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Friday, February 25, 2011

A Pregnancy Book Primer: The SOB's guide to pregnancy

Even though this book is
out of print, you might find
the deep discount over-stock
copies to be cheaper than
toilet paper. (Hey, this is the age
of recycling, after all.)
If you're like me, you've probably heard that The Skeptical OB wrote a pregnancy book, How Your Baby is Born. She touts it on her blog page and says, "You can order it through Amazon!" Well, I checked there, and lo and behold, it's out of print. (Apparently there are several copies starting at the bargain price of 11 cents if you're interested.)

Rather than waste the money, I saw that there is a PDF copy available through her advice website, "Ask Dr. Amy," or you can just peruse the headings on the website. (If you have a pressing question, you can actually go through PayPal and transfer funds in exchange for advice. Considering she's not technically practicing medicine anymore, is this even legal? It kind of reminds me of Lucy's advice stand in The Peanuts comic strip.) Anyway, there are four major headers with a few points in between, which leads me to believe this is a very short book.

Considering her rather acerbic nature on her blog, I was curious to see her take on things like vaginal breech birth, VBACs, epidurals and if she even touched on home birth at all in her book.

I had a laugh when I read her take on pain relief:
There is probably no area of obstetrics that generates more anxiety and more controversy than the subject of pain relief. That's not surprising when you consider the reputation childbirth has for being so painful. The truth of the matter is that the reputation is well deserved.
Really? That makes it sound like everyone's pain tolerance is the same, and everyone will (and should, because if you don't there's just something wrong with you) find it the most excruciating experience of their entire lives. She throws the NCB crowd a bone in saying that if you are prepared, it might not be as bad, and to be prepared, you have to be informed. (by reading her book, perhaps?)
Unfortunately, to promote natural childbirth, some of its supporters have claimed that using the breathing techniques makes childbirth, at best, painless or, at worst, only slightly uncomfortable. Neither scenario is true.
It's obvious that she is concentrating heavily on the Lamaze method, where breathing is key. But it involves so much more than just hoohoo-haahaa, and I wonder if she perhaps reached this conclusion by watching Dr. Huxtable deliver babies on The Cosby Show. She sort of sets it up by saying that labor may not be what you expect, insinuating that you'll soon ditch your plans for a natural birth and probably scream for the epidural - never that it happens the other way around. I find her stance on natural birth, especially her vehement opposition to it on her blog, to be perplexing, consider it's rumored that she gave birth naturally to two of her four children (something she rarely mentions). So it must not have been that bad, then, if you did it not once, but twice, right? She does, to her credit, mention the risks of epidurals and says they "are not trivial."

(Click here and you'll find useful natural birth techniques that include much more than just breathing, which does help, by the way. It certainly beats hyperventilating.)

In the heading under "Fetal positions," she gives brief mention of breech positioning, laced with her authoritative tone and scare tactics:
A baby cannot breathe until the head is successfully delivered. Therefore, strenuous efforts must be made to deliver the head as quickly as possible in a breech presentation. Unfortunately, these same efforts, which are required to save the baby's life, may cause serious, permanent injury. This is the main reason that breech vaginal deliveries are considered hazardous.
She does mention, thankfully, that a baby in breech presentation prior to 36 weeks is nothing to worry about. Even after that, though, a baby can and often does still turn. I wonder how many primary cesareans could probably be avoided if practitioners would just wait for labor to begin, in giving the baby a chance to turn even at the last minute.

She also mention cervix checks, but there is no mention that perhaps they are unnecessary or that you even have a choice in the matter. (I wouldn't expect many mainstream pregnancy books to address this, either, unfortunately.) She adds that while the initial check might be uncomfortable if the cervix isn't dilated very much, "each additional exam" will be easier for mom as she makes more progress. Is this the "Cervical checks, early and often!" approach?

One of the problems with multiple cervix checks is that it can make you feel let down and disappointed if you're not progressing fast enough for your doctor while in labor. Not only that, but repeated exams can introduce infection. Dr. Amy says, as part of the procedure, "You watch him or her don the sterile glove." (More on that here.)

On things like prenatal testing, she mentions the AFP test and that it should be used more to determine risk factors, not absolutes. While this is true, I was unimpressed with her failure to admit that it has caused more false positives and stress in a pregnancy than necessary, leading many to question its role in prenatal testing. She also mentions amniocentesis, and while she argues that it can do more harm than good to certain women, those for whom it might benefit are those who receive an abnormal result on the AFP test. Aside from the risk of injury because of obvious needle jabs during the procedure, she also fails to mention that amniocentesis also increases your risk of infection or miscarriage, which is about 1 in 400 to 1 in 200. Depending on your situation, you may want to forgo that altogether, especially since more advanced, less invasive ultrasounds can often give you accurate results.

Moving on to induction of labor: The SOB, in typical shock fashion, states that the "mortality rate of babies born after 43 weeks is double that of babies born on time." (On time being a relative term, I suppose.) For those after 44 weeks, "the mortality rate is triple." Unfortunately, this fear is why many women are induced for post-dates when they're literally only one day past their "due date." This thinking seems, no doubt, to lead to many questionable inductions and probably even more unnecessary cesareans. And while the risks of going that far past dates does sound scary, it doesn't mean it's the same for everyone, and there are things you can do to check on baby's status without agreeing to an induction. This is a very personal decision and one subject to much scrutiny from just about everyone. (And let's not forget to mention that many educated, informed women do go past their due dates and deliver healthy, live babies.)

Perhaps what The SOB should talk about are the very important reasons you might be that late, like your dates were off or your cycle is different from that of others. Not everyone, contrary to the due date wheels at your OB's office, ovulate at the same time and have a perfect 28-day cycle.

