Down with the I.V. league

“You’re thirsty? Do you want some more ice chips?” Most women laboring in U.S. hospitals, no matter how thirsty or hungry they may be, must resign themselves to sucking and munching on ice. I munched my way through that rite of passage with my first baby. Enduring labor and birth has been compared to enduring and completing a marathon. Both feats are extremely physically taxing, but you would never expect a marathon participant to run without drinking or consuming any kind of fuel. Hospitals across the country expect laboring women to do just that, but is this deprivation really necessary?

When a patient must undergo general anesthesia for emergency surgery, there is a risk of stomach contents being inhaled into the lungs (also known as “aspiration”). Hospitals ask women to refrain from eating or drinking in order to reduce the risk of death from pulmonary aspiration. Even with these precautions in place, however, there is no guarantee that a woman’s stomach will be empty in the event that she needs general anesthesia. The risks of death from pulmonary aspiration are miniscule—1 in 1,250,000. Furthermore, deaths from pulmonary aspiration in these situations have more to do with anesthesiologists’ errors than whether a woman has had food or fluids recently. It is very uncommon for a laboring woman to require general anesthesia. Most of the problems arising in childbirth can be recognized and addressed without such extreme measures being taken.

What do hospitals offer as a “substitute” for food and drink? Intravenous fluids (IVs). Yes, IVs provide fluids, but quite often they provide too much, particularly when mother is given a “bolus” (large amount of fluid) before receiving an epidural (an attempt to prevent the blood pressure drop often resulting from epidural anesthesia). Fluid overload resulting from IV fluids can lead to other complications, among them:

* Fluid in mother’s and baby’s lungs.
* Diluted blood, leading to anemia and decreased oxygen supply to the uterus and fetus.
* Newborn jaundice, as excess fluid causes baby’s red blood cells to burst and release bilirubin (yellow product of red blood cell breakdown).

Aside from these issues, an IV will also hinder a laboring woman’s ability to move while in labor. Movement, particularly in early labor, is an effective way to cope with the pain of contractions. Lying strapped to a pole and a monitor in a bed will increase a laboring woman’s discomfort greatly. Additionally, when a laboring woman remains lying in a bed for an extended period of time, labor will not progress as effectively as when aided by movement and gravity.

I remember how strange it was to me when I came home from the hospital after my first baby was born and found that my legs and feet were swollen with fluid for a few days. I had heard plenty of pregnant women complain of swollen ankles and feet, but I had not experienced any swelling while pregnant. It surprised me to see swelling afterward. I also noticed swelling in my face and hands in the pictures taken of me just after my daughter’s birth. I can’t prove that it was the result of I.V. fluids, but I feel fairly confident they were to blame. Here's a picture of me in my swollen post-partum state...Lovely, eh?

When I gave birth to my second child, I chose to see a group of nurse-midwives who delivered at a small community hospital where they had, finally, convinced administrators to allow laboring women to drink. Instead of being given an I.V., I received a “hep-lock” which is simply an I.V. needle inserted in a vein but without the fluids. They like to have an “open vein” in case of an emergency. I spent less than three hours of my labor in the hospital because I had already progressed to about 6 centimeters upon arrival, and my labor progressed quickly afterward. I think I took a few sips of water when I felt thirsty, but not a lot. It was wonderful, however, to not be tied to the I.V. pole. I was also pleased to notice that I experienced no swelling afterward. Here's a much less frightening post-partum picture...
Not every laboring woman will be given the option to bypass IV fluids. Some hospitals have strict policies, and women who are induced, given narcotics or epidurals, or a c-section will have no choice but to submit to an I.V. Every intervention alters the birth process, however, and the more interventions, the more complicated the birth process becomes. I encourage women to avoid unnecessary interventions and trust the process of birth. Seek out care providers who honor and respect the birth process and will advocate for your right to experience birth as you wish, including eating and drinking if you choose. You and your baby are worth the effort.

For more info, see the "Evidence Basis for the Ten Steps of Mother Friendly Care."

Tips for avoiding tearing and episiotomies

Giving birth for the first time was one of the most empowering experiences of my life. My water broke, my contractions started, everything progressed smoothly, and, less than six hours later, my baby girl was born. It was an ideal birth experience, except for one thing. That one thing made my next few weeks of recovery extremely painful. I tore. I really tore.

Despite the painful recovery, this was actually the lesser of two evils for me. Though some caregivers continue to cut episiotomies in as many as 80% of their patients, medical research does not support routine episiotomies. Studies from as far back as the 80s made it clear that routine episiotomies have no benefits and carry real risks. One of the most detrimental risks is that episiotomies can lead to further tearing, sometimes extending into the anus. These fourth degree anal tears almost never occur without an episiotomy. In addition, a spontaneous tear may only reach into the surface layers of skin, while an episiotomy cuts into far more layers. Episiotomies are rarely warranted and should be reserved for those unusual emergency cases. Ultimately, even without all the evidence, I just didn't want someone cutting me. I knew, going into my first birth experience, that if I had to choose between them, I would choose to tear. And, tear I did.

The best case scenario, obviously, is neither. The best outcome is a happy, healthy baby and an intact perineum. So how does a woman improve her chances of keeping her perineum intact?

