"Don't eat... the #1 Cause of Death During Labor is Aspiration!"

(Title taken from one of my most loved/loathed blogs, www.myobsaidwhat.com)

The New York Times recently summarized the results of a study on eating and drinking during labor. Conventional practice forbids eating and drinking everything, except some ice chips here and there. Reason for this: if Mama has a full stomach (even of liquid), she could vomit and choke while under general anesthesia during a c-section. But general anesthesia is only used for emergency c-sections, because it is the fastest acting type of anesthesia. Most c-sections are not emergent, however- the nice thing about labor is that it usually lets you know something's wrong well in advance. Mama usually has at least an hour, usually many more, of bad signs (irregular fetal heart rate, meconium, weaker and spaced out contractions, stalled dilation) before the decision of a section is even brought up. And in that hour, maybe you transfer from home or birth center to the hospital, and in the hospital, your doctor or midwife starts taking some necessary interventions to avoid that section. So if you do make the decision for a section, you get a regional anesthesia, mosey on over to the operating room fully aware and not nauseous, without the danger of aspiration. But given this usual c-section course of events, mamas are still forbidden to eat or drink.

(I HATE ice-chips. Some people like them but I despise them. When I'm thirsty, I drink, I don't chew and hurt my teeth with stupid, useless ice chips. When I'm in labor, even if I'm in a hospital and they don't let me have anything but ice chips, as soon as that nurse leaves my room, hand me my liter of coconut water and I'll be a happy girl.)

In the Times article, a doctor spoke about this antiquated reasoning using a great parallel: ' “My own view of this has always been that you could say one shouldn’t eat or drink anything before getting into a car on the same basis, because you could be in an automobile accident and you might require general anesthesia,” said Dr. Marcie Richardson, an obstetrician and gynecologist at Harvard Vanguard Medical Associates in Boston.'

Thankfully, the study found that there is NO harm or benefit to eating or drinking during labor. Some hospitals are finally lifting the ban on drinking, so women can drink if they want to. Yay!

But I'm interested in the study's claim that there is no benefit to eating and drinking during labor. The uterus is a muscle, and muscles need hydration and energy in the form of carbohydrates in order to work effectively. I've heard a number of doctors and midwives say that proper hydration is crucial to the effectiveness of contractions and mamas' energy when pushing time comes. And I've seen that when contractions slow and become less effective, midwives and doctors blame dehydration and push liquids or IV fluids. I couldn't read the whole study, unfortunately, so I couldn't tell if every woman in the study had an IV- I have a feeling that they must have, if eating and drinking had no benefit. With an IV, extra liquid is indeed unnecessary, for the mama's purely physiological functioning.

But what about her emotional functioning? I believe so fully that labor is the most intense example of the mind-body connection. When women feel strong, they birth strong. Their emotional state sends cues to their body, telling their body whether the environment is safe enough for a vulnerable baby to enter. If mama feels out of control, can't make decisions for herself, feels trapped, her body is going to read that and slow its birth process, because there must be some danger in her environment causing her to feel that way, and her body won't risk allowing a baby to enter into that environment.

Imagine: you've been laboring for 15 hours without anything to drink. Your mouth and throat feels like cotton and all you get is three or four ice chips every twenty minutes. Forget about plain old discomfort in your mouth- what about some compassion? Someone to actually listen to you, validate your frustrations, instead of threatening you with death during an emergency c-section, when the question of a c-section, nonetheless an emergency c-section, hasn't even been raised. Before, you were thirsty and tired. Now, you're worrying about an emergency c-section and vomiting into your lungs. What kind of message does that send to your body? Maybe your body says- there's way too much anxiety here for a baby to be born. Then you've got a self-fulfilling prophecy (well, nurse or doctor or midwife self-fulfilling prophecy): they say c-section, and a few hours later, you get c-section. Not necessarily because they forced it on you when they decided, but maybe because that one tiny remark set off a chain of events in your body, preventing the birth of your baby in any way except surgically.

So, enough with the pessimism, because the results of this study are wonderfully promising. I promise, my next post will be a happy one- just like more births will be if women eat and drink as they please.

Nina's Needlepoint!

It's finished! She's going to put it on a pillow, which we'll put on our designated breastfeeding chair at Metro Minis. Don't worry, I'll also document the progress of the pillow...

Unnecesareans

The WHO recently released results of a survey in which they found that nearly half of all births in China are surgical. China's c-section rate is 46%. I hate to get over-dramatic, but this is appalling. Not because I'm so ideologically attached to vaginal birth, but because this is actually really, really dangerous. The WHO recommends that a nation's cesarean rate should be no higher than 10-15%. Above 15%, the risks of cesarean surgery outweigh the advantages to moms' and babies' health. Looking at it from another perspective, that means that, under ideal maternity care conditions, only 10-15% of labors will truly necessitate surgical intervention in the form of a c-section, and 85-90% of labors will progress normally and safely.

So, to explain why, when the cesarean rate is above 15%, the risks of c-section surgery outweigh the benefits to mom and baby. These risks exist with any c-section, but when the life of the mom or the baby depends on immediate delivery, these benefits of saving the lives of the mom and her baby outweigh the risks of the surgery alone.