While she does mention testing like non-stress testing and biophysical profiling, I see more and more people saying their doctor is ordering an NST out of the blue well before the baby is even overdue. (Just one more way of turning the normal into the abnormal?)

She does add that sometimes things like AROM to induce labor does not always produce contractions, and the longer the water is broken, the greater the chance of infection. Unfortunately, what neither she nor many other books will tell you is that those crummy vaginal exams every hour on the hour will increase your risk of infection. And while the old "24-hour rule" is normally in place, some physicians give you less than that. (I read that one doctor routinely gives a measly eight hours. Seriously? How pathetic.)

As far as rupture of membranes, she states that "in almost every pregnancy, the membranes will rupture naturally at some point before the baby is born." I find this hard to believe, considering the popularity of AROM to speed up labor, whether it needs it or not. Although I couldn't find exact figures, some estimate that roughly half of women received an amniotomy in labor, and another link suggested that only 10 percent of women have spontaneous rupture of membranes.

I had AROM with my VBAC labor, and while my daughter's head was engaged, I was not fully aware of the risks of the procedure. Nor was I asked; it was implied that it was something that would be done as a matter of course, regardless of how I felt about it.

Some studies suggest that among those who received amniotomies, it did not speed up labor as compared to the group of women with SROM. Although, of course, The SOB disagrees:
It is well known that when the membranes rupture during the active phase of labor (either naturally or artificially induced), the contractions often become stronger and more frequent. Sometimes, this is all that is needed to speed up a labor that has been making minimal progress over many hours.
A citation, please?

It is also well known that the bag of water shouldn't be used to jump start labor in the absence of contractions, although that still doesn't stop doctors from doing it too soon. There is also the risk of cord prolapse, where the cord comes out before the baby's head, causing fetal distress. Unfortunately, she doesn't mention this risk, but rather says it can be used to detect fetal distress or check for meconium in the amniotic fluid. (insert guilt trip here) "Rupturing the membranes artificially can provide valuable information for taking proper care of your baby." Or not. What it could provide is a speedy trip to the OR for an "emergency" c-section, if nothing else.

And of course, it seems every mainstream book I've read either lists absolutely no risks of inductions, including Pitocin, or glosses over them. The SOB's book seems to be no exception, and it seems she has a way of filtering the truth because of her own rose-colored view of obstetrics.
Pitocin is administered initially in minute quantities, and the amount is gradually increased over 20-minute intervals until contractions begin. The fetus is monitored during administration of Pitocin to make sure that the amount given does not cause the baby stress or contractions that are too frequent. If labor has not started within 12 to 24 hours after application of prostaglandin gel, the mother is readmitted to hospital to receive Pitocin through an intravenous line.
I think the only part of that statement that I'd consider remotely true most of the time is that you'll be monitored. The downside to all that monitoring? You'll be confined to bed, and won't be allowed to labor comfortably or move around much, if at all, which is a natural coping mechanism that many women find helpful. Because of restricted movement and increased monitoring, more induced women tend to ask for epidurals, and thus the "cascade of interventions" begins.

I wish more pregnancy books would be upfront about the truth about Pit - that in some cases, it can be a good thing, but not enough to justify its widespread use. To augment labors that are already progressing normally, albeit a bit slow (by the doctor's standards) - not every slow labor is a sign that something bad is happening. And the idea that every doctor only "administered it in minute quantities" is probably the biggest lie I've ever heard.

Fetal distress from Pitocin is barely mentioned in passing, and inductions can lead to greater numbers of cesareans, especially in first-time mothers. Strangely, this is not mentioned, but The SOB does write about it on her blog, which I do remember caused much head-spinning among members of her camp.

Not only that, but I've also heard from many women who were strongly encouraged not to go home or were not even given the option. There is the risk that a failed chemical induction can lead to a last-ditch effort to jump start labor through AROM, suddenly you're on the clock for contractions to start, and you're in for the long haul.

While The SOB does go into some risks of Pitocin, they're not given much emphasis. She mentions that careful monitoring again, to make sure contractions aren't too close together, blah blah blah. "It is easy to decrease the frequency of contractions just by lowering the dose of Pitocin," she claims, but it seems like few doctors do.

The best way to detect fetal distress in labor is apparently through fetal monitoring, which
is the best method of monitoring your baby during labor. It is the one piece of equipment that is routinely used in all labors, both normal and abnormal.

Since The SOB loves to cite studies so much, perhaps she'd like to look at this one, which suggests that continuous EFM isn't quite what it's cracked up to be, often failing to detect true cases of fetal distress and leading to increased cesarean rates because of false readings. And when she says it's "routinely used" even in normal labors, it's like saying, "This is what's done, despite the conflicting evidence you've read, so get over it."

Every once in awhile, though, The SOB surprises me and appears quite rational about some things. About cesareans, she does note that while lifesaving, they appear to be more common than is normal, and that about 1 in 5 women will have one "recommended" to them. The most common reason, she cites, is CPD, even though, she adds, the only way to tell that is once labor has started. She actually uses the phrase "unnecessary c-section," which shocked me - and says that "there are undoubtedly some unnecessary c-sections that are done presumably because of CPD," (which some sites state is "quite rare.")

She adds that a number of unnecesareans are done because of suspected cases of fetal distress that really aren't, but doesn't mention the fallibility of the much-revered EFM in leading to those cases. And while she does say that fetal distress is a common cause of c-section, she doesn't blame the oft-misused Pitocin as a culprit.

And in case you were wondering, searching for "home birth" on her site won't produce many results, unless you want to be directed to her biased (and now abandoned) website devoted entirely to blasting it.

