Combating Gestational Diabetes

Jenni Rongey, a co-Chapter Leader for the Tarrant County Birth Network, wrote this post for the Banned From Baby Showers readers.  I've known Jenni for a few years - she was Jillian in the BOLD Fort Worth production of  "Birth" two years in a row.  She had a VBA2C almost 2 years ago and you can read her birth stories here. She also works as a birth assistant at a local birth center.  She is a wealth of knowledge and I hope you walk away with a new perspective on dealing with gestational diabetes after reading Jenni's comments.  Thank you, Jenni, for sharing your expertise and story with us here.

"Diabetes has affected every part of my life but none quite so deeply as pregnancy. I have personally experienced many of the complications and risks associated with Type II diabetes in pregnant mothers. Multiple miscarriages, strict diets full of counting carbohydrate to protein ratio, insulin injections, pre-eclampsia , c-section, induction leading to an emergency c-section, babies with under-developed lungs that were separated from me for hours or days after birth.

Funny thing is I’ve also seen a diabetic pregnancy where none of those complications reared their ugly head. That was my pregnancy too. So what changed you might ask? I stopped listening to my doctors list off all the reasons why I was high risk and I couldn’t have a normal, uncomplicated birth. I realized that the only thing that separated me from my friends that had normal, low risk, out of hospital births was that I had blood sugar
levels that fluctuated from high to low and they did not. I just needed to figure out how to control my blood sugar levels without medication. Figure it out I did and like so many of our modern day diseases it was all about diet and lifestyle.

What I want to discuss are the measures a woman that has been diagnosed with gestational diabetes mellitus (GDM for short) can take to help boost her chances of having the birth she wants. Merely getting a birth without all the interventions is an uphill battle for someone with gestational diabetes. It’s even harder if you desire a natural birth or one out of the hospital. The best thing you can do is to educate yourself and keep your blood sugar tightly controlled and educate yourself. Did I mention that you need to educate yourself?

First you should know that gestational diabetes can be readily controlled without medication. It takes some planning and determination to stick with your plan but aren’t the things that are most important in life worth a little work? Let’s get to work.

10 Things You Need to Know to Keep GDM under Control

1. Understand Gestational Diabetes – 
Gestational diabetes is a condition where a woman that has never been diagnosed with diabetes suddenly has high glucose levels in the third trimester of pregnancy. Insulin is an important hormone in the body. Its two main jobs are storing fat for future use and escorting glucose (sugar) into the body’s cells where it can be used for energy. When a woman becomes pregnant her body naturally becomes insulin resistant to a degree. This means that some of her cells start refusing to let insulin do its job. Extra glucose is left circulating in her bloodstream where it ends up being metabolized by the fetus. This is the body’s way to secure a steady stream of energy for the fetus as it grows. By the third trimester the mother’s insulin resistance is higher so that extra glucose can be secured for baby’s fat stores before birth. In most women, the insulin resistance isn’t noticed because their pancreas puts out ever increasing amounts of insulin to keep blood sugar levels normal. However in some women, the pancreas just can’t keep up and despite high levels of insulin in the blood stream, blood sugar levels remain elevated. Being diagnosed with GDM does not mean you are diabetic. It can mean however, that you have a greater chance of developing type II diabetes in the future. Learn to take care of it now and you greatly reduce that risk.

2. Understand the Actual Risks of GDM
• Big Baby Syndrome - Insulin works in the body by taking glucose out of the blood and putting it in cells for energy. It drives glucose first to muscles, then to the liver, and finally to store in fat. If your blood sugar
remains elevated the baby’s pancreas is left to deal with the excess. It will produce extra insulin which will help store glucose as excess body fat. That is how an uncontrolled diabetic mother can have a baby that is
too large. If your blood sugar is tightly controlled this is not an issue. By the way, if you do have a large baby there are several squatting style birth positions that open the pelvis by an extra 30%. This is a lot of wiggle
room. A large baby alone is not a reason for an automatic c-section.

• Low blood sugar in the newborn – If your blood sugar has been chronically high or is high during labor then your baby may be born with low blood sugar. Remember that your baby’s pancreas puts out extra insulin to help get rid of the excess glucose in its blood. When the supply of excess glucose is shut off by birth, the pancreas still takes a while to slow down production of insulin. This can result in low blood sugars. Symptoms of low blood sugar in the newborn can be hard to see but they include irritability, lethargy, excessive hunger, and rapid pulse. For a baby exhibiting signs of low blood sugar the best cure is to put the baby to the breast early and often. Usually no other treatment is needed to help stabilize blood sugar as long as it is not dangerously low.

• Significant increase in interventions – The most dangerous risk of being diagnosed with GDM is merely being labeled as a gestational diabetic.  A woman diagnosed with GDM has up to a 50% increased chance
of induction or c-section just by being diagnosed. She may also be subjected to frequent sonograms, non-stress tests, and other invasive and unnecessary procedures. Many doctors want to induce around 38 weeks to “make sure the baby isn’t too big.” If you keep your blood sugars tightly controlled and within normal range your risk of having an overly large baby is no greater than a woman without GDM. Educate yourself so you can defend your choices if it comes to that. If a natural or low intervention birth is what you are wanting, you will need to be ready to fight for it. The best thing you can do is keep your blood sugar in the normal range. Ready for the how-to?

3. Eat a Diet That Does Not Raise Your Blood Sugar and Insulin Levels.
If a food raises your blood sugar it will also raise your insulin. The pancreas will fight hard to put out extra insulin to take care of any extra glucose in the bloodstream. The damage inflicted by excess insulin circulating in the body is enormous but for the purpose of GDM I will distill it down to one important complication, pregnancy induced hypertension. Insulin raises blood pressure and this is part of the reason that women with uncontrolled blood sugar in pregnancy are at a higher risk of developing pre-eclampsia. So exactly what foods will raise your blood sugar and insulin levels? Glad you asked!

4. Go Grain Free
Grains are the number one culprit in high blood sugar with sugar close behind. Are you surprised that sugar isn’t in first place? Unless you are drinking gallons of corn syrup laden soda and eating Snickers for snack
everyday (and if you are, quit that!) most people consume more wheat, corn, rice, and oats than sweets in any given day. This makes them the number one food to control. Do you really need to cut out all grains, even whole grains?  The answer I’m afraid is yes, at least until you have had a week or two of absolutely normal blood sugar readings. Then add in whole grains, if you must, one serving at a time. Pay careful attention to how you respond to any particular grain. I personally can’t even look at rice without my blood sugar hitting the ceiling but small amounts of corn or corn tortillas can usually be tolerated. If you monitor your blood sugar carefully you will know when you have reached the upper limit of your grain intake whether that is one serving a day or four. Along with grains you have to watch your intake of starchy vegetables, mainly potatoes and peas. White potatoes are the vegetable world equivalent of white bread. Sweet potatoes offer great nutrition with a much lower impact on blood sugar. What about sugar? Obviously sugar needs to be severely limited in your diet (even if you aren’t dealing with GDM.) Have you noticed that most of our favorite desserts and treats pair grains with sugar? Talk about a double whammy. So what’s a pregnant girl to do? Eat fruit…..just kidding! Check out recipes for grain free treats that are sweetened with honey, maple syrup, or other unrefined sugars. There are thousands of tasty recipes on the web waiting for you. If you are the experimental type in the kitchen you can start trying out wheat flour alternatives like almond or coconut flour.

5. Eat Whole, Real Food from Good Sources
Grass-fed meats, wild caught fish and seafood, and pastured chickens and eggs should make up the bulk of your protein. Local, seasonal, and hopefully organic vegetables will give you your best source of vitamins and minerals.  Organic fruit should be eaten in small quantities. I can hear the rumble of, “Sheesh! I’m not made of money,” out there. I know. I’m not either. Figure out your priorities. If you eat a lot of eggs but rarely touch red meat then spend your money on pastured eggs, and go ahead and buy standard grocery store meat. That small amount won’t be your undoing. You get the idea.  Dairy is questionable for some people struggling with blood sugar issues.  Usually cheese has very little impact on blood sugar but milk is actually quite high in sugar (lactose.) It will just take a little experimentation to decide whether or not milk will be an option for you. For those of you that are Weston A. Price devotees, and you know who you are, raw milk generally has less of an impact on blood sugar than pasteurized. Always eat dairy in the full fat form. It will slow the impact on your blood sugar plus the vitamins and calcium in dairy foods require fat for your body to absorb them.

