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Friday, 29 August 2014 11:05

My Birth Shame: A Doula's Confession

Shame and guilt appear to be accepted aspects of motherhood. There is very little a mother can do that doesn’t make her susceptible to being shamed into feeling like a ‘bad mother’. If you formula-feed, you are denying your child a healthy start. If you breastfeed past the first year, you are a hippie attachment parent who can’t let their baby grow up. If you go back to work early, you are abandoning your child. If you stay home, you have no ambition (I have done ALL these things by the way). The list goes on…

 
Shaming also extends into the birthing world, and birth shame is personally something that I have carried with me for some time now. When I was pregnant with my first son I had planned the birth that many doulas dream of. I had the midwifery team, the doula, my home birth supply list, and even a spot in my backyard picked out for planting my placenta. It was going to be a peaceful, primitive and undisturbed birth experience, complete with rainbows and unicorns. Well, it turns out (in case you didn’t know) that things don’t always go as planned, and I ended up in the hospital at 36.5 weeks facing an induction.


Induction is a bad word in the birthing community. It should be avoided like the plague! And I was a doula, so shouldn’t I know better? Shouldn’t I be ‘informed’ enough to know the risks? Against what I was taught I went ahead with the induction. After 12 hours of labor my son was born, and was immediately whisked away to the Neonatal Intensive Care Unit (NICU). Instead of making memories of our first gazes, or taking pictures of his tiny feet, I was left in the birthing room without a baby. Were my choices the reason that my baby was in a cold incubator all alone? Was I the reason that we missed out on those first precious moments together? My shame convinced me that our mother-child bond was compromised by my failures. All I could see was that I hadn’t been good enough, that I hadn’t tried enough, and that I hadn’t been smart enough. Maybe if I had refused Pitocin, the birthing process wouldn’t have been so hard for my son. All the things that I could have done differently swirled around in my head.


As a doula, I felt somewhat like an imposter for not having the intervention-free birth that I had envisioned. I would share my birth story with other moms and doulas, but I felt the need to justify all of my actions and to explain all the medical reasons that led to an induction so that I wouldn’t be judged. Luckily, with time, the shame simply morphed into disappointment. I was soon pregnant with my second and I had convinced myself that I would do things entirely different this time around. But unfortunately many of the same problems that plagued my first pregnancy started creeping up again, and it looked like my rainbow-coloured home birth was just a fantasy.


After 37 weeks of a very emotional second pregnancy, I made the decision to be induced before my medically necessary 'deadline date' (cue audible gasps). I was exhausted and worn down by a difficult pregnancy. And I was sick of being treated like a ticking time bomb. I was done with the blood tests, the ultrasounds and the non-stress tests. I was just done. I knew it was the ‘wrong’ choice to make, and I carried a lot of shame over it. I didn't tell anyone about my choice (until now!) because I was afraid that I would be judged by other moms, and by other birth professionals. But after some self-reflection I have realized that it wasn’t the wrong choice to make, because it was the right choice for my family in that moment and it involved so much more than simply weighing the medical benefits and risks of an induction. My fears, my hopes, my past experiences, my knowledge, my insecurities, and the information I was given were all factors in my choice to be induced. And people can judge my birth choices all they want, but I am no longer going to let their judgments cause me shame. I am proud of myself, and I am proud of my births.

 


Being a mom can be the source of so much guilt and feelings of failure. Let’s not make birth one more thing that we fail at as moms. Let’s support each other and the decisions that we make, even if they were ‘uninformed’, or based on fear or pain. Let’s watch our words and our thoughts, because they can have a big effect on how a woman remembers her birth experience. Let’s not project what we feel is an ideal birth onto someone else…it may not be what they consider ideal at all. And let’s focus all of our 'judgey' energy on making the maternity care system better, and not on shaming the women within the system.

