|June 27, 2001|
Volume 3, Issue 26
|Midwifery Today E-News|
“Vaginal vs. Cesarean Birth - Part 3”
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Quote of the Week:
"We must give women the opportunity to challenge their fears, to work with them and birth through them. Not only will this change each woman, it will change the political and medical climate in which they make these choices."
- Connee L. Pike-Urlacher
The Art of Midwifery
Ask the mother if you may take a "new family" photo right after birth (and any other photos she might like to have). Carry a loaded camera in your doula bag and have it ready for use. There's no gift so special for a couple than the first photo of their baby and a photo of the new family together! Be sure to have two sets of prints made--give one set plus the negatives to the couple, and keep the other set as a visual memory of the birth for yourself. One of my most precious possessions is my doula album in which I have a photo of each new family I've served!
- Helen Moore, CD (DONA)
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Researchers identified 155,519 white women and 75,556 black women who had first and second singleton pregnancies. For the black women, 26% of those who gave birth before 37 weeks in their first pregnancy had a preterm infant the second time. For white women, the rate of repeat preterm birth was 19.9%. The earlier the first birth, the higher the possibility of preterm birth the second time. Risk factors for increasing levels of second preterm birth were young age, unmarried, less education, and late entry into prenatal care. Preterm was considered to be before 37 weeks gestation and was further broken down into moderately preterm, 32-36 weeks, and very preterm, 20-31 weeks. Results were also analyzed by birth weight: low birth weight was considered to be below 2500 grams; moderately low birth weight, 1500-2499 grams; very low birth weight, less than 1500 grams.
- J of American Medical Assoc 283 (12), pp. 1591-1596.
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What Do You Think?
Editor's note: This is the final installment of responses to a news item [Issue 3:23] about an American obstetrician who believes vaginal birth creates "needless" pelvic floor disorders later in a woman's life. The news story appeared to favor cesarean section as an acceptable alternative.
The overriding medical paradigm still acts as if women's bodies are defective and teaches women to dissociate from their bodies from an early age so that they don't trust their own wisdom about how to birth. Nor is the variation in natural processes and knowledge sufficiently regarded as the basis for obstetrical protocol. Why then be surprised that some of these women are unaware of how to prepare for, move through and heal from intrusive birthing practices?
How fortunate that medical professionals can now accurately document the damage their practices induced. And of course the implication is that women's bodies are faulty and will need "protection" from those inherently high risk vaginal births.
We do not assume all hearts are defective and need to be surgically altered or replaced by pumps simply because SOME (the ones with heart-weak constitutions) cannot function well when the effects of toxic lifestyles and dissociation from emotional stressors cannot be corrected by surgery. Rather, risk factors and ineffective therapies are identified and environment taken into account.
Why not be proactive and provide opportunities for women to rediscover, explore and teach each other the beauty and power of their body and birthing wisdoms, evolved from eons of genetic pressure? Women's bodies and birth work in MANY cases because we have evolved for it to work or we wouldn't be here. What works survives. There will always be variation in the "norm." Some will be superbirthers, some poor birthers. We are not carbon copies in uniform environments. It is when interference outstrips the body's ways of dealing with change that health is compromised on both the physical and spiritual levels.
Perhaps it is too audacious to suggest that the intervening 20 years' worth of hindered wisdom, further dissociation and nonsupportive healthcare practice also contribute significantly to the final dis-ease state. Having worked for the last 15 years within a healing paradigm that recognizes individual physical constitutions, I believe that women vary in their health potential, and that some women are more susceptible to carrying long-term damage into their reproductive organs. But more surgical births are not the answer.
- Julei Busch, B.Sc., S.C., midwifery student
The research states there is no difference in perineal floor damage for cesarean vs. vaginal delivery at 40 weeks. Apparently it is the weight of the baby during the last four weeks of pregnancy that may cause urinary sphincter tone loss and other pelvic floor damage. In order to prevent this damage, the c-section must be done at 36 weeks.
This means OBs are not taking into consideration the prematurity factor, which in the case of elective cesareans is a "preventable" neonatal complication. The Hippocratic Oath to "first do no harm" has been ignored. How many newborn infants will needlessly die from routine cesareans performed at 36 weeks? I am sure as the 36-week cesarean increases, the neonatal death rate will increase.
This is certainly another argument to do away with OBs and send all pregnant women to midwives, let midwives refer the "high risk" women to perinatologists, and let the obstetrician revert to just being a gynecologist.
- Sandra Stine, CNM
The very idea of this doctor's proposal burns me more than my son's 15" head did! I have had seven natural deliveries and I have been scolded because my pelvic muscles are still tight. This man would not be able to even try such a scheme if women didn't embrace it hook, line and episiotomy. I am appalled by the number of women who still believe obstetrics is synonymous with godhood. A large part of this acceptance is ignorance and a belief in myths. I have been told more times than I could remember that since one's mother had to have everything either tacked back in place or removed, then she probably will, too. There are many who don't want to learn any further than what their OB has told them. It can be extremely frustrating when I try to talk with them about a more natural alternative.
