The positive impact of prenatal exercise

The following is a re-post of my August 2008 post Wanna Improve Your Odds?:

I mentioned back in April that I had been skimming the book Exercising Through Your Pregnancy, by James F. Clapp M.D. I was really impressed at that time with the amazing benefits of exercising through pregnancy. But I didn't read the book in-depth. I decided earlier this week that I wanted to take a closer look. Now that I've read several of the chapters and examined the data thoroughly, I am telling you... it absolutely blows me away.

There are risks inherent in pregnancy and childbirth, but we can do things to minimize those risks. We all know that good nutrition is essential for pregnant women. Poor nutrition often leads to pre-term and low-birthweight infants as well as pre-eclampsia in mothers. Eating well is one of the absolute best things you can do for your unborn child's physical and neurological growth. But now I'm convinced that exercise may be just as important.

I won't go into all the benefits of prenatal exercise here. I'd just like to focus on one set of benefits in particular--the effects of exercise on the course of labor. You might remember my very early post about the benefits of doulas. Having a doula assist your labor and delivery reduces many chidbirth risks significantly. Prenatal exercise has even more pronounced benefits.

Women who continue exercising regularly through the end of their pregnancies (three times a week for at least 20 minutes at a moderately hard to hard level of exertion) demonstrated the following reduced risks during the birth process...

* 35% decrease in the need for pain relief
* 75% decrease in the incidence of maternal exhaustion
* 50% decrease in the need to artificially rupture membranes
* 50% decrease in the need to induce or augment labor with pitocin
* 50% decrease in the need to intervene because of abnormalities in the fetal heart rate
* 55% decrease in the need for episiotomy
* 75% decrease in the need for operative intervention (forceps or cesarean section)

In addition, check these out...

* More than 65% of the exercising women delivered in less than four hours.
* 72% delivered before their due date (but fewer of them delivered before 37 weeks--preterm--than the control group). The exercising women delivered, on average, 5-7 days earlier than active women who did not exercise regularly.
* Significant reduction in the incidence of umbilical cord entanglement.
* Much lower incidence of fetus passing meconium from distress.
* Umbilical cord blood samples indicated that babies of exercising moms remained relatively stress-free with plenty of oxygen. They seemed to tolerate the stresses of labor and delivery better than the control group.
* The exercising mothers' infants were, on average, 14 oz lighter but overall growth was not compromised.
* Placentas of exercising mothers are larger, more efficient, and healthier-looking.
* Infants born to exercising mothers were more alert postpartum and needed less consolation from others.

(All of these results are taken from Dr. Clapp's studies as reported in Exercising Through Your Pregnancy. See this fabulous book for even more amazing benefits.)

It blows my mind.

Imagine how huge the risk reductions would be if you exercised through pregnancy AND had a doula. Whoah. We can do so much to avoid the pitfalls of pregnancy and birth. It gives me so much joy and hope to know that I am not at the mercy of chance. I have a great deal of power over my circumstances when it comes to pregnancy and birth. It is a wonderful thing to be able to choose to pro-actively reduce risks and bring so much benefit to myself and my babies. I love it!

Thank you, ABC News

For raising awareness about the many problems with our maternity care system in this country and the rising maternal death rate.

Now let's change things.

Happy dispatch

My cousin(-in-law) has two adorable boys. She had hoped to give birth unmedicated with both of them, but pitocin threw a huge wrench in things and necessitated pain relief, so she's extremely determined to avoid induction/Pitocin with the birth of her current baby-in-utero. So I was positively giddy with excitement when I got this email from her this morning:

I had my first prenatal appointment today. Long story short, everything is great. She had no trouble finding the heartbeat - about 165 bpm, loud and strong. I love that noise. :)

And the practice I'm going to? GOLD MINE. Seriously, I could not be more impressed. They will let me go two weeks overdue without inducing, and when they do induce, pitocin is sort of a last resort. They had a sign up boasting their statistics (and I would too if I had their numbers):

* 7% cesarean rate
* 32% epidural rate
* 11% induction rate
* less than 1% of newborns are admitted to the NICU
* 6% vacuum delivery (no forceps)
* 72% intact perineum rate (no tears or cuts)
* jacuzzi tubs are encouraged for use during labor and delivery
* eat and drink whatever you want during labor
* no IVs unless medically necessary
* no routine episiotomies
* no continuous fetal monitoring unless medically necessary
* birth in any position you would like
* have as many family members and/or support people at your birth as you would like, including baby's siblings

I mean, seriously!? Are you kidding?! And this is at a HOSPITAL. I could not believe it. I actually asked if they do VBA2Cs, and while they don't advertise it, they will definitely sit down with women, look at why they had two previous cesareans, and the practice has attended successful VBA2Cs in the past. I think I might email [my 2-cesareans friend] about it, just in case she wants to have another kid and wants a hospital option - we're only like 1.5 hours away.

Anyways, I was there for over an hour and a half, explaining my past experiences and what I'm hoping for this time. I met with the NP who does most of the prenatal visits (since the CNM is often busy doing deliveries), and she's great. I'll meet with the CNM (who does all of the deliveries) at least 2-3 times before I go in.

Oh, and the walls were covered with birth announcements (as you often see at OB/CNM clinics), and what struck me was how big these babies were - most were over 8 pounds, and there were quite a few that were over 10. I was so impressed to see these big babies next to this poster of amazing birth statistics and such a low cesarean rate. Seriously, can we never move?! If we lived [here] forever, I think I would end up having 15 babies with these people.

Anyways, all is well. I'm getting so excited about this little one. :)

Ask Busca: Breaking Water?

Elizabeth asked:

I have a question I'd love you to explore on your blog. In many of the birth stories I've read, Moms mention having their water deliberately broken by their midwife or doctor. Can this ever contradict a woman's internal timetable for the birth? Does water sometimes not break when it should, stalling labor? Is this practice ever considered an unnecessary intervention?

Busca's babble:

Artificial rupture of membranes (AROM, or amniotomy) is very common. Some care providers routinely break the bag of waters in an attempt to speed labor, especially in women who "fail" to follow the standard labor progress curve (at least one centimeter every hour). AROM is also used to induce labor, sometimes accompanied by prostaglandin gel and/or Pitocin. When an internal electronic fetal monitor is needed (to check baby's oxygen levels), AROM is performed to gain access to the fetal scalp. Sometimes AROM helps doctors or midwives determine whether a baby is in distress--as indicated by meconium in the amniotic fluid.

Can AROM ever contradict a woman's internal timetable for the birth? Certainly. Henci Goer, in her book The Thinking Woman's Guide to a Better Birth, explains, "[I]f left alone, two-thirds of laboring women reach full cervical dilation with membranes intact, and there are advantages to this" (p. 101). The amniotic sac and fluid serve a valuable purpose--not just during pregnancy, but during labor as well. Once a woman's bag of waters is ruptured, the chance of infection increases. Because of this, doctors and hospitals generally require that a woman with ruptured membranes give birth within 24 hours. (The chance of infection is much lower if vaginal exams are avoided.) So the membranes protect both mother and baby from infection. The fluid cushions the fetus and umbilical cord. Once the membranes rupture, the risks of cord compression and abnormal fetal heart rate patterns increase.

Early amniotomy also carries the frightening risk of umbilical cord prolapse. When a baby's head has not descended well into the pelvis, the gush of fluid can carry the umbilical cord into the vaginal canal where it will be compressed by the descending fetal head. This is an obstetric emergency requiring an immediate cesarean. My blogfriend, Sarah, recently shared her experience witnessing a doctor perform an unnecessary early amniotomy resulting in a cord prolapse and emergency cesarean. Oh that story made me seethe!

Does it hurt to leave the membranes intact? A recent Cochrane review of research assessing the use of AROM in spontaneous labors came to this conclusion:

Evidence does not support the routine breaking the waters for women in spontaneous labour. . . . Amniotomy has been standard practice in recent years in many countries around the world. In some centres it is advocated and performed routinely in all women, and in many centres it is used for women whose labours have become prolonged. However, there is little evidence that a shorter labour has benefits for the mother or the baby. There are a number of potential important but rare risks associated with amniotomy, including problems with the umbilical cord or the baby's heart rate. . . . The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged (Smyth RMD, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006167. DOI: 10.1002/14651858.CD006167.pub2, emphasis added).

So, AROM carries known risks and apparently few benefits, at least when used routinely as it so often is.

When left alone, sometimes the amniotic sac never ruptures--births "in the caul." I sometimes wonder whether my second daughter would have been born in the caul since my sac remained intact until my CNM broke it at 9 centimeters. Navelgazing Midwife says this about AROM and births in the caul:

I'd heard about an OB that was so disgusted with AROM that he offered a $50 bounty for every caul birth and shelled out thousands before calling the game... proving that it is possible and isn't dangerous and not AROMing did not slow labors down, but, in fact, helped women cope better.

She also shares some of her fascinating experiences witnessing births in the caul. When handled correctly, there is no harm to being born in the caul. Navelgazing Midwife's conclusion? "I find, as time goes by, that I touch membranes less and less. I believe they are there for a reason... will break when ready... and serve a purpose we might never know" (source).

For two out of my three births, my membranes ruptured before the onset of labor. In the future, should my sac remain intact (as with my second birth), I think I'll request that it be left alone.

Inspired by Martha: Part Two

How to have a successful unmedicated hospital birth, Martha-style...

1) Determination!
One of the things that makes Martha so inspiring is that she weathered her pregnancy and birth with TWO heart diseases (aortic valve stenosis and hypertrophic cardiomyopathy). This put her in a higher risk category than the average pregnant woman, but she was still determined to pursue a natural birth, despite the skepticism/concern of her cardiologist and OB. She said:

I left their offices many times over the next couple months sobbing all the way back to work. I felt trapped because I was in my final months of pregnancy and didn’t want to go to the trouble of changing doctors. I trusted them both to take care of the heart issues because they had worked together in the past on pregnant women with heart disease and that was very important to me. . . . [They] had no stats or studies to back it up, but their main concern was the risk natural childbirth would pose to my heart. I could never really get to the bottom of it, but I was CERTAIN natural childbirth would pose no extra risk to my heart. I felt just the opposite, actually.

2) Avoid being induced, if possible!
I remember the week or two before Martha gave birth. Our mutual friend mentioned that Martha's doctors were really pressuring her to be induced. I was so hopeful she would be able to avoid an induction! Pitocin would put an unmedicated birth virtually beyond reach (not to mention the stress it could put her body and her baby under). Here's what Martha had to say about that harrowing time:

The final month was the worst because they made me have extra fetal monitoring twice a week which made me anxious and worried because each visit threatened induction because my amniotic fluid levels were all over the map. I knew being induced would put all hopes of a natural childbirth out of my grasp so I prayed more fervently than ever to be spared from induction. . . . I also had many pep talks with Sienna. “Now, listen little lady. We can’t be induced. It’s not an option. So, I need you to just stay inside as long as possible and keep showing the doctors what you can do.” She was so obedient, I wanted to lean over and kiss her after every appointment but couldn’t reach my belly with my lips. Adam had to take care of that for me. The last couple weeks I was put on bed rest which nearly drove me to drink. I would not wish bed rest on my worst enemy. . . . The due date came and went. Due dates are a stupid, cruel thing. They mess with your mind and make everyone under the sun badger you about why your baby’s not here yet. Poop on due dates. I’m not telling anyone mine next time.

3) Faith!
I really believe one of the reasons Martha succeeded was because of her enormous faith. You really cannot tackle natural childbirth without faith... whether it be faith in God, faith in the birth process, faith in your body, or faith in yourself. Martha's deep faith is so inspiring to me:

I found great comfort in Ether chapter 12. The more I learned about faith, the more I knew it was my answer. Faith precedes miracles and I needed a major miracle. Faith brought about the impossible, like moving mountains, and I needed a mountain MOVED. Each time after fetal testing, I was sent home. Each time I KNEW it was a miracle. I still didn’t know what the end would bring, but I just kept my faith fine-tuned and told God what I wanted and left it up to Him.

4) Hang out at home as long as you (safely) can!
I really think the birth outcomes in our country would vastly improve if women would spend most of their labors at home. Rushing to the hospital too early is a mistake many women make. The artificial lighting, restrictive policies, and strange faces and environment lead many women's labors to stall or slow down, which leads hospital staff to either send her back home anyway or start intervening in the birth with Pitocin, etc. At home, a woman is on her own turf, can be upright and mobile, and can eat or drink as she wishes--all things that will facilitate her labor process. Martha was fortunately able to spend all but the very end of her labor at home. Here are some excerpts of her birth story. I hope you don't mind that I nearly pasted all of it, Martha! It was just so great, I couldn't help putting so much of it here:

Wednesday at 2 a.m. I got up to pee for the umpteen bajillionth time and also ate a plum and read my scriptures (Ether 12, I love you!). At 2:30 a.m. I peed again and heard a little PLOP. Water breakage, folks! This was the sign I was looking for. I woke up Adam and called Dr. Marralle’s operator. I told the operator my water had just broken and that I was ready to come in. The operator told me Dr. Marralle’s instructions were to come in when my water was broken AND when I was in active labor (contractions 5 minutes apart, lasting 60 seconds, for one complete hour). I thought this was odd because Dr. Marralle had told me several times that I’d need to come in if my water broke OR if I was in active labor. Huh. The operator seemed pretty confident so I agreed to call back when I was in active labor. Adam went back to sleep and I tried to lie down and wait for active labor.

Contractions did keep coming but they were quite irregular. I couldn’t get comfortable in bed and just walked around the house and leaned over the table or desk or wall, or knelt down over my ottoman when a contraction would hit. I timed and wrote down each contraction and from 5 – 6 a.m. they were in the ACTIVE zone. By this time I’d thrown up my plum – twice – and had much more water gushing out of me from below. Isn’t labor PRETTY? Adam awoke when he heard me groaning in the front room around 6 a.m. and came out to help. I hadn’t wanted to wake him up because I thought at least one of us should be well rested for the big day ahead. I also didn’t know how he could help me, since he couldn’t exactly BE me and that’s about all I wanted at that point. However, when he came in and started rubbing my back and encouraging me, it helped immensely.

I told him to call back the operator and she gave him the go-ahead to come in. We gathered our things, he ate breakfast and emptied the dishwasher (of course he did!) and we both showered. By this time my contractions were just a couple minutes apart, and I knew we needed to get this show on the road. I remember getting into the car and telling Adam, “I can do this,” signaling that I was ready to do this natural childbirth thing because I still felt in control of my contractions. However, in my head I thought, “But if this lasts all day, I CAN’T do this.”

I was making quite a bit of noise through my contractions and I liked it. Well, I wouldn’t say I liked it, I guess I just felt sort of cave-womanish, which freed the inner natural childbirth hippie in me, which I liked. Sitting in the car was totally uncomfortable. I did have a pillow behind my back which helped and a pillow in the front that I was squeezing to death. I closed my eyes and just wished away every bump on the road. Hoag Hospital is in Newport Beach, about 20 – 30 minutes from our house. We had two freeways to conquer but it was 7 a.m. and the traffic was moving great. I think I opened my eyes three times and knew we were making good time. We got there a bit before 7:30 a.m. Adam valet parked and I leaned against poles, walls, Adam, whatever I could to get me up to the 5th floor: Labor and Delivery! The nurses stared at me as I leaned against the wall and did this thing with my feet like a bull does when he’s getting ready to charge. I thought about that later and thought it was quite symbolic. Ha!

Adam was very calm in getting us checked in at the front desk and meanwhile the nurses could see they needed to get me to a room fast and acted accordingly. They tried to put me in the wheelchair but I declined. I didn’t want to have my grand entrance be as an invalid and, more than that, I did NOT want to sit. That is the LAST thing that felt good on my back. I got to the room and they made me strip down and throw on a gown. . . . They had me climb on the bed for fetal monitoring and a cervix check. I wanted to decline that up front as well and let them know from the start that I wanted to MOVE a lot and not be confined to the bed. But I figured we’d have a look to see how far I was dilated and then I’d voice up.

The nurse stuck her fingers up there and announced, “You’re dilated to a 9.5!” I looked at Adam and said, “That is the BEST news I’ve EVER heard.” We were both shocked. So were the nurses. The head nurse, Kim, tried to get to the bottom of why I had waited to come in so late. I told her my conversation with the operator. She wanted the name of the operator. I didn’t have it. In my mind I wanted to give that operator my first born, yes even the first born I was about to birth. I am convinced she was an angel sent from heaven and was the reason this natural childbirth was happening... and happening NOW! For some reason Kim asked if I wanted medication or an epidural. I answered no to both and thought it odd that she’d even ask since it was obviously too late. . . .

The nurse asked if I’d had an urge to push. I hadn’t put it together until she asked, but YES, in the car, I DID feel like I had to take a giant crap. I didn’t understand the urge, though, because I had thrown up all the food that would be necessary for a bowel movement. So THAT, my friends, is the urge to PUSH. Kim said, “Well, within the next half hour, you can push.”

Meanwhile, Dr. Marralle came in, the nurses (about five or six of them), were bustling around the room, hooking me up to all sorts of things, or just staring for general amusement. A sweet middle-aged nurse came to my bedside and introduced herself as Cindy, a student nurse that was on her first day here. I loved her immediately and grabbed her hand. I made her hold it the whole time while Adam was on the other side, holding my other one. When she let go at one point I grabbed it again. There was no way she was leaving my side. I needed her cold, thin, strong fingers as much as I needed Adam’s warm, bigger, strong fingers. . . .

I had about eight pushing sessions and it all lasted about 25 minutes. Adam was tremendously helpful throughout it all. Long ago we had established that he would be my “focal point” during labor and delivery and several times when it seemed like I was losing it, he would say, “Martha! Look at me! You’re doing great.” He was very reassuring and my #1 cheerleader. He just kept telling me how wonderful I was doing and I was believing it!

Something that was making me lose a bit of focus was every time I put my head up to push, I could see three nurses in the back of the room just watching me. I think two were the baby nurses and one was a student nurse. I wanted to say, “Are you enjoying watching this? My crotch? My pooping and peeing all over the doctor while I try to push this impossible baby out? My head turning all sorts of shades as I nearly explode? Oh, good.” . . . I was annoyed, but tried to stay focused on the people that were helping me: Cindy, Kim, Adam and Dr. Marralle. I chalked it up to either it being protocol for baby nurses to wait in the room until the baby comes out or maybe, since Hoag has a 98% epidural rate and a 30% cesarean section rate, they had never seen the spectacle that is natural childbirth. I forgave them later as they helped me breastfeed and told me how amazingly I had done. One of their great compliments was, “I didn’t even hear one F-word!”

I didn’t feel the baby’s head pop out, I think because of the local anesthetic on my perineum. I was waiting for that infamous “ring of fire” feeling, but it didn’t come. Anyway, the head DID finally pop out, wouldn’t you know it. Adam said, “Martha, the head’s out!” I think I gave a little squeal of disbelief with a, “REALLY?” Just one more push and out came the slithery little body! It was incredible. Dr. Marralle held her up and I said possibly the dumbest thing ever, “It’s a baby!” Wow. Way to state the obvious, Marth. But there she was, seriously, a baby, a big baby, one that was just moments before making me totally miserable and ugly and grunty and fat and purple and crampy! She was out and it was allllll over. I immediately felt SO much relief. They put her on my chest and the first thing I noticed were her long scraggly nails. Baby nails are tiny miracles unto themselves. I just looked down at her head of black hair while the nurses wiped her off. Dr. Marralle asked me to give one more push and out came the placenta. I looked at Adam and said, “That felt gross.” He said, “That looked gross.” Dr. Marralle had Adam cut the umbilical cord, then she got busy sewing me up. Dr. Marralle’s comment after it all was, “Well, don’t plan on it being that simple next time, young lady.” Classic Dr. Marralle. I didn’t care, though. Nothing anyone could have said would have ruined that moment.

Are you feeling warm and fuzzy now? Me too. :-)

Post induced by Pushed

I'm rereading Pushed. 'Cause it really is that good. And I swear I want to quote a sentence from every paragraph... but I'll limit myself to a few quotations.

"An induction absent a solid indication absolutely increases all risk to mom and baby. . . . Just by the mere fact of induction, you've now intervened in a pregnancy that otherwise would have continued, and you've already increased the risk of C-section."

"Macrosomia is not a reasonable indication for induction."

(Laura Riley, MD, medical director of labor and deliver at Massachusetts General Hospital and former chair of the ACOG practice committee, qtd in Pushed, p. 8-9)

"That one kills me [said in reference to the idea that babies can't fit]. The maternal pelvis is a very well-constructed and flexible body structure in late pregnancy."

"The predictive ability of amniotic fluid volume as an indicator of anything for an otherwise healthy pregnancy is extremely low. There's just not evidence to support it."

"It just defies logic that half of women get an artificial version of a hormone that the body normally produces during labor."

(Ellen Hodnett, professor of nursing at the University of Toronto, member of the Cochrane Collaboration's Pregnancy and Childbirth review team, qtd in Pushed, p. 10-13)

Alright... now I'm going back to my book. You probably don't need me to tell you to expect more quotes over the next week or two. ;-)

Response to a resident's comment

I received a comment on this post today:

As a resident physician I'd like to note that your rant on pitocin was pretty uninformed. You were given oxytocin following delivery for uterine atony, to prevent HEMORRHAGE, the cause of much maternal mortality before your god-awful pitocin was synthesized.

Furthermore, take a look at the medical literature concerning fetal death rates before and after the discovery of oxytocin. Placental abruption, cord compression, hypoxia in utero, chorioamnionitis secondary to prolonged labor times...these were all huge killers of newborns, but you'd likely not KNOW it because you know nothing about medicine. If you're going to complain publicly please try and do it in an informed fashion, lest you mislead women and have them make bad decisions at the hospital.

I started a response in the comments section, but decided the exchange was worth its own blogpost. So I'll paste my response here.

Dear Anonymous resident physician:

I think you're referring to this post. I'm curious what parts of the original post were "uninformed."

You, not having been present at my birth nor privy to my medical charts, can't claim to know the circumstances that led to my being administered Pitocin. I don't have a doubt that stopping a postpartum hemorrhage is a valid use of the drug. Postpartum hemorrhage remains one of the leading causes of maternal death to this day. In fact, prolonged use of Pitocin during labor is one of the risk factors for postpartum hemhorrage. A friend of mine bled excessively following a long induced labor.

I never said I shouldn't have been administered Pitocin. Honestly I don't know because I haven't looked at my charts myself, and I was never given the details while in the hospital. It's possible that the hospital where I delivered gives every woman Pitocin following labor as a precaution. Regardless of those details, the fact is that it interfered with our bonding as I suspect it does for many mothers. Drugs, even when needed, are unfortunately not without harmful side effects. You can read the list of Pitocin's side effects (including postpartum hemorrhage) here. I shared my own limited experience with Pitocin merely to illustrate one of the possible harmful side effects of the drug. So far I'm not seeing anything I've said that qualifies as "uninformed."

I never said Pitocin shouldn't be used when necessary. I'm absolutely grateful for the fetal and maternal deaths prevented by Pitocin. As I said in the original post, "Pitocin has its time and place." But I am simultaneously appalled by the injuries often inflicted when Pitocin is unnecessary. You can't debate the fact that Pitocin is being abused when used without medical reason. You can't ignore the voices of those women and babies harmed by the drug either. I don't have a problem with Pitocin when it's necessary, but I definitely have a problem with it being used "like candy in the OB world" and leading to unnecessary suffering.

You're right that I know nothing about medicine, and I never claimed to. But I have spent the last 6 years of my life passionately studying birth--which is a natural process. Birth has little need for medicine most of the time, but I have always acknowledged that I am grateful for modern medicine for those cases when doctors and medicine become necessary. The lives of women and babies I love dearly have been saved by those wonderful modern advancements.

You're right that I like to rant about Pitocin. And I will keep ranting until doctors stop abusing it. If you aren't aware of those abuses, try googling the new birth buzz-words "Pit to distress" for starters.

It is certainly not my intention to mislead women. On the contrary, I'm on a crusade to educate women so they can make truly informed decisions. I would definitely appreciate and welcome any feedback that would help me to better inform women or to correct any misinformation I may be disseminating, but so far I think I've only shared the facts.

Re-post: To the women of the world

I've been reminiscing about two years ago when I started this blog and thought it might be fun to do a re-post of my very first post ever... which also happened to be one of my first publications ever--an opinion piece in the newspaper. It was a long-time goal of mine to have something I had written published. And it was all the more satisfying and fulfilling because I was able to educate people about something I was passionate about in the process. Here it is...

After two years of reviewing 15 years of medical literature, a team of national experts has come forward with this reality: Many of the routine medical interventions used in births in the United States do not improve outcomes for mothers and babies. Some even cause harm.

Their findings demonstrate increased risks and problems with many prevalent interventions including labor induction, cesarean section, continuous electronic fetal monitoring, routine use of IVs, amniotomy (artificial breaking of water) and withholding of food and liquids. Though these interventions have become commonplace and viewed as part of "advanced" and even "superior" medical care, this study indicates these practices are not improving outcomes in most cases. In fact, they often create more problems than they eliminate. These findings will appear in the winter 2007 supplement to "The Journal of Perinatal Education" in a summary report entitled "Evidence Basis for the Ten Steps to Mother-Friendly Care."

This is not the first time these facts have been brought to the nation's awareness. Time and again researchers, activists and organizations, such as the Coalition for Improving Maternity Services, have tried to create change by raising awareness about the problems with maternity care in the the United States. Generations of women have recounted their birth horror stories over and over to each other. Scores of women wear the physical and emotional scars of unnecessary medical interventions.

Who is listening?

Does anyone care?

Let me use the words of Thomas Paine from his fiery call to arms, "Common Sense," with just a few of my own insertions: "Every quiet method for [change] hath been ineffectual. Our [appeals] have been rejected with disdain; and only tended to convince us, that nothing flatters vanity, or confirms obstinacy in [an old, broken system] more than repeated petitioning." The methods we have used thus far have been passionate and have brought about small victories, but the changes most needed have yet to be recognized or addressed by the mainstream medical community. We need a new approach.

Buckminster Fuller said, "You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete."

Women and mothers of the world, I call on you to "build a new model." The time for complaining, pleading and persuading is over. Those methods have been tried, and they have done little. It is time to say, "Enough!"

Let us no longer accept mediocrity and "go along blindly" with any procedure. Let us no longer tolerate practices that have been shown to cause us or our babies harm. Let us stop playing the victims and start creating the reality that we all deserve — the absolute best maternity care possible. Let us demand the best of the best for ourselves and our babies.

We cannot underestimate the power of women united in behalf of themselves and their children. "There is a woman at the beginning of all great things," said Alphonse de Lamartine. Imagine what we can accomplish if we unite our efforts. Imagine what we can create.

Pitocin on the brain

I've got Pitocin and induction on the brain. In large part because I'm about halfway through Pushed, by Jennifer Block, and just finished reading about the consequences of Pitocin and labor induction. Here are some sobering excerpts...

"A British midwife told a researcher that the sounds women make when they're on artificial oxytocin [Pitocin] are hauntingly different: 'It's a panic, it's a scream and it's different from the noise they make when they're working with their bodies. . . . It sounds like someone's being murdered'" (p. 135).

"And with an epidural deadening the body's natural pain threshold, staff can keep upping the dose, which can lead to contractions that fire like a machine gun or that last for minutes, during which time the fetus is oxygen-deprived. This is called hyperstimulation. It is not uncommon and would be considered a trauma--beyond what is normal" (p. 137).

"A recent ACOG survey found that in 43% of malpractice suits involving neurologically impaired babies, Pitocin was to blame" (p. 137).

"Even Williams Obstetrics offers a sobering history: 'Oxytocin is a powerful drug, and it has killed or maimed mothers through rupture of the uterus and even more babies through hypoxia from markedly hypertonic uterine contractions'" (p. 138).

"A 2004 study out of Australia found that autistic children were twice as likely to have been born without natural labor, either by elective cesarean or induction" (p. 139).

Pitocin use in U.S. hospitals has increased alarmingly in the past couple of decades. In 1990, only 9.5% of labors were induced. In 2006, in a study of 5500 low-risk, first-time mothers, 40% were induced and 70% received Pitocin at some point during labor (see Pushed, p. 5-6).

I can see these stats reflected all around me. I know very few women who have given birth without Pitocin dripping through their veins. If it's true that 70% of low-risk first-time mothers are given Pitocin, then it's no wonder birth horror stories and epidural use are the norm. How strange that so few women know what normal birth actually feels like. Instead they have a warped and painfully skewed misrepresentation. We are human beings, but yet so far removed from the most basic human experience.

The truth is that we really don't know how these highly-medicalized births may be influencing and possibly damaging our society. Oxytocin is the hormone of bonding and love, so some suspect that these births (virtually devoid of natural oxytocin) may be partly to blame for the increased violence, autism, and other mental and psychological disorders running rampant in our modern world. Pitocin (and cesarean sections) may also influence how we bond and how we respond to our children as parents.

I've never had Pitocin in labor, but I was given Pitocin through my IV following my first daughter's birth to help slow my bleeding. It wasn't until a couple of weeks ago that I had an epiphany about that Pitocin drip. It's almost certain that once Pitocin was introduced into my system, my body stopped or slowed its own oxytocin production. Artificial oxytocin doesn't produce the same bonding effects as the hormone produced by our own bodies. It wasn't until roughly a week after her birth that I "fell in love" with my daughter. I thought there was something wrong with me... why didn't I love her right away? I'm now quite certain that Pitocin interfered.

There are certainly plenty of women who fell in love with their babies at first sight even with Pitocin or cesareans. But not all women do. Everyone's individual body chemistry is unique. If I could struggle even having had an unmedicated, wonderful birth experience, I have to wonder what it would have been like for me if I'd had drugs or a cesarean... I shudder to think where those paths might have taken me...

Then I contrast those struggles with my most recent birth, and I'm in awe. As my births have gotten progressively more "natural," bonding has gotten progressively easier. And my parenting style has gotten progressively more responsive. I spent the first couple of weeks after my son's birth feeling blissed-out and totally and madly in love with him. In fact, I could hardly bear to be separated from him. What a change from my Pitocin-jolted postpartum experience!

Pitocin has its time and place. But there's no question that it--and the droves of women and babies receiving it needlessly--are being abused. Will we stand by and let this abuse continue?

The Doula Difference

I wrote this post last month for my personal/family blog, but I wanted to re-post it here for those of you who haven't seen it. :-)

I think every laboring women needs a doula. And here's why...

1) Doulas are nothing new.
A lot of people, when they first hear about doulas, think... oh, that's new. But it's not at all. For thousands and thousands of years women have been supported by other women during childbirth. We watched an awesome film at our training called "The Timeless Way" which showed the history of childbirth starting with ancient artifacts and moving to more modern depictions. I was struck how the very same image was represented through sculpture, wall carvings, pottery, and art over and over and over again. It is the "classic birth triad"--an upright laboring woman supported from behind by another woman, with a midwife in front ready to catch the baby. It has only been in the last century that this "classic birth triad" has all but disappeared. Doulas are not new. Modern obstetric practice is what has strayed (very far, I might add) from the time-tested norm.

2) Women need a "buffer" (i.e. Hospitals and drugs mess with birth).
Don't get me wrong. I am so grateful we have hospitals and drugs to handle birth complications (which do happen!). But, really, when used excessively (as they are) they mess with birth big time. The hospital with its policies (no food or drink, IVs, restriction to bed, bright artificial lighting, time constraints, flat on back or semi-recumbent positions for pushing, etc.) is really the least ideal place to facilitate the birth process. And pretty much any and all of the drugs hospitals introduce into the process screw up birth's carefully orchestrated hormonal responses, often leading to the need for further interventions to counter-act the drugs' side effects. So... here's my point... because 99% of American women give birth in hospitals (80-90% of those with drugs), there is a dire need for a buffer of sorts--something or someone to help women and babies come out of the modern birth machine as unscathed as possible. Doulas can be (and are being) just that buffer. And, I should add, sometimes epidurals just don't work (or only work on one half of a woman's body). Plus you still have to get through early labor (0-4 cm) before most doctors/hospitals will allow you to get an epidural. For some women, even early labor is killer. So it's a good idea to have someone present who is trained to help you cope with labor pain (even if you plan to get an epidural)!

3) Birth is women's work.
We put a lot of pressure on dads (particularly first-time dads) to be the sole support for their wives in labor. The fact of the matter is that it's overwhelming to many of them. They are often at a loss when faced with their own difficulty in seeing their wife's pain while simultaneously trying to help support her through that pain. A study comparing first-time fathers' and experienced doulas' participation in birth showed that males touched their laboring partner only 20% of the time while doulas touched them 95% of the time. They also spent less time with the women and were close to them less than the doulas (Bertsch et al. 1990). I absolutely believe that a husbands' presence can be vital. I would never want to give birth without Ax by my side. But I also believe that the assistance of wise, experienced women is also vital for laboring women. As much as a husband's support is wanted and needed, he is a man and can't ever understand what his wife is experiencing. Experienced women offer a different and much-needed emotional support. Doulas are also trained to assist fathers, giving them suggestions for ways to help their wives when they are unsure how (or are reluctant) to step in and help. My first "doula" did this beautifully.

4) Doulas are proven to improve outcomes for mothers and babies.
Study after study has shown that doulas have a profoundly positive impact on birth outcomes. Check out these numbers (from one of my doula training handouts):

When all the studies are calculated together, the presence of a doula reduces:

* Cesarean sections by 50% (!)
* Length of labor by 25%
* Oxytocin [Pitocin] use by 40%
* Pain medication [opiates] use by 30%
* Forceps deliveries by 40%
* Requests for epidurals by 60%

Other findings:

* Decreased maternal fever
* Decreased newborn admissions to NICU
* Decreased sepsis workups on newborns
* Decreased infant health problems

Long term benefits:

* Increased mother/infant bonding
* Decreased postpartum depression
* Increased success in breastfeeding

Who wouldn't welcome those amazing benefits?! As my doula trainer so aptly pointed out, if a doula were a machine, every hospital would have three of them.

I'm not telling you all this to drum-up business for myself. Even if I was looking for clients, I wouldn't be charging anyone. I'm telling you this because I am (excessively) passionate about helping women have wonderful, satisfying birth experiences. Doulas can work wonders, but I don't think most women are aware of just how much difference a skilled doula can make. I just had to spread the word!

As for me... I've got two fabulous births under my belt, and I'm a trained doula myself, but I am still going to have TWO doulas (and two midwives) at my next birth. I am thrilled that we will be surrounded by supportive, experienced women as we bring our first son into this world. I feel confident that their loving presence will make this our best birth yet.

P.S. If you'd like to hire a doula but can't afford one, have no fear! There are always doulas willing to volunteer their services. It's a generally universal doula belief that all women should have access to doulas regardless of ability to pay.

More awfulness

I remembered reading that Pitocin can lead to newborn jaundice, so I was doing a quick bit of internet research and stumbled upon Drugs.com's page about Pitocin's side effects. I already knew they were bad, but I guess I didn't realize they were this bad. Holy moly. Click over and take a look. Be sure to read more than just the "for the consumer" portion for the real juicy details. If that list doesn't scare you away from an unnecessary induction or labor augmentation, I don't know what will.

P.S. If you've been told you "need" to be induced (or your doctor has offered to induce you without a medical reason), be sure to check out "Saying 'No' to Induction," by Judith A. Lothian, PhD, RN, LCCE, FACCE, before you make your final decision.

Two Tidbits Courtesy of Midwifery Today

I subscribe to Midwifery Today's weekly E-News, and found a couple of things in today's email worth mentioning.

Induction and Meconium Aspiration Syndrome

Part of this issue of E-News contained an excerpt from a Midwifery Today article entitled, "The Problem Is Induction, Not Meconium," by Gail Hart. Meconium is the fetus's thick, dark-colored first bowel movement, and, when found in the amniotic fluid, it is a sign of fetal distress. Meconium itself is not generally a problem unless it gets into the fetus's lungs--meconium aspiration syndrome (MAS). It is generally accepted that meconium is more common the longer the pregnancy goes, but that may be simply because those pregnancies are most likely to be induced. Gail Hart shares the findings of a study indicating that the factor most strongly associated with MAS was induction, not being postdates. This makes sense when you remember that drug-induced contractions can be abnormally intense and long, restricting oxygen supply to the fetus. It follows that fetuses being born by induction would experience more distress. Just one more strike against pitocin/induction in my book, as if I needed any more. Check out the actual excerpt from Gail Hart's article here.

Infant Formula and DHA/ARA

The other tidbit I wanted to share was especially disturbing. I have for the past few years been a big proponent of everyone making sure they get their omega-3 fatty acids, especially DHA, but this issue of E-News shared the dark side of the omega-3 craze as it applies to infant formula.

Based on a report presented by the Cornucopia Institute (a corporate watch-dog group), the DHA/ARA added to many infant formulas is created from fermented algae and fungus and is structurally different than the DHA/ARA found in breast milk. The FDA isn't even convinced of the safety of these algal and fungal DHA/ARA additives! Apparently some infants fed DHA/ARA formula have even suffered from severe diarrhea, vomiting, dehydration, and seizures until being switched to a non-DHA/ARA-supplemented formula. Some infants even suffered death. Despite the FDA's reservations, these additives were somehow still approved for infant/human consumption.