Published in Birthing Styles

When it comes to birth, there are so many options and so many questions to think about it is enough to make any mother's head spin.  Should I consent to cervical checks? My provider is talking induction, is that a good choice for me? While every mother has the right to make a decision for herself and for her child, those decisions can be difficult when you don’t know the facts. Listed here are a few of your options in birth, along with the pros and cons of each. When you educate yourself on your birth choices, you are more likely to do what you feel is best for you and for your baby. You’re also more likely to have positive feelings about your birth experience.

Inductions have become very common.  The rate of induced labor was as high as 23% by 20091. It is suggested that the rate of induction is as high as 42% (possibly higher in some areas) as of 20122. A medical induction of labor typically consists of a vaginal suppository such as Cervidil, or Pitocin given via intravenous line, the use of a Foley catheter, or sometimes by additional methods or a combination of two ore more methods. Sometimes inductions are used for medical purposes, when baby needs to come out quickly but mom wishes to try to avoid a cesarean. Others are “elective” inductions.

Perhaps mom wants to induce labor because her pregnancy is difficult and/or she is tired of being pregnant. In some cases, the birth is to be scheduled for a convenient date. In other cases, the mother has talked to her provider and has been convinced that induction is a good way to go. In some instances it is suspected that she is carrying a large baby that will only get larger and more difficult to push out, or perhaps the baby is full- or post-term. For some mothers, knowing that they will have their baby in their arms by a certain date brings them relief and they are more comfortable with that. 

Inductions CAN be beneficial at times. If mom has a medical problem and continuing the pregnancy poses more of a hazard for baby than letting him continue to grow undisturbed (such as preeclampsia, diabetes, kidney disease, or cancer), the benefits for an induction for mom and baby may very well outweigh the risks. 

Induction can be beneficial to mom and baby depending on different factors. If it is medically indicated that the baby needs to be born sooner, induction may be the way to go. And in many full-term mothers and babies, induction is successful. If the cervix is favorable and baby is ready, an induction can go smoothly and without any complications. But medical evidence (such as a high cesarean rate of 1 in 3 mothers4) indicates that if mom and baby are healthy, it is best to allow baby to come when he is ready. Check out the Bishop Score (a tool used to predict how successful an induction may be) and talk with your provider for more information on risks and benefits associated with induction of labor.

However, an induction can make labor more difficult. In many hospitals, it is common practice to require induced mothers to be hooked up to an IV, a blood pressure cuff, and to external fetal monitors due to the increased risks. For most women who wish to remain active in their labor, this can prove to be an issue. It is difficult to remain mobile when you are tethered to so many machines that have short cords. Medications used to induce labor such as Pitocin can trigger unnaturally strong and irregular contractions, which sometimes come without a break in between. For some mothers, these contractions are too painful and they request an epidural, which has risks of its own and may lead to birth by forceps, vacuum extraction or cesarean section.

For most low-risk pregnancies where mom and baby are both healthy, an unnecessary induction of labor can carry more risk of harm to both than benefits. For the first time mother, an induction of labor more than doubles her risk of a cesarean section3. Since there is no way to be absolutely certain of how far along a mother is in her pregnancy (unless she is 100% sure of her conception date), there is always a risk of inducing a baby that is not ready to be born. Some mothers have electively been induced only to realize that their baby's lungs were not fully developed, and that their baby was a lot smaller than previously estimated. 

Sometimes induction doesn’t work for mother and baby, or it has undesired results. Inducing agents can cause fetal distress, or in rare cases, uterine rupture- which can be an emergency situation. In some cases where the mother has an unfavorable cervix, induction doesn’t work or baby becomes distressed, ultimately resulting in a cesarean section.

For some mothers, they are unsure whether they wish to have a vaginal birth or to opt for a cesarean birth. A cesarean birth has its pros and cons. By acquiring knowledge on the topic of cesarean birth, you can make the best decision for yourself and for your baby.

A cesarean birth has some perks. For the percentage of women who fear the pain of labor and/or the pushing phase of birth, a cesarean birth may be preferred.  Other mothers wish to have a set date for their baby to be born versus going into labor at what may be an inconvenient time. In some cases, it is thought that a mother’s pelvis is too small for her to birth vaginally. Vaginal birth after cesarean (VBAC) is not an option for her so she opts for a cesarean delivery. A mother who delivers by cesarean without being in labor will typically not have the soreness, nor any tears or stitches associated with a vaginal delivery. She will not be in labor for hours on end; in a scheduled cesarean section a baby can be born within the hour, then mom and baby will be sent off to their recovery room and/or nursery.