Like many other mainstream pregnancy books, they may be useful if you don't want to "birth outside the box." Unfortunately, while under the guise of informing women, they do much the opposite, which can be very confusing for someone who isn't sure of what her options are. This book, like so many else, will probably leave the reader with the idea that she doesn't have any at all.

More reading (much of which contradicts what you'll read in this book):

Cesarean Deliveries Rise Alongside Rate of Induced Labor - Time
Reasons to Induce Labor - Giving Birth Naturally
Test Leads to Needless C-Sections (regarding EFM) - Stand and Deliver blog (excerpted from the original article at The Philadelphia Enquirer, which has been removed)
Your OB (Midwife) Still Does What? #5: Cervical Exams - Birth Sense
How Likely is an Infection After Water Breaks? 

Thursday, February 24, 2011

What to expect when you're reading What to Expect When You're Expecting

According to most women, when you
read this book you can expect to be
given a major guilt trip, anxiety about
every calorie you put into your mouth,
and the idea that while you should
enjoy your pregnancy, you should
also log every symptom that might
suggest spontaneous combustion.
I don't go to book stores very often, but when I do, I always manage to end up in the childbirth section. It's like there's a tractor beam pulling me in - I can't help it. It's interesting to see what's on the shelves and what people are reading; sometimes nauseating at the same time.

When leafing through pregnancy books I usually check out their opinions and "advice" on two things first: inductions and cesareans. Both are serious problems in American maternity care, and what they say about it will sway me to either think it's right on the money or absolute tripe. Lately some of the books I've seen would make better toilet paper or campfire starters than anything else.

If you gathered a crowd of 200 or so pregnant women into one room and asked them if they've been reading any pregnancy books lately, I bet nearly all of them would have read What to Expect When You're Expecting. I'll admit, I even read it. Somewhat religiously, at first. And while it might be good for basic information (like, "Why do I have funky discharge?!") there are so many other books out there that should be considered.

If it's any indication of this book's popularity, look on any bookstore shelf, even at Target. There's probably two dozen copies of WTE for every one copy of Ina May's Guide to Childbirth, which doesn't mean you were lucky enough to get the last copy. It means the 24 copies of WTE are much more popular, unfortunately. Why? Because most people don't realize that along with everything else, you're getting overdosed on the typical 'abnormal as normal' pregnancy fare. Time to change that!

Not to discredit Heidi Murkoff, (who, for some bizarre reason, I thought was a nurse at first) but perhaps her book is a reflection of how she and so many people are unwitting victims of the modern obstetrical "system." The biggest complaint I often hear about this book is how alarmist and fear-mongering it is (especially when it comes to the infamous "Best Odds Diet"), and yet in some ways, they de-emphasize the things that women should be concerned about.

I do have an older edition of this book (that I bought at a yard sale for a quarter - about all I was willing to spend), but I'm sure not much has changed. On the "What to Expect" website, I looked up Pitocin and labor inductions, just to see what came up. Things like 'being overdue' came up, blah blah blah. Of course she can't be a smartass (like me LOL) and add, "Just because your doctor wants you to..." to the list.
"The amount of Pitocin given will be carefully monitored; you'll get enough only to reinvigorate your contractions."
I don't want to go so far to call Ms. Murkoff a liar, but I know that countless women across the country could probably say that this statement is far from the truth. Especially this laboring mom, who recounted her testimony on a discussion board about the "Pit to Distress" phenomenon on
"...he did instruct the nurse to increase the pitocin until I “cried” so that I would “beg for an epidural” and “give up my stupid plans for a natural childbirth.”
(Unfortunately, but understandably, this doesn't appear anywhere in the book either.) And, as far as fetal distress is concerned, WTE cites the most common reasons for it being multiple pregnancies, high or low levels of amniotic fluid, uterine growth restriction, gestational diabetes and preeclampsia. The word "Pitocin" doesn't appear anywhere on the page.

Nowhere on the page does she mention the risks of induction, but this misleading little gem is offered up:
"Once your contractions are in full swing, your labor should progress just as a non-induced labor does."
About AROM (artificial rupture of membranes), she says that the patient might notice a gush of fluid and then hopefully labor will start. It's been my experience that a gush of fluid means the baby's head is not in position, and this can cause an increased risk of cord prolapse, which can be very dangerous to the infant. And neither does she mention that while cord prolapse is rare, it can be caused by having your water broken while in labor.

Another complication that's mentioned is shoulder dystocia. WTE prefaces it by saying:
Only one percent of babies weighing six pounds have shoulder dystocia; five to nine percent of babies weighing more than nine pounds have shoulder dystocia. 
This statement kind of scares me, simply because women are already falling in droves for the 'big baby' scare that usually sends them for an induction or c-section in the first place. And we also know that Pitocin can lead to shoulder dystocia, depending on the way it's given. But again, it's not mentioned.

She does go on to say that a change in mom's position might help the baby's positioning, and that you may want to get into the best position that allows your pelvis to be as open as possible. Unfortunately, in reality this isn't always possible, nor allowed, during labor - as most women are confined to bed and not allowed much freedom of movement, and often told to push while lying on their backs or in a "c" position , which is just about as bad.

To her credit, she does say that episiotomies are often unnecessary and not part of routine practice anymore; that IV lines are often not standard procedure and includes advice on what to do if you don't want one, and acknowledges that restricting fluids during labor is 'fortunately far less common these days.' I'm not sure if I believe that either: I still read accounts from lots of women who say their hospital would not allow anything but ice chips during labor. She adds that IV lines can make a woman feel tied down to the bed and disable her freedom of movement, and they make childbirth seem like an "illness (which it isn't)." Unfortunately, she doesn't mention on her site what to do when your care provider insists you do these things, even though they have dubious efficacy.

