Waiting for Babies

In honor of waiting for my co-writer's new baby, a few words on due dates.

First, how do we come up with a due date? There are several methods for determining the likely timeframe of delivery, including the gestation calculator wheel, Naegele's rule, lunar reckoning, Wood's method, Mittendorf's study, and ultrasound.

Naegele's Rule is probably the most common formula. It is calculated by:
Date of Last Menstrual Period + 7 days – 3 months = EDB

Naegele's rule assumes a 28-day menstrual cycle with ovulation around day 14, so it does not account for individual cycle variations from woman to woman. If a woman is fairly certain of the conception date, she can use an adjusted version of Naegle's rule:

Date of conception + 7 days – 3 months = EDB

The majority of women deliver within 10-14 days on either side of their due date, but only about 5% deliver on that exact date.

However, there are some other factors that should also be considered in determining a due date, including:

  • Family gestation history
  • Average menstrual cycle length
  • Cycle regularity
  • Characteristics of the last two periods
  • Date she thinks she conceived
  • When fetal movement was felt
  • When heart tones could be heard

If you factor in the above questions, you may conclude that there is a more holistic way of guessing when to expect a baby than the pregnancy wheel they pull out in the OB's office at every appointment. For example, a woman who regularly has 35-day menstrual cycles likely ovulates a week later than the woman with a 28-day cycle. At the end of pregnancy, this may mean induction for being post-dates, which can lead to unnecessary cesareans (and even premature babies).

However you calculate it, and no matter how well acquainted you are with the statistics, it is HARD to wait for a baby, especially after you reach the estimated date of delivery. It's hard for Amie and me with our own babies, and it's hard when we wait for our friends and families (we try so hard not to be those people who call every day to ask if you're still pregnant).

I recommend that my clients start planning something fun every day when they get to the end of their pregnancies. Having something to look forward to can help maintain your sanity when you really hoped labor would have begun by now! Some ideas:

  • Go to a movie
  • Eat at a nice restaurant. You will miss tablecloths in the coming years.
  • Get a pedicure or massage
  • Make your postpartum pads
  • Spend romantic time with your partner
  • Work on a project around the house

Finally, remember that the end of pregnancy is hard, but newborns are awfully sweet and worth the wait. Good luck, Amie. I hope you don't get too far down the list before baby girl makes her debut.


Home Birth in the NYT

A great article on home birth in the New York Times today. Be sure to look at the accompanying slideshow!


If You Have 15 Minutes

Be entertained by Doc Gurley's Lost Tampon video. You will thank me.

I have a girl crush on her.


Labor Nurse's Perspective on Birth Plans

Check out this post on birth plans from the Rebirth blog. She brings up some important points about why birth plans are so often treated with derision.

What resonated most with me was this:

And then I've seen very inflexible birth plans that request things like no fetal monitoring (absolutely impossible in the hospital) which basically ask for things that are better for a home birth. These types of birth plans I have no problems with in regards to what they want or not want, but often scratch my head wondering if these couples have taken into account that they are giving birth in a hospital. As much as I feel continuous fetal monitoring or even IVs are not necessary in every birth, some hospitals have environments, protocols, etc that don't "allow" for this. I really think those who want to avoid all interventions look into alternatives to birth sites because the second you step into a hospital you give up some things, like complete control. I wish this wasn't the case, and try very hard as a nurse to let women know about informed consent and choice, but there are very few hospitals I know of that go with any request a woman has.

It's so important that women realize what is and is not realistic in hospital birth. For more on this, read You Buy the Hospital Ticket... You Go for the Hospital Ride. Giving birth in a hospital is different than giving birth at home. Wonderful, fabulous, and low-intervention births happen every day in hospitals, but they are still hospitals. Why would you go there if you basically want to have a home birth? Walking into a hospital in labor and announcing that you reject all its care is a recipe for disappointment -- and possibly a terrible birth experience, because your expectations and reality will be so different. Why set yourself up for this?

If you're planning a hospital birth, find out what the standard procedures are. Then talk to your doctor and your doula about how you are work with any aspects you want to avoid (i.e. a saline lock instead of being hooked up to an IV). Going in with realistic expectations -- and a realistic, well-researched birth plan -- will greatly improve your odds of having a satisfying experience. And isn't that what we're all looking for when we write these plans?


Interesting article about "Mommy Lit" and natural childbirth

From Mothering magazine's website.

Most compelling quote of the article:

"Even if the genre is simply reflecting what is going on in the mainstream, it is nevertheless unfortunate to see mommy lit either completely overlooking natural birth or poking fun at it.