A cesarean delivery also has its downsides. While it can be a lifesaving procedure, medical evidence indicates that when used for convenience rather than necessity, a cesarean delivery may pose more health risks for both mother and baby5

For baby, risks are minimal but include risk of being cut. Risks to baby are also similar to induction risk in the sense of scheduling a cesarean too early and baby being born prematurely. For mother there are more risks6. There are immediate risks of hemorrhage, infection, of medical supplies being left inside the abdominal cavity, of other organs being damaged, of blood clots of the leg or lungs, or in very rare cases, risk of death. Evidence shows that mothers who deliver by cesarean are more likely to develop adhesions from scar tissue, or to have problems with future pregnancies (for example: infertility, miscarriage, and problems such as placenta previa or placenta accreta)7. 

Postpartum, a mother who underwent a cesarean delivery will typically have a longer, more difficult recovery as she has undergone major abdominal surgery. She will have to keep an eye on her incision to be sure there is no sign of infection or it doesn't open, and the incision will have to remain clean and dry. Caring for a newborn is difficult even without having undergone surgery, so mom will need extra help if possible. 

When giving birth, you have many options and many decisions to make. Mothers can benefit from doing some extra research over the course of pregnancy. Learn about all of your options, along with the benefits and risks of each, and make the best decisions for your family. Talk with your partner and care provider and discuss your preferences and birth wishes. 


Sources


1. Care Process Model: Management of Labor Induction 2012 Update. https://kr.ihc.com/ext/Dcmnt?ncid=51061830

    Surprising Facts about birth in the United States. http://www.babycenter.com/0_surprising-facts-about-birth-in-the-united-states_1372273.bc?page=3

2. State of Maternity Care. http://www.improvingbirth.org/2012/11/state-of-maternity-care/

3. Time for a Change? Induction of Labor Increases Odds of Cesarean Delivery. http://www.theunnecesarean.com/blog/2010/8/2/time-for-a-change-induction-of-labor-increases-odds-of-cesar.html#sthash.bYYuSWTI.dpbs

   Induction of Labor. http://ican-online.org/induction-labor

   Labor Induction Boosts C-Section Risk. http://health.usnews.com/health-news/family-health/womens-health/articles/2010/06/22/labor-induction-boosts-c-section-risk

4. Why is the National US C-Section Rate So High? http://www.childbirthconnection.org/article.asp?ck=10456

    Cesarean Birth (C-Section). http://www.medicinenet.com/c-section_cesarean_birth/article.htm

    C-Section Rates in US Stabilize After Eight Years of Steady Increase. http://www.news-medical.net/news/20120619/C-section-rates-in-US-stabilize-after-eight-years-of-steady-increase.aspx

5. Pros and Cons: Elective C-Section. http://abcnews.go.com/Health/story?id=3291512&page=1

    ACOG: Vaginal Delivery Recommended Over Maternal Request Cesarean. http://www.acog.org/About_ACOG/News_Room/News_Releases/2013/Vaginal_Delivery_Recommended_Over_Maternal-Request_Cesarean

6. and 7.  Risks of a Cesarean Procedure. http://americanpregnancy.org/labornbirth/cesareanrisks.html

    C-Section: Risks. http://www.mayoclinic.com/health/c-section/MY00214/DSECTION=risks

    Cesarean Section- Risks and Complications. http://www.webmd.com/baby/tc/cesarean-section-risks-and-complications

Friday, 08 February 2013 18:00

The Cascade of Interventions

The Cascade of Interventions aka the Snowball Effect

In a hospital setting where your care providers are actively managing your labour, once you have one intervention it makes more interventions more likely to be needed in order to remedy the effects of the previous ones.

