Awareness

It's April again... it seems to come faster and faster every year. And I'm back-- I know, I said I was done, but... well, in birth advocacy, it seems there's no "done" until every baby and every mother has the best birth possible under their respective circumstances. Of course this year was special: it was an ICAN conference year, and the conference was wonderful, as always. It went too fast (as usual) and I didn't get nearly as much accomplished as I'd hoped, but I wouldn't trade that four days for anything. We are truly "gentle angry women," and I am honoured and proud to join my sisters in what has become a sacred pilgrimage every two years.

Now... Awareness. It seems like a simple concept: being in the moment, experiencing life as it comes. In practice, awareness is exquisitely difficult, at least for me-- in terms of the cesarean epidemic, it's excruciating. Let me illustrate.

The CDC numbers are out for 2009 (the most recent statistics); the United States currently boasts a 32.9% cesarean rate. That number has risen every year for the last thirteen-- and it's more than double the highest rate recommended by the World Health Organization. Effectively one-third of all women giving birth in this country are having their babies surgically removed, exposing them and their infants to risks that include haemorrhage, infection, injury to bowel and bladder, respiratory difficulty, and, yes, death... now, or in later pregnancies. C-sections are no laughing matter; they are most assuredly not "just another way to have a baby. That said, many of these surgeries are undoubtedly necessary, and certainly when they are everyone involved is glad that there are skilled surgeons available to intervene. But in the majority of cases, surgical delivery is not warranted, and too often, mother or baby suffers because of it. Baby has transient tachypnea of the newborn that devolves into neonatal respiratory distress syndrome, leading to a stressful (and costly) stay in the NICU. Mom develops a wound infection and has to be re-hospitalized. Breastfeeding relationships are compromised. In a future pregnancy, mom is diagnosed with placenta accreta or another problematic placental issue that can lead to uterine rupture (yes, even without attempting that controversial VBAC thing), placental abruption. The end result can be utter devastation.

And this has what, exactly, to do with awareness? Well, I'm getting to that. Firstly, being aware means understanding that all of the above goes on every single day. True, most cesareans come off without a hitch-- "mother and baby are doing well," as many an excited new father has announced proudly to his friends and family. But... not always. And we should never lose sight of the fact that terrible things happen: while one mother is recovering without incident and enjoying her new baby, another is... not. I refer you, for example, to  the heartbreaking story of Liz Logelin, which now graces the New York Times bestseller list, thanks to one remarkable father and his determination to turn his personal tragedy into inspiration and support for others.

I work in maternal-infant health. It's a rare day on my unit that we don't get a c-section up from L&D. Some are scheduled, elective surgeries that are usually (but not always) repeats. Others are non-elective-- rarely true emergencies, most are what I would term unnecesareans, which Jill discusses much better than I can. Usually these are the "failed inductions"-- moms are brought in and given drugs (pitocin, cytotec) to force them into labor. Too frequently, they don't work-- well, of course not, since any sensible pregnant body will fight against such a thing to protect itself and its offspring-- and then it's off to the OR. "Time to get this baby out," the OB will say, when in reality he's probably thinking, I really don't want to be up all night, clinic will be a bear tomorrow, and I'm tired of listening to the wife nag when I'm late again for dinner, so let's get this over with right now. Mom is exhausted, confused, frightened; she readily agrees when the experts tell her that her baby is in distress and if they wait much longer he could die. When it's all over, the OB comes out covered in glory-- he saved the baby, after all!-- and mom is just grateful that all's well that ends well.

I see this scenario over and over. So often, in fact, that I and all my coworkers consider it routine. Another c/s coming to room 3. Get an IV pole and a pump for the SCDs. CBC for in the morning. Clear liquids now, regular diet in the morning. Foley catheter out and dressing off in 24 hours. Epidural stays in till post-op day 2; expect discharge on POD 3. No big deal; it's just another delivery.

But it's not. And that is so hard to keep sight of, day in and day out. I don't know what my hospital's cesarean rate is (they are not required to release those numbers to the public, just to the health department, and the stats are lumped in with those from the county's other hospitals), but based on what I see, I would expect it to be higher than the national average-- probably at least 35%, maybe closer to 40%. On some days it's much higher-- there was a string of Fridays back in January and February where we were doing 5 or 6 sections each day, which was 75-100% of the total deliveries on those days. Coincidentally (!), our NICU admissions soared during that period as well...

Commonplace. Routine. So normal, in fact, that a day without a surgical delivery is remarked upon by nurses, doctors, even housekeepers. How does one maintain awareness, then, in such an environment?

I tell myself every work day that, even though for me it's just another day at the grindstone, for my patients, it's the beginning of the rest of their lives. They will remember what I will not. It helps... but not enough.

So. It's April again. Almost May, now. I renew my promise, every year, to cultivate awareness in my life, to be fully present for these new mothers and families, for the babies who are welcomed earthside in what believe to be less than optimal circumstances. I bear witness. It's all I can offer.

Just about to that point...

... when I think I have to throw in the towel and say, "I'm done."

The caesarean rate keeps climbing, even when the birth rate in the United States actually goes down. Intervention rates continue to skyrocket. No one actually seems to care, except the minority of us who do, and we keep talking in circles. There is a bare handful of individuals who are walking the walk, so to speak, but I don't seem to be one of them.

So, I'm done. For now, anyway. Ironic that it's on Solstice Day. The Wheel keeps turning, but I seem to stay firmly in place... doing no one any good at all.

Brightest Blessings to you all, with all my heart. Peace of oak and ash and thorn, of root and crown, of leaf and bough, of earth and sky. Of wind and water... of well and womb.

And love. So much love.


~Willow

I Can Dream, Can't I?

Jill over The Unnecesarean posted this a few days back: "Obstetric Violence" Defined as a New Legal Term in Venezuela. It is, in a word, awesome. I would dearly love to see this enacted here in the States. I mean, read this:

The following acts executed by care providers are considered obstetric violence:

    (1) Untimely and ineffective attention of obstetric emergencies; (2) Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available; (3) Impeding the early attachment of the child with his/her mother without a medical cause thus preventing the early attachment and blocking the possibility of holding, nursing or breast-feeding immediately after birth; (4) Altering the natural process of low-risk delivery by using acceleration techniques, without obtaining voluntary, expressed and informed consent of the woman; (5) Performing delivery via cesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman.

I mean, how incredible is that?? Seriously? Could it be any clearer? Medical personnel may not interfere in birth unless they are explicitly requested to do so. Okay, so it doesn't say that precisely, but that's the take-home message: When we want your help, we'll bloody well ask for it!

I'm not an idiot; I know perfectly well this would never, ever fly here in the US. (And truthfully, I doubt it's well-enforced in Venezuela-- but yay them for even codifying it!) It's all about liability and CYA and the almighty dollar. Maternal and child health come in way behind in terms of importance and influence-- still later comes any value placed on the childbirth experience, for mom or baby. Those of us who do value the experience-- who see it as a rite of passage, as seminal event in a woman's life, something to be honoured and empowered-- are accused of selfishness or derided as "hippies." Which brings me to another pertinent (and fabulous) blog post of recent vintage, here at The Truth About Traumatic Births, which succinctly and politely explains how every mother is entitled to frame her birth experience any way she pleases. One woman may view her cesarean as a life-saving God-send; another may see it (as, I confess, I do) as nothing short of brutalisation and near-death. Those of us who fall in the latter category are not horrible selfish people and evil mothers who placed our birth experiences over our children's wellbeing... but I digress.

Bright Blessed Autumn!

Fall is my absolute favourite time of year-- the crisp air, the falling leaves, the way the light seems to slant at an angle. It's also an incredibly busy time for us in the birth world-- babies, babies everywhere! We joke at work that we're reaping the consequences of all those holiday parties nine months ago.

Unfortunately, more babies means more atrocities, at least where I work. More cesareans... more mothers subjected to unnecessary surgeries, more infants struggling with the effects of being not-quite-term due to elective inductions and c-sections. It's frustrating and demoralizing, and I've decided to do something about it-- but more on that later. For now I just want to wish you all joy of the season, what I think is "the most wonderful time of the year," and offer heartfelt blessings of wind and branch, storm and sea, earth and sky. Bendithion!