Popular culture is not just a mirror, it also shapes who we are and how we decide to live. Mommy lit will no doubt be read by a whole slew of expectant moms and in many cases will have some impact on decisions they make about having their babies. I'd say it's time for some diversity in mommy lit's birth stories. "


The Void that is Postpartum Care in America

I just started reading a most phenomenal jewel of a book called After the Baby's Birth by Robin Lim. Two quotes just from the preface and opening chapter have struck me:

"...I came to see more clear how my sisters in the West could expect little or no postpartum care or support, either from health-care providers or from friends and family. The modern lifestyle, embraced by the West, sought after and imitated all over the world, has so fractured families that postpartum women today accept and expect to be isolated. [bolding mine] I wonder at a culture that decades ago put men on the moon, yet chooses to ignore the most significant life passage of women." (xi)

"All too often, the only postpartum care an American woman can count on is one fifteen minute appointment with her doctor, six weeks after she has given birth. This six week marker ends an arbitrary period within which she is supposed to have worked out most postpartum questions for herself. This neglect of postpartum women is not just poor healthcare, it is abusive--[bolding mine]particularly to women suffering from painful physical and/or psychological disorders following childbirth." (4-5)

In cultures across the world, newborns and postpartum mothers are viewed as sacred and in a vulnerable state of being of both body and spirit. As such, they are nurtured and cared for. I suspect that now that puerperal fever is largely a thing of the past due to a better understanding of germ theory, more sanitary practices, and antibiotics, that as we lost some of the physical vulnerability of this time period (mercifully, the vast, vast majority of women in the West survive postpartum), we also lost respect for the spiritual and emotional vulnerability.

There are many interesting, beautiful traditions for postpartum women across the world. "Warming" the mother is common to many cultures. Some bury warm coals under the postpartum woman's bed. Some women are to sit on a fire warmed rock every morning, and it is also common to place a warmed rock on the woman's abdomen. There are taboos revolving around certain foods, and it often requires that the mother consume only warm liquids like tea and soup. These practices not only warm the body, but the soul. Touch is also a familiar component to these rituals. In some cultures the responsibility falls to the midwife to come give the mother a massage or rebozo treatment designed to "bring the bones back together." In others, the mothers or grandmothers of the postpartum woman provide this life affirming touch. In America, we too have our warming ritual, if you are lucky enough for someone to bring you a warm blanket after birth. The difference is, whereas the aforementioned traditions go on for weeks, women in our culture are "cared for" (and I use that term very loosely) for a few days or less.

Today I was reading a post on a message board for moms from the mother of a 2.5 week old who was feeling overwhelmed, sleep deprived, and isolated, looking to reach out to other mothers. She got some wonderful suggestions, but what stood out to me was the comment from one poster that said "If you are feeling depressed, don't worry, there are many antidepressants compatible with breastfeeding." While this is certainly true, and I would never ever advise against someone going on such medications if they feel like they need them, it made me wonder if we are handing prescriptions out to women who are really seeking encouragement and camraderie. Much as a laboring woman asking for drugs is sometimes actually asking for more support from those around her, I can't help but feel like we are ignoring a mass of women when we hand them a pill instead of loving guidance and help.

I have been working as a hospital doula now for 2 weeks and have spent a few shifts shadowing another doula on the mother baby unit. What has been eye opening for me is how little rest these women are getting in their very brief stay at the hospital. I have seen mothers drifting off falling asleep while they try desperately to pay attention to the presentation of how to put together their breast pump. I have seen a mother who had a cesarean not 12 hours earlier whose hospital phone rang no less than 5 times in the 15 minutes we visited with her. This same mother was distraught and exhausted and told us she had had visitors all day long. These mothers are also struggling to get to know their baby, learn how to breastfeed and recover from birth which for many also means recovering from major surgery. What I have also noticed is while these rooms may be brimming with stuffed animals and flower arrangement, I have yet to see a care package for mom, a stack of magazines or her favorite food or drink. The focus is on coming to see the baby, and respect for the mother and her passage is lost. It is no wonder we have a whole generation of women suffering alone through isolation, a sudden, crushing loss of identity and postpartum depression.

What can we do to improve the state of postpartum care in America? I believe it's obvious we need better medical care including at least one home nurse visit in the first 2 weeks after birth. For a greater discussion of this, see Ina May Gaskin's article "Masking Maternal Mortality" in the March/April 2008 edition of Mothering magazine. But aside from that, what can we women, birth professionals, mothers, sisters, aunts, grandmothers, and friends of postpartum women do to help fill this void? And what can the postpartum woman herself do to create the support system that is so sorely lacking for them?

