Not that we didn’t know this already…

…but reducing the rate of Pitocin reduced the rate of emergency C-sections and vacuum or forceps deliveries. Click here to read the whole article. One thing that was (negatively) intriguing to me, is that the hospital’s Pitocin rate prior to the change was 93.3% — almost every woman planning a vaginal birth (at least, I assume the numbers would exclude planned C-sections; and didn’t include postpartum Pitocin use) got Pitocin either to augment or induce her labor. Even after the protocol change, over 3/4 of the women still received Pitocin.

h/t to Empowering Birth for the link

Also, in light of the whole “Pit to Distress” conversation, the above article had a link to a AJOG paper, which it cited as evidence for suggesting that pitocin not be increased more frequently than every 30 minutes (although many hospitals currently increase it every 20 minutes). The paper had the following abstract:

Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes and was recently added by the Institute for Safe Medication Practices to a small list of medications “bearing a heightened risk of harm,” which may “require special safeguards to reduce the risk of error.” Current recommendations for the administration of this drug are vague with respect to indications, timing, dosage, and monitoring of maternal and fetal effects. A review of available clinical and pharmacologic data suggests that specific, evidence-based guidelines for the intrapartum administration of oxytocin may be derived from available data. If implemented, such practices may reduce the likelihood of patient harm. These suggested guidelines focus on limited elective administration of oxytocin, consideration of strategies that have been shown to decrease the need for indicated oxytocin use, reliance on low-dose oxytocin regimens, adherence to specific semiquantitative definitions of adequate and inadequate labor, and an acceptance that once adequate uterine activity has been achieved, more time rather than more oxytocin is generally preferable. The use of conservative, specific protocols for monitoring the effects of oxytocin on mother and fetus is likely not only to improve outcomes but also reduce conflict between members of the obstetric team. Implementation of these guidelines would seem appropriate in a culture increasingly focused on patient safety.

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The “D” Word

I really just don’t like the word “delivery” in reference to the birth of a child. I just hate it. I didn’t used to think this way, and I commonly used it like everyone else. But when I gave birth to my first child, I had such a feeling of empowerment that I just couldn’t bear to think that I had been “delivered.” Nor did it ever seem like my baby was in danger, and needing “deliverance” from my body.

From the OneLook Dictionary Search, here are the “quick definitions” of the word deliver:

verb: carry out or perform (“Deliver an attack, deliver a blow”)
verb: save from sins
verb: deliver (a speech, oration, or idea)
verb: utter (an exclamation, noise, etc.) (“The students delivered a cry of joy”)
verb: bring to a destination, make a delivery (“Our local super market delivers”)
verb: throw or hurl from the mound to the batter, as in baseball (“The pitcher delivered the ball”)
verb: hand over to the authorities of another country
verb: free from harm or evil
verb: give birth (to a newborn)
verb: pass down (“Deliver a judgment”)
verb: relinquish possession or control over
verb: to surrender someone or something to another (“The guard delivered the criminal to the police”)

In general, the word deliver means to take from yourself or your possession or your control and give it to another (such as a pizza delivery guy), or else it means to save from a negative outcome (as in God saving you from your sins). Even in “deliver a speech” the thought is that you have an idea in your head that you take from your brain and give it to the people in your audience. But did you notice that not one of those “quick definitions” says that “deliver” means the act of catching a baby at his or her birth. Yet isn’t that one of the most common usages?

When I had my second baby, I didn’t call the midwife in time, so my sister caught the baby. I can’t tell you how it grated on my nerves to hear my mother and everyone else say, “You know that Lisa delivered him!?!” Oh, she did, did she?? And what did *I* do, sit on my thumbs all day?? All the focus was on my sister who showed up just a few minutes before the birth, and who simply did not drop the baby. Where is “delivery” or “deliverance” in that?

In the old days, as you can see from reading the King James Version of the Bible, which was first published in 1611, it was said when Mary gave birth to Jesus, that she “brought forth her first-born son.”

In Jane Austen’s book Sense and Sensibility (written exactly two centuries later), one minor character gives birth, and the birth announcement in the newspaper said that she “…was delivered of a healthy son…” While this shows that the verbiage was changed — deliver is in the passive sense, rather than the active “bring forth” — it still has much of the focus on the woman or the birth-passage itself, in using the word.

Fast-forward yet another two centuries, and we see that when we say that someone “delivers” a baby, we refer almost exclusively to the person who catches the baby — it may be a doctor, nurse, midwife, passerby, or someone else, but the woman is not even in consideration at all, except if she catches her own baby, in which case it is usually said with much surprise — “Did you know that she delivered her own baby??” How did we get to this point — to go from all women delivering their babies to no women doing so?

This is not just a matter of semantics. Words are powerful! I don’t like “deliver” because of the passivity it currently implies — at least in the area of birth — as well as the emphasis it places on the birth attendant, to the exclusion of the women who do the work of birth. How many women look to their doctors for salvation, unnecessarily? How many women look to their doctors to bring their babies out of their own bodies and into their own hands (perhaps by way of forceps, and almost always by way of the hands of several other strangers, and many times with an enforced separation of hours in those first precious hours after birth). Of course, sometimes doctors do actually deliver mothers and/or babies from harm — they save them; and they do deliver the baby from the woman’s body to her arms by way of a beneficial C-section. How much better it would be, though, if women could harness their own power, and feel their own ability in giving birth, rather than looking to those who are outside their bodies to see how to do it. What a change occurs when women give birth, rather than are delivered!

So, as long as the word “deliver” means the one who receives the baby at birth, I do not use it to describe the act of giving birth (with rare exceptions). Yes, I have it as a tag sometimes; and it is implicit in “Labor and Delivery”; but for the most part, I simply refuse to use the word. Which makes it difficult when talking about when the placenta follows the baby, because it sounds weird to say that “the placenta is born.” I suppose that’s what it is, but the typical clinical term is the “delivery of the placenta” which I don’t like. However, I do occasionally use that phrase, simply because it’s easy, and as long as the mother births* the baby, I’m okay with the placenta being delivered.

[Yeah, I know “birth” is technically not a verb, but that is a discussion for a future post.]

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Vertical birth

Here is an article entitled, “Peru Embraces Vertical Births to Save Lives.” How does birthing in an upright position save women’s lives? That’s a good question, because here in the good ol’ U.S. of A. most women give birth in a horizontal position, or some variation thereof, and our maternal mortality is less than that of Peru. Here’s how — women in Peru were hesitant to go to doctors, medical clinics, or otherwise place themselves in the hands of medical professionals when they were giving birth because they didn’t want to be in a horizontal position. So, Peru is encouraging these medical professionals to let the women give birth in old-fashioned, natural positions. This means that more women are going to doctors in the first place, and these women who are generally poor and at higher risk than the average American woman are going to be giving birth in a place where they can get quick medical help if necessary. The article mentions a woman who had to hike several hours from her home to the nearest medical clinic. Being several hours away from the nearest medical help is nearly unknown here in America, where most people probably live within an hour’s drive from a hospital. But there’s more to it than just that.

Peru’s health ministry has said vertical birthing positions can be healthier for women by reducing pressure on the uterus and large blood vessels that can affect the amount of oxygen going to the baby. Standing or sitting during childbirth also tends to reduce labor and delivery time, according to the health ministry, and allows the mother to watch the birth better than if she were lying down.

This link has some really good graphics of vertical positions — most of the typical drawings that depict labor or the birth of the baby show the mother in a horizontal position.

One of the commenters on this excellent blog post said,

After giving birth, it really seems like a special form of torture to force a woman to birth on her back. My worst contractions were the ones that happened when I was lying in bed. Agonizing.

Also in the comments, a doctor chimes in with how she helps women into good (vertical) positions, even when they’ve had epidurals — I strongly suggest that anyone who is currently pregnant or who may have another baby read those comments and bookmark the page for easy reference, so that you can know (and show your doctor, nurse, hospital) that it can be done, and some doctors are doing it! It’s far from typical, and you may need to do some serious campaigning and lobbying to assume these positions (even without an epidural when you have full control over your own body, but especially with an epidural when you’ll probably have to rely on nurses to help you into position), but it is so much better for you and the baby.

I’ll pull a couple of quotes from that doctor:

I have a policy of no operative vaginal delivery without trying a full squat first, and it almost always works. [This means no forceps or vacuum.]

My nurses were way skeptical at first, but after seeing a few babies come sailing out quickly in a squat they are all big believers now….