Blogroll

I don't know how may blogs you follow, but these are some recent MUST-READS, in case you missed them. I love, love, love these writers!

Kmom is my heroine and my inspiration-- I want to be her when I grow up! Here she takes on elective inductions, and this one is her latest in a series on healthy birth practices.

And speaking of heroes-- this guy rocks my world! Check out his latest on the Joint Commission Core Measures for Birth, then see what he thinks about birth locations, should he ever have to choose one. Finally, here is his wife's amazing homebirth story (which sort of answers the question above!).

It's hard to be a birthkeeper in a culture that doesn't value birth-- and it's even harder to feel compassion for those who can't admit that their births have caused them hurt. My friend the VBACWarrior manages both, and I think she is simply incredible.

Jen keeps tabs on all the research and calls physicians to task when they deserve it. Her evidence is unassailable, and she disseminates it to the public at large. Her website is the best around when it comes to pulling together all the pertinent news about birth.

Finally, Monica is spreading news and offering support to both English- and Spanish-speaking moms on Poder y Parto (Power and Birth). In this one she eloquently explains why mothers matter as much as babies where birth is concerned.

Who am I missing? I'm sure there are quite a few-- let me know if you see any blogs I need to be following, 'kay?

Blessings of a lovely spring (which always reminds me of birth),

Willow

Cesareans: A Rant for CAM

I have opened the "new post" page half a dozen times, meaning to start something (anything!), but I keep getting distracted and forget what I was thinking about or where I was going with it. Nothing seems to stick... I know I have stories to tell, opinions to elaborate upon, but when I actually sit down to write, my mind goes blank. It's like Blockbuster Syndrome: a well-documented (by me, at least) disorder in which one wants to rent a movie, one has a mental list of several films one would like to see, and then when one enters the video store, it's "Movie? I wanted a... what? Video? What's that? Um..." Very, very frustrating.

(If I were clever, I would now present some interesting obstetrical analogy here. Rest assured, I have nothing.)

So. It's Cesarean Awareness Month once again! Yes... let's go with that.

I kicked off CAM with an elective primary section. Well, not me, personally, of course. My patient, a 24-year-old primigravida, delivered her son by cesarean on Friday... for absolutely no reason at all. There were no indications-- nothing in her history to necessitate major abdominal surgery. The OB's dictation states "The patient, over the course of this pregnancy, has requested a cesarean." There is no indication that he counseled her about her apparent fear of labor and delivery, or tried to dissuade her in any way from taking what is unquestionably a more dangerous route for herself and her child. He finishes, rather weakly, "She does show some signs of CPD."

Um... CPD? Really? Really?? Forgive me; I know "CPD" is a convenient label, the diagnosis of choice for physicians wanting to justify their surgical terminations of their patients' pregnancies. But shouldn't one give a baby a chance to negotiate the pelvis before pronouncing it "disproportionate"? How, exactly, does one diagnose "cephalopelvic disproportion" without allowing the passenger to give it a go, so to speak?

This gargantuan baby, by the by-- so monstrous as to be unable to fit through his mother's pelvis, according to the OB-- weighed in at a whopping 7 lbs, 11 oz. And the mother came from recovery complaining of intractable pain-- pain that took several doses of morphine to manage,leaving mom too groggy to breastfeed initially-- so baby is now on formula. Chalk up one more success for the American way of birth.

Here's another one: a 17-year-old sectioned on Friday-- a few hours after my patient-- is walking the halls. When asked, "Why did you have your cesarean?" she replied, "Because I was 38 weeks and my baby wasn't in the birth canal."

/jawdrop/

Honestly, what is wrong with these obstetricians? Why is that acceptable-- to cut open a teenager and give her such a ridiculous reason for it? In reality, this girl was a failed induction: after 12 hours of pitocin (cranked up to the max, no doubt), she did not dilate past 3 cm. Why? Because she wasn't ready to go into labor. Her baby was not ready to be born!

Does she know that? Of course not. She trusts her doctor. He said so; it must be true. I happen to know-- because a friend of mine was at the nurses' station and heard the conversation-- that the three cesareans that were performed back-to-back-to-back last Friday (that's not including the scheduled elective primary I alluded to above) were done for no more pressing reason that the respective OBs (including the 17-year-old's doctor) wanted to be done with their patients. In the words of my friend, another obstetric nurse, "They didn't want to mess with them all weekend."

That's right. Three babies were surgically removed from their mothers because three OBs didn't want their weekend plans interfered with. Tell me, please, whatever happened to "First, do no harm"???

The mom who elected her cesarean is hurting. She asked me earlier, with tears in her eyes, "How long is it going to hurt like this?" I could only tell her that I didn't know, it varied from woman to woman, but that it would get better... slowly but surely. And in my heart-- I shouldn't admit this, but I'm human-- I couldn't feel totally sorry for her... because she chose this, you see. She elected it.

Cesareans suck. Recovery hurts, even without the added challenges of caring for a newborn. Didn't she think to ask? Did she think that by circumventing labor, she would avoid pain? Why didn't her doctor tell her what she was in for?

Judging by the patients recovering from cesareans today on this floor, doctors play all their cards close to the vest. They don't see fit to share much information with anyone. Can I blame a primip for fearing labor-- something she's probably seen only in idiotic Hollywood depictions-- when it's the OB, the so-called expert in birth, who perpetuated the fear and granted her wish for an unnecessarean?

How to Have a Hospital VBAMC

It's difficult-- nearly impossible, in some parts of the country-- to find an obstetrician who will agree to "let" a mother attempt to use her vagina for its biologically mandated purpose once she has had a cesarean. As access to hospital VBAC gets more and more rare, many moms opt to stay home, choosing to labor and birth with a midwife or on their own. Others, though, still want to have their babies in the hospital, but refuse to submit to a repeat cesarean. These mothers may plan to stay home as long as possible in labor, waiting until the last moment to notify their OB and go to Labor & Delivery. Sometimes this works-- "showing up pushing" can mean that even a VBAC-wary doctor won't have time to object, when they walk into the room and the baby is already crowning. Other times, though, the ploy fails: there are many horrible stories (see Jennifer Block's Pushed for details) of mothers arriving in the emergency room in hard labor, and being forced instead to undergo a stat section. One dear friend experienced just that: as she neared the end of a perfectly normal labor, she was wheeled into the OR, screaming, "I do not consent!" No one listened; she was cut against her wishes. Another brave mom I know had her crowning baby shoved back up the birth canal and then removed surgically-- again, without my friend's consent.

If having a hospital VBAC is difficult, finding someone to attend a VBAMC (vaginal birth after multiple cesareans) is that much harder. Even though ACOG itself admits that two c-sections are not an absolute contraindication to VBAC, it's a rare OB who will agree to attend a trial of labor for a VBA2C, and only then if the mother has had a previous vaginal birth (not necessarily a VBAC). Higher-order VBACs(those occurring after three, four, and even more cesareans, as documented here) by Kmom in hospitals are nearly unheard of; the majority of OBs, and even many midwives, consider the risks unacceptable. In fact, there are few studies that look at VBAMC, and a recent study even suggests that VBA3C moms face risks comparable to any other VBAC mother. Of those risks, the most loudly trumpeted is uterine rupture-- something a mom who wants to labor after multiple cesareans is likely to be told is nearly inevitable in her case, even though this assertion is not supported by the evidence. Faced with this fearmongering tactic (referred to by birth advocates as the "dead baby card"), most would-be VBAMC mamas back down, defer to the "expert" obstetrician, and schedule a repeat cesarean-- which will be coded as "elective"-- and honestly, who can blame them? Aren't doctors supposed to know best-- aren't they there to protect our interests as patients, to keep us safe? To do no harm?

It is well to keep in mind that physicians are human, and humans, no matter their ideals or sense of altruism, are ultimately most concerned with their own best interests-- precisely why every pregnant woman, regardless of circumstance or desired birthplace, must educate herself and become her own number-one advocate. ACOG is, first and foremost, a trade union, and it does what such organizations do best: it protects its members. Obstetricians, because they deal intimately with such a life-changing (life-beginning!) process, are targets of litigation- because in our society, if something goes wrong with a delivery, if a family is presented with a so-called "bad baby," they naturally look for someone to blame. It's common wisdom among OBs that "the only c-section you get sued for is the one you don't do"-- in other words, if a baby sustains injury or lasting damage during a vaginal birth, the first question a lawyer seeking reparations will ask the OB is, "Why didn't you do a c-section?" (Or, in this day and age, even "Why didn't you do a c-section sooner?")

Fear of litigation drives medical care in this country, especially where mothers and babies are concerned. Obstetricians pay some of the highest malpractice insurance premiums in the business. So perhaps it's understandable that they panic in the fact of what they see-- what they are conditioned to see-- as unacceptable risk, such as VBAMC.

Dr Wells (note: all names and a few details have been changed, in compliance with HIPAA laws) must have experienced a chill when he got the call from the medical exchange Wednesday night: his 25-year-old patient, Anne, was in labor. Anne has three older children: five, three, and eighteen months. Anne has had three c-sections.

At just 37 weeks' gestation, Anne hadn't expected to go into labor. Her (arbitrarily and probably unwisely) scheduled fourth c-section was still a week away. When she realized that she was having regular contractions only a minute or so apart, it dawned on her that she might behaving this baby sooner than later. She went to the nearest emergency room-- at a small local hospital with no L&D and no maternity services. She was triaged, and the ER nurse quickly determined that she was definitely in labor: Anne was completely dilated, with a bulging amniotic sac. Dr Wells was paged and implored to come, stat!

Dr Wells hit the road running. As soon as he arrived at the emergency department and checked Anne, he called for her to be taken to the nearest OR at once. The staff balked; they did not have the necessary equipment on hand for a cesarean, much less to care for a late preterm infant. Dr Wells-- who, it must be said, is well known for his colorful vocabulary-- cursed and called the nearest large hospital with a level III neonatal intensive care unit, demanding that they send a team at once. The NICU staff demurred, stating-- quite reasonably-- that they would be unable to provide a comprehensive neonatal resuscitation team, with all the requisite personnel and equipment, in time. The physician argued, insisting that a nurse and respiratory therapist must jump into an ambulance at once and drive at full speed to attend a stat section fifteen miles away. Again, the NICU declined, at which point the nurse manager was treated to an unexpurgated rant by the OB.

And Anne? She was still in labor, and within twenty minutes of the irate doctor's arrival, she delivered a healthy seven-pound baby girl-- vaginally, without complications of any kind, right there in the ER. Mother and daughter were transported to the larger hospital, to our mother-baby floor, where I was privileged to care for them until they went home yesterday. When I asked her how her recovery was going, she laughed and said, "It's a world away from a c-section!"

When her OB rounded, he spent less than a minute in his patient's room-- and nearly half an hour with her chart. Dr Wells's main concern, it seemed to me, was to fully document the incident-- concerned, as always, that a lawsuit of some kind might be in the offing. He wasn't interested in the implications: Anne had escaped major surgery-- a surgery he had mandated-- and had instead had an uncomplicated VBAC. She and her baby were happy and healthy-- isn't that all that matters?

Not to this obstetrician. He had lost control of the situation. Instead of a calm, routine cesarean, he was forced to race across town in a mad dash to catch a baby in a hurry. Apparently, non-bankers'-hours obstetrics are not his cup of tea. Will he encourage VBACs for future patients? I doubt it. Will he permit Anne to labor again, if she becomes pregnant in another year or so? Unlikely... he will probably scare her to death with what-if tales of horror, and insist that she submit to a cesarean at 36 weeks. What's one more preemie, if he can continue to circumvent birth?

I'm at a bit of loss, myself, as far as how to feel about this story. I'm thrilled for Anne, who had a quiet everyday miracle of her own in a rural emergency department. But I'm honestly not sure she understands what she accomplished-- or how she did it. I don't know for certain that she's ever even heard the term VBAC-- I'm positive, given that Dr Wells has delivered all her children, that she has never been offered the opportunity to even go into labor, much less have a vaginal birth. If she gets pregnant again, will she go back to Dr Wells, knowing what she does now? Will she demand a VBAC, or will she schedule another section?