But when a c-section is done on woman whose labor falls into the 85-90% that are normal and healthy, mom and baby are exposed to these pretty scary risks completely unnecessarily. Immediate risks to the mom include: infection, surgical injury, blood clots and stroke, emergency hysterectomy, less early contact with baby, depression and psychological trauma . Long term risks to the mom include: chronic pelvic pain, difficulty passing bowel movements, increased likelihood to be injured during future surgeries, future infertility, depression and psychological trauma, and maternal death. Short and long-term effects on the baby include: surgical cuts, breathing problems, difficulty breastfeeding, and asthma throughout childhood and beyond. And if the mom wants (and is able, despite the risk of fertility problems) to become pregnant and deliver again, here are the risks to both her and her baby: ectopic pregnancy, placenta previa, placenta accreta, placental absorption, uterine rupture, stillbirth or death shortly after birth, low birth weight, preterm birth, fetal malformation, and central nervous system injury to the baby. (all above found here)

Now, China's rate is pretty scary, but how does our country fare? In 2007 (most recent data available, from Choices in Childbirth's New York Guide to a Healthy Birth), 31.8% of births were done by c-section. In New York state, it was 33.7%. Rates in the New York city metro area vary, but no hospital has a rate below 15%. The lowest is 18.5% at North Central Bronx Hospital (whose maternity ward is staffed entirely by midwives, by the way). The highest is 52.7% at Lawrence Hospital-Bronxville in Westchester.

It was not always this high. Let's compare cesarean rates to maternal mortality, if we want to see a quick correlation between c-section and maternal health. In 1987, the year many of my peers were born, the US c-section rate was 24.4% and the mortality rate was 7.2 deaths per 100,000. We have to use 2003 now for the most recent data. In 2003, our c-section rate was higher, 27.6%. Guess what was also higher? Our maternal mortality rate: 12.1 deaths per 100,000. I'm not saying that this absolutely means that c-sections cause more maternal deaths, because that is beyond my powers of statistics to prove. I am saying that the conventional wisdom of c-sections allowing birth to be safer is completely false, and that most people hold this conventional wisdom is very dangerous for women's and babies' lives.

Why why why why why why why why??????????

Reasons are hard to quantify. This one is a myth though: that women are choosing c-sections as a matter of convenience. When women say they chose the c-section, they also say that they didn't get to that decision on their own, but from pressure from their doctors about time and convenience, and inadequate and biased information given about the risks. Other reasons include a general lack of faith in vaginal birth and "low priority of enhancing women's abilities to give birth," "side effects of common interventions" (a common cascade: epidural, epidural slows labor, pitocin to speed labor, pitocin stresses the uterus and the baby, baby is stressed and uterus isn't working right, c-section), casual attitudes about surgery and c-section in particular, limited access to information and awareness of the risks, and again, providers fear of malpractice claims and lawsuits (a bit plagiarized from Childbirth Connection- they just say it so good!)

I'm sick of talking and thinking about this. My solution: midwives. They specialize in protecting safe, vaginal births. Obstetricians are great surgeons and indispensable for the 10-15% of births that require c-section. But for the 85-90% of births that don't, let's save women's and babies' lives by letting midwives take care of them. A funny parallel is this: OBs are SUVs that you only need in conditions you'll find yourself in 10-15% time. Midwives are regular cars that do the trick the rest of the time, quite well.

On that note, I'm out. With my phone attached to me at the hip for when one of my clients needs some doula love.

PS: I didn't come up with the awesome title of this post, it comes from the title of a really good blog, http://www.theunnecesarean.com/blog/).

Back to Doula-land

I'm back, after a completely doula-free, off-call holiday period. It was weird not being on-call, and it's hard to be on-call again. I keep double-checking that my phone is on, if I have enough hard copies of birth plans in a client's file, if my birth ball pump is in my bag.

My last week was a blitz of work at Metro Minis, potential-client meet-and-greets, prenatals with clients, and the always exciting, always overwhelming Birth Focus Meet the Doula Open House, which is basically speed-dating for doulas. Good news: I was only able to interview with three couples, but I got hired by two of them! I'm chalking a lot of it up to the fact that I'm one of the more experienced doulas of my lower-priced level...

Tomorrow, I'm going to an orientation for the doula program at Healthy Start Brooklyn. Healthy Start is a federally funded program that is trying to address infant mortality, low birth weight, and racial disparities in perinatal outcomes. I'll be matched with women enrolled in the program and it seems like I won't only be their birth doula, but also in some ways, their whole-mom-life doula. Part of prenatal meetings won't just be determining who'll be around to help immediately postpartum; they'll also be about helping the mom put in outlet covers, cabinet locks, and setting up the crib and changing table. Before I ask questions like, "Do you want to be able to eat and drink during labor?" I'll have to determine if they have food security at all. And If I see any evidence of domestic violence, I have to report and address it. This is going to be intense. But these are the women who could benefit from doula care the most, so I'm excited to try.

Nina at Metro Minis is making a needle-point representation of the international symbol for breastfeeding. It's hilarious and awesome. Here's the symbol, but I've got to take a picture of the actual needle-point when its done: