited for the woman who calls out the offending person. I have waited for the person who says "You are going to have to give me more information" or "I think I can understand the concepts at play here if you would please take the time to explain them to me."

Why don't they?

Because they have been trained for nine months or more that their role in birth is to passively accept what is done to them in order to secure the ultimate, best-case outcome of a "healthy mother and a healthy baby".

The bar is lowered and the rules are strongly implied. And women follow them. Giving up their rights. Their power. Their birth.

A compelling reason to choose care under the midwifery model if at all possible, or at the very least to choose your medical birth attendant with extreme, thoughtful care.

If women consistently demand a practitioner/patient relationship that is respectful and cooperative in nature, I believe that practitioners will respond. Under this new dynamic, the practitioners will be able to give better care to more empowered patients and everyone will have a better birth experience.

Why the ACOG's new VBAC guidelines don't matter. There. I said it.

I am not one of those people who loves to deliver bad news. Nor do I especially enjoy raining on somoene else's parade. Believe me, Im no Debbie Downer.
That's why I struggle to write what I am about to write. I don't want to say what I have to say. And yet, I feel I have to say it.

I should preface this post by admitting my prejudice against and, to some degree, cynicism about the American College of Obstetricians and Gynecologists. Anyone who has read anything historical about birth in America can probaby guess why. For those who have not, I can only say that there have been in the history of women's health care in this country a series of smear campaigns launced by obstetricians against midwives. Wildy successful campaigns. The kind of campaigns that only lots and lots of money can buy. So, when I read that the ACOG has revised its guidelines regarding vaginal birth after cesarean (VBAC), I can't say I breathed a huge sigh of relief and thanked the heavens that they have finally come around.

I seriously doubt that they have come around.

What I think, rather, is that there has been a major shift in attitude toward birth in America in the past few years, thanks, in part, to Ricki Lake's documentary The Business of Being Born, but also because women have been spreading the word amongst themselves that birth is not something we have to take lying down. I believe that this has had an impact on the profit margins of the members of the ACOG and that these new guidelines have more to do with convicing women that they can trust their OB and they are not going to be railroaded into a medicalized birth just because they had a cesarean birth previous to this pregnancy.
Much like the guided hospital tour that features cozy birthing rooms that you may only use if we decide you are low-risk enough to not deliver in the sterile operating room "just in case" and whirlpool tubs that are almost never used because the stars have to be aligned just so with staffing just right and your baby's monitor strip looking a certain way in order for us to feel it's safe for you to be in water, I believe that these guidelines are one more way that physicians and hospitals are attempting to manipulate women into a false sense of security over having their babies at their facility.

And if this sounds super cynical, it's probably because the few years I have spent learning about the medical model of childbirth have given birth to a super cynic.

As in many cases, I think an anecdote might best explain to you why I don't believe these new guidelines mean a damn thing.

Sometimes RNs from one unit "float" to another maternity floor in a hospital, so nurses not only have a chance to work with women who are in labor but also women who are trying NOT to go into labor as well as women who have just recently had their babies. While one nurse I know in a nearby hospital was floating on the postpartum unit, she encountered a woman at the end of the hall who was recovering from her second cesarean section.

She was a chatty one, so my friend got to hear her story. It made her cry.

First of all, she was one of the many women living under the impression that her first cesarean section was performed in order to save her baby's life. She believes that everything was going along just fine (as it was) when suddenly "the baby's heartbeat dropped and they had to do an emergency c-section". Never mind that she had time to get a spinal and a bikini cut. The baby's life was in danger and she had to have an Emergency Cesarean. She's so grateful to her doctor. He saved her baby.

Now, I was not present at her first delivery. Nor have I seen her medical chart. I will tell you right now, up front, that I have no idea what happened at her birth. But I've seen enough cesarean sections to know that we leave the impression with just about every woman that if we had waiting a minute longer, her baby was going to die.

She explained that she was "all set to try a VBAC this time". "My doctor told me all along that I was a good candidate for a VBAC and we really wanted to try. But then I went into labor and we got to the hospital and they asked us to sign that consent."

At this point in my friend's story, I knew which consent she was referring to. The VBAC consent. "We do so few VBACs that I actually only read it one night when it was slow and I stumbled upon it in a file drawer." my friend explained. "I was appalled." She said it read as if you were being asked to participate in some kind of unproven, experimental and highly dangerous act.

Now you might think, well, yeah, there are risks to every procedure and women have a right to know about them. And you would be right in thinking this. This document, however, looked nothing like the consents people sign when they are coming in for a regular labor and deliver, or even a planned section.

The first thing one would noticed about the consent was the font. It was several sizes larger than on the cesarean consent. Risks were indented and enumerated. Words like rupture and death to fetus and mother jumped out at the reader.

But let me remind you that a natural (without inducing agents) VBAC is safer than a cesarean section. This was not mentioned. It also was not mentioned that if this woman chose a repeat c-section, she risked damage to her uterus that might prevent her from having a normally implanted pregnancy in the future. Nor did it mention that cesarean sections also carry serious risks to mother and baby, as I said before, to a slightly greater degree than VBAC.

This nurse continued: "I remember looking at it and thinking 'There's no way Id have a VBAC if this was the only information I had about it'."

And that's what this mom she was now caring for said, too.

"We looked at the paper and we just thought. Woah. This is too risky."

They asked their nurse for her advice. And...this is the real clincher... here is what the nurse said, according to this woman, whom I believe had no reason to lie to my friend:

"Well, if it was me... I think that a one percent chance of dying might as well be a hundred percent chance. It's just too risky."

Forget the facts. Im offering you my fear-based opinion, instead. It's what I do.

And so, the woman said, "That did it for us."

Now, Im not suggesting this nurse had some kind of agenda. Or even if she did have an agenda that she herself knew it existed. But I want to know: Is this nurse offering this same advice to women who undergo the major abdominal surgery known as a cesarean section? I highly doubt it. Here is someone who apparently knows nothing about the relative risks of the two types of birth, offering "advice" to a frightened couple that is based on nothing but her own fear.

And she is not the only one. I have heard of a trusted physician, when asked about vaginal delivery of twins, tell a patient that the cesarean is a sure thing, but with the VBAC "you just don't know" because "we can't control it." (Never mind that trying to control vaginal birth is what obstetricians do.)

I have heard of nurses commenting "what time should we open the OR" when report is given including a woman who is attempting VBAC. They don't even call it VBAC in most hospitals today. They call it TOLAC. Trial of Labor After Cesarean. In other words, "We'll let you try it, honey, but meanwhile Im going to be scrubbing in the back."

I have heard of an attending physician who approached a woman whose baby was fine, but who unfortunately did not successfully produce a baby vaginally (after cesarean) in the alloted time and say "You tried, but now I think it's time for your section."

Your section. You know, the one we've had waiting for you.

Maybe Im Jaded. But it's not because I'd rather be.

The ACOG's new guidelines don't mean a damn thing because something very important has not changed: The medical model of childbirth does not assume that we should trust birth. Many obstetricians and labor and delivery nurses (probably the majority, but I can't prove it) don't trust birth. And as a result, women are not being given the support they need during prenatal care and labor to successfully VBAC.

And that is why The New Guidelines don't mean anything.

Oh sure, they look good on paper. But as long as fear and control dictate the course of labor for women who opt for obstetrical "management" in-hospital, they don't mean squat.

And no, you can't squat, either. It's not safe.

Inch by Inch, Row by Row...

Having grown up in Baltimore, I remember thinking my mother was absolutely insane for enjoying gardening. I mean, really. Middle of June and already in the 90's at ten a.m. and you're going to spend the morning on your hands and knees pulling up weeds?
And then, I moved to Western NY, lived on the top of a big hill in the Middle of Nowhere, met some really awesome, wonderful organic-growing kinda people and feel in love with dirt.
I spent most of my life believing I was not a gardener, but it turns out, I am.

I have also spent most of my life feeling like the people around me just did not get me. And, ultimately, when "blame" for this was assigned, I always assigned it to myself. Something was wrong with me. There was always something... just... not... quite... well, you know.
While I am certain that everything I have seen and done during my adult life has come together in small increments to finally help me reach a place where I can embrace me and my quirky world-view that seems so at odds with most "mainstream" folk Ive met in my life, I also can safely say that if I had to choose one precise moment when everything came together and crystalized into clarity, for me it would be the moment my daughter was born.

For me, it all came down to power. My belief that I was weak. My knee-jerk response of pushing down of my power the moment it reared its head. My willingness to give up my power in exchange for love.

Had I chosen to give birth to her in a hospital, Im not sure that moment would have held the same weight as it did. That is not to say that the way *I* did it is better than the way someone else did. But, it was definitely the best way for *me*. Let me just say, for the record, that it hurt. A lot. I thought there was no way it would be as horrible as the Pitocin birth I experienced with my son, but it was. It was frightening. Had I been in a hospital, I am certain that I would have succumbed to my fear and pain and gotten an epidural.