This book - and the fact that it's sold millions of copies since it was first introduced - is downright scary. If you're just looking for something to cover the basics, then maybe you might get something from it, but otherwise I'd put it down (or in the garbage, which is where I think my original copy went) and move on to something else. Quickly. As one mom once put it, "I saw this book really cheap somewhere and bought it, just to keep it out of the hands of some poor, unsuspecting victim."

Our ideas of birth are already dysfunctional and abnormal enough without this "pregnancy bible" doing more damage.

Tuesday, February 22, 2011

What "the other side" is saying about NCB literature

Is NCB literature perhaps more balanced than some would
care to admit?
I got into an interesting conversation with some readers of an infamous anti-natural childbirth blogger (and that's all I'm going to say about that, since I will not link to her site and run up her traffic meter from my blog). We were discussing childbirth books, and what's currently out there on the shelves.

It was also a refreshing change of the normal pace of that blog, where most people are just as into their "woo" as they think we are. In light of the series I'm doing on pregnancy books, this conversation really piqued my curiosity.

I really haven't found any good literature on birth outside of the natural childbirth movement. And I've seriously tried. The natural childbirth people have their problems, but they've reflected on the subject far more, and in far more profound ways, than anyone I've ever found who *doesn't* think that an unmedicated birth is the ideal. I've learned some things by reading real medical journals (the popular websites run by places like Mayo and John Hopkins really don't have enough information to be helpful), but even leaving aside questions of trustworthiness, they just aren't responsive to many of the questions people have about birth. There are no arguments, just claims. They're not actually engaging the natural childbirth people at all.

This blog (the anti-natural birth blog) is about the closest thing I've found to a "popular" medium for opposing the ideals of the natural childbirth movement. That's why I come here sometimes, but frankly, it's not impressive. Even from a scientific standpoint, it doesn't treat a lot of the most pressing questions. For example, one of the biggest obstetric controversies of the last 10-15 years is on misoprostol (Cytotec) induction. Put it in the search bar. I found only one very brief reference to the issue. Useless.

The reason most birth-interested people ultimately favor natural birth is because that's the only viewpoint that's seriously represented in the literature. There are no compelling spokespersons for any other point of view.
My eyes were widening. What? Are we willing to admit that perhaps the out-of-the-mainstream pregnancy books might be offering more useful information to women? *gasp!*

Here's another interesting, slightly puzzling, take from another commenter:
No actual experts are writing for lay people on childbirth- at least, not outside of the trite, middle school level stuff in baby books. NCB, on the other hand, has a wealth of accessible, appealing information; it ranges from outright incense burning woo to Henci Goer type psuedoscientific research...  
I think the imbalance in available reading material is a problem. It doesn't signify much if all the correct info is in scientific journals for experts, when the people pushing out the babies are flooded with NCB dogma before they even get to the OB's office.
(Incense burning woo? Seriously?)

In reference to studies, books and hot-button topics like Cytotec inductions, the first commenter adds this:
It's something the natural childbirth people talk about a *lot*. Maybe that's just them being crazy, but if part of your purpose is to answer the claims of that general camp of people, it's definitely something that should be discussed. When people in those communities discuss it constantly, and people on the other side say nothing, it starts to look like a cover-up, whether or not that's the case.  
You don't say. *sigh*

She does go on to say that often mainstream books and agendas fail to adequately draw on the psychological and social aspects of birth, and I agree. I find that is often the driving force among women who seek a "birth outside the box." And, in a surprising twist, she offers up this tidbit:
Finally, it's not been my experience that natural birth supporters are uneducated losers with no grip on scientific literature. 
Thank you! Finally! If only the rest of the world could admit this.

And either this person is delusional, lying or lives in an alternate universe, she thinks natural childbirth books "dominate" the discussion:
I agree that the NCB crowd is dominating the discussion. There are tons of books and websites dedicated to NCB beliefs. These sources are easy to access for laypeople and often compile many issues together (so you don't have to hunt down different sources for epidurals and for c-sections, etc.). I agree that if all you can find is NCB literature you are more inclined to think that the NCB viewpoint has a lot of support.
I wish that were the case. Although I do think, as someone else pointed out, that it could be based on geographical area. I pointed out that in my searching the stacks to see what was really out there, I surely never came across more than two or three copies of well-known pro-NCB books, and that was total inventory between two major booksellers.

If "we" have a corner on the discussion, I'm surely not seeing it. Perhaps blogs are getting traction and making waves among the birthing community, which is understandable considering the Internet in all its glory is a big medium for information-gathering. But I'm still not seeing it when I walk into my bookstore, nor when I talk to any of my friends or the public-at-large, who really have no idea what true natural childbirth even means.

The first commenter adds this:
I think the that the very superficial books are sometimes "mainstream", and most of the practice is basically according to the medical model, but if you want to dig a little deeper and think about the issues more it's all NCB, and there aren't many compelling, intelligent *replies* to the NCB arguments. It mostly seems like the medical establishment is just hoping that the majority of people won't investigate NCB enough to care.
Ding! Someone hit the nail on the head. Of course, a delusional response was quick to follow:
I don't think the medical establishment really thinks about NCB much at all. They aren't putting out information to counter NCB rhetoric because such rhetoric is barely on their radar. They put out accurate information. 
If that were the case, we wouldn't need books like Ina May's. Because doctors and hospitals would be giving much more accurate information through their childbirth classes, or promoting it more heavily during the birth process. I wonder, do the people who really think this way actually talk to real live people who have just given birth to find out what their experiences are?

If the natural childbirth movement really is perceived as more informative in its realistic coverage of birth issues, then that's a definite plus, especially if the "other side" is willing to admit it. I hope that means we're doing something right.