6. Don’t Worry About Fat in Your Diet
If it’s good fat that is. Fats are necessary to human health. Fats feed our brain,  give our cells structure, and keep our skin glowing and wrinkle free. Fats help us metabolize vitamins A, K, and D. Good quality fats are necessary to  properly nourish mom and baby. The problem is figuring out which fats are  good and which are not.  Saturated animal fats from pastured and grass fed  animals are great! Grass fed beef is high in omega 3 fatty acids. Pastured lard  is full of heart healthy monounsaturated fats. If you eat pastured bacon save the grease and cook your eggs in it just like Grandma used to. Butter, cold pressed coconut and olive oil are all good choices that are easy to find as well.  Steer clear of processed vegetable oils, even canola oil. These oils become oxidized and rancid during processing. To hide the awful smell they are chemically bleached and deodorized. Sounds yummy right?

7. Check Your Blood Sugar Often
How can you know if you are successfully keeping your blood sugars level if you don’t check? Get a glucometer and check your blood sugar several times a day. Yes I know it’s tedious but trust me, it’s better than having to inject insulin twice a day. Your care provider should go over the values that you are looking for but just in case, your fasting blood sugar should be below 100mg/dl and under 140mg/dl two hours after a meal. Consider your glucometer your most important tool to helping you stay on track.

8. Exercise! For Real, Do It!
Consistent exercise is a major key to blood sugar control. When you do any exercise you move large muscle groups. To fuel those large muscle groups your body will direct glucose out of your bloodstream and into the cells of the muscles. Exercise can have a large and immediate blood sugar lowering effect.  If you exercise consistently it will boost your metabolism and make you more sensitive to insulin. Over time regular exercise will help to keep your blood sugars lower. I’m not talking about hours every week at the gym. Moderate walking several times a week for as little as 30 minutes has a huge impact on your insulin sensitivity.  Consistency is what’s important here. The more consistent you are the more benefit you will see. If you find that following all of these recommendations isn’t quite getting the job done there are a few more tricks up my sleeve.

9. Great Supplements
Choose quality whole food supplements that support metabolism and lower blood sugar levels. A whole food prenatal may be in your best interest. It is generally believed that people with metabolic disorders, and GDM is one, have a harder time absorbing nutrients. A whole food prenatal vitamin is more readily available to your body. A whole food chromium supplement is a must.  Chromium is a necessary mineral that helps regulate blood sugar. With depleted soils it is impossible to get all you need from food. Cinnamon is another valuable supplement for lowering blood sugar. While you can buy cinnamon capsules, just sprinkling some on your food everyday is a tastier way to get it. Certain brands carry Chromium blends specifically for blood sugar control that contain cinnamon as well.

10. Coconut Oil 
I know I went over fats earlier but coconut oil is a special one. Coconut oil when taken as a supplement supports your adrenal system, boosts metabolism, and lowers blood sugar. You can take up to 3 tablespoons a day if needed. If you have been on a low fat diet then start small. Begin with 1 teaspoon before each meal and work your way up. You may find benefits at a low dosage or you may need to go all the way up to 1 tablespoon before each meal. You can stir the oil into herbal tea or take it straight from the spoon.

As with anything regarding your birth, the better educated you are the better chances you have of getting the birth you desire. Gestational diabetes is not a one-way ticket to a c-section or induction. With some planning and dedication you can have the birth you envision. Happy healthy birthing to you!

*I am not a doctor or licensed medical professional. I have done my research and these are the steps I took to control my blood sugar during pregnancy. If you have been diagnosed with GDM and are currently controlling it with medication you need to start this diet under supervision of your care provider. You will need to very carefully monitor your blood sugars as you wean off of medication."


For more information, I wrote a post about testing for gestational  diabetes earlier this year, including the criteria set by the American Diabetes Association.

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Group B Strep

Not a catchy title, huh?  It's a test that all pregnant women are offered around 36 weeks.  I'm not going to lie to you, it's not my favorite topic, mostly because I don't like how it's handled, regardless of where you are giving birth. I've been doing a lot of research on GBS lately.  Allow me to share my findings.

What is Group B Strep, or GBS? 

Group B Strep, or GBS, is a bacteria that lives in the intestines, urinary, and genital tracts of many healthy people. It is generally not serious in adults, but can be life-threatening to a newborn. Most adults do not have symptoms, but occasionally will develop an infection, such as a bladder infection or urinary tract infection. 

Testing:

The Center for Disease Control (CDC) and the American Congress of Obstetricians and Gynecologists (ACOG) recommend that all pregnant women be screened between 35-37 weeks of their pregnancies to determine if they are carriers of GBS. The pregnant woman's vaginal and rectal areas are swabbed during the screening. According to The March of Dimes and the CDC, approximately 25% of pregnant women are found to be colonized with GBS. 

Treatment:

If found positive, antibiotics are administered through an IV during labor. Ideally, antibiotics are given at least 4 hours before the birth. Oral antibiotics given before labor begins has been found to be ineffective, as the bacteria reproduces very rapidly. To date, the only proven strategy to protect a baby from early-onset GBS is IV antibiotics.

 

Two types of Group B Strep: 

1.  Early-onset GBS:  Can cause pneumonia, sepsis, or meningitis.  Symptoms include fever, trouble breathing, and drowsiness.  Symptoms often begin on the first day.  About half of all GBS infections are early-onset. Babies who develop early-onset GBS are more easily treated than late-onset GBS.

2.  Late-onset GBS:  Usually begins between 7 days and 3 months of age.  Symptoms include fever, coughing, congestion, trouble eating, drowsiness, or seizures.   Treatment of antibiotics during labor does not prevent late-onset GBS.   After birth, baby can get GBS from other people who have the infection.  Babies who develop late-onset GBS are not easily treated and are more likely to die.  At this time, there is no prevention for late-onset GBS.

If left untreated, the chances of a baby developing a GBS infection (born to a GBS-positive mother) is 1 in 200. If the mother does receive antibiotics in labor, however, the odds are 1 in 4000 of the baby developing GBS.

There are three significant risk factors that place a GBS-positive woman at risk for her baby developing Group B Strep: 

1.  Fever during labor

2.  Prolonged rupture of membranes (PROM) - water is broken 18 hours or more prior to delivery

3.  Pre-term labor (PTL) - labor begins prior to 37 weeks

If a woman tests positive (or does not know if she is positive or not) and does not receive antibiotics during labor, her baby will receive antibiotics after he/she is born. 

Written by Donna Ryan, Birth Boot Camp.  Adapted from:

GBS Prevention in Newborns, Centers for Disease Control and Prevention, http://www.cdc.gov/groupbstrep/about/prevention.html, May 7, 2012.

Group B Strep Infection, March of Dimes, http://www.marchofdimes.com/pregnancy/prenatalcare_groupbstrep.html, March 2010.

What I Think:

Now that the facts are out of the way....  I've seen this handled so many different ways, and to be honest, they all make me feel kinda yucky.  The CDC is working on a vaccine for GBS, so more options will likely one day be available to pregnant women.  

If a woman is having her baby in the hospital, this is pretty cut and dry.  If she tests positive, she'll have antibiotics in labor.  If she has her baby before she has time to have a full round of antibiotics, they'll treat the baby with antibiotics.

But what about the woman birthing outside the hospital? I've seen several women told to follow a certain regimen so she will test negative at 36 weeks -- tricking the test, in my opinion.  Like mentioned above, if GBS is present, it will grown very rapidly.  I've also seen a number of women prescribed a "vaginal wash" which does not necessarily kill the Group B Strep but does reportedly kill the beneficial bacteria in the vagina.  One of the benefits to a baby being born vaginally is being exposed to that beneficial bacteria.

You should be able to have antibiotics, however, regardless of where you are having your baby.  Check with your care provider on her protocol.  

I've written about my personal feelings about antibiotics here before. I'm not a fan unless truly required.  The GBS symptoms in a baby with early-onset GBS are pretty clear, pretty quick.  The antibiotics given in labor will not prevent a baby from developing late-onset GBS.  With that being said, you still cannot ignore the numbers.   The use of antibiotics during labor in a woman who tested positive for Group B Strep significantly decreases the chances of her baby developing Group B Strep.

