Belly Tales

I’ve been sick as a dog for the past three days, for the second time this season (I was so sick right before Thanksgiving that I actually lost my voice and had to call in sick to work…something which I NEVER do).  Luckily I’ve had the past 3 days off to recover, but I’m due to be back at work again tomorrow, and I’m not sure how my voice will hold up.  I keep coughing up icky green stuff, and I feel like this is potentially moving into my lungs.  I’m so rarely sick!  It must be all of the chronic stress of being a new midwife which has absolutely blitzed my immune system.  Joy.  At least I’m over the contagious part of it, so that when I’m at work tomorrow I won’t be getting pregnant women ill as well.

In any case, I’m not up for writing much of anything, but I found another amazing video over at Sage Femme’s, and thought I’d share it too.  It’s been up at Sage Femme’s for awhile, and I’ve seen it before, but since I only just recently learned how to embed You Tube videos, might as well polish the new skills, w00t!  This one is ultimately brought to you by the folks over at International Cesarean Awareness Network.  Just goes to show what a bogus diagnosis “cephalo-pelvic disproportion” (CPD) often is, and what a VBAC can accomplish when it’s actually allowed to proceed (which is why the declining VBAC rate is an absolute tragedy).  Baby heads are made to mold, and pelvises are made to stretch.  Given enough time and patience, I believe that almost all babies, regardless of size, will make their way into the world.   And just look at the triumph on these women’s faces.  Talk about blowing a raspberry to the entire technocratic fear-based model of birth!

National Advocates for Pregnant Women just concluded its 4 day Summit To Ensure the Health and Humanity of Birthing Women in Atlanta, GA, this past weekend. This summit, one of the first of its kind, was organized by NAPW and NAPW’s director, Lynn Paltrow, to explore the grey area where pregnancy, birth and the law intersect. In our increasingly litigious society, the debate about reproductive choice and reproductive freedom is not limited only to the debate over abortion; women are constantly facing difficult decisions, constrictions and legal battles on a daily basis simply to be allowed to give birth where they want, how they want and when they want. It seems like one of the overt aims of this conference was to widen the terms of the discussion and to get the reproductive rights advocates talking with the pregnany and birth rights advocates, demonstrating how these two debates are really just different ends of the same spectrum, and how all womens’ rights are being constricted, whether they choose to have children or whether they choose to have an abortion.

The Summit program covered everything from the overbearing and disempowering birthing machine in this country to our culture’s rampant fear of birth, from the legal restrictions being placed on VBACs, contraception and abortions to the disturbing rise in fetal rights, where mothers with substance abuse problems are prosecuted for “child abuse” on behalf of their unborn fetus, instead of being offered the care and treatment they need….and so much more, more, more. I really wish I could have attended! NAPW even offered several bloggerships to a few of the lucky feminist, birth and reproductive rights bloggers who were able attend. Too bad we didn’t get a longer winter break; school started again on January 9th, alas.

It’s been absolutely fascinating reading the reports and thoughts of many of the bloggers who were able to attend. I’ve linked to a partial list of the blogs on the Summit, so that you can read for yourself. It’s almost as good as being there (although not quite).

Feministing: Semi-live blogging from NAPW Conference

Gymno: Sick Blogging

Gymno: Summit Day 1 (cont.)

Is there no sin in it: NAPW Conference is happening now!

bird in a bottle: More Lynn Paltrow love (and a prelude to Blog for Choice Day)

bird in a bottle: Language and Gender, Part Deux

bird in a bottle: Why I want to be Dorothy Roberts when I grow up

Angry Black Bitch: Thoughts inspired by sessions

Angry Black Bitch: Thoughts inspired by debates, particularly the VBAC v. cesarean delivery debate.

Pandagon: NAPW Summit kicks off

Pandagon: NAPW Summit: end of the 1st Day

Bitch PhD: Join this Organization

Women of Color: The first part of the conference

And even more from brownfemipower here and here and here, and finally: Midwives of Color.
Oh, and this is just too cute not to pass on.

And finally, a word or two from the demi-goddess herself: Lynn Paltrow’s article in the San Francisco Chronicle, On the Anniversary of Roe v. Wade

Well, huh, this isn’t really news, but better late than never: a very well balanced article from the New York Times examines many of the issues which contribute to the declining rate of VBACs in this country, including doctors’ rising fear of uterine rupture, hospitals’ difficultly in staffing the necessary number of qualified doctors to support and provide VBACS, women who are more than happy to schedule their second, third and fourth (and primary!) cesarean, and women who desire a VBAC and feel betrayed by the lack of options available to them in their area.

Many women are willing to take the risk [of having a VBAC], and the hospitals’ stance has become a charged issue, part of a larger battle over who controls childbirth. Some women say their freedom of choice is being steamrolled by obstetricians who find Caesareans more lucrative and convenient than waiting out the normal course of labor. Doctors say their position is based on concern for patients’ safety.