Monday, February 21, 2011

A Pregnancy Book Primer: An introduction

It's easy to tell a first-time mother to "go read a book" when she has questions about pregnancy and birth. The question is, which one?

I would argue that usually, the more informed you are, the better equipped you are to make better decisions regarding your pregnancy care. Theoretically you should be able to cut through the crap that might be dished out - whether it's from well-meaning, opinionated relatives and little old ladies or an overbearing obstetrician. Because of a number of things, your OB might not have the time to fully go over every little question and concern that you have. Many people find that when under the care of a midwife, the visits last longer and are far more relaxed, giving the mom time to gather her thoughts together and ask questions about her care.

Pregnancy books can be a good thing to read when you don't want to call your doctor at 3 a.m. asking him about round ligament pains or odd twinges you might be experiencing. However, you shouldn't feel that you're inconveniencing your doctor by calling him, either, which unfortunately many women do.

I do remember one woman lamenting that even though she read books, it still didn't change her outcome and she had a disappointing birth experience. "Maybe I didn't read the right books," she said, as if somehow she failed and could have done better. Unfortunately, while I don't think it's her fault at all, she touches on something that those in the birth advocacy community regularly decry: that some pregnancy books are definitely better than others.

In choosing pregnancy books, I think it depends on what kind of experience you want to get out of it. Some women are very determined to go all natural (meaning, not just vaginally, but truly natural) and others decide beforehand that they will ask for the epidural. I'm not criticizing anyone who requests pain medication; I did in my VBAC delivery (although it was Nubain, not an epidural) and realized later that it didn't do a bit of good and I could have gotten through without it. I do think, as I thought before I delivered my first child (and well before I became a Birth Nerd), that it's helpful to remain open-minded about pain relief, because everyone's experience is different. You are not going to feel pain the same way another person is.

For this reason, I am hesitant about books that are written from the author's perspective. So far I've seen quite a number of books (more on that later) that are very negative, pessimistic, sarcastic and grating when it comes to childbirth pain and being pregnant in general. What Vicky Iovine (author of The Girlfriend's Guide to Pregnancy) felt about her pregnancies is not the way everyone feels about it, and while pregnancy does indeed "suck" sometimes, I think it's a matter of perspective. Nothing taught me that lesson more than experiencing annoying and painful pelvic pain towards the end of my third pregnancy, only to realize that when it went away, it meant my son's head was no longer in the birth canal - in fact, no where near it. I might as well have purchased my advance ticket to the OR right then and there.

The tone the author uses is important as well, I think. Does the author come off as authoritative? Superior? Judgmental and harsh? Sarcastic? Warm and open? All could play a role in how you perceive birth, both for good and bad. How they treat certain topics is important, too - harping constantly on things like diet and weight gain, while totally ignoring the real threat of cesarean or failed induction, for example, might also tell you a lot. Look for signs that they tend to blame the mother for certain things (especially weight gain) rather than see the overall picture: that sometimes labors are harder, longer and more painful because of hospital policies that are often outdated and not as useful as they claim to be (again, more on that later).

As far as knowing what you want out of your birth experience, you might find that there's more out there than what everyone else experiences. Being influenced by negativity and pessimism do not help women to think outside that box at all, which is very unfortunate - and only reinforces the negative attitude we have about birth in our society. Knowing that there is more out there beyond What to Expect is key in deciding what you want - or don't want - in a birth.

Thursday, February 17, 2011

A bitter birth nerd

The other day I posted this question as my FaceBook status: "Do you ever think sometimes that you just need to step back from birth stuff for a moment or you'll explode?"

I was kind of surprised that some wholeheartedly agreed yes - although I'm not sure why I was. Normally I love the writing, the reading, the interacting with others - but sometimes I just get so bummed by the situations of people around me - people I don't even know - and don't know how to put my finger on those feelings.

I lie awake and think, What is wrong with me? I can feel a tension, an undercurrent, and I'm not even sure what it is. I realize that I worry, for other people. Women I don't even know. I can't read "certain blogs" (ahem) before bed because I will stew and seethe fitfully through an entire night's sleep. I lie there and wonder, How am I impacting anyone? Who am I really helping? Why does it seem that so few women agree and that so many women are sucked into the vortex of unnecessarily abnormal birth? How can they not see it? 

Sometimes I think, Will my blog just keep going on forever? What will there be to write about? What kind of advocate will I be in 10, 15 years or will I even be one? I like to consider myself a "birth nerd," not a "junkie," mostly because I know certain people (the same people who write those "certain blogs") consider that statement laughable, perhaps derogatory (even though they themselves live, eat, breathe birth, just a different kind of birth). I never started out on this path intending to be anything other than a mom, and somehow careened into something else. I never dreamed I would come to this point.

Knowing what I know now, and in sharing the experiences of other people, it's hard not to be bitter and hopeless about things sometimes. Especially in the comments I received on my last post, I was disturbed by the responses I got. I feel angry for these women, wondering why some of them aren't angry, too. Thankfully, some of their husbands stood up for them and confronted the doctor. But then what? What did it change? If we keep hearing how this happens, how it's legitimized, what has it really changed?

It's hard not to get defeatist or angry over other people's decisions, knowing that it's a decision I would never make for myself. But then I remember, they're not me. So it doesn't matter what they do. It ultimately doesn't matter what I think.

My niece just gave birth to her first child, and as usual, the end of her pregnancy was miserable. Just like it is for just about every woman. I know many women suffer in physical and emotional ways that are far above the norm, and I don't want to make light of their ailments. My niece was uncomfortable, but said she did not want to induce without a medical reason. I took that as a good start and offered advice, as did many of her friends: avoid Pitocin. I tried to encourage her the best I could, offered tips on how to manage labor and blah blah blah. The usual "Your baby will come when he's ready" stuff that us Birth Nerds like to tell everyone, which sounds crummy and well-meaning to her, but hey - it's the truth.

When she posted pictures of herself on FaceBook after she had the baby, I found myself scrutinizing them closely. A shot of her husband standing next to a sterilized cart of medical instruments, no doubt "just in case." I thought, I am being an idiot, but honestly - I do it all the time. I'm not sure if this is good, bad, normal or what - but I wondered, Did she get a cesarean?! I was so hoping not, that she had gone into labor on her own and just let the baby do his thing.

My mom called the other night and asked me if "I'd heard." Apparently they never told any of our side of the family, until my sister blabbed. Of course, I had a sinking feeling when I saw that picture of her, smiling, hugely pregnant and in her hospital gown. Few women in true, active, unmedicated labor look like that, I thought. And if they're medicated, they don't look like that, either. My mom sounded kind of disgusted, which secretly pleased me: "She got induced."

I knew it. My heart kind of sank.

I told her I had tried to help and knew she was uncomfortable, told her that it could potentially raise her c-section rate, and her group of friends and I told her to avoid the Pit. I kind of thought, Geez, why even ask for advice and sympathy when you're just going to ignore it? She suffered just like the rest of us do, and then later I read status updates on how awful she felt and what a "rough recovery" it was. Yeah, no kidding, honey. I don't want to say, I told you so, but ... well, I told you so. I can even picture a possible scenario (God I hope not): I tore so badly with my last birth, why don't we just schedule a cesarean this time and avoid all that?!

It's hard not to get too caught up in other peoples' decisions. My mom even told me, "Don't take it personally." I try not to, but I still can't help looking at pregnant women in public and wonder, Where are they giving birth? I bet she's had a cesarean. I wonder if she'll get an epidural? It's the most absurd conversation ever, and yet, I bet I'm not the only one who does it.

Sometimes in conversation with strangers we'll start talking about babies, their upcoming birth and whatnot, and something will slip: "Oh, I'm due on July fourth." I immediately picture the woman on the operating table, told her "fluid was low, baby was big!" kind of crap perhaps because her doctor had a Fourth of July picnic to go to that was more important. You can't just open up a can of worms with strange women in public like that. At least not unless you want them looking at you like you've grown a dozen heads and suddenly started talking in Pig Latin. I wish I could tell them. So much to say, so little time. So few people who really want to hear it.

I know my niece, and many like her, made a decision. Was it the right one? I don't know. I don't know if even she knows that. I don't know how much she knows about birth, or why she's feeling like she is, like she got run over by an 18-wheeler. I don't know if she'll make that connection the next time she's in labor, if there is a next time.

I don't know how much of her choice was really hers, in the end. I'm not sure if she's knows that either. She may have read some books, asked some friends, but in the end, did it matter? Maybe she thought, That's not what my doctor is telling me, or That's not what the pregnancy book I read said. Just some crazy relative talking out of her ass, that's all.

I know I can't make decisions for other people, and that every birth is unique. I'm not feeling their emotional pain from having weaned themselves off their antidepressants and rounding the corner into a possibly monumental bout of postpartum depression. I'm not feeling the physical pain of SPD. But I have felt the physical pain of cesarean, the emotional pain that everyone tells you to get over because you should "just be happy you have a healthy baby!", the psychological stress of wondering how much I'll have to fight for the birth I desire, should I ever get pregnant again. And I can see what might lie ahead for my niece and others like her, because I've already been down that road and don't want someone else to go down that path, either. At least if they don't have to.

Some thoughts that sum up what I wish I could tell people, that I wish they could understand:
When we treat high risk women with all that we have to offer, we lower their risk. When we treat normal women as high risk, we make them sick. - Michael Klein, MD
Any decision that is made without research and education, is NOT a fully informed decision. It is a decision based on fear and/or one that relies on dumb luck. - Health, Home and Happiness

Tuesday, February 8, 2011

The Obstetrical BS Series: Membrane sweeps without permission?

What your doctor - and everyone else - is essentially saying
is that because you're pregnant, you have no rights.
So "get over it."
This topic has come up every now and then: mom is going in for her routine (eyeroll) cervix check, but something is different about this one. It's taking longer, the doctor's really rooting his or her hand up in there, and it's wayyy more painful than what you're used to. What could possibly be going on?

Ten bucks says Dr. Pitocin is doing a membrane sweep. And unless he bothered to ask you what you thoughts were about having one, or bothered to explain what he's doing (before he does it!), he has no business whatsoever being up there like that. I repeat: no business. Your body, your vagina. Period.

Just today I saw this question come up in the Yahoo Answers pregnancy forum: "Unbearable pain from internal exam?"
this Dr came shoved her fingers in me really hard i was gona jump out of the bed!! it was soooooo painful and she kept pushing her fingers in and tells me to open wider! which i didnt, i was in so much pain! i couldn't even breath! she took long time checking i did felt her fingers inside my cervix the whole time. she said i am 1 CM dilated with long thick cervix, baby is not even engaged yet. so, why did she take that long to check my cervix and why was it breath taking pain???? now am way to scared to give birth! the pain was unbearable!
I think my blood pressure went up a few points after I read that one. I try so hard not to get furious, or at least not to let it show, slinging harsh words around, but it's so hard. Sometimes you feel you have to simply to drive the point home that this is not normal. Not even close. 

I was prepared to get a million thumbs down, and one reader told her to "suck it up." I wanted to reach through the screen and slap her into cyberspace. 