Personally, I was never tested for Group B Strep with any of my pregnancies.  Knowing what I know now, maybe I would have been.  If I would have tested positive, I can't say what my choice would have been.  And I'm not about to tell you what your choice should be.  The numbers quoted by the CDC and March of Dimes are lower than what I've read elsewhere.  Some areas of the country report as high as 40% of women test positive for GBS. 

Talk to your care provider and to your partner.  As with everything else, do your research.  Make an informed decision.  If you are planning an unmedicated birth, this is but a blip on the radar.  Not a big deal, just something to be aware of and plan accordingly.

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It's Just an IV -- What's the Big Deal?

I posed a question on my Facebook page this weekend asking if an IV was required at your place of birth.  As expected, the majority of those birthing in the hospital said yes.  I recently had an IV when I went for a colonoscopy, and I must admit, I did not like it.  My number one complaint is that feeling of cold fluid running through my veins.  Not a fan. 

What about for labor though?  Should an IV be a part of a normal labor?  The hospitals think so.

Let's face it -- nearly everyone who finds themselves on the Labor & Delivery floor will have an epidural.  Or an induction.  Likely both.  Before an epidural is placed, a mom will receive a couple of bags of IV fluid.  Epidurals are notorious for causing the blood pressure to drop, so these fluids are necessary.  Here's why they want you to have an IV when you walk through the door:  The minute you say you want an epidural, they can give it to you.  Otherwise, they have to wait for these IV fluids to be administered.  They believe that you will eventually beg for the epidural, no matter how many times you say that you want an unmedicated birth.  I hate to sound paranoid - or make others paranoid - but the truth is quite ugly when we talk about IVs.  You will very likely have other things running through an IV besides saline water, with pitocin at the top of that list.  Even if you don't have pitocin during the labor, you will assuredly have it after your baby is born to "aid" in the delivery of the placenta.  If you have an IV, you won't even know pitocin was added.  They simply do not ask your permission. 

Antibiotics are often added to an IV.  This is given, typically, under three scenarios: 

1) Mom develops a fever.  This could be due to infection, but epidurals cause fevers in many women.  Since we aren't sure either way, antibiotics are administered.
 
2) Water is broken so antibiotics are given routinely, you know, just in case she might develop a fever.  (Can you hear my eye roll?)   

3) Mom tested positive at 36 weeks for Group B Strep and antibiotics are standard procedure.  This post is not a post about GBS, but suffice to say, antibiotics are very necessary if the baby actually acquires GBS on the way out of the birth canal, but only 2 out of 1000 babies that are born to GBS-positive mothers will be affected.   One-third of women will test positive, so that is a lot of women receiving antibiotics -- just in case.   I have strong feelings about antibiotics from my own personal experiences, but you may not care one way or another.  Maybe you feel that it is better to be safe than sorry.  It's a decision each parent needs to make for themselves.

Is an IV ever necessary in labor?  In short, yes.  A woman in labor should be eating and drinking plenty of water.  Water is crucial in helping the uterus work effectively.  Without it, the uterus can become "irritable," often making an IV necessary.  Under these conditions, she'll often experience contractions close together and intense, but only lasting about 30 seconds.  An IV might help her stay hydrated and therefore causing more effective contractions.  If a mom can't keep fluids down, she might also require an IV.  As with all interventions, there is a time and place for everything.  IVs should not, however, be a routine part of a normal labor. 

 It seems that many moms end up consenting to a hep-lock, which is an open vein.  If they need to give you an IV quickly, they won't have to "fumble" to find a vein.  To quote one of my Facebook readers, "They said it was in case there was an emergency and I started to bleed out.   I said "If you're telling me if there isn't anyone here that can save me in an emergency if I dont have an IV line in already then I need to leave because I don't feel safe." They laughed, said good point and left me alone."  The hospital group I refer to in the Fort Worth area, the UNT Health Nurse-Midwives, have not required even a hep-lock for my students unless there was a medical reason to do so.  

One more thing I found extremely interesting about IV use in labor.  This can have a negative effect on breastfeeding.  Mellanie Sheppard, IBCLC, explained this at a Tarrant County Birth Network meeting one evening:  When a woman has IV fluids, she becomes swollen and puffy until the extra fluid has time to leave her body.  This can include extra fluid in the breast.  A woman who didn't think she had flat nipples before now may have a problem with the baby latching properly.  She might be started on a nipple shield and thus started down a road that could have been prevented by simply avoiding the IV in the first place.  

Last week I wrote about various policies that contribute to the high c-section rates and neglectfully left routine IVs off that list.  It should have been there.  Drink your water.  Talk to your care providers.  If you are choosing to birth in the hospital, search out the care providers who practice evidence-based maternity care.  You will likely have to concede on some issues, but choose your "battles" carefully and thoughtfully.   

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Electronic Fetal Monitoring -- Is it really saving babies?

 As Tim McGraw's biggest fan, I subscribe to a number of Country news emails and Facebook groups.  I skip over most of it, but sometimes I'll see something that catches my eye that is not even related to Tim.  As you can imagine, it usually has to do with someone having a baby.

A couple of weeks ago it came across my News Feed that Jewel was showing off her new baby.  She lives in this area of Texas, about an hour from me, and because we have about a 50% c-section rate, I was very curious how things turned out for her.  (I had heard that she had desired a "natural birth.") 

The story goes that she was doing Hypnobirthing -- no details available.  Could have been self-study or CDs, maybe a class.  So I assume that desiring a "natural birth" really did mean an unmedicated birth, not just a vaginal birth.

The article went on to describe how violent the Braxton-Hicks contractions were and put the baby at risk.  Yadda, yadda, yadda... she had an emergency c-section that miraculously saved her baby.


The singer, who studies hypnobirthing, was eager to have a natural birth, but things didn’t work out as planned. When Jewel started having early Braxton Hicks contractions, Kase’s heart rate dropped. She admits, “I feel lucky to be pregnant in the modern age where they could actually tell he wasn’t well during those contractions.”  

In the end, Jewel says her scheduled birth plan wasn’t what was important to the young family. “We felt thankful that we had good doctors and a good hospital nearby, and that everything was OK,” she says. “I’m so lucky that we have a healthy baby boy. That’s all I cared about.”

I can't help but think this poor reporter got his terms mixed up about the contractions, and there's little information to go on from there.

Regardless, how many women have had c-sections that truly believe they were necessary -- that their baby would have died without the surgery?  Countless.  The year the Electronic Fetal Monitor was introduced, we went from a 5% c-section rate to 23%.  Studies have shown time and again that a baby who is truly in distress will be picked up with intermittent monitoring.  (Side note:  "intermittent" means different things to different care providers.  It may mean during and between a couple of contractions per hour, or 20 minutes per hour.  Find out what intermittent means at your place of birth.)

One of the problems with the continuous monitoring is the lack of communication between the birth team and the parents.  Mom is monitored from down the hall, and when a nurse does walk in, she tends to look at the monitor and not the laboring woman.  Another problem is obvious:  mom can't move around and help her baby out.  The baby is left to figure it out on his/her own. 

Problem number 3:  Any time a mom receives drugs of any kind, she'll be put on a monitor to be sure the baby is handling it OK.  This can mean hours and hours of a baby being exposed to ultrasound.  That's what Electronic Fetal Monitoring is -- ultrasound.  I've written posts on the risks of ultrasound in the past.  Click here and here and here.  You need to decide how comfortable you are with this intervention.

Problem number 4:  The biggest problem of all is simply that they have to do something with the results of the readout.  Take a baby that has a cord around the neck, for example.  This baby will have decels of the heart rate on the printout.  They aren't sure why the baby's heart rate is dropping, but better safe than sorry, right?  Lawsuit alarms start going off and a c-section is performed.  The baby is fine (Jewel's baby looked great!), but there is this perception -- or defense mechanism -- that thank goodness the c-section was performed and saved the baby. 

Was the baby ever in trouble?

We'll never know.  But now, because it's so hard to find a VBAC-friendly doctor, we've put this mom on a c-section path for all her children -- unless of course she becomes informed of her VBAC options.  As an OB, this is exactly where I want her.  Easier for me and twice as much money.  Few women will question the c-section because it makes her look like a bad mom.  She trusts her doctor.   It's easier to believe that the surgery saved the baby.

Another side note:  The cord around the baby's neck occurs in about one in three births.  When a c-section is performed where the cord is around the neck, the OB often makes a big deal about it, making the parents feel like this was very dangerous.  It's not.  The OB or midwife, after the head is out, will simply lift it over the baby's head.  It could be wrapped around the neck several times!  The most I've seen from one of my student's was 4 times!  Had she stayed with her original hospital and OB -- who required continuous monitoring -- she assuredly would have had a c-section.  Instead, she had a fabulous water birth with CNMs at a different hospital.

So, I feel bad for Jewel.  Maybe her baby really was in distress, but I suspect that the doctor didn't want such a public birth taking a chance at going sour.  Given the high c-section rate in our area, perhaps he was less comfortable with (unmedicated) vaginal birth than cesarean birth.  He knew he could perform a mean c-section and spin it like he saved the baby.  Again, just me speculating.  I do believe that she was likely another victim of our broken maternity system and doesn't even realize it.  While I always advocate for women being informed of their choices in childbirth, sometimes ignorance is probably quite blissful.

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MY List of Things You Can Do to Avoid a C-Section

I've seen a couple of lists lately about the top 5 things a woman can do to avoid a c-section. While I think these lists are good, they differ from my personal list. I thought I'd take the time to write out my list. I guess I'll keep it to a top 5 as well, so as to not overwhelm anyone.

Education for both husband and wife: Some women are able to advocate for themselves in labor, but most are not. Preparation on the front-end is huge. Dad needs to know what is going on and how he can help. He needs to know what's normal and what's not. He needs to know the questions to ask. Having a doula will help with a lot of this. The doula cannot speak for mom, but dad can. I love The Bradley Method for this reason. Both individuals take responsibility for their role in the birth.

Careful Choosing of a Care Provider: Also huge. All the education and preparation in the world won't matter a bit if you have chosen a care provider and/or hospital who is determined that you need to be rescued from your pregnancy, labor and/or birth. This is the step where, if you ignore the red flags popping up during the education/preparation phase, it will bite you in the end. If you are getting information and statistics about your doctor or hospital that make you second-guess their philosophies, don't ignore them. It's never too late to switch care providers. I've had people change in the middle of labor! Typically, care providers like to see you for the last month of your pregnancy. I changed care providers at 33 weeks with my third pregnancy. A bit nerve-racking, but worth it for a great outcome. You will only give birth to this baby one time. Don't take on the "maybe for the next baby" attitude. Do it this time! Do it for this baby! If you don't know where to start, ask your out-of-hospital educator or doula for referrals.

Keep Moving - Don't Lay Down and Take It: Remaining in a hospital bed is one of the worst things you can do. They can/will strap a monitor on you and "watch" you from the nurses station. Health care at its finest! Laying around for your labor leaves it all up to your baby to make its way out. Baby needs movement. He is moving around, changing position, trying to find the easiest, most comfortable way out. If mom is moving -- walking, sitting on birth ball, pelvic rocking, rotating hips, even standing -- she's using gravity and movement of the pelvis to help her baby descend and get into a good position. Mom will have less vaginal exams (which often lead to Failure to Progress diagnosis), less time on a monitor (which often leads to a false-positive signaling fetal distress), and usually a more comfortable and faster labor. What's good for mom is usually what's best for baby.

Drug-Free Birth: I'm not just talking epidurals here. I'm talking inductions as well. Pitocin is a drug. Prostaglandins (cervical ripeners) are drugs. Baby may react "fine" to induction drugs, and he may not. There's no way to know how your baby will react. So trust in your body to start labor on its own. Don't be induced. Stadol, Nubain, Demerol -- they are all drugs that go to the baby. There will be physical results to the baby when they are born if they received these drugs -- more sleepiness, "laziness" at the breast, depressed breathing. If mom had educated and prepared herself during the pregnancy, she probably skipped this step. It's a tough thing to hear a mom's birth story and realize that her c-section was a direct result of her own actions -- induction, pain-relieving drugs, trusting her doctor, and not educating themselves on the normal process and what to do and what not to do. A woman is 50% more likely to have a c-section if she is induced, and four times as likely to have a c-section if she has an epidural. These are numbers that we simply cannot ignore.

Remain Low-Risk: If you do not take care of yourself and become high-risk, you give up a lot of power. You need to physically prepare your body to give birth by regularly doing pregnancy exercises. You need to eat the required nutrition to grow a healthy baby. A well-balanced diet with plenty of protein will benefit both mom and baby. The old saying "eating for two" does not mean eating for two adults! Be wise and mindful in your life choices. Practice relaxation every day. This will help with all aspects of your life, even after the baby comes. Keep stress out of your life as much as possible. Choose pre-natal tests wisely. There are so many that are done these days. Find out why it's being done and what they expect to do with the results. You can opt NOT to do them. Some may unnecessarily put you in the high-risk category if you test positive.

Of course, I must mention that every now and then I do have couples that do everything right and still have a c-section. I recently had one of these and it broke my heart. This mom worked so hard. I truly do not know what she could have done differently. You can't feel bad about a c-section that comes out of a situation like that. I feel sad for her. She really wanted a natural, unmedicated birth, and was so prepared. ICAN will be an important part of her healing.

My c-section rate of people who take my class is 14%. Some of those were necessary and some were not. Most that were not necessary can be traced back to one of these steps. One other way that can often help prevent a c-section is not rushing off to the hospital the minute your water breaks or you realize you are in labor. The longer you are there, the more excited everyone is to intervene.

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More Evidence About the Dangers of Ultrasound

I found a link about some other studies on ultrasound. There are a couple of posts under this link. They are short and easy to understand. The evidence is compelling. Check it out.

Next time your doctor says, "I don't know why 'Bradley' is so concerned about ultrasound," and tries to tell you how safe it is and that Bradley Instructors are the only people out there who care, they couldn't be further from the truth.

Evidence is mounting. Check it out.

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Beta-Endorphins and Their Affects on Pain Perception in Labor

I have come across the most fascinating graph dealing with beta-endorphin levels at different times in a woman's life. I want to share it with you.

This made me think back to the "Is Labor About How Tough You Are?" post I wrote several weeks ago. Interestingly, we all agreed that labor is NOT about how tough you are.

I have previously mentioned that the body produces endorphins in labor -- when drugs do not interfere with the natural process -- to help a laboring woman "deal with" the intensity of labor. When an epidural is introduced, those endorphins are squelched. It used to be advised that women let the epidural wear off when it's time to push, but most women found this too difficult. (I was one of them with my epidural birth.) A big part of the problem is that her body is not producing those endorphins at an increasing rate to coincide with her labor. Being flat on her back is a pain-inducing position to a woman about to push her baby out, so it is a double-whammy!

Beta-Endorphin Changes During Pregnancy and Labor:

Non-pregnant: 58
First trimester: 58
Second trimester: 33 +/- 1.9
Third trimester: 49 +/- 2.7
Early labor (cx < 4 cm.): 202 +/- 32
Advanced labor (cx > 4 cm.): 389 +/- 78
Postpartum: 177 +/- 22
Awaiting cesarean birth (not in labor): 151 +/- 23

This, to me, is proof that our body knows what to do. "Pain tolerance" is a moot point when looking at these numbers.

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Autism Links to Ultrasound and Other Obstetrical Procedures

I teach in my Bradley class about the risks of ultrasound. This is so controversial to begin with. No one wants to believe that there could be complications or problems with using this device that American parents are so in love with!

Simply put, ultrasound changes the way cells grow. Ultrasound has been linked to a number of things, but the one I want to focus on here is autism.

One in every 150 kids has a form of autism in the United States. This rate has grown tremendously over the last decade. Now let's talk about ultrasound for a moment. When I had my first baby, in 1996, nearly 13 years ago, I remember desperately hoping that my insurance would cover it. Back then, they didn't do them unless there was a "medical reason." (I don't remember my "medical reason".) Gradually, the reasons started including things such as accuracy of the estimated due date. Now, everyone's insurance covers ultrasound, usually not just one, but several. I even had a student last year who had a doctor who routinely did ultrasounds every week starting at 36 weeks. Parents are excited about this, not knowing the risks they are taking with their baby's well-being. Rates of increased ultrasound usage correlate with the rate of autism diagnosis. They have both risen dramatically, simultaneously.