First, I believe we need to address the early visitor issue. Everyone loves to see and hold a new baby. But again, we are talking about women who are in the hospital for 24 hours, not getting to rest because the nurses are checking in on them and their babies every few hours, learning to breastfeed which can be highly challenging, and often recovering from surgery. We wouldn't expect to go see Aunt Sally 4 hours after her appendectomy, and the same respect should be given a woman who has had a cesarean. I propose that no visitors come to the hospital the first day, and if they do, be limited to immediate family and the closest friends for less than an hour. Remember, in most hospitals rooming in is standard, and these mothers are not going to get a full night of sleep. There will be plenty of time to meet and cuddle this wonderful new blessing once the new family is settled at home.

How can the postpartum mother enforce this? Some tips are quite simple. Don't call anyone while you are in labor except for those you want with you either at or immediately after the birth. When you do call to let family and friends know you've had the baby, tell them you will be happy to see them once you get home. This alerts them to the fact that you are not inviting them to the hospital. What about those who will show up anyway? Tell your nurses to mark you down as "do not announce" and they will not tell anyone you are there. Let them know you would like your visitors cleared through the nurse's station and have them place a sign on your door when you are resting/feeding and prefer not to have visitors. Please realize this is not a hardship for the nurses, they actually like to limit your visitors. It is their job for you to have a full, speedy recovery, and they realize that you resting is the best way to get that. They will not mind at all being your gatekeeper.

I realize this all probably sounds harsh. But I assure you that once you have given birth, you will understand more of what I am saying. And I will also tell you that the most crucial time to your postpartum healing is 8 days after birth. The more rest, relaxation, and general being taken care of you can arrange for, the quicker the rest of your recovery will go. You are not denying people access to your baby. You are ensuring that you are healthy enough to care for him/her in the very demanding weeks to come.

Birth professionals, I implore you to impress the importance of these 8 days on your clients prenatally and encourage them to set forth the rules I have suggested for postpartum visitors.

This post will continue with more tips on how to build your own network of postpartum care, but for now I must sign off!


Hospital Water Birthing in Syracuse, NY!

Check out Kristen Oganowski's VBAC, hypnobirthing, hospital water birth story. Hers was the first water birth at Crouse Hospital in Syracuse, New York. Her birth from the perspective of her doula, Chris Goldman follows Kristen's account. This is a wonderful, inspirational birth story, but even more encouraging are the comments following both articles that indicate hospital waterbirth is on the rise in Central New York.

One of my favorite parts of the article follows. KUDOS to Dr. N, a shining example of what OB's can and should be to birthing women today:

"And then he [Dr. N, Kristen's OB] turned to my nurse and said, "Well, it looks like you aren't getting her out of the tub!" But then he took the time to tell her the following: "Look at how beautifully she's doing. Look at how natural and normal this is. She's pushing on her own, and no one is yelling 'PUSH' in her face; no one is counting for her." And you know what? My nurse started to get really excited about this birth."


Great news for the women of Santa Fe!

An email from Julie Gorwoda, CNM and Director of Nurse-Midwifery Education at the University of New Mexico. This triumph should inspire all of you who live in areas without Nurse Midwifery care as an option in your hospitals to sharpen your pencils and write letters. Make some waves and help the women in your community to have access to safer, more personalized care.

"After 63 years of clinical nurse-midwifery presence in Santa Fe New Mexico, we are happy to announce that women in Santa Fe may soon have a CNM-attended BIRTH at St. Vincent's Hospital! The vote from the Medical Executive Committee today was groundbreaking and paves the way for full-scope nurse-midwifery care in this city, one of the last hospital-holdouts against CNM intrapartum care in New Mexico. 2008 UNM graduate Maria Theresa (Maite) Redondo-Cladera will be the first nurse-midwife at this facility after strong support from Ob/Gyn Dr. Cindi Lewis and Maite's FP employers at La Familia Medical Center, especially Dr. Gary Giblin. The three of them worked long and hard to make this a reality.

Catholic Maternity Institute was founded in 1945 in Santa Fe by CNMs who were also Medical Mission Sisters. It was one of the earliest midwifery services and also the first university-affiliated nurse-midwifery education program in the US. Midwifery leaders from CMI also incorporated the American College of Nurse-Midwives in Santa Fe in 1955 but CNMs were excluded from the only hospital in town until today. This victory for women and midwives could not have come without years of support from consumers and the midwifery community's education of thoughtful physicians.