Formulas supplemented with DHA/ARA are marketed as being "more like breastmilk," suggesting to consumers that they are somehow healthier than other formulas. In fact, scientific studies are inconclusive regarding the benefits of these DHA/ARA additives. Martek Biosciences Corporation, a manufacturer of these additives even acknowledges: "Even if [DHA/ARA] has no benefit, we think it would be widely incorporated into formulas, as a marketing tool and to allow companies to promote their formula as 'closest to human milk'"(source). Here's what the Cornucopia Institute concludes about the motives of infant formula manufacturers: "Given the safety concerns and doubts within the scientific community, it is clear that the infant formula manufacturers’ claims are marketing tools designed to sell more formula, and sell it at a higher price"(source). So what it really comes down to is money. Are we really surprised? Of course not. They're corporations and it's their job to make money. Adding DHA/ARA sells more formula, regardless of the fact that it's very different from the DHA/ARA in breastmilk and may actually be dangerous.

Unfortunately, parents are too busy or too trusting to ask any questions about it. I know for a fact that, if I had needed to feed my infants formula, I would have gone with the DHA/ARA version because I would have believed it was better. Get this... just yesterday I bought some Yoplait drinkable yogurt. Which kind did I pick? The one that said "with DHA" on it, of course! I looked at the label this morning, and, sure enough, it has "omega-3 DHA algal oil"--the very stuff implicated the Cornucopia Institute's report! Marketers certainly aren't stupid. They know omega-3 DHA is all the rage. I'm especially prone to buy into the notion that anything with DHA is better, regardless of where that DHA came from. Oops.

Included in the Cornucopia Institute's report is the following disturbing tidbit (evidence that infant formula marketers have done their job very well): "According to the National Alliance for Breastfeeding Advocacy, mothers have contacted health care providers asking the following: 'I want the breast milk formula,' or 'I want the formula with breast milk in it,' and asking questions such as 'whose breast milk is in the formula?'"(source). Oh my.

While I do find all of this disturbing, I also recognize and accept that infant formula is a life-saver for infants who are unable to breastfeed. And, given this fact, I do believe that formula manufacturers should do everything they can to create a product as close as possible to breastmilk. Unfortunately, in the end, it's just a sort of lost cause because breastmilk is something technology, no matter how advanced, cannot duplicate. While formula saves some lives, it will never be ideal. I'll end with this quotation from the International Baby Feeding Action Network:

"While researchers fiddle with the balance of fatty acids in infant formula, and deal with the additional uncertainties of the complex cascade of interactions that each adjustment provokes within the omega families, breast milk will always be the simple, perfectly balanced source of each essential nutrient."(source)

For more info, see...
Midwifery Today, Volume 10, Issue 11
"Replacing Mother — Imitating Human Breast Milk in the Laboratory"
"C-sections, breastfeeding, and bugs for your baby," by Jeff Leach

"Promoting, Protecting, and Supporting Normal Birth: A Look at the Evidence"

Check out this article from the Jan/Feb 2008 issue of the Journal of Obstetric, Gynecologic, & Neonatal Nursing. Here's the abstract:

Interfering with the normal physiological process of labor and birth in the absence of medical necessity increases the risk of complications for mother and baby. Six evidence-based care practices promote physiological birth: avoiding medically unnecessary induction of labor, allowing freedom of movement for the laboring woman, providing continuous labor support, avoiding routine interventions and restrictions, encouraging spontaneous pushing in nonsupine positions, and keeping mothers and babies together after birth without restrictions on breastfeeding. Nurses are in a unique position to provide these care practices and to help childbearing women make informed choices based on evidence.

And here are the concluding paragraphs which I love!

Nurses have an opportunity to provide leadership in pushing hospitals to provide evidence-based care that promotes healthy outcomes. Nurses will begin to question orders that do not reflect best evidence in the same way that we question medication orders that are not appropriate. We can begin by asking ourselves and our colleagues why a care practice is happening in the first place. Is it for the convenience of the staff or "hospital efficiency" or is it for the best interest of the individual mother and baby? Does it reflect outdated research or the best available evidence? Is it rooted in fear of a poor outcome or a lawsuit or in confidence in women’s ability to give birth normally? Is it based on rituals and routines or individualized care?

While changing practice will take hard work and challenge some of our long-held beliefs, nurses will reap great benefits, along with mothers, babies, and families. Reducing interventions and easing restrictions will change the focus of intrapartum nursing from medical management to nursing care. And there will finally be time for providing comfort and support, the traditional hallmarks of labor and delivery nursing care.

"The Birth of a Breastfeeding Baby and Mother"

Check out this column by Judith A. Lothian (PhD, RN, LCCE, FACCE) in the Journal of Perinatal Education. Here's the abstract:

"In this column, the author describes the way in which the normal, natural process of labor and birth prepares both mother and baby for breastfeeding. Birth practices including induced labor, routine interventions, epidural analgesia, and separation of mother and baby disrupt the process of early breastfeeding for mother and baby. Normal, natural birth sets the stage for uncomplicated breastfeeding."

Five Ways Pitocin is Different than Oxytocin

I have been doing some research about oxytocin and stumbled upon this great overview of the ways Pitocin and oxytocin differ in the process of labor. If you're considering an induction with Pitocin or are just curious, check it out!

Little known facts about Pitocin and induction

"Pitocin is the most abused drug in the world today." ~Roberto Caldreyo-Barcia, MD, former president of the International Federation of Obstetricians and Gynecologists

• Pitocin is not approved by the FDA for elective (patient or provider convenience) inductions or stimulation of labor (moving things along).

• Pitocin generally produces contractions that are much longer, more intense, and more painful than normal contractions....

Read the rest of this post over at my new website!