[On moving mothers numbed by epidurals] The hardest part is moving all the wires we have going with an epidural – external fetal monitor, external contraction monitor, urinary catheter, IV, epidural line, and blood pressure cuff. We have it down to a science now, though – we unplug everything that unplugs, pull all wires to one side, flip or move the mama, and replug everything in, passing them under the mama’s belly if we’ve moved to hands and knees. I enforce with my labor clients and my nurses that the mama’s comfort is our number one concern and the monitors are our job to keep track of. So mama moves as she needs to, and we chase the cords.

[She talks about how an active-birthing mom was very active during and between the pushing contractions…] Finally, she pushed out the baby’s head in a squat but almost sitting over one leg, so that leg was flexed and the other one a little extended, and then for baby’s big, tight-fitting shoulders, she first knelt, then leaned back on her hands and lifted her hips in the air and the little linebacker finally slid out…. The thing that always impresses me about a spontaneous second stage in an upright mother is that it’s not a matter of getting in one position and pushing the baby out, but most mamas move frequently including during contractions. In the 3 long pushing contractions she had, she probably changed position 15 times – and with that baby’s kind of sticky shoulders, I’m glad she was freely mobile and able to wiggle all over and push him out! That, in my experience, is what a true upright birth looks like! Most docs, though, would be driven nuts by having the baby be such a moving target (of course he was never more than a couple inches from the floor and could have easily just slid onto the pads on the floor) and having to get on the floor themselves.

For my own part, I cannot imagine lying down to give birth. It’s just too weird and unnatural. I was in hands-and-knees position for both births, and it was very beneficial. The pushing phase in my first birth lasted 40 minutes and I did have a 2nd-degree tear, although the baby was only average size; and my second birth took just a few contractions, no tears, and the baby was just a bit over 9 lb.

I just had to add a postscript here, because I just read something that totally boggled my mind. It was a comment from one L&D nurse on another L&D nurse’s blog, and she said that she had one mom with a “thick epidural” pushing in a semi-upright position because the woman had such severe nausea and vomiting when she was lying down. The doctor came in, and chastised the nurse because the mom was in a semi-sitting position. He believed that women could push better lying all the way down, because the baby had a better chance of going under the pubic bone. Somehow I doubt there is any evidence to support this hypothesis, yet a lot of evidence against it.

The Birth Survey

If you are pregnant, or gave birth within the last 3 years, you have the opportunity to participate in an exciting project! Go to The Birth Survey website to find out more about it.

There is so much on the website, it’s impossible to just pull out the best parts, because then I’d end up copying and pasting almost everything, but here is just a taste:

The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.

Whether you had (or are planning) a drug-free, intervention-free birth or a scheduled C-section or anything in between, I encourage you to participate in this survey. Information given will be beneficial for all women, to let them get the type of experience they are wanting. Did your care provider lead you to believe that you would have the type of birth experience you wanted, only to change all the rules once you got into labor? Other women need to know that. Did you have to fight to get an epidural? Other women need to know that. Did you have an awesome L&D nurse? Other women need to know that.

With approximately 4 million births each year, that means that there are 12 million women who can give their opinions and experiences. This could transform maternity care in the United States!

Can I refuse…?

People often have a question about what they can refuse, when it comes to pregnancy. I’m not really sure why they even question it, except perhaps just because they’re so used to doing what they’re told to do without questioning anything. This post is inspired by a question somebody put into a search engine and came across my blog. The short answer is, yes, you can refuse anything you want! This is still a free country, right? Until you become a ward of the state, or are given a court order for something, you can refuse any medical procedure. Whether it would be wise, beneficial, or risky to do so is another question entirely.

In thinking on this question, I remembered a column a woman wrote about her experience when placed on bed-rest during pregnancy. Much of the column was about how mind-numbingly boring it was, and how difficult it was to lie in bed day after day, week after week. She did some research and found that bed-rest has been prescribed for generations for all types of pregnancy ailments, but very little research has actually been done on whether or not it is even beneficial. Apparently, her doctor told her that there was no guarantee bed-rest would help, but he recommended it anyway. She could have refused. Why didn’t she? Because a person in a white coat suggested it. She says that she was “placed on bed-rest,” even though the doctor could say he merely suggested it. It’s true he didn’t enforce it, but that is what happens when the medical professionals are given that amount of authority in our own minds — a suggestion becomes a command.