Thankfully someone spoke up and agreed with me - which made me breathe a sigh of relief that yes, someone else gets it and no, I'm not being alarmist or paranoid. 

I've heard a number of laughable, startling and downright hideous answers to this perennial question, like:
Yes, they can and they will. Do not be surprised that you are not consulted on any procedure. 
And why not? Are you any less human once you become pregnant?
Are you serious, or just looking for a way to sue for some free money because I don't think that a doctor would do that without consent.
This was after a woman asked if it was considered sexual assault. Because everyone knows women just make up stories about things their doctors have done to them, just to get attention.

This person seems to think there must have been something wrong with the mother, as if she were apparently stupid or something for not realizing what was happening:
I find it hard to think of a situation under which that would happen. Did you think he was doing something else? How do you have your membranes stripped without consent. Was he holding you against your will?
And at least this person realizes that it's not the sign of a "good doctor," but doesn't agree that it's assault:
I think that's a bit of a stretch. Its not a sign of a good doctor, but its definately not sexual assault.
Then what is it, exactly?

One woman, who had her baby at home, "dealt" with the OB at the six-week checkup, surprisingly:
My husband was the one that confronted him on the issue and he apologized.
(Yay for awesome husbands!) And just the fact that this OB apologized acknowledges that he knew what he did was wrong.

It's important to note that many - probably more than half - of the stories I came across were from mothers who weren't even 38 weeks pregnant.

Just because he's your medical provider, doesn't mean he has any right to do anything to you without your consent. You are more than just a pod ready to eject a foreign body; you are a human being, who is carrying another human being inside of you. If you don't want to be induced, don't want checks of any kind, then doing an uncalled for membrane sweep is a violation of your rights, as well as the rights of your baby: because it's done in an effort to basically evict your unborn child from its cozy, warm surroundings, where 90 percent of the time, it's better off anyway.

Unfortunately because people think "vaginal exam" when they think obstetrician, they consider this part of the job, and part of the highs and lows of pregnancy. Some of the time, the mother might not even know what's happened, and that kind of creeps me out. I wonder - if a physician does a membrane sweep but yet it hasn't been mentioned to the patient, and she doesn't really express concern, does it get documented? What if mom were to go back and look at her records?

Perhaps this is just another reason why many doctors are reluctant to show you your records: because they don't want you seeing that they did something without your permission.

If this woman were in an empty parking lot at midnight, loading her car with groceries and approached by a stranger who attempted to rape her, this would be assault. But because the man is her obstetrician, that's supposed to make it okay, I guess.

Just like with rapists, these "professionals" get away with it because no one complains. And in this case, the reason why no one complains is because much of the time, no one is quite sure what's being done to them is a problem. Or that it's really being done to them. Too much trust is placed in their hands, and just like a sexual perpetrator, they continue to abuse because they have your trust. I'm not comparing OB's with perps in the sense that they necessarily get off on what they're doing, but in a psychological sense, perhaps they do enjoy the sense of superiority it brings them. I don't think that's limited to obstetrics, but perhaps medicine in general. While there are very fine physicians out there in all fields, no doubt many of them do have a power-tripping God Complex.

No one would ever tell a rape victim to "suck it up." We realize it for the violation that it is.

It's also important to realize that by justifying these procedures as "part of the pregnancy routine," you are normalizing the abnormal: it represents an erosion of the pregnant woman's rights. This is not the first time such a thing has happened in obstetrics (or other medical disciplines), and certainly won't be the last, I'm sure. Take for instance:

• The case of Dr. Allan Zarkin, who carved his initials into the abdomen of a patient after her cesarean. While his lawyers argue that Dr. Zarkin was suffering from a brain disease that impairs his judgment, one wonders why, then, he was practicing medicine in the first place, especially considering he had shown strange symptoms and bizarre behavior up to a year before the incident. No one reported it. In fact, he was made medical director and continued to perform botched operations during his tenure, and was also granted hospital privileges somewhere else after Beth Israel Hospital in NYC revoked his privileges. According to one site, he continued to practice medicine after this case.

• The case of a Kentucky woman who sued her physician after he branded the initials of his alma mater ("UK") into her uterus and then had the nerve to show her the video footage of the surgery. Not surprisingly, many people commenting on the case think that the woman was only out to make a quick buck, and really didn't have a case.

Dr. James Burt routinely performed disfiguring genital mutilation on patients for years, even after admitting to having done so without their consent or knowledge. This wasn't in some jungle colony where people practiced FGM as a matter of culture or religion; this happened in the United States. Burt supposedly chose "weak women" who were unlikely to press charges. Apparently a break came in the case when a retired nurse finally spoke up, after years of silence for fear of losing her job.

What do you do, when not only can you not trust your physician, but the nurses who work with him? The last line of defense in protecting you from dangers that you can't fight against, because you're not even conscious? And why did it take so long for patients to come forward?

The answer is probably as complex as it is simple: because we tolerate this kind of behavior among those in positions of authority, simply because they're in that position. Whether it's a simple vaginal exam or a surgery, it's essentially the same thing - a violation of your bodily rights and your trust.

Just like you were taught when you were a child, no one should touch you inappropriately without permission. Not even your doctor. If he's worth his salt, he will explain to you what he's doing before he does it, not during.

Don't assume that your doctor "would never do anything like that" to you or anyone else.  It sounds weird, ridiculous, maybe even paranoid. Ask yourself, "Why does his being a doctor make this okay? Just because he's a doctor?" Sorry, not a good enough answer.

Don't worry about making your doctor "mad." Remember, he's not your daddy. He's not going to ground you for breaking curfew. The more you know ahead of time, the more it will help you to make the best decisions possible. You can change doctors up until the last minute, and do not feel badly for "firing him" as your care provider even while you're in labor.

If your doctor does do something that you feel violates you, speak up. There is no reason why this stuff should be considered normal or acceptable, just because you're pregnant. Again, it helps to know what's truly normal and what's absolutely necessary before agreeing to something, but unfortunately you might not get the chance. Do not be afraid to say something, even if you think "it won't do any good." When OB's routinely do these things without so much as the blink of an eye, they probably never expect that someone would complain, and they usually don't - which is why they continue to get away with it.

• Practice informed consent, and if necessary, informed refusal. Just because your doctor says so, doesn't mean you absolutely must do something, no matter how unpopular it might make you become among him or his staff. If your doctor suggests doing a particular procedure, inform yourself as much as possible about it whenever you can. Would you undergo major heart surgery without researching it first? Would your doctor even entertain the notion before doing the surgery. Definitely not. Pregnancy and childbirth shouldn't be any different.

More reading:
A License to Rape - Birth Without Fear Blog
Dr. James Burt - Wikipedia 
Uninformed Non-consent - The Deranged Housewife
Doctor brands woman's uterus during hysterectomy - Owning Pink
Doctor sued for 'branding' patient's uterus (a different story from the Kentucky case)

Thursday, February 3, 2011

Gullibility and the Pacific Northwest Tree Octopus

The Pacific Northwest Tree Octopus: perhaps you've heard about it. Does it live in the water? Does it live in a tree? Does it even exist?

Apparently this 'endangered species' is extinct - because it's not even real.

A study was recently published by the Pearson Publishing Company that suggested kids were being dumbed down because of the Internet, and weren't able to discern if what they were reading was real or not. The group set up a fake website and asked seventh grade students to research the octopus, and no one realized the website was a hoax. Some students apparently refused to believe it was fake even after the study's leaders revealed the truth about it.

In the comments section for this article, people were quick to jump all over our legendarily poorer performing students and essentially blame them for not having enough critical thinking skills. I disagree. Perhaps the people who conducted this study aren't familiar with the Snopes website?

I feel badly for these kids, because many at that age level are often brainwashed with ideas about environmentalism and politics by their teachers. Parents are one thing - you are entitled to raise your kids with whatever ideology you want. But it is not the teacher's job to tell the student what to think, merely how to think. There is a big difference. Nor should the teacher be injecting his or her personal feelings into the argument. (I know some teachers who do this, and can't believe they still have jobs.)

One mom piped up and said her child's school was repeatedly showing Al Gore's An Inconvenient Truth in class. If environmental issues are your thing, that's fine; but skeptics are quick to point out that Gore's movie is not all "truth." Separating the wheat from the chaff, so to speak, doesn't appear to be a problem only among kids. And if it's coming from the mouth of a teacher or other school official, they're probably more bound to believe it, simply because that person is "trusted."

I think the kids' hesitation in realizing the whole thing was a hoax comes from two different things: one, kids are taught that most adults are to be respected, and that they have authority; that they are right. What kid wants to believe that an adult would intentionally lie to them about something so serious an issue as this? Secondly, animal endangerment and environmentalist issues are currently hot-button topics that evoke a lot of emotion and passion from both sides, and kids want to feel - like anyone else - that they can make a difference in such a popular concept. My personal take, as a parent, is that no one is telling us we shouldn't be good stewards of the Earth; but sometimes I think it's taken to an unbelievably ridiculous level at times: like in the case of the parents who killed both themselves and their child (the second child survived a gunshot wound to the chest) because they were concerned over their "environmental impact." Crazy, or just extremely gullible?

Perhaps you've heard about Orson Welles' famous science fiction hoax War of the Worlds, a radio production that convinced thousands of people that Martians were invading the planet. Sure, we couldn't Google it to look it up - and with no TV, you certainly wouldn't see reporters on the scene, giving updates every twenty minutes. But while this broadcast was being aired, millions of people were literally freaking out. And for what?

I've also read that TV viewers would often approach actors who played doctors on television and ask them medical questions. Or that when the popular Dick Van Dyke Show went off the air and Mary Tyler Moore starred in her own self-titled series, that they purposely made her character single, because the writers were afraid viewers would think she had divorced Dick Van Dyke. Seriously? Can we not separate fact from fiction at all here?

Or how about commercials that feature medical "products" that come with a disclaimer that "the doctor portrayed in this broadcast is a paid actor." Because you're more inclined to believe what they're telling you if it comes from a doctor (or at least someone who dresses like one) - someone who is usually esteemed and upheld as a paragon of trust and knowledge. Yeah, right.

We see the same kind of behavior among many pregnant patients and their obstetricians. Because that guy has a white lab coat on and a degree hanging on the wall of his office, it means he's right - even if what he's saying doesn't quite add up or is completely false, unbeknownst to us, it sounds better, more right, if it comes from him. So some crazed madwoman with a passion for natural birth has no medical degree - but can shove reams of paper under your nose that directly contradict what your doctor is saying - and she's the one who's wrong?

The words "just talk to your doctor" make me cringe. Because often when we do, we hear things like:
• "20 to 25 percent of women can't dilate to 10 centimeters."
• "[If you eat and drink while in labor], your poop could be sucked into the vaginal canal..."
• "Come in for a vaginoplasty...we'll make you tight as a teenager again."
• "The vagina is a very dirty place for a baby!"
• "It's illegal everywhere but maybe New York," to a mother interested in a VBAC.

No word on whether these OB's were that gullible (or just dumb), or were just hoping their patients were.

More reading:
Mythbusters - the only guys (and a girl, too) with enough guts to prove how adults are sucked into thinking nonsensical crap is true, too.