Meanwhile, a story from yesterday’s New York Daily News charts the rising cesarean rate in hospitals, citing which five hospitals in New York city have the hightest rates: New York-Presbyterian Hospital Columbia (a whopping 39.6%, which still seems monumental even when you factor in that NY Presb handles many of the highest risk births in this city—the method of handling them is obviously cesarean), St. Vincent’s Hospital Staten Island (39.5%), Brooklyn Hospital Center (38.5%), New York Presbyterian Weill Cornell (37.1%) and finally, Flushing Hospital (37%).

Powerful numbers, indeed. If this continues, the Healthy People 2010 goal of a 15% cesarean rate for first time mothers and an increase the VBAC rate to 63% will seem laughable, rather than even remotely attainable.

Last week I had an exam in Neonatology, and my teaching project and a presentation in Neonatology all due at the same time, so it was a bit hectic. This week, the only thing on my plate is a few modules and some studying for the upcoming final exams, and a write-up of my teaching presentation, so I’m taking a justified, (albeit brief) break, and blogging for a delicious change.

I was looking back over some of the posts I’d written about hospital birth over the past year and a half, and I feel that the time has come to eat some crow. Not a huge amount of crow—not a grilled crow steak with onions and salad and the works, but maybe a crow kebab or crow pie appetizer. I think I was feeling very burned out this past summer, very very tired of all of the hospital birth BS, and I think a lot of that had to do with how very tired I was of working as a nurse. I was (and am) ready for change, and ready to be working as a midwife, and now that I’m actually more than halfway through my IP clinical rotation, and am finally (FINALLY!!!) catching babies, it’s as if a large piece of the puzzle has fallen into place. Suddenly, everything feels right in the universe, and I’ve been so ridiculously happy lately, now that I am actually doing what I have wanted to do for so long—this glorious, miraculous, beautiful work that has called to me for over 5 years now. So, the burned out feeling is gone, and in it’s place is a refreshing sense of growth, because I am learning so much right now, and heading in such a fantastic direction, and things finally feel like they’re moving. It’s slowly dawning on me that school will in fact be over (probably much sooner than I’m ready for), and that I will indeed be a midwife someday (really, truly!!).

The point being, the hospital where I’m currently doing my clinical rotation flips a lot of the hospital-birth stereotypes on their heads, and maybe this has a lot to do with the fact that midwives are employed by this hospital, and respected by this hospital (and the OB Dept., which says a lot right there), and do a lot of the work of running the labor and delivery floor. I can only write from my experience, and this is what I’ve seen: 3 years of working as an L&D nurse in two seperate hospitals, and I’d say that at least 90% - 95% of all births involved an epidural. A woman without an epidural was either making a huge and difficult point to labor “naturally”, or had simply managed to show up to the hospital fully dilated and unable to recieve one in time before she delivered. I can’t say that the majority of births I’ve seen have had at least a 1st degree laceration, but I do feel that at work, an intact perineum is often a rarity, and a very pleasant surprise. Women, as a rule, are not allowed to eat or drink during labor. The squat bar often sat gathering dust in a corner, the birthing balls were rarely (if ever) used, and getting a woman out of bed was always a very rare and unexpected treat, that often required a lot of fighting for. It was never the norm.

And this is not to say that there are no fights to be fought at the hospital where I am currently doing my clinicals, but I’ve been paging through my delivery book (21 births so far, believe it or not!!!) and noticing that more than halfof the woman I’ve worked with haven’t had any analgesia or anesthesia on board (14 out of 21, to be exact). The majority of them have had intact perineums. I’ve used the squat bar more times in the past 7 weeks than I have used it or seen it used in the past year at the hospital where I’m working. The women on the floor are almost always given clears to drink, which is a much better deal than being NPO (i.e., not allowed to eat or drink anything), and some women are even allowed to eat some lunch in the early part of their labor or induction. And while getting a woman out of bed still causes a lot of eyebrows to be raised, I’ve seen it happen at least 4 times so far, and once we even got the woman out of bed, off the monitor, and into the shower, where she would have remained if only someone could have stayed in the room with her to fend off the anxious nurses trying to get her back on the monitor.

Oh, and VBACs! Did I mention that this hospital does VBACs? And not just attempted VBACS, but actual, squalling-baby-born-vaginally type VBACs?? Very very pleasant surprise. I think I can possibly count on one hand the number of successful VBACs I’ve seen at Tried and True Hospital.