Henci Goer wrote in The Thinking Woman’s Guide to a Better Birth, in a discussion on why VBAC hasn’t become routine (p. 163),

Reluctant doctors like to believe that hey haven’t much influence over their patients, but that is clearly not the case. Several studies have found that when doctors genuinely encouraged women to have VBACs , most of them did, and when they said nothing or acted neutral, most women didn’t. Finally, when obstetricians discouraged VBAC in women who wanted to try it, none of them did.

So, can you refuse things? Yes. Anything short of a court order. This goes for vaginal exams, ultrasounds, electronic fetal monitoring, IVs, hep-locks, enemas, restrictions on food and water, restrictions from moving, etc. Hospitals have policies set in place partially by their insurance companies to protect them from malpractice claims. You may have to fight, and it may not be pretty, but you as a patient have rights. You may not like to deal with the hospital staff who disagree with your choices — I’ve heard some down-right nasty comments from offended and rude nurses. But it’s your call. Technically, anyway.

Priceless Birth Pyramid

An Epidural Story

I once watched an episode of “The Baby Story” on TLC, in which the woman (a first-time mom) planned on having an unmedicated birth. She took no childbirth classes, had no information prior to going into labor on how to achieve that goal. My sister was like that–just assumed that since women had been having unmedicated births since the dawn of time, that all she would have to do is “just say no to drugs” and it would happen. Little did she know how difficult it would be at the hospital.

Once my sister was admitted to the hospital, she was made to stay in bed. This was supposedly so the umbilical cord wouldn’t prolapse, but the possibility of that happening is extremely small. If the cord doesn’t prolapse when the water breaks, then it almost never does–like one in a million chance, regardless of what the mom does, or what position she is in. My sister was told to lie in bed and be still so the EFM could monitor the baby’s heartbeat. She wasn’t even allowed to get up to go to the bathroom….but they wouldn’t bring her a bedpan when she requested it. So, she unstrapped herself and went to the bathroom, and then the nurse came in and scolded her for taking off the monitor.

In this particular video birth story I saw, the mom is admitted to the hospital, and does everything “by the book.” After a few hours of lying on her back in bed, with a blood pressure cuff on one arm and an IV in the other, she has reached her limit. She so terribly wants an unmedicated birth, but she just doesn’t know how to accomplish it–the contractions are just hurting too badly. Yet, as I watched her, I realized that she did actually know what to do–she just didn’t understand that what she wanted to do was what she needed to do. She thought that she had to follow hospital policy, which included forced bed rest and continuous fetal monitoring. She thought it was best for her baby, safest for her child to stay in bed, unable to move.

Here is what I saw: she was lying in bed resting between contractions, then another contraction would start. She would lie still as long as she could, and then start whimpering and shifting her body around–unable to really move, because of her arms being essentially tied down with machines, and her belly strapped to the monitoring belts. She was valiantly trying to make it through the contraction in that position, which I can say from personal experience is one of the worst positions to be in during a contraction. What I saw was this woman having to force her body to stay in the “proper” position, while her whole being was trying to move into a different position. What she needed was to be off of her back, but she couldn’t do that and do what the hospital wanted. So she chose to be a “good little girl,” and she was in a lot of pain, because she was lying on her back. I was literally yelling at the woman through the TV screen to get off her back. And I could tell that her body was yelling at her to do the same, but she just wouldn’t listen to it. She listened to the “experts”, instead of her body. Now, who do you think was more expert in what she needed for labor–some nurse she didn’t know, or her own body?

After suffering through multiple contractions in that position, she whimpered to her husband, “I…. just…. need………. something.” She didn’t want drugs, remember. She also didn’t ask for “drugs,” in particular. But she needed something to be able to make it through the contractions. This isn’t because contractions are necessarily so horrible that all women need drugs or should take them–it’s because lying on your back during labor is usually about the worse position to be in, and makes the contractions much more painful. The “something” that she needed was sympathy and support from her husband (he was her only labor companion), but even more so, she needed to be in a better position. Her husband, knowing she had wanted to go without drugs, softly asked her if she wanted an epidural. Defeated, she nodded her head and accepted the epidural.