Jaundice: another risk of pitocin

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Jaundice is the yellowish tint caused by elevated levels of bilirubin in the blood. Bilirubin is produced when the body breaks down old blood cells, and is processed by the liver for elimination through the bowel.  A small amount of jaundice is normal in newborns, usually peaking about the 2nd-4th day and disappearing entirely by 2 weeks or so as the baby’s liver becomes effectively able to process the bilirubin.  In more severe cases, the baby turns a bright golden color on the face and extending over the body.

Severe jaundice can come from anything that requires the red blood cells to be replaced – injury during a difficult birth, for example, or infection or illness.  It can also come from medications such as Pitocin, synthetic oxytocin given to the mother during labor to speed up or strengthen her contractions.

Pitocin carries a host of risks, from uterine rupture and postpartum hemorrhage in mom to increased heart rate, seizures, and brain damage in baby.  A risk that often pales in comparison, but is still incredibly important, is the negative effect Pitocin-related jaundice has on breastfeeding.

A jaundiced baby is normally very, very sleepy.  Too sleepy, in fact, to eat or do much of anything besides nap.  A certain amount of napping is normal in newborns, but these rest periods are interspersed with periods of alert observation and clusters of feedings.  A jaundiced baby just sleeps and sleeps.  Common advice to undress the baby, tickle the toes, etc, to wake him up for feeding just doesn’t work.

Add to this the treatment for jaundice: baby sleeping under and on special lights designed to help break down the bilirubin.  Because baby isn’t sleeping next to his food source, he isn’t stimulated to wake and feed by the smell of mom’s milk.  Because mom doesn’t have baby rooting at the breast as often as if he were skin-to-skin, her supply doesn’t increase as much.

The end result: Baby doesn’t gain weight, mom is frustrated, and all too often the advice to supplement with formula is the beginning of the end of the breastfeeding relationship.  Mom feels like a failure for not being able to breastfeed, baby misses out, and no one benefits except the formula company.

Unfortunately most moms in the hospital are given Pitocin as a routine intervention, even if labor started naturally as it’s supposed to.  It’s no coincidence that many moms struggle to establish breastfeeding even when they are supported by family and friends and have access to board-certified lactation consultants.  When given Pit, many moms don’t know to question this (or any other) intervention, or to ask how this might have an effect on their ability to normatively feed their babies.

We all want every birth to end in healthy mom and healthy baby.  But birth is so much more than just that!  How you give birth matters.  Routine interventions (meaning those that are done to most women as a matter of course and not because they are specifically needed by a specific woman) can affect you, your baby, and your sanity.

I urge you to question interventions that are offered to you.  Ask what the risks and benefits are.  Ask what the alternatives are.  Ask what would happen if you did nothing and instead let nature take its course.  And ask yourself: Is this right for me?  Is it necessary? Will this intervention put me in a place I want to be, or will it ultimately lead to more frustration down the road?  Once you work through your decision-making process, one of two things will happen:  either you’ll say, “No, we really don’t want to do that.  But we’ll let you know if we change our minds.”, OR you’ll realize that you really do need the intervention and then you can accept it with confidence, and with an advance plan to handle the side effects as they come.

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Schedule your private class now!

In 2013,  I will be resuming regular group classes.  (Schedule coming soon.)  Accordingly, my rates for private childbirth classes will increase to $300 beginning 01 January 2013.  If you’re interested in a private class, schedule before the end of the year to take advantage of the current rate which is $250 and includes a goody bag, class materials, and a fun and active workshop that will give you the tools you need to cope with labor.

Spots are filling up quickly so be sure to reserve your class time early!

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How dilated are you?

“Relieved” by RoadFun, Flickr, Creative Commons license

A question universally shared by women near term is, “Am I about to go into labor?” And, in American obstetric culture at least, a nearly universal practice is the weekly pelvic exam, in which the cervix is examined for signs of dilation, effacement, position, and consistency that might indicate labor is near.  Have you ever thought about this intervention, why it’s done, what it’s for, and whether it’s right for you and your baby?

In examining the evidence, there appears to be a correlation between vaginal exams and premature rupture of membranes.  Practically speaking, once the membranes are ruptured, most care providers are going to insist on induction within 24 hours to prevent maternal infection – infections that are directly caused by digital exams.  Many of these cases could be prevented by not doing vaginal exams after the rupture of membranes, or in fact, at all.  (Interestingly, this does not hold true for monogamous sexual intercourse, perhaps because the partner’s normal bacteria are already present and controlled by the immune system.)  Additionally, there are concerns that the introduction of a gloved finger into the vagina can sweep harmful bacteria such as Group B Strep into the birth canal where it can contact the baby during birth.

Having a pelvic exam can also be uncomfortable.  Many mothers feel crampy and tender afterwards.  Due to the cervix’s many blood vessels, which can be easily ruptured by pressure, some mothers experience spotting which can then lead to unnecessary worry and stress.

I’m going to stick my neck out here and say that the routine practice of weekly cervical checks is not beneficial to mothers. It doesn’t predict when labor will begin and in most cases serves only to make mothers anxious.  Imagine the following scenarios:

You are 38 weeks and at your weekly appointment, you are told that your cervix is about 3 cm.  The dr also mentioned something else about your cervix but in your excitement you forget what she said.  You expect you’ll be in labor any minute now!  You rush home, double-check your birth bag, and call your mother to share the good news.  Your doula says not to panic, that over half of women don’t go into labor naturally until 41 weeks or after, and that many women stay slightly dilated for several weeks, but to call if anything starts happening.  A few days go by, and nothing happens.  Over the weekend, you are at home without work to distract you from the fact that you still aren’t in labor.  All you can think about is that you had expected to be holding your baby by now.  Then at your next weekly appointment, you mention that you are very frustrated with still being pregnant.  Your dr offers to induce labor.  This seems like a great idea!  However, you didn’t know to ask about your Bishop score and now that you’ve been induced, your cervix isn’t dilating quickly enough.  The pain of the Pitocin-induced contractions was too much to handle and you requested an epidural.  Now you’re confined to bed and your dr says that your baby isn’t tolerating the Pitocin well, so you’re going to need a cesarean section.

Or what about this:  You have your weekly check and are told that your cervix is 1cm dilated, in an intermediate position and about 25% effaced.  You are also told that the baby is -3 station.  That night, you feel a trickle of fluid.  Maybe this is it!  The next day, you still aren’t feeling any contractions, but you have had a constant trickle of fluid all day.  By the third day, you begin to be worried, so you call your care provider.  They are very concerned and ask you to come in.  Upon arrival at the hospital, they check you and you’re still at 1 cm.  You are told your membranes have ruptured and that they’d like to keep you overnight for observation.  You are told to lie flat in the bed, and you receive many internal exams as well as an ultrasound “to be sure there is enough fluid left”.  By the next day, you have begun to run a fever and you don’t feel well.  It looks like you’ve gotten an infection and will need antibiotics and an induction. The nurse says as she’s prepping you for induction, “It’s a good thing you were here when this infection started or your baby could have been in serious danger!”  You remember from your childbirth class that cord prolapse is a very real risk of AROM and induction when the baby’s head is still high in the pelvis, and now you are worried.  Should you have done something differently?

These scenarios are hypothetical but all too common.  Having cervical checks doesn’t guarantee a c-section (if it did, our national c/s rate would be much higher than 35%) but for many mothers, the weekly exam is the first step in a long list of cascading interventions that end in harm to themselves or their baby, or a type of birth that was unwanted.

For the low-risk mother carrying a low-risk baby, it is healthiest to avoid any intervention that provides little or no benefit but increases risk.  Cervical checks are no exception.  I recommend to my students and clients that they think about refusing weekly checks unless their dr can offer a very compelling reason to do them – something better than, “We just want to see how you’re progressing.”   Confident mothers know that they will go into labor when they and their baby are ready, and not a moment before.  Cervical checks can be reassuring, but they are not a crystal ball by which we can see the future of our births.  So it’s best when they’re used appropriately and not routinely.

Now, how to avoid the weekly check? Easy! As I learned in my childbirth classes when I was pregnant, you can just say, “I think I’ll skip the exam this week.” Or, if you know the check is the only thing they’re going to do at your appointment, cancel it. Your dr is not going to be sitting at dinner that night wondering why you didn’t come in for your vag exam, I promise you.  In the end, being an informed parent will help you to birth safely and with confidence, in the way that is right for you.

References:

Lenahan, JP Jr., Relationship of antepartum pelvic examinations to premature rupture of the membranes. Journal Obstetrics Gynecology 1984, Jan:63(1):33-37.

Kurki, Dr. Tapio and Dr. Olavi Ylikorkala.  “Coitus during Pregnancy is not
Related to Bacterial Vaginosis or Preterm Birth.”  Am J Obstet Gynecol  169
(5) November 1993: 1130-4.

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Baggage and birth – an opinion post

On a personal note, there are things about being a doula and CBE that make me uncomfortable.  The biggest is the issue of money.  I am very, very uncomfortable when it comes to asking for payment.  Although I firmly believe that doulas are the best thing to happen to childbirth since, well, midwives, I find it hard to quote someone a price for my work.  Same for my birth prep classes.  I understand that what I do has immense value to parents-to-be.  I know that with every doula client and every Lamaze student, I put hours and hours of work into preparing to help them have their ideal birth.  I spend many, many hours educating myself on every facet of birth in hopes of learning the one obscure nugget of truth that can make the difference to someone who is struggling.  My clients and students always, always praise me to the skies.  Most say that they couldn’t have done it without me.    All of this has value.  And I firmly believe that the laborer is worthy of his hire – in a more earthly quote, “I do the work, I get paid.”  Easy.

But still.

When I’m talking with a mom or a couple about how I can help her achieve her birth goals, and the conversation comes around to my fee, I can feel myself becoming physically agitated.  Tense forehead, stiff back, jittery feet.  Is it the idea that a lady does not discuss money?  Or is it that I love what I do, and believe in it so much, that I believe every woman is entitled to care like mine and therefore I feel weird asking for payment?

This, like birth, requires introspection.  We all carry baggage when it comes to life, and to the creation of life.

Maybe we’ve seen too many dramatic births on TV. Maybe we carry baggage about our bodies – our culture is steeped in the message that we are all too fat, our breasts are too small (or too large), our genitals are disgusting and require special vaginal washes or frequent pantyliner changes or whatever just so we can leave the house without embarrassment. Maybe we’ve heard too many birth horror stories from family members, friends, and strangers in the grocery store who can’t resist scaring pregnant women.

Much of our birth baggage starts in our early lives, before we ever think about becoming parents.  As teenagers, our friends all call their periods “the curse”.  We see scantily-clad women and get mixed messages about what breasts are really for.  We’re told we need yearly gynecological visits starting in puberty to “be sure everything’s still normal” – as if our bodies are so fragile that they might break at any moment without careful monitoring.

In an attempt to make us “good girls”, we are not given good education about our bodies and how they work.  Once we become adults and sexually active, we still don’t know as much as we should.  Maybe our partners are circumcised, which in turn causes their keratinized glans to remove our natural lubrication, and without knowing any better we feel it’s our fault for not being “wet enough”.  Maybe we have difficulty reaching orgasm, or feel weird about our thighs, or sex hurts in some way and we don’t know why but are embarrassed to find out so we just accept the notion that it’s our fault.

All of this can erode a woman’s confidence in her body and her ability to give birth.  This emotional baggage can pop up in the most inconvenient way – when a woman is at her strongest and most fragile during labor. – with potentially disastrous results. But there are ways to get some confidence back.  The first and most important is education.  By learning exactly how our bodies work, and how to help instead of hinder those natural processes, we can increase our confidence that our bodies are working as they were designed to do.

Another is to confront head-on our scary issues.  Maybe this means having a sweaty conversation with our partner.  Maybe it means acknowledging that we have some trauma in our past that isn’t our fault.  Maybe it means understanding that we have made bad choices in the past (in prior births, for example), and that we must admit the mistake and go on to do better next time.  And almost always, it requires a change of attitude and a change of action.

So what does this mean for me?   I resolve, the next time I give a quote, to look the other person in the eye, smile confidently, and name my fee knowing that it is both reasonable and still somehow not enough for the valuable work I do.  After all, it’s only baggage.  I can learn to put it down and walk away.

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How to get what you want in the hospital

Most of the parents-to-be who hire me do so because they desire a normal childbirth but want to avoid as much of the discomfort as possible.  Only slightly second to that is the desire to have a normal birth in the hospital despite hospital policies and procedures that often run counter to a physiological birth.  A doula can help with that – by helping parents voice their desires and advocate for themselves, by providing information, and by suggesting alternatives to offered interventions.

Right after my mother became ill, I wrote a list of ideas for working with the rehab staff for maximizing her recovery.  It occurred to me that these could be adapted to hospital birth as well.  What do you think of the following list?

  • Be firm but polite.  No need to put people on the defense, but it is important to convey an attitude of confidence and also that you are convinced that a solution will be reached.
  • Say what you want.  Don’t say, “I don’t like the dr, blah blah, complain, complain, I’m mad.”  Say, “I’d like intermittent auscultation, not continuous monitoring.” Or, “We prefer to skip the bath and eye ointment.” Leave your emotions out of it.  No one cares how you feel, they just want to reach a solution and get on with the rest of their day, so get to the point.  (Nicely.)
  • Explain yourself.  Say, “It looks to me like this is what’s happening.  Does it seem that way to you?”
  • Ask and ye shall receive.  Don’t just complain or sit in your room and stew.  If you need something, ask.  “We’d like to labor in the tub for a while.”
  • Use a facility that fits the level of care you need.  A low-risk mother and baby do not need a hospital with a tertiary NICU, high c-section rate, or anything else that indicates a high-technology birth.  Use such a facility and it’s likely that you will end up with a higher-technology birth whether you need one or not.
  • Request a room that fits the level of care that you need.  Likewise, if you and your baby are low-risk, request a room with a tub, birth ball, birth stool, rope, TENS,  telemetry units, etc.  A low-risk mother can and should use water, movement, and other non-pharmaceutical pain relief methods offered in some hospitals, as well as intermittent auscultation or other monitoring that allows freedom of movement.
  • Make them feel like collaborating with you.  Say, “What can we do to solve this problem?”  When people view your problem as a shared problem, they are more motivated to find a solution.
  • Go up the chain of command.  Don’t be afraid to say, “Can I speak to your supervisor about this?”
  • Ask for the written policy.  This especially works if you are told, “We can’t.”  Often you hear, “I can’t” when what they really mean is, “I won’t” or “I’m not allowed to offer this to you.”
  • Make a new friend.  Get the name and phone number of someone that can help you with problems as they arise.  Become this person’s best buddy.  Call them as needed, remind them of your name and, if you are not the patient, who your loved one is.  Make it a point to speak to them if you see them in the hall.  Don’t let them forget you.  Be the squeaky wheel.
  • Listen.  When you have your health and your baby’s health on the line, it’s easy to get freaked out about every situation that arises, and then miss crucial information. Take a deep breath, and really think about what the other person is saying.  Not only will you hear something you need to know, but you are showing respect for the other person and hopefully gaining an ally.  You like for people to listen when you talk, right?  Remind yourself that you’re not exempt from treating others nicely just because you are having a baby.
  • Educate yourself.  No one is going to chase you down to tell you the hospital’s policies and that the staff will laugh at you behind your back because your birth plan is 6 pages longer than it needs to be.  A hospital birth class is sometimes a “how to be a good patient” class in disguise, but it does provide valuable information about how you can expect to be treated at that facility.  So does the free hospital orientation. Go to it.  If nothing else you will get an idea of what is/is not provided so you know what to pack in your birth bag.  And it should go without saying, but every parent should take a comprehensive childbirth education course like mine.  The more you understand about your baby, your body, and the process of birth, the better equipped you will be to work with your body and not against it.  Even if you’re planning to get an epidural or aren’t sure about the mythical “natural birth” – you still need to understand what you’re about to do.
  • Get some fresh air.  Most hospitals have some sort of outdoor area – a courtyard, balcony, or such – where patients can go.  (Not a smoking area though – you don’t want to be breathing secondhand smoke!)  Sometimes parents get bored or start feeling “stalled-out, stuck in their room for 12 hours.  So start walking!  For healthy, low-risk moms, a change of scenery, some fresh air, and a good walk (taken at mom’s pace and accompanied by her partner or other support person) can be just the thing for a healthy labor.
  • Ask for more time.  No, not a longer hospital stay. Ask for more time if an intervention is offered and you’re unsure about it.  You don’t have to give an answer on the spot.  Say, “We’ll call you when we decide.”  or, “Can you give us about 15 minutes alone to make a decision?”
  • Ask for less time.  Your baby is born, everyone is healthy.  Hooray!  There is no reason to stay  a full 24 or 48 hours if you don’t want to.  The showers are scary, people barge in whenever they feel like it, and Dad is sleeping on a pink plastic chair while you are uncomfortably battling postpartum sweating and chills in a room where you can’t control the thermostat.  If you are tired of being in the hospital, tell them that you’d like to get the pediatrician to discharge your baby as soon as possible so you can go home.
  • Get help if you need it.  If something isn’t right or you are unsure whether it’s normal, speak up.  Sometimes (especially if the birth was difficult) it can take a couple of visits from a lactation consultant to get breastfeeding right.  Get the help you need.  The resources are there if you seek them out.

Any more to add?  Leave a comment and tell me how you were able to get the birth you want in a hospital setting.

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Group B Strep and IV antibiotics during labor

**Spoiler alert**  The Cochrane Collaboration finds that IV antibiotics during labor for GBS is not evidence-based.

While researching a different topic, I realized that I rarely address Group B Strep in my classes.

Group B Strep is a bacteria that can colonize people of any gender or age with no symptoms.  It generally lives in the urethra, vagina, or rectum.  It can be introduced into the vagina by vaginal exams, wiping back to front, or other seemingly-innocuous behavior.  Whether a woman tests positive or negative at the 36-week mark is often a matter of chance (whether the naturally-fluctuating bacterial levels are higher or lower on the day of the test) and test results at 36 weeks can be the opposite of test results taken at onset of labor.

As with any offered test, it’s an important topic and not a decision to be taken lightly. Moms considering this test should ask themselves what they would do with every possible result.  For a positive result, if the caregiver is an OB/GYN, the typical course of treatment is to give IV antibiotics starting at onset of labor.

Absent IV antibiotics, around 1 in 200, or 0.05% of babies will have complications from GBS.  This drops to 1 in 4000 with the IV antibiotics. Possible complications range from pneumonia to meningitis and can very rarely be severe causing death.  In contrast, risks of IV antibiotics can include:

  • allergic reaction
  • thrush (yeast infection of baby’s mouth and mom’s nipples)
  • severe bacterial infection (MRSA, c difficile, e coli infection)
  • antibiotic resistance

Other risks of IV therapy are less tangible but equally powerful.  When a laboring woman is put on an IV, she is generally confined to a bed.  She then becomes, not a woman in the process of becoming a mother, but a “patient”.  She can’t move around, so her pain level increases drastically.  The birth becomes longer and harder.  Other interventions are more likely.  The psychological effects on her labor can be devastating.  It is to every laboring woman’s benefit to avoid any intervention that keeps her unable to labor normally, and IVs are no exception.

The Cochrane Collaboration states that “This review finds that giving antibiotics is not supported by conclusive evidence.”  In other words, the scientific literature demonstrates that there is no benefit to IV antibiotics during labor.

In my class I teach the BRAIN process for informed consent or refusal of medical procedures.  If I were being offered IV antibiotics for GBS, I would personally use the following type decision-making process:

  • Benefit:  avoiding GBS infection in my baby
  • Risk: other serious bacterial infection, thrush (which all but kills breastfeeding), antibiotic resistance (possibly making it so that my child might not be able to take antibiotics for other illnesses in the future)
  • Alternatives: use of garlic/yogurt as suppository to raise the levels of beneficial bacteria in the vagina (no scientific evidence either way on this, and it’s likely to be ineffective, but it is something I’d be personally willing to try), oral antibiotics before the birth (no evidence that this works either, but it can make caregivers feel like they’ve done something), or hibiclens wash before and during labor (this is what I’d try, personally, because it does lower bacterial levels, it’s successfully used in Europe instead of IVs, and there are little or no side effects.  The Cochrane summary states that there have not been enough studies to determine whether it actually works to reduce GBS infection in newborns. )  “nothing” is always an alternative too.
  • Intuition – Speaking as a mother, I feel uneasy with a treatment that reduces the rate of an infection that my baby has only a 0.05% chance of getting in the  first place, but carries a much higher risk of causing my baby to get an equally serious infection later.  It’s not helping much if we avoid GBS but then have to deal with life-threatening c diff or MRSA.  From the scientific evidence, however, it’s hard to say because not much research is being done on alternatives.
  • Nothing – what if  we did nothing?  Again the chance of the baby acquiring infection is low, so doing nothing is a valid choice for moms who desire this.  A risk of refusing treatment is the feeling that one might be endangering the baby’s life, or that one is being a bad patient or will make the caregiver unhappy.  Additionally it should be noted that life is not without risk, and doing nothing might very occasionally result in GBS infection of the baby..  Also to be considered is that GBS infection usually manifests itself in the first 24 hours, when most babies are still in the hospital and therefore in a good position to be treated, whereas other severe bacterial infection that can occur as a result of IV antibiotics will manifest within the next few weeks.

Again, this is an example of the BRAIN thought process according to my values and priorities for my family.  Every family must make their own choices and take into consideration the risks they can live for themselves and their family, with as well as their care provider’s recommendations and the available scientific evidence.  Please note that this blog is not intended to be a substitute for medical advice, only to provide information families can use to make their own medical decisions.
View the Cochrane Summary here:  http://summaries.cochrane.org/CD007467/intrapartum-antibiotics-for-known-maternal-group-b-streptococcal-colonization

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What does a doula do?

After a long hiatus, I’m finally able to do doula work again.  Hooray!  I love helping moms and their partners.  I love hearing moms talk about their birth goals. I love helping empower them to reach those goals.  And most of all I love seeing the look on a mom’s face when she says, “I did it!  I really did it!” after her baby is born.  As a self-confessed birth junkie, I am constantly researching ways to help laboring women be more confident, more comfortable, and more satisfied with their birth experience.  I love being able to put my skill set into practice.  I am so happy that my life has eased up enough to allow me time to resume doula work.

“Contraction” by eyeliam, Flickr Creative Commons license

What does a doula do, you might ask?  A doula is a paid labor support person who provides emotional, physical, and informational assistance to a laboring woman.  Doulas provide continuous care, “mothering the mother” as it were.  In my doula practice, I provide the following services:

  • Continuous support.  I stay with the laboring mother from the time she needs me until she is cleaned up and settled into bed and has fed her baby for the first time.  You may already know that the research shows that having a doula reduces the instance of c-section, vacuum or forceps delivery, pain medication, and negative feelings about the birth experience.  Or, stated a different way, moms who have continuous support from a doula have safer and more pleasant birth experiences.  Amazing!
  • Birth team support.  I do not take over the partner’s role, I supplement it. I am there to help the birth team come together and support the mom. Often dads in particular are hesitant, but having a doula can really take the pressure off of a partner.  If dad needs to take a breather, grab a sandwich or nap, or becomes overwhelmed by emotion (after all, it’s his baby being born, too) – I’m there to give him a break and let him come back into the birth with a stronger game.  If dad is worried about forgetting what he learned in their childbirth class, no sweat – he doesn’t have to remember every little thing, because I will.
  • Emotional support.  As a mom of 3, I understand the widely varying emotions that accompany birth.  Whether a mom is feeling sadness, anger, fear, determination, or jubilation, I am there to validate her feelings and give her a safe space in which to express herself.  (I give this same support to partners, too.)
  • Informational support.  Sometimes parents need a sounding board, a source of information about an offered intervention, or just a little bit of confidence in making a decision.  I’m there with a fairly large knowledge base, a nonjudgmental attitude, and an unbiased approach to decision-making.  I have a growing library of birth and parenting books for clients to borrow. And I’m available for questions by phone or email starting the day I’m hired.
  • Private class/workshop.  All of my doula clients receive my private childbirth class as part of my doula service.  This is a workshop for the mom and her entire birth team.  I provide handouts, show appropriate videos, answer questions, and get everyone up and moving and grooving… it’s like a really fun dress rehearsal for labor!  And it lets me get really connected with what mom wants and values most from her support team, so I can be a better doula for her particular needs.
  • Massage.  As part of making mom relaxed and happy, one of my specialties is massage… hand, foot, back, forehead… whatever it takes to make a mom comfortable.  I carry a variety of massage oils for every situation, whether a mom needs something to help her feel relaxed and blissful, or a pep-me-up to help her get up and moving.  I’ve even had training in aromatic essential oils as regards pregnancy and labor – what oils are safe to use and what oils are most effective in particular situations. This is one of my favorite types of care to give; I am always amazed by the power of simple human contact in labor.
  • Equipment.  When I go to a hospital birth, people often eye me strangely because I bring such a large bag full of… stuff.  I carry everything I think a mom might need, from birth balls to hand combs to kneeling pads for the hard floor, because, let’s face it, what works in labor can change from minute to minute and I’m going to do my best to be prepared for anything.
  • Knowledge.  As a Lamaze educator I teach a wide variety of coping strategies for labor.  I can suggest positions or movements as needed.  And I reassure parents that what they are experiencing is normal and expected for birth. Most of all, everything I recommend is based on scientific evidence, not tradition .
  • Postpartum support.  My fees include a postpartum visit if requested.  Moms have the same need for support and information postpartum that they did in birth, perhaps more as their focus has shifted from their own needs to their baby.  At this time, I assist moms as desired with postpartum comfort measures, breastfeeding, and whatever else she might require, including help with babywearing or elimination communication.   Many moms like to discuss the details of the birth (I provide a copy of my notes if requested) and I like to admire the baby.
  • Unbiased support.  When I’m at a birth, I am there just to help the mom.  I don’t work for the hospital, the doctors, the nurses, or the midwife.  My only goal is making the mom have her ideal birth however she defines it.

Other things I offer:

  • I wish this weren’t so, but occasionally a mom will feel bullied by her caregiver into interventions she doesn’t want or isn’t sure is necessary.  This is where a doula can really keep a labor on track.  Just having someone beside her can help a laboring woman find the courage to say “I want to try other options first”, “If I want _______, I’ll ask but please don’t offer it again” or even, simply “No thank you.” Or I might remind a mom who seems hesitant about a procedure that she can refuse it if she wishes.  I do not interface with the nurses or doctor, but if I know a mom is strongly against a procedure that is about to be done without her knowledge or consent, I might say to her or her partner, “It looks like they’re prepping to do _______, which was not on the birth plan. How do you feel about it now? Would you like to request an alternative (or no) procedure?”  I am a professional and try to keep interactions so, while still working 100% for the mom and her needs.
  • I do not provide any medical services or act as a monitrice.  I do have a very small amount of midwifery knowledge, but if a problem ever arose, I would use my knowledge in the Good Samaritan way and call 911 while providing basic first aid only.  That said, some moms might still feel better knowing there is another person there to help in case of the rare problem that might crop up while laboring at home.
  • Labor plans can change.  Most women are healthy and low-risk, but sometimes medical conditions can crop up and alter the birth plan.  A mom might change her mind and decide to get, or not get, an epidural.  I can roll with the changes, and I always make sure to give a mom what she needs at a given moment.  And if a cesarean becomes necessary, I can support mom through that procedure as well.
  • If there is a situation involving the baby’s medical needs, having a doula means the dad can stay with the baby while I continue to support the mom (and will keep her informed as well as I can, moment by moment, about the baby’s status.)
  • I don’t like to talk too much about this because I wish it never happened to anyone, but – loss of a baby does happen and I encourage all my clients and students to at least formulate a plan for that.  If it were to happen (and I hope and pray not) I am there to help in a sensitive and respectful way.  I would assist in whatever way required – protecting a family’s grieving space, arranging for photographs to be taken, or simply being a shoulder to cry on.  (And obviously, without saying the stupid things some people say to those who lose a child.)

And a few more notes on my doula practice:

  • I am open to all types of families, from married couples to single moms to LGBT families.  And I can help tear down the barriers that often crop up when a mom of a less-mainstream lifestyle is trying to advocate for herself with her caregivers.  Not every laboring mom is a heterosexual married woman, but ALL moms deserve a safe and pleasant birth.  (This holds true for my birth prep classes as well.)
  • I am particularly interested in assisting teenage mothers.  Teenagers are often the least able to advocate for themselves in birth; more on that topic coming in a future post. Suffice it to say that for a young mother, having someone there who is responsible only to her and who cares only that she is safe and comfortable and empowered, can make all the difference in her emotional and physical well-being.
  • I offer a very flexible payment plan because every woman deserves support from a doula regardless of income.

Are you pregnant?  I’d love to talk with you about how I can help you achieve your ideal healthy birth.

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Push for Your Baby

Have you seen the new Lamaze campaign, Push for Your Baby? I love this quote from one of the dads: “The doula and I were working to put pressure on Cherington’s body where it would relieve the pain.” Having a trusted birth partner, whether it’s the mom’s partner or mom or doula, is SO important to helping the mom to give birth! But I digress. Anyway, watch the video and then go check out Lamaze International’s Push for Your Baby resource page.

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Science and Sensibility: Henci Goer refutes elective inducion safety claims

Have you visited Science and Sensibility yet?  You should.  This excellent blog examines the scientific research being done on birth and birth interventions, to see whether current birth practices are evidence-based.  I had to share this post.  In my opinion, elective induction is (along with vaginal exams and IVs) an extremely common birth intervention.  It’s considered safe because it’s so widely done, but as with anything there are risks to offset the benefits.

Sound boring?  Ok, I’ll distill it down a little.  Researchers compared two groups of women, those who spontaneously went into labor and  those who were induced.  On the surface, the results appear to show there is no extra risk of perinatal mortality (the baby dying during labor or within a month after birth.)  Dig a little deeper and you find that the entire group of women who were induced were ultra-low risk.  The women who went into labor on their own were included in the study even though many of them had medical conditions that classified them as high or higher risk..  kidney disorders, fetal abnormality, diabetes, liver disorders, etc.  So it was a biased study intended to support a generalization that you really can’t make from this study.  Of course the babies in the electively-induced population were as healthy  – they and their moms didn’t already have problems before birth!

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So what can we learn?

  • “…more women delivered via cesarean surgery in the electively induced group.”
  • “…more babies were admitted to special or intensive care nurseries after elective induction at every week through 40 weeks”
  • At every week of gestation, more mothers had an instrumental delivery (meaning by vacuum or forceps.)  This is problematic because it carries risk of injury to the baby, and does cause injury to the mother as episiotomy is required.

Ms. Goer also points out the following:  “An excess of instrumental deliveries is concerning primarily because of the increased likelihood of anal sphincter injury; however, an excess in cesarean deliveries is far more serious, carrying as it does increased likelihood of severe maternal and perinatal morbidity and mortality in both current and future pregnancies.”  Parity makes a difference.  In first-time mothers, induction can double the chance of a casearean.  However, researchers chose not to report outcomes by parity.  Hmm… wonder why?

We can see from this study how the numbers can be manipulated to show a conclusion that might not be completely valid. It makes good sense for parents to consider all the evidence and become informed decision-makers when it comes to their maternity care.  Without a really good medical reason, it’s still safest for mom and baby to let labor begin on its own.

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What to Reject When You’re Expecting

Consumer Reports has written a great guide to things to avoid when you’re expecting.  They further the report by adding 10 things to do when you’re pregnant and 5 things to do before you even become pregnant.  This is great information in an easy-to-digest format.

What to Reject When You’re Expecting

My only addendum?  If your baby is persistently breech, seek out a care provider who has training and experience in vaginal breech births.  With the proper skills in attendance, vaginal breech birth is safe and doesn’t compromise a woman’s future pregnancies and births as a cesarean does.

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