And have I mentioned lately how much I’m enjoying my clinical rotation so far? And these births!! All these beautiful births!! I’ve caught so many babies so far! I feel so blessed, and so lucky, despite the exhaustion and over-worked brain and tired legs and mounds of homework. I stayed late one night and caught three babies in a row, one right after the other—women I’d been laboring with all day, and had been examining all day, and watching as their cervixes changed from 2 cm to 6 cm to fully dilated, and was then lucky enough to be able to catch all of their babies. Afterwards, at around 2:00 in the morning, as I was finally leaving, I stopped by the postpartum room of the first woman I had delivered that night (she was a successful VBAC!!) to say goodbye. She had been wearing a gorgeous woven cloth rosary around her neck throughout her entire pregnancy and birth, and she pulled it off and gave it to me, and I walked down to the lobby with tears in my eyes, cradling the beautiful rosary. It is such an honor, and such a gift, to be able to be with women at the moment of their births, and to be able to catch their babies. Some days I can’t believe my luck and good fortune, because that’s really what it feels like to me. I am such a lucky woman! This really is the best job in the world.

Whenever news abour labor and birth hits the mainstream media, I sit up and take notice. The fold-out section on Women’s Health in this sunday’s New York Times certainly caught my attention, and while perusing it, I read the following tidbit in Eric Nagourney’s article about shifting health guidelines for women:

Caesarean Birth

There was a time when women who had already given birth by Caesarean section would never be allowed to have their next child naturally. Doctors considered the practice too dangerous.

That thinking changed about two decades ago. Doctors are now taught that in most cases, vaginal birth after Caesarean - often referred to as VBAC (commonly pronounced VEE-back) - is only slightly less safe than having another Caesarean.

But try getting a hospital to allow it. After years in which the number of VBAC’s went up, many hospitals, concerned about medical complications and legal liability, have begun forbidding the practice.

Part of the concern is that the stresses of labor may put so much pressure on the old incision site that the uterus can rupture, putting baby and mother at serious risk. Even advocates of VBAC say that it should be done in hospitals that are equipped to deal with a problem.

The American College of Obstetricians and Gynecologists counsels that most women who have had what is known as a low-transverse incision Caesarean should be offered a chance to give birth vaginally. (The group advises against it with women who have had a “classical” Caesarean incision.) Epidural anesthesia is fine, the group says, but inducing labor should be discouraged.

According to the preliminary birth data for 2003, the cearean section rate is at an all time high in this country, coming in at a whopping 27.6%. Meanwhile, the report issued by the CDC noted that the VBAC rate has fallen abysmally from it’s high of 31% in 1998, and is now down to 10.6%. What I want to know is: what’s happening here? Why is the VBAC rate falling so precipitously?

The overall risks of a VBAC are low, but there is always the possiblity of uterine rupture, which occurs in approximately 1 out of every 2,000 births, and is pretty serious, of course, since it puts both the mother and baby at risk, depending on the severity of the rupture. However, a repeat cesarean is hardly risk free: not only does it bring with it the usual risks associated with abdominal surgery (risk of infection, anesthesia complications etc.), but the risks of infection and surgical complication are higher with a repeat, and the chance of incorrect placental implantation or placental accreta with future pregnancies is much higher as well. If a woman has one repeat cesarean, she will almost unequivocably be having a cesarean with her third child and fourth child too, and the risks associated with those cesareans will just keep rising each time.

I do wonder how much fear of litigation is affecting this. When a cesarean is viewed as the “safer” option, the consevative approach, the correct course of action and the solid defense that will hold up in court, then of course a nice, clean, quick cesarean would seem much more preferable to a long, drawn out (i.e. normal vaginal birth) VBAC, with its inherent risk of uterine rupture and potential malpractice claim. Even though the chance of uterine rupture is very low, when the cost of defending a malpractice claim is so high, I wonder if a lot of doctors just don’t think it’s worth it anymore?

A very large and comprehensive study of the risks of VBAC versus elective repeat cesarean was published in December, 2004 in the New England Journal of Medicine. This study found that the overall risk in having a VBAC was low, but nevertheless, slightly higher than the risks involved in having an elective repeat cesarean. Hospitals have been limiting the number of VBACs for several years now, and there are several hospitals which flat-out refuse to do VBACs, even if their attending doctors (not to mention the women giving birth) are willing. If a hospital was on the brink, perhaps this study has just offered up the unequivocal proof they were looking for, and tipped them over the edge, into the No VBAC zone.

ACOG still recommends that women with low-transverse incisions and no other obvious risks attempt a VBAC before having a repeat cesarean. The Healthy People 2010 guideline is recommending a 37% percent VBAC rate by 2010, so we’ve got a long ways to go to reach that, in not a lot of time. However, as Eric Nagourney’s article in the New York Times pointed out, guidelines keep changing, and what was seen as sound, incontrovertible medical practice now is often found to be questionable 10 years down the road. VBACs changed the landscape, challenging the old medical idea of “once a cesarean, always a cesarean”, but now perhaps we’re in the middle of a cesarean backlash, as the VBAC rate keeps plummeting. We can only hope that 10 years down the road, VBACs will be on the rise again, and the notion of “once a cesarean, always a cesarean” will be something relegated to history books.