It seems to be a process of educating one woman at a time. And it can be a long uphill road when the area medical staff are not mamatoto [mother-baby] friendly, regardless of the sheep's clothing they wear. The high rate of cut perineums, extractions and sections speaks for itself. One mother at a time, we need to teach women that God made their bodies to function with strength. We need to teach them how to listen when their body is speaking, building that bond between mother and child so the little one arrives to rejoicing even if through pain instead of being viewed as "a royal pain" before they are born. Women are cut apart from their children as they are being "delivered" and society racks its brain to understand why child abuse is soaring.
- Mel, agent of social change
It seems there has been a significant change in the instructions birthing women
get right at the stage of crowning. When my child was born 23+ years ago, I'd
read somewhere that if I felt the stinging sensation, I should react by NOT pushing
for an instant--just drop back a little. That happened, I did it, and didn't tear
or need any cutting. I was 38 at the time, which was considered "elderly"
back then. However, I was at home as well and the midwife did extensive perineal
massage for the whole pushing stage. These days, women are urged to "push
through the stinging." I think that's wrong and a contributing factor to
- Suzanne Fremon, doula and hypnobirthing practitioner
I highly recommend finding a copy of the book "Episiotomy and the Second Stage of Labor" by Kitzinger and Simkin and reading it cover to cover.
- Natalya Lukin, CPM
It is one thing when doctors cite true medical reasons for a necessary cesarean. It is another when they shout "convenience" and "women's right to choose." ....Doctors want to give choice to women, freeing themselves from having to contrive a diagnosis to explain and excuse a cesarean. Obstetricians are not trained in normal, natural birth practices, obstetrics being a surgical field. The cesarean section has become the solution to any and all "problems" that may arise in pregnancy and labor. It makes the justification easier if they can claim "Patient Choice Elective Cesarean" as a reason for the surgery. Obstetricians blame the mom for unnecessary surgery they themselves perform, as the abuser blames the abused for the act of violence.
Does the use of informed consent protect women from manipulation and coercion from the doctor? OBs are well aware that they can "consent you into making whatever decision they are more comfortable with," according to a local physician. Just a few choice words spoken with emphasis, such as "Your baby will die if you go into labor" or spoken with detachment, such as "It doesn't matter" leaves the decision up to the patient, and can persuade a mom to choose whatever the doctor wants her to. Doctors hold an authoritative position, which gives weight and power to their opinions, easily overriding the mother's opinion, desires, and rights.
An administrator at a local hospital is quoted as saying, "The most cost-effective way to deliver babies would be to schedule every one of their births. Line them up, Monday through Friday, from nine to five." He added he was not advocating it. Interesting though, isn't it?
....The physician sees the real benefits of elective patient choice cesareans, not the birthing family. Obstetricians will continue to encourage the birthing mom to sacrifice her body on the operating room table until women begin to take responsibility for their birth.
- Pam Udy
A BUTCHER'S DOZEN: Read Nancy Wainer's remarkable article about c-section and VBAC.
Read more great articles from Midwifery Today issue 57: VBAC and Cesarean Prevention
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Midwifery Today's Online Forum
Could we discuss birth language--words that are routinely used that might block a woman in a subtly negative way e.g., deliver: pizza, not babies. I prefer the word BIRTHING the baby; contractions: sensations; ruptured membranes: released membranes; false start: warming-up sensations?
Forums Reply: Oh yes language is SOOOOOOOOO important!!
To share your thoughts and experience, go to Midwifery Today's Forums. Click on "Aspiring Midwife Chat" and "Birth Language." PLEASE DO NOT SEND YOUR RESPONSES TO E-NEWS!
Question of the Week
Editor's note: E-News received several wise and heartfelt responses to last week's question about how to comfort a pregnant/birthing mom who has a history of having been sexually abused. The responses will become the main feature of next week's edition of E-News. Our sincere thanks to all those who offered their kind replies.
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What are the essential elements of good prenatal care? How does prenatal care create better birth? As a midwife/doula, what do you hope to accomplish in the prenatal period with a pregnant woman?
Please submit your response by June 30, 2001 to firstname.lastname@example.org. Your responses will be considered for publication in Midwifery Today, our quarterly print magazine.