I had read about the possible link between ultrasound and autism about 5 or 6 years ago. It made so much sense to me. There has always been warnings linked to ultrasound, but I rarely talk with a pregnant woman who has been made aware of any warnings before having an ultrasound.

For example, a study in 1993 found that babies exposed to ultrasound were twice as likely to develop delayed speech. According to the FDA, "While ultrasound has been around for many years, expectant women and their families need to know that the long-term effects of repeated ultrasound exposures on the fetus are not fully known."

Researchers reported, in 2005, "Obstetric ultrasound should only be done for medical reasons, and exposure should be kept as low as reasonably achievable (ALARA) because of the potential for tissue heating. Temperature increases in utero have been shown to cause damage to the developing central nervous system of the fetus." In 2006, a study warned that exposure to ultrasound can affect fetal brain development.

Because there are no obvious deformities or problems at birth, we assume that all is well and "normal." It is likely several months or even years later, as the parents are going through testing, no one asks -- yet -- "How many ultrasounds did you have in your pregnancy?" I think that day will come though. As a side note -- what did you learn from all those ultrasounds? Probably that everything was just fine. Even if you were checking for something periodically, what would the difference have been in just waiting until the baby was born? Rarely can anything be done in utero. So why have all these ultrasounds to begin with?

Ultrasound, just like ANY drug in labor or pregnancy, has NOT been proven to be safe. Think about that for a minute. Take Tylenol for example. Women are told that it is "safe" to take it, but that is not necessarily true. It just hasn't been proven to be unsafe. Ibuprofen, on the other hand, has been proven to be unsafe. We know ultrasound changes cellular growth, we just aren't sure exactly what this means long-term. Links are starting to be made now, finally, after 30 years of use -- and damage.

Other research shows that populations exposed to ultrasound have a quadrupled perinatal death rate, increased rates of brain damage, nerve cell demlyienation, dyslexia, speech delays, epilepsy, and learning difficulties.

One more interesting note about ultrasound and the development of the baby. Ultrasounds, along with many obstetrical testing practices, has a high false-positive rate, meaning that parents are told something is, or may be, wrong with the baby. This causes the production of stress hormones in the mother which can have long-term effects on the baby's neurological development and behavior.

It is important to know that ultrasound is not just the scan where you see the pictures of the baby. Ultrasound includes the doptone used to hear the baby's heartbeat at your appointments with your doctor or midwife. (You can hear the baby's heartbeat with a stethoscope after about 20 weeks. This takes more skill, and if your provider is younger, they probably have no idea how to find the heartbeat of the baby without the doptone. If this at all concerns you, you should request to hear the heartbeat by stethoscope.) Another form, and perhaps the worst of them all, the Electronic Fetal Monitor, or EFM. This is often strapped to the mom for hours in labor, especially if she has drugs in her system. Once again, I have just given you another reason to not have drugs in labor. You'll still be monitored, but only a fraction of the time will be required, or needed.

I have to end this post with a simple, trust your body. Trust your baby. You will be seeing him or her in a short time. The risk of ultrasound simply is not worth it. If your doctor or midwife is pushing you to have more than one ultrasound (I understand wanting one to check things out), examine the reasons and the possible results. Can anything really be done during the pregnancy? Usually not.

For those of you who are curious, I pulled this information from a magazine called "Pathways to Family Wellness". Other obstetrical procedures linked to autism include: mercury in pregnancy, including the Rhogam shot, flu shot, dental fillings, and fish. Other procedures linked to autism: induction, epidurals, restricted laboring positions, forceps and vacuum extraction, C-sections, and umbilical cord clamping. Of all these things, ultrasound was at the top of the list.

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The Dangers of Prematurity

I have really wrestled with what to write about from the Controversies in Childbirth Conference. We've been so busy around here lately, it's given me time to mull things over.

I will reference a talk given by Lucky Jain, MD, MBA from the Conference. I feel that the information he gave was so astounding, all should be made aware. Briefly, a short biography of Dr. Jain: He is currently the Richard W. Blumberg Professor and Executive Vice Chairman for the Department of Pediatrics at Emory University School of Medicine. He also serves as the Medical Director of the Emory Children's Center. In addition, he is an investigator at the Center for Cell and Molecular Signaling and holds a joint appointment in the Department of Physiology.

Obviously, a smart and well-educated fellow.

The information he gave was so well researched, clear, and concise, they let him go over on his time. He is the only individual that was allowed this privilege. I believe that if pregnant women had this information, they would make wiser decisions during pregnancy.

The topic Dr. Jain was speaking on was "Are C-sections Causing Premature Births and Adding to NICU Costs? I think we all know the answer to that question.

Babies are presumed to be "mature" at 34 weeks. He posed the question, is it safe to deliver a baby after this time? The answer is yes and no. 50% of babies born at 34 weeks will be in NICU. While we have decreased the rate of stillbirths in this country, prematurity has dramatically risen.

What are the long term effects of prematurity? Dr. Jain had a very distinct picture of a baby's brain at 35 weeks versus the brain at 40 weeks. There was a HUGE difference. The 40 week brain was significantly more developed.

Studies have found that 74% of handicapped adults were born between 33 and 37 weeks gestation. In addition, babies born before 37 weeks are five times more likely to be in special education by the time they are in kindergarten through fifth grade.

While the baby's body looks fairly well developed in the last trimester, this is the time when the brain is developing. Cholesterol, yes, you heard me right, and good foods, including proteins, are essential in the baby's brain growing and developing. Each week, day, even hour, that a baby stays in the womb is invaluable.

Another interesting item Dr. Jain addressed was Fetal Lung Fluid. I must admit, this was the first time I've heard of this. I took comfort in seeing that most of the other people in attendance didn't seem to know much about it either! According to Dr. Jain, fetal lung fluid is produced to inflate the lungs and pours out into the amniotic fluid. This is how the lungs are checked for maturity during pregnancy by checking the amniotic fluid. When labor is allowed to start on its own (no induction!), the valve that releases this fluid is shut off. The fetal lung fluid levels gradually decrease over the course of days leading up to labor. It really is true that the baby triggers labor. If a C-section is done without the onset of labor, the baby does not receive this message. This is a contributing factor to C-section babies having a more difficult time breathing. According to Dr. Jain, a C-section should NEVER be scheduled to take place before 39 weeks and it is crucial that the dates are correct. He felt strongly that it should be later than that, if done at all. The average in the US is 38.2 weeks, however. Remember, the average means that there are many babies being born on the lower end of that number. According to United Healthcare, if a baby is born before 38 weeks, he is twice as likely to be admitted in the NICU.

I hope you will ponder this information and share it with your friends and family who might be pregnant. The womb really is the best place to grow a baby -- not an incubator in the NICU.

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Appropriate Use of Intervention & Medication for Labor

By now, you know that I believe that fear is NOT a reason to have an epidural. The lack of education and preparation are the reasons, I believe, that the majority of American women choose to have pain medications in labor. This is also why women are choosing to have a C-section, never experiencing a single contraction -- fear.

You might be shocked to know that I believe that there are appropriate times for intervention and/or medication. I'd like to share such an experience one of my "DVD couples" had this past week. It's been several days since I spoke with her and I've had a birthday party for my 3rd child, a baptism, company, and Easter, all take place since our conversation. Some of the details are fuzzy, but you'll understand my point without all the details.

They were planning a homebirth and this was their first baby. Labor started on its own, as it should, and she labored for a number of hours with contractions about five minutes apart. They spaced out to 10,15, 20 minutes apart after a time. It would pick back up though and continue for hours at five minutes apart again. Several hours into the labor, she had an appointment with her midwife. She had a vaginal exam and found that her water had broken -- probably in the bathtub because she wasn't aware of that happening -- and was told she was 100% effaced and dilated 3 cm.

She continued laboring at home throughout the day. Her midwife checked in on her that evening and still, she was dilated to a three. This is where my memory fails me. I do not remember at what point they decided to go to the hospital, and really, it doesn't matter. She was near the 24-hour mark of water breaking, but everyone was doing fine. Her cervix just was not dilating. When she arrived at the hospital, they did start her on pitocin, but not terribly high. They also started her on antibiotics as a precautionary measure because of the ruptured membranes. It should be noted, there was no sign of infection. She labored this way for 4 hours and still did not dilate past a three.