If you know anyone on the Medical Executive Committee or St. V's administrators, please thank them and send your letters of congratulation to Maite at amniotic22@yahoo.com. Her years of intelligent, extremely capable nursing care of laboring mothers at St. Vincent's made her the logical first CNM choice for this hospital. And tell your sisters, cousins and friends from Santa Fe they don't have to go to Albuquerque or Las Alamos for a hospital birth anymore! Blessings to Laurie Holmes, CNM who attended women at home in Santa Fe for several decades and the other Santa Fe CNMs who kept the porch light on in the "City Different" for over 63 years.

Please pass on the good news!"

Recommended Reading for Your Weekend

First, I strongly suggest that you check out Linda's take on the latest ACOG nonsense. As always, they want to make sure that women are "protected" from these outlaw midwives and their dark and dangerous ways.

One of their claims, that midwives are mostly self-educated, really chaps my hide because:
1) It's untrue -- even midwives who don't attend a formal school are still trained by other midwives. And hey, isn't an internship basically an apprenticeship for an MD?
2) The autodidactic spirit of the women I know who work in birth impress me so deeply. It's a passion for learning that I simply don't see in many other professions. It's condescending to imply that you have to go to medical school to get an education about birth.

The snobbery and sexism implicit in these ACOG statements always gets me down. I wish I could say that they have no impact on me, but that would be a lie. In fact, one of the biggest reasons I had for enrolling in midwifery school is the fact that I think my education will be more respected this way. It's not the only reason (others being that I like structure in my studies, and that one of my preceptors strongly encouraged it as a condition of taking me on), but it was certainly a big one.

That said, Pam's words on this still resonate with me:
[Midwifery education] has to be personally defined. We are not all the same, nor do we all learn the same. I cannot even begin to speculate what this would look like or have to encompass for it to be "ultimate". Each family, each community, has a different need. If we all are trained the same and think the same and practice the same, where is the midwife for people who want something different for their birth?

School is the beginning, not the end, of an education.

Anyway, I also recommend that you check out the CDC's latest report on breastfeedng practices in hospitals and birth centers around the country. It's predictably frustrating. One of my favorite bloggers, Rachel from Women's Health News, has a tidy summary of the report.

The thing that is so disheartening to me about it is the pervasiveness of giving healthy, full-term infants formula supplementation, even when their mothers indicated that they were breastfeeding. Just as these facilities don't trust women's bodies to birth their babies without interference, they don't trust women's bodies to nourish those babies after birth. Routine supplementation flies in the face of everything we know about breastfeeding and the nutritional needs of the newborn. But what really eats me up is that the systematic undermining of women's confidence in their bodies. It hurts the breastfeeding relationship, it hurts the mothering relationship, and it hurts other women's confidence before they've even conceived. When is the medical profession going to stop focusing on harassing midwives and direct its attention to actually keeping mothers and babies healthy? Good breastfeeding practices would be an excellent place to start.


First International Post!

I'm spending the summer in Costa Rica with my family. Despite roughing it in the jungle, we do have high speed internet service, so I shall continue to contribute.

First, I'm late to the table with this, but I have to point out two important headlines:
Premature Births Increase Along with Cesareans Our haste to get babies our before they're ready is being recognized (at last!) as not such a good thing.

After Cesareans, Some See Higher Insurance Costs Adding insult to injury, many women are finding it difficult to find insurance after their surgical deliveries. My only glimmer of hope in response to this is that it will spark some backlash against our c-section-happy status quo. Being uninsurable is a huge deal. Of course, the insurance industry is largely responsible for the high rates of cesareans we're seeing these days -- the fear of malpractice lawsuits, not to mention insurance companies refusing coverage to OBs who support VBAC, etc, etc, got us where we are today. Now, painfully ironic though it may be, insurance carriers are complaining about the higher costs of the situation they helped create.
What's the birth situation in Costa Rica? Almost all women have their babies in hospitals, and many have to travel to get there. There are midwives here, but they have to practice underground to avoid prosecution (as in some states in the US, having a b`aby at home is not illegal, but practicing midwifery is). In the Talamanca region, where I am, the local indiginous population, the Bri Bri, are facing persecution for birthing at home. The government is now threatening them with prosecution for any bad outcomes of a home birth. The result is that pregnant women are sleeping in the streets as they approach their due dates, rather than facing an 8-hour walk down the mountain and into the city while they're in labor. Birth Without Boundaries is here working to change that -- I'm hoping I can help.