In our Western society culture, there has been a tendency to turn pregnancy and childbirth into a medical experience. One intervention can lead to another in a cascading sequence of questionable procedures, many made necessary only because of a previous intervention.

We are lucky to live in the time of modern medicine, however medical interventions such as labour induction, pain relief, and cesareans—measures that have saved many lives—have been overused.

When you intervene uneccessarily with nature's role, generally there is a waterfall of effects that occur because one things leads to another.

Doctors need to inform their patients of all the risks instead of assuming we don't need to know. It is our bodies, after all...

Facts - did you know that:

  • The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent.
  • In the past twenty years, the cesarean section rates have nearly quintupled in the US to 23.8% in 1989 and nearly quadrupled in Canada to 18.3% in 1987-8.
  • Of 11,814 women admitted for labor and delivery and attended by midwives to 84 freestanding birth centers in the US, 15.8% were transferred to the hospital and 4.4% had a cesarean section. Although the women were lower than average risk of a poor pregnancy outcome, their cesarean rate is one-fifth of the national average.

This is a wonderful representation of how one intervention can snowball into the next from "Thinking Woman's Guide" by Henci Goer.

1. Changing into the hospital gown

Putting on the hospital gown shifts the balance of power from woman to hospital.  Her perception of herself shifts, and she sees herself as a patient, in the care of “experts,” rather than as a woman confident in her ability to birth on her own terms. This simple act may also make the woman feel less comfortable, feel cold or she may be concerned about modesty as well, which increases stress and makes relaxation harder.

2. Continuous Electronic Fetal Monitoring (EFM)

The major effect  of continuous EFM is that it keeps the mother immobile in bed. The use of EFM is not evidence-based, and even ACOG (American Congress of Obstetricians and Gynecologists) admits it has had no effect in improving outcomes for babies .  Evidence shows that Intermittent EFM with a handheld Doppler is just as effective as continuous EFM at identifying babies in distress.  The only effect continuous EFM has had is that it has increased the cesarean section rate.

3. Getting the IV

IV’s restrict a woman’s mobility and make it easier to administer fluids and medications that can interfere with natural birth.  Sometimes, IVs can be helpful, especially if a woman is unable to tolerate oral hydration, or in an emergency situation.  In normal labor, women need to be free to move their bodies throughout labor, and should be encouraged to change positions frequently.  Having an IV can hinder that. The IV is also simply uncomfortable, annoying and may interfere with her focus on relaxing with contractions as well and make holding hands with her support person more uncomfortable or impossible. Even a hep lock can be bothersome in the same ways. The perception that having an IV readily available is helpful in an emergency is not evidence based. Many times this IV port is not working well enough to handle an emergency and must be restarted.

4. Labour Augmentation with Pitocin

The use of synthetic oxytocin (Pitocin®) makes labor more painful for the mother, and more difficult for the baby to tolerate. There are studies that show Pitocin may interfere with the body's natural ocytocin hormone production which may hinder the mother's natural efforts in the pushing stage, may contribute to postpartum hemorrhage and may interrupt her bonding with her baby, contributing to postpartum depression. http://www.birthresourcenetwork.org/resources/54-pitocin-the-whole-story

5. Pain Relief

Because the contractions are so intense with Pitocin, the mother frequently will choose to receive an epidural for pain relief.

6. Restriction of Movement

An epidural keeps a woman confined to bed for the duration of the labor and birth.  Being unable to move restricts the woman’s ability to help her baby get into a good position for birth. It may also hinder the baby's ability to move, too.

7. Contractions Slow Down

Epidurals can slow labor progress, which results in increasing dosages of Pitocin® to increase contraction intensity and frequency, which can lead to an even greater need for pain relief and greater risk of fetal distress.

8. Progress Slows or Stops

Assuming the woman reaches full dilation, the epidural can interfere with the woman’s ability to push effectively.

9. Fetal Distress

Hard contractions, combined with reduced blood pressure and the lack of blood flow to the baby, can cause the baby to go into distress.

10. Cesarean Section

After having exhausted all of the tools at the obstetrician’s disposal, this one option remains.

 

 

Published in Labour

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