I just knew this story was going to end with surgery. The doctor, who was the back-up doctor for the LM, suggested at this point that they increase the pitocin and she have an epidural. She had only slept a few hours during the labor and was exhausted. This was a hard decision for her -- I could hear it in her voice when she told me that she consented to the epidural -- but she made the right decision.

She slept during the next few hours while the pitocin took over. The next time she was checked, she had good news! Her cervix was dilating! She labored the last hour without pitocin or the epidural and pushed her baby out on her own.

Had she not listened to her medical team, who, I must add, was giving good advice, she would have had a C-section. Yes, she did not have the quiet, undisturbed homebirth she had planned for, and there will be some emotions there to deal with. But she avoided surgery. Why did this happen to her? Who knows. Maybe it was about the baby's position. Maybe she couldn't relax enough. Maybe she was apprehensive about giving birth at home, even subconsciously. She may never know. But she will, I believe, be able to have a peace about her birth. She used intervention and medication, not because she was afraid of the process, but because she needed that assistance.

I have another example from another DVD couple last fall. This was to be another out-of-hospital birth, but she went almost 3 weeks over her "due date." Her biophysical profile, etc., had been good, up until this point. Her midwife had become concerned, if I remember correctly, with fluid levels and thought she should go ahead and be induced at the hospital. She had a great back-up doctor. This mom was induced and labored without an epidural for many hours. She remained dialated to a nine for several hours when the cervix started to swell. This is not a good thing. They recommended an epidural so she could relax and sleep. It worked. She had a vaginal birth.

Sometimes, we (okay, I) focus so much on the "evils" of medicated birth, we loose sight that it can sometimes help avoid surgery. I would absolutely rather see a mom have a medicated birth than a C-section. These were good doctors who wanted the same thing for these moms. They respected their wishes and were anxious to help them achieve this goal. Many doctors would have just done a C-section on both of these women.

I can honestly say that I don't know what could have been done differently to avoid having medication or intervention in either of these labors. Had they not been planning out-of-hospital births to begin with, they likely would have ended up with c-sections earlier on. I do believe that planning homebirths, even though they both transported, were contributing factors to still having vaginal births.

Both of these women were educated and prepared. It reminds me of something our midwife with our 3rd baby told us: "Birth is 90% in your head and 10% what happens to you."

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Birth of a Family

I wanted to share this email from a DVD student that gave birth last weekend. I have wanted to put it up here all week, but it's been Spring Break and we were dog sitting THREE dogs. Darcy also had her 4th birthday party. So it's been a little crazy around here!

I enjoyed this birth story for a number of reasons. This couple, before switching to a midwifery group in a hospital, was with an OBGYN at a hospital with a 60% C-section rate. It took a lot of courage to change their birth attendant and birth place towards the end of pregnancy, but they are so thankful they did. FYI -- I left the names of the midwife, nurse, and hospital out of this story on purpose – you'll understand why as you read the story.

“We headed to the hospital around 11 am yesterday. Got there and they did an initial check. I was at 5 and a -1 station. The nurse we had was great. She brought in a birth ball for us, encouraged me to eat whatever I needed and drink as needed. I got in the bathtub/jacuzzi just to help me relax around 2. Transition set in probably around 2:40, and I started pushing around 3:00. We found out later that the policy at (the hospital) is not to let people have a tub birth, but at that point I wasn't getting up, and my midwife practice was awesome. They let me labor exactly how I needed to. We had never even considered giving birth in the tub, but it felt so great to be in the water that I didn't want to get out. Donna--I'm a pretty reserved person. I'm very polite--you know, the whole pooping thing. I made noises during pushing that I didn't know I was capable of. My throat is still sore today from my grunting. I didn't scream, but I was definitely loudly yelling. My midwife, told me at one point, "I know you feel like you're out of control, but you're completely in control. You sound great." It was very encouraging. The pushing was just like you described it, feeling like you have to poop, then the burning when the head is coming out. When he finally made his appearance at 4:41, he had the cord wrapped around his neck four times. I didn't even think to panic because the midwife and the nurse didn't at all. They just unwrapped it and immediately put him on my chest skin to skin. He pinked up right away. He's seven pounds even and 19 3/4 inches long. I did tear slightly, but it was in two places on my labia. My midwife said it wasn't bad at all. All in all labor was just shy of 12 hours. Much quicker than I expected.

So, my thoughts after this are that I'm so glad we went through Bradley. As soon as the birth was over I was able to get up, move around, hold my baby and walk the room with him, hug my family, and eat! It was so worth it to be able to move--and I don't feel like recovery is as big of a deal. Also, every time they checked the heart beat during labor it was nice and strong, around 150. The nurse and my midwife both told me later that if we had been on constant monitoring then they would have probably picked up distress with the cord being around his neck so many times, which could have ended up with a c-section of course. It's awesome that we knew what we wanted and were able to make that happen. Thank you SO MUCH for helping us with this! Also, I honestly believe if we had a doctor and the cord was wrapped around his neck, then they would have gone into emergency mode and I would have been separated from my baby. That might not be true, maybe I'm now skeptical of doctors, but I am SO GLAD we were with the midwives.

Kyle wanted me to tell you that he's sorry he couldn't get back in touch with you yesterday. His phone died, and I didn't have your number stored in my phone. Oops! He also wanted me to tell you thank you so much for all of your help--not just yesterday, but with the classes. We both are still on a high from the whole experience.”

First of all, hats off to the midwife and nurse for trusting this mother, her desires, and most importantly, her needs. They encouraged her to listen to her body and follow her instincts. They were even willing to "break the rules" in order for this woman to do that. They trusted birth. I also loved that they encouraged her to eat and drink in labor. They wanted her up and moving, not strapped to a fetal monitor, which, as mentioned, could have potentially led her to a C-section.

Anyone who has sat through my class knows I spend a lot of time talking about poop -- poop stories, as we call them. We have some good laughs about it, but it is a very serious issue for many women. So serious, in fact, that I've seen a C-section happen because she was so afraid of pushing out something other than just her baby. So, I loved her comments about being reserved and "polite" -- followed up with being shocked by the sounds she made as she pushed her baby out. I encourage women to sound out their contractions, which makes people uncomfortable when they are not exposed to natural birth and its associated sounds. Ina May Gaskin talked about this in "Orgasmic Birth."

Another item I wanted to address was the cord being around the neck four times. She must have had a long cord to do that! One in three babies will have the umbilical cord wrapped around their neck, so it is very common. The midwife will just slip it over the baby's head. I have heard this time and again as a reason for a C-section. Or I've heard comments like, "It's a good thing the doctor did a C-section because the cord was wrapped around the baby's neck," like the c-section saved the baby. It is very common to have the cord wrapped once or twice around the neck -- not so common to have it wrapped FOUR times! So glad they had a midwife to calmly handle the situation without all the unnecessary drama.

I had the opportunity to talk with her husband a couple of days after the birth and he was on a total birth high. This is something I see with couples who work together to give birth without medication or interventions: it brings them closer together and the men have a deeper admiration for their wives. The husband who sits back and lets the doctors take care of everything does not feel this same sense of accomplishment as the man who actively helps his wife give birth. This particular husband and new father simply gushed over what his wife had done. He said that it was "awesome" to see his "Southern Belle" do something so amazing. He pointed out how cool it was to see her give birth, and then after the placenta was born, she got up and walked to the bed with blood running down her leg. I think he thought she was amazingly tough, and yet so feminine! He said the next baby will be born at home! This is an experience that will be imprinted on his heart forever.

Congratulations Jessica and Kyle. Thank you for allowing me to be a small part of this experience in your lives.

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The "Big" Baby

Contrary to everything you may have been told, a big baby is a good thing!  Women have become afraid of giving birth to a big baby because their doctors, and even some midwives, have instilled fear into these mothers.  When a woman hears the phrase "birth trauma," do you think she's excited to start labor and give birth?  Of course not.  A woman's body is less likely to start labor when she is fearful.

How does your doctor know the size of you baby?  Ultrasound?  While ultrasound can be a useful device in estimating a number of things, when it comes to the size of the baby, it can be off by more than 2 pounds, either way!  So if you have a doctor telling you that you are carrying a 10-pound baby and a C-section is the way to go, you likely are NOT really having a baby that big.  Do not allow a doctor to conveniently (for him/her) cut you open because he/she is afraid of your "big" baby. They do not trust your body to give birth if they are recommending a C-section.  I have a lot of confidence in a woman's body being able to give to birth to the baby that her body allowed her to grow.

And what if you are carrying a 10-pound baby?  Congratulations!  My dad was 10 pounds, born at home.  So was his brother.  My grandma, who I lovingly call a "hillbilly," lived on the land. She ate the food she grew.  She knew where her food came from.  And she grew healthy, big babies.  

Most women are afraid to birth a big baby because they are afraid they will tear at the time of birth.  You are actually more likely to tear with a smaller baby than a bigger one.  How can this be?  A small baby tends to come through the birth canal faster and the skin, or perineum, doesn't have as much time to stretch.  A bigger baby allows the skin more time to stretch over the baby's head.  I've seen women be fearful of a bigger baby, because, surely if they tore with a 6-pound baby, an 8-pound baby would be dreadful.  Just the opposite is true.  

I have a lot more to say on the subject of tearing, episiotomies, etc., but I'll reserve that information for those lucky enough to take my class!  Wink, wink. 

I would also like to point out a very important statistic:  The #3 reason for a C-section in America is for CPD, or cephalopelvic disproportion, but only 1/2500 women actually has this very rare condition.  This is when a doctor says that your baby is too big to fit through your pelvis.  The only way for a doctor to truly diagnose this condition is when a woman is in labor and has spent a considerable amount of time pushing or has had an X-ray.  No one is going to do an X-ray on a pregnant woman, let alone in labor!  

We all know the tiniest women who have birthed 9 and 10-pound babies.  You cannot tell by looking at woman's hips whether or not her baby will fit through them.  During labor, there are hormones released to help soften the cartilidge within the pelvis.  It shifts with the baby, allowing more room for him or her to pass through.  The baby's head will also mold to fit through. Understanding the process of birth instills confidence in this natural process of the baby passing through the pelvis.  

True CPD was more common in the 19th century when a lot of women had suffered from rickets, causing the pelvis to be misshapen. Very rarely does a mismatch occur with the baby's size and the mother's pelvis, but there is no way for a doctor to prove it, so it is used as a diagnosis very often, even in pregnancy when a woman has never even experienced labor!  Give me a break!

Let's talk about that "birth trauma" we hear so much about.  Specifically, shoulder dystocia, is seen more often with bigger babies, but certainly not as common as the doctors make it sound. This is when the head is born, but the shoulders are "stuck."  Honestly, the baby doesn't have to be huge for this to happen -- just to have really wide shoulders.   A doctor will usually deal with this by giving the mom an episiotomy and then by breaking the baby's collarbone.  Ina Mae Gaskin, who I consider to be the nation's leading midwife, has a different approach, called The Gaskin Manuever:  have the mom get on all fours and lift a leg.  This will release the baby's shoulders. I have done this with one of our births.  It's amazing.  

Briefly, let's contemplate what is believed to be a "big baby."  What do you believe to be a big baby?  If 7 1/2 pounds is average, does that mean anything over that is "big."  I don't believe so. I do not consider a baby in the 8 pound range to be "big" -- just healthy.  We want this!  I, personally, think that once a baby is over 9 pounds, they are "bigger."  I love asking moms that have "big" babies if they tore, and I am constantly amazed by the amount of moms that say no, or very little.  

I had a mom in my class a few years ago that gave birth to a 12-pound baby with a 1st degree tear.   She gave birth in a hospital with a midwife.  Her family and friends couldn't believe that no one knew the baby was going to be so big.  They insisted that if she'd had a doctor instead of a midwife, they would have known.  I made the point that if she'd had a doctor who was expecting a 12-pound baby, she would have had a scheduled C-section and not the wonderful birth experience that she did.  

 

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Why NOTJust a Hospital Childbirth Class?

After the home water birth of our third child, it was becoming evident that I was going to have to teach childbirth classes. I was bombarding every pregnant woman I encountered with information about why natural birth was the best (remember, I have done it both ways) and she shouldn't even consider the epidural. I found myself warning moms-to-be about the interventions in the hospital she was certain to encounter. I loved playgroups and baby showers, as they were places that these topics were certain to arise.

Abby was nearing her 2nd birthday when I finally decided to send in my application to be a Bradley instructor. I was consumed with information on natural birth for the next several months. I lived and breathed it. I had some anxiety about how I would get students in my class. The internet, even in the last 6 years, has come a long way. The Bradley website was in its infant stages, for sure.

I remember calling one of the local hospitals and talking to them about teaching natural childbirth classes there. She laughed and told me, first of all, that no one wants a birth without medication; and second, I would not be allowed to teach Bradley in a hospital. The curriculum was set. I would not be allowed to teach why an IV is not necessary, or why intermittent monitoring is safer for mom and baby than continuous fetal monitoring. The list goes on and on.

Yes, I would have more people in my classes, but I would be working for the hospital. Not for my couples. I could not teach them about evidence-based care. I knew immediately I couldn't teach in a hospital. Women deserve to be informed. I, as an Independent Natural Childbirth Educator, do not work for any doctor, hospital, or even a midwife. I work for the couples I teach. I am not restricted on the information I can teach. Most childbirth educators in the hospitals are extremely frustrated by this, and yet, their hands are tied.

Here is a rare-known fact: A hospital needs to maintain an 80% epidural rate in order to keep an anesthesiologist on the clock 24 hours a day. It's big money. Every intervention racks up a bigger bill. The hospital wants you to have the epidural! They don't want you to have information that will empower you to make better choices that will cost them money. This is absolutely true. U.S. hospital policies are based on financial considerations. They are not based on evidence, research, or good medical care. Birth is the largest source of income for American hospitals totaling more than $50 billion dollars on childbirth, more than any other country in the world, and yet with some of the worst outcomes in infant and maternal mortality.

Don't you see the irony? It's a natural process, that, if allowed, doesn't need intervention. But what a money-maker. It reminds me of "A Bug's Life," where the ants do whatever the grasshoppers say because they are afraid of what might happen if they don't. The grasshoppers know that the ants could overpower them in numbers, but they do everything they can to intimidate the ants to "keep them in their place." The grasshoppers even convince the ants that there are bigger bugs that they will protect them from, but in reality, the only ones they need protecting from is the grasshoppers. Don't you love the end of the movie when Flik sees the fear in Hopper's eyes and he realizes that they are stronger than the grasshoppers, that it is the grasshoppers that need them -- not the other way around?

And so it is with the doctors. They create fear. Childbirth classes in the hospital prepare you to be a good patient, not a good consumer. You are told what to expect when you get to the hospital. There is no preparation for natural birth. It's not "if" you have an epidural, but "when" you have an epidural. Notice the way it is phrased, also. The epidural is given ownership. Women say "my epidural," not "an epidural." The nurses say things like, "Honey, you better get your epidural now while you still can."

If you are giving birth in a hospital, I actually do encourage you to take your hospital's childbirth class so that you know what they expect of you. Learn their policies. I've been told by people who have done this that the hospital is like "training wheels" for my class!

People are reading this blog all over the country. If you are interested in doing my class by DVD, great. I'll get you all set up. Regardless of whether you are able to take my class, you need to be in an independent class, outside the hospital. Be sure your instructor works for you and no one else. You'll get the evidence-based information you need and deserve.

Women don't need all this craziness surrounding birth. We certainly don't need to be spending the kind of money that we do in order to get our babies out of our bodies. Your body will do that all by itself, for free.

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The Needs of a Laboring Woman Are More Easily Achieved at Home

A woman is labor has specific needs. These include darkness, solitude, quiet, abdominal breathing, physical relaxation, the right to move around in different positions as she needs to, and support and encouragement from those around her. These are not in any particular order.

In "Orgasmic Birth", midwife Ina May Gaskin talked about how birth used to take place in a woman's bed, likely the same place the baby was conceived. When birth moved from the woman's bed to the hospital, everyone pretended that there was no sexual nature to birth. When a woman feels free to make laboring sounds, she sounds like she's having (great) sex. This makes people uncomfortable. The drugs used in childbirth take care of this "problem".