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Re: dilating "on time" [Issue 3:24]:
Emmanuel Friedman, an obstetrician, did a study of women in labor. Having the inability to birth, he assumed that averaging women's labors would predict the safest delivery. This curve states that dilation under 1.2 cm/hr for primagravidas and 1.5 cm/hr for multiparas is abnormal. This study is the basis for hurry-up obstetrics seen in the hospital setting today. Of course, it would never occur to physicians to allow each woman to birth in her own time--that would not be profitable for hospitals and physicians. Anon needs someone telling her she can do it, not echoes of doubts that implant images in her mind that she is unable to keep up with the rest of Friedman's curve. In the absence of fetal distress, she should just say no to the cesarean section.
- Lynda Comerate, RN, BSN, PHN, LCCE, HBCE
When talking about VBACs, the birth attendants and midwives I know prepare VBAC women to have slower labors than their friends. Many of us theorize that the wise uterus will create a gentle labor to put less strain on the incision.
- Karen Ehrlich, CPM, LM
More on the language of pregnancy and birth [Issues 3:24 & 25]:
I am a practicing chiropractor and my wife is a CPM. It seems to me midwifery is undergoing many of the struggles my own profession went through not so long ago. May you learn from our successes and failures.
One of the more subtle ways professions become assimilated is by adopting the language of medicine to describe non-medical events. It is a very slippery slope regarding professional identity. There are many historical examples of this in chiropractic, osteopathy, nutrition, etc. Though I am not an expert in the politics of midwifery, I do see some disturbing shifts toward assimilation. For instance, each protocol that relies more heavily on lab work and/or diagnosis shifts the professional focus from health to disease. Dangerous territory. Diagnosis and treatment of disease is clearly the practice of medicine.
Who will define the terms of practice for midwives? State regulators? (Anyone following the struggle in North Carolina or Indiana may have a sense of how scary this can be.) MANA? Accredited midwifery schools? Practicing midwives? Your clients? The AMA?
Though it may seem easy to pass terminology off as semantic nonsense, very clear and unique definitions of professional objective and central area of interest are crucial as a profession grows and attempts to gain legal footing. What exactly is it that makes midwifery unique, distinct, and not part of or a subset of any other profession? The daily language used to describe the philosophy, science, and art of midwifery should reflect your uniqueness and objectives. This is the very beginning of winning the ability to practice free of medical interference and/or control. With these clear professional boundaries established, I even think that it could be argued that OBs who care for women with uncomplicated, normal, natural pregnancies are practicing midwifery without a license. Don't sell yourselves short!
- Brad Eldridge, DC
Can anyone suggest articles/books to support the claim that midwives have lower episiotomy rates than OBs and better outcomes? I am teaching a birth class and one husband (in med school) wants the "proof."
I recently heard about a town near London, Ontario that is having an obstetrician crisis. In order to give these caregivers a day off, the obstetrics department is having to close for about one weekend a month. If I lived in that town, I would volunteer as a doula at the hospital during those hours to help cover for emergencies. I wonder if the hospital has considered putting these doctors on call, and bringing in doulas for the regular hours to cover for them? Is this practical?
I just read that Congress is planning to open another round of HMO debate.
CNMs are reimbursed about $600 for a home delivery. The cost of a hospital birth to "out of pocket payers" is $5,000+ depending on services. Prenatal appointments are made in a centralized location, are 5-8 min in length, and the woman gets "policy and procedure" standardized births. Homebirth is time-intensive, and labor is often long and tiring, especially for a first birth. $600 per birth doesn't cut it! Would Medicaid reimburse DEMs as much as CNMs? $600 is an insult and barely covers my expenses.
Congress is not thinking about "homebirth" or midwifery care. They have their minds on other agendas, mostly medical. They are influenced by the AMA. They lump prenatal care into an "illness" category.
Clients who are now "private pay" would have the "Medicaid" option. Sadly, maternity services for all Americans would leave out the "homebirth" option, except under physician consent. The DEM and CPM are left out of the loop.
We need to act as a group. WE need to address Congress about the need for all women to be provided with the opportunity to have a homebirth with a DEM, CPM, CNM (midwife of clients choice). How can Congress know there are alternatives that work if we don't do our part to inform them? It is important for us to begin the process of unification, rather than divide our energies state by state.
- Sandra Stine, CNM
Re: the woman with acute glomerulonephritis [Issues 3:22 & 24, in which three E-News readers responded by suggesting evalution by a specialist, sufficient hydration, supplements, and high protein intake]:
This is a concerning exchange to have been published. This issue is being discussed as if it is normal and desirable that homebirth midwives should be taking care of women with severe kidney disease instead of referring them for medical care. The philosophy here seems to be "homebirth as the first priority" rather than safety as the highest priority. What special knowledge/training qualifies each of these women to be experts on pregnancies of unhealthy women? Is this what is meant by "each one, teach one"? I hope that this was an oversight.
- Ina May Gaskin, CPM
The abdominal massage described in Issue 3:25 for constipation is also a lifesaver for really painful gas that you can feel bubbling around in there. You practically can feel the bubbles descend as you massage.
- Susan Skinner
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