A midwife with whom I work says that she believes that women get the labor and birth that they need. For whatever reasons the Universe holds, the labor they experience is a gift. I believe that I needed my second labor to be as painful as the first so that I would find my power. In the midst of the fear and pain, I learned that I could do a really really hard thing. Mary's birth was not what I would describe as serene. Or particularly gentle. What I would say about it is that it was powerful. I was powerful.

I discovered my power, hidden for so long beneath the layers of self-doubt and fear. Beneath the by-products of just-wanting-to-be-loved-no-matter-the-cost. And once my power was revealed to me, turning back was simply not an option.

Everything changed.

I have spent most of my life believing that I am too selfish to be a truly good person, too weak to make a sacrifice that really matters. I was never doing enough. Never giving enough. Always expecting that someone else would have sacrificed more. And then I became a parent and I learned exactly how far I was willing and able to go for the benefit of my children.

Im intent upon spending the rest of this life believing what is true about myself. And that is:

I am a powerful woman. I am a giving person. Things grow in my care.

And here's a little bit of tangible proof. My first Real Garden. One where things actually grow. It feeds me. It fills me with delight.
.

My gorgeous, happy children. I give to them and they grow. They feed me. They fill me with delight.

Suffer the Children

Early this morning, I was saddened upon reading this email from a friend of mine who is a nursing mom. She sent it to me because the hospital where this happened to her is the hospital where I have worked in the past. I have changed the name of the hospital to protect, well, myself, for one, and to some extent the hospital, as this woman's attitude and actions do not reflect the philosophy of the hospital or the culture that it purports to value... and I have removed my friend's name and number from the end of the letter.

The letter went like this:

...Last night, I took my 4 year old son to the emergency room at X Hospital in X, NY. I was breastfeeding my 2 week old newborn while registering my son, when the woman at the desk in the ER asked me if she could get me a blanket to cover up. I told her no thanks, I am comfortable and I have a blanket for my baby already and she's comfortable. She continued on, saying (and I'm paraphrasing), no, I mean to cover up while you're doing that. I said no, I am not uncomfortable nursing in public. She continued on, being quite pushy, saying that "it is a children's hospital, and there are children around" and they shouldn't see what I am doing. She repeated this statement a few times, getting very pushy. She continued to strongly insinuate that I was going to do the other children harm in the waiting room if I nursed my infant there and they happened to look.

I told her that she had no legal claim, and that in NYS I have every right to nurse my baby wherever I am, and I do not have to cover up. She actually said to me that I could nurse my baby, but the law says that I have to cover up, and she would get me a blanket.
I couldn't believe it! At a hopsital that says they support breastfeeding in the ER!

I told her that she was wrong, that the law in NYS does not say that, and that I will not cover the baby's head up while she is nursing. I told her that I could not believe that she was giving me grief for feeding my baby, and here I was trying to bring my son into the hospital for a head injury, and that I was not going to continue to have this conversation with her.

I walked away disgusted into the waiting room. What should I do to be sure that this NEVER happens to another mom and baby there? Can you be of some help?
Thanks

Ive read this scenario over a few times now. There are, as you can imagine, many things about this scenario that are just plain wrong. Right there on the surface. You really dont have to dig. Giving the benefit of the doubt to everyone involved, employee, mother and even corporation, it is at the very least an example of the ignorance that pervades this part of the world regarding breastfeeding, its normalcy and a woman's right to do so wherever she is legally allowed to be.

That, in and of itself, on a day when the stars are aligned just so, is enough to make me, well, angry.

But upon further consideration, I think the thing about this woman's response to a nursing mother that really makes me feel sad (and angry!) is the idea that she actually believes that the sight of a woman breastfeeding is something from which she needs to protect the children. Im not sure if her arrogance or her ignorance offend me more.

Children all over this planet, in industrialized nations and third-world countries grow up accepting breastfeeding as a part of everyday life. And those children do not require therapy secondary to PTSD from seeing a baby at the breast. Why is that? Because breastfeeding is Normal. Not sexual. Not perverse. Not exhibitionist. Normal. For insert-your-deity-here's sake, it's the way were are made to nourish and be nourished.

I really started to get angry when I thought about the environment in the E.D.. The culture, if you will, that this woman was trying to protect. There is a large flatscreen television in the E.D. that, at least every time I walked past, was perpetually tuned to SpongeBob Squarepants. This is a television show that I won't even allow my ten year-old to watch. Why? Because it is an adult show that masquerades as a children's program. Complete with adult humor, gratuitous violence, adult situations, loads of sarcasm, disrespect and veiled adult (sexual) references. Were I to take my children to the E.D. at this hospital, I would most likely have to find a seat away from the television. No seat, however, is out of earshot. So, like those who were exposed against their will to the sight of my friend nursing her daughter, I would be forced, along with my children, to consume this television program.
I believe that there is a lot more about SpongeBob Squarepants that warrants protection of our children than the sight of a woman feeding her baby.
What does this say about our values at X Hospital in X, NY?

Who's putting a blanket over SpongeBob?

I say that half tongue-in-cheek, but... truly.
What do we value that we are so willing to plop our children in front of animated innuendo for hours and hours but are frightened into a frenzy at the prospect of them seeing a partially exposed breast performing exactly as nature intended it to perform?
From what are we protecting our children?

Thinkin' bout home-born baby birth stories

Today, Ian will be playing at Seamus's house after a much-too-long time spent in different states. Kinda got me thinkin about Seamus being a home-born baby too. And, although I have never heard his mom's complete birth story, I have heard bits and pieces that equal enough to know a few things.
There was no threatening that if she did not do x y or z, her baby would be in grave danger and possibly die.
There was not a single time when anyone put his or her gloved hand up inside Chrissy's vagina and broke her water while saying "I'm going to break your water now" without discussion, consent or warning.
There was nobody who took her baby from Chrissy before she was ready.
Nobody tried to talk to her about an epidural, even though she clearly state she did not want an epidural, "Just in case you change your mind later".
And Seamus came out of Chrissy's womb, after whatever number of hours passed, without the benefit of forceps or a vacuum device or surgery and he lives these eleven years minus-one-day to tell about it.
And Chrissy gets to own her birth and tell her story without any mention of fetal distress or emergency procedures.
Not because she was lucky.
Because when you sit on your hands and let birth do its thing, far far fewer unexpected issues present themselves. When you educate your client for nine months prior to the event, when they are schooled in nutrition and REALLY what to expect and they take responsibility for their birth with you as their partner and guide but NOT as their boss or their savior, women can give birth. Most of the time, without your "help".

So, what's it gonna take...

What's it gonna take to get me writing on this thing again, anyway?
Oh it's not for lack of ideas. Ive got plenty. I think it's more like for lack of a moment when some small hands are not pulling mine away from the keyboard while some Big-Brotherly eyes are not watching every keystroke I make from a computer at a large corporate health care facility that shall remain, at least in theory, nameless.
I think this morning's journey to new depths with regard to "Conversations about how scary and dangerous birth really is" among my esteemed colleagues is just the ticket/inspiration Ive been hoping to find.
And the timing, truly, could not be better. Right on the heels of my just-now-published article on Water Birth in PG Magazine and what has been described as a beautiful, calm waterbirth at a hospital, attended by my friend Shannon, comes a thoroughly disturbing, but sadly, not surprising conversation among Mother-Baby nurses aka Nursery Nurses this morning.
I am not employing hyperbole when I say that there was a general disdain for the very concept of water birth happening at our hospital among a number of staff members, while others simply felt there was a lack of communication about what they were to expect and what was expected of them at these births.
Thankfully, I was employing my new "I am not a member of this tribe. I will never be accepted by this tribe. I am merely here, temporarily, to learn from this tribe." Self-talk Techniqure for Sanity Maintenance in the Ethically Mismatched Workplace.
So, what Im trying to say is that, for the most part, I remained calm, unemotional, and kept my mouth shut.
Yes, I kept my mouth shut while a secretary described how deep her distaste for "that woman" (one of the midwives who delivers at home and has priviledges at my hospital) and her belief that people who want "that kind of birth" should stay home and "let their baby die". Yes, those were her words.
Let.Your.Baby.Die.
Cause, you know, statistically speaking, natural, hands-off homebirth is so must riskier than being in the hospital. Oh, no wait, that's the OPPOSITE of the truth.
But how would she know the truth about birth? Why would she need to know the truth when she's got fear. Fear and a loud voice. All ya need.

And what's it gonna take to get my big ol behind back in school so I don't have to share oxygen with people who spout this kind of hate-talk?
Well, maybe it's going to take a new state law that radically alters the way midwives can practice in New York and pretty much opens the door for a gal like me to set up a safe, ethical, progressive and supportive birth services practice for the women of Chautauqua County and their families without the permission of some physicians who may see me as a threat and a dangerous woman in general.
What? We have that now?
Sweet.

I guess I should take my New Mantra, my newfound tongue-holding ability, my inspiration to keep on blogging, my tuition reimbursement and my dangerous ideas and get to steppin, then. Im pretty much thinking Ive got what it is going to take.