Some women are, what I call, silent birthers. Some are not. It really doesn't matter which category she falls into. What does matter is that women feel free to do whatever they need to during their labor and birth. Often, a woman who is vocal during labor is perceived as not handling labor well. This is not at all true. Deep, abdominal breathing and sounding it out as she exhales, is very beneficial for mom and baby. Baby is getting good oxygen and mom's vocal cords remain open and loose. It's very hard to tense up when she's breathing and sounding out her contractions in a low relaxed voice. I have a friend whose husband had kidney stones a few years ago. He found himself using some of the Bradley techniques they'd learned with the birth of one of their children. He said that he definitely learned that the low, controlled sounds were much more soothing and relaxing than the high-pitched sounds that created tension.

A woman no more wants to be watched in labor than she does when she's having sex. I'll return to a comment from Ina May (gotta love her!) that we have "shy sphincters". It's no wonder women are diagnosed with "failure to progress" so often. A woman really needs to be left alone to labor. It cannot be rushed. Adrenalin is the opposite hormone from what a woman needs to release in labor, which is oxytocin. If an animal is laboring, she will go off by herself, to her home where she feels safe and knows her surroundings well. If she suddenly feels threatened by a predator (in this case the doctor threatening a c-section), adrenalin kicks in and labor will stop. It will only resume once she feels safe again. In a hospital, this opportunity usually does not present itself again, as the baby was most likely surgically removed from its mother's body. Bottom line -- a woman needs to labor where she is comfortable and not rushed or watched.

Bright lights are not conducive to relaxation. Imagine if you dimmed the lights right now in your room. Wouldn't you automatically feel more relaxed and private? Bright hospital lights are often the first thing a new baby sees after its birth -- not very relaxing to the baby either.

A woman in labor is "in labor la-la land" when she doesn't have drugs in her body. She is listening to her body and focusing on controlled breathing, relaxing, imagining the baby coming down and her cervix opening up. When people are talking in the room, it is extremely distracting to most women. The fewer people in the room, often the better. But in the hospital, a woman has little or no control over who is in the room at her birth. At home, she has total control over this and will usually put a lot of thought into exactly who she would like to attend her birth. She is very comfortable with this group of people.

I have written quite a bit about EFM, or Electronic Fetal Monitoring, on this blog, but it must be mentioned here again. A woman must move around in labor. Not just for her labor to progress, but to help her baby out. When the uterus contracts, it tips forward. When a woman is laboring on her back in a hospital bed, it hurts. When you are chained to the bed by the EFM, you cannot move. This is bad for your labor and bad for your baby. This is not good medicine. It is a legal issue. End of story. When a woman labors and births at home, this is not a concern. Her midwife will monitor the baby at least once an hour, which evidence has proven to be adequate. A baby truly in distress will be picked up.

Birth is a natural process. When I say this, everyone agrees. But I think that there are very few people who believe in the natural process of birth and trust it. Women are missing out on this wonderful experience because they are afraid. They are not bonding with their babies as they should. They are not breastfeeding as often or as long as they should. What is wrong with us?

I hope this has been helpful to those who think that it is irresponsible to birth at home. When you understand the needs of a laboring woman, you can start to understand how the hospital is not set up to cater to these needs. If a woman wants to have a truly natural birth, free of interventions, the only place she can do that in America, is in her own home, in her own bed.

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Some Hints to Avoid the "Drama" in the Hospital

The last post I wrote about dealt with choosing a home birth over a hospital birth. I got some great comments, but this one brought up a great question.

Anonymous said...

I check your blog a lot, and I have a question. I have one baby and much of the 'drama' happened to me. After reading your posts, it kind of "clicks" as to why certain things may have happened. I didn't have a C-section but almost had to. I am not one who loves drama, but I just didn't know.
Anyway...my question. I plan on having more kids, and honestly, most likely in a hospital again. (don't hate me) What all can I do away with as far as normal procedure at the hospital. You mentioned vaginal exams in this post. Is that mandatory if birthing at a hospital? What are some things you would suggest that I request (or demand) at the hospital next time.

This was my response:

""Anonymous," I loved your comment/question. First of all, let me just tell you how pleased I am that you have picked up some of the reasons for the "drama" in your previous birth through my blog and will do things differently next time around. Been there, done that!

Second, I don't hate you (!!) for wanting to have your next baby in a hospital! If you are not comfortable birthing outside of a hospital, your labor and birth will be harder, not better or easier. Being comfortable with your birth place and attendants play into your "emotional relaxation." You need to do what feels right to you.

Based on what you said in your comment, I assume that you will most likely switch your birth attendant and/or hospital and will not be having medication with the next baby. I assume you had meds the first time around.

With those assumptions in place, I do have some suggestions. First off, in order to avoid as many routines in the hospital as possible, you really need to labor at home as much as possible. Think of birthing at the hospital, not laboring there. No induction, as that automatically puts you on that road of intervention and possible C-section.

You are choosing to birth in the hospital, so there are some routines that will be unavoidable. These include: initial vaginal exam, initial monitoring strip (usually 20 min.), blood pressure check, etc. Some of these are not such a big deal, but others are. If you are chained to a fetal monitor (EFM) the entire labor, you will not be able to help your baby out with the use of gravity and movement. These are essential to labor. Intermittent monitoring is worth fighting for.

I don't know where you live, and all hospitals have different policies, so it's important that you find out their monitoring policy. This is a legal issue, not a medical one. In fact, medically, you are better off to have intermittent monitoring, usually once an hour through a couple of contractions and between them as well. A baby who is truly in distress will be picked up. (The fact that you will not be induced or have drugs in your system has greatly improved your chances that your baby will not be in distress.) EFM has a high false-positive rate and has contributed heavily to our outrageous C-section rate in this country. You will find that hospitals that do not require continuous monitoring have a lower C-section rate. This is often a hospital policy, but it's possible that your doctor or midwife will sign that off in your chart that intermittent monitoring will be fine for you because you have no drugs in your system. If you have drugs, of course, you actually do need to be monitored because of the dangers to the baby.

Another policy to avoid is the routine vaginal exam. The number two reason (followed only by a repeat C-section as #1 reason) for a C-section in this country is "failure to progress." I like to call it, "failed to progress on our time schedule." If a woman is left alone, without the pressure of performing, feeling comfortable with the people attending her birth, supporting her, she will give birth in her own time. The hospital is very unlikely to let you hang out laboring for longer than 24 hours. A lot of the time, we think of this as an issue of the time limits enforced for a broken bag of waters (another topic for another day), but I see this all the time. Insurance is also an issue here. They don't want you laboring, taking up space, for 40 hours. If you are not having vaginal exams (which really don't mean a darn thing), they can't tell you that you are not dilating. Again, you need to know the hospital's policy and also your doctor's. If you both come to an agreement that is acceptable to you, make sure it's in your chart. Better yet, labor at home and be dilated to a 7 by the time you get to the hospital! This will solve a lot of problems.

"Middle Aged Mama" had recommended a doula. I would tend to agree. Recently, I had a student who was at a hospital that had some crazy policies; no walking after your water has broken, continuous monitoring, and vaginal exams every 2 hours. What labor can progress under those circumstances?! No wonder North Texas has a 50% C-section rate! Their doula got them to agree to intermittent monitoring, being out of bed walking the halls even though her water had broken, and vaginal exams every 4 hours (still too excessive in my book), but great improvement. It was a long labor and without their doula advocating for them, I am almost certain this woman would have had a C-section.

As far as "demanding" your wishes, I feel like that is never a good idea. It is crucial that you do the footwork early in the pregnancy, interviewing and touring the hospitals in your area. I liked the advice to talk with other women who have birthed there recently. A piece of advice, however, be sure that they had the kind of birth that you want. If they loved their doctor and hospital but had an induction, epidural, and possibly a c-section, I'd suggest looking elsewhere!

Be prepared (I'd love to see you in my class -- DFW area -- or take my class online!). Be polite. No one wants to be accommodating to a rude, bossy woman, or father, for that matter! Kindness and knowledge will get you closer to the birth you desire.

Know your options. Change providers or hospitals if you have to. You will only give birth to this next baby one time. You can do it. It's YOUR birth."

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