1. Choose a midwife, or a doctor whose practice is evidence-based. The typical midwife's philosophy of birth is one of non-intervention. Most midwives tend to avoid episiotomy and are aware of the best positions and techniques to avoid tearing. I saw a group of certified nurse-midwives with my second daughter's birth, and was relieved to hear, at my first appointment, that 70% of their patients end up with intact perineums. I had only a very minor tear--what my midwife described as a "skid mark"--and my recovery was vastly superior to the first. If you choose to use a doctor, be sure that he/she practices evidence-based medicine, is aware of the research against episiotomy, and understands your desire to remain intact.

2. Exercise regularly. We all know exercise is beneficial to our health, but it's also beneficial to your perineal tissues. Women who are physically active are less likely to end up with episiotomies and are more likely to retain strong pelvic floor muscles post-partum. General exercise is great, but doing exercises specialized for the pelvic floor--"Kegels"--will not only strengthen those muscles, but also increase your awareness of how those muscles function so you can learn how to fully relax them for birth.

3. Have a doula present for your birth. A doula is a trained labor support professional. Research has shown that a doula's presence reduces a laboring woman's risk of requiring pain medications by 36% and forceps deliveries by 57%. Epidurals and forceps deliveries are both associated with increased incidence of tearing and episiotomies, so a doula is handy to have around when you're trying to stay intact. Doulas are the most highly rated providers of labor support and work wonders in improving women's birth experiences, so it won't just be your perineum that thanks you.

4. Deliver in an upright, hands-and-knees, or side-lying position. Research clearly indicates that the worst possible position for delivering a baby is the very position most hospitals direct women to take--on the back, legs stretched out wide, feet in stirrups. The best positions for avoiding perineal trauma are unconventional in most U.S. hospitals, but the evidence is clear. If you want to maximize your chances of staying intact, don't let hospital conventions hold you back. Be sure your caregivers know of your intention to deliver as you choose--upright, on your hands and knees, or on your side. Fortunately, the best positions for avoiding perineal trauma are also the ideal positions for a smoother, easier delivery, so you won't be sorry about breaking with convention.

5. Use "spontaneous" pushing rather than the conventional Valsalva method. Most women in U.S. hospitals are encouraged to take a deep breath, hold it for ten seconds and bear down--the Valsalva maneuver. Breaking with convention in this case is also beneficial for your perineum. Women who push spontaneously are more likely to avoid tearing. Spontaneous pushing typically involves shorter periods of pushing and more breathing in and out which promotes relaxation of the perineal tissues. A woman following her body's instincts and impulses will deliver her baby far more easily, efficiently, and painlessly than one who is being coached to disregard her body's guidance.

Episiotomies should be rare, and tearing isn't inevitable. Women who arm themselves with information and support can travel through birth uplifted, empowered, and intact. I, for one, intend to do just that the next time around.

Back in the saddle again

No, I'm not pregnant. :-) But I jumped back in the saddle of being a "natural childbirth advocate" last weekend. I suppose when I put all my birth books on our new bookshelves in the living room, I also sort of "shelved" that passion for a while. Plus, having moved to a new place, I suppose I've been busy with other things--one of them being making new friends. And I guess I haven't felt ready to expose myself as a birth nazi and lose all those newfound friends just yet. ;-)

But, as most people who know me well are aware, if you bring up the subject of birth (and not in a "OMG! Give me the epidural!" sort of way) and seem interested or open to my views, you will find that I have a way of going on and on and on and a very difficult time shutting up. One of my favorite things in the world is to talk birth with others who are willing and eager. If you don't want an earful, well, don't bring it up.

Well, we were at a Halloween party last Saturday and we ended up sitting by some neighbors. We hadn't had the opportunity to really sit and talk with them before (partly because the wife has been awfully sick with her pregnancy), but we did get a chance to talk at the party. I don't even remember how the subject came up, but my new pregnant friend asked me if I had given birth without drugs. My radar detector started beeping like crazy, and I said, "Yes." Then she did what would make any natural childbirther salivate--she started asking me questions! And she seemed genuinely interested as she listened to me tell my birth stories! Oh my... I had forgotten how much I love talking about this stuff.

My new friend is pregnant with her second child. She had Pitocin with her first labor because her water broke and then her contractions didn't start. The Pitocin-induced contractions came one on top of the other without any breaks. She started screaming at the nurses to give her an epidural but they told her they couldn't until she dilated more. They reassured her that she would be able to get the epidural soon, but she yelled at them more: "You're lying!" She was in so much pain that she was out of control. Needless to say, she isn't a huge fan of Pitocin. She said, "Pitocin is evil." An now I have one more story to add to my list of reasons why I get irate and start foaming at the mouth when I hear the nasty word.

I can't recall now why, but she has a feeling that the labor with her second child is going to go very quickly and that she may not have time for an epidural. And she said that the booklet her doctor gave her has very general and fairly unhelpful information about how to cope with labor pain (surprise, surprise). I gleefully offered my collection of birth books for her to check out. Then we arranged that I would give her my copy of The Birth Partner, by Penny Simkin, the next day. I put a scrap of paper into the chapter on coping measures so she could find it easily. Oh how I love sharing this stuff!

I also hosted a baby shower for a new friend this past weekend. She is due to have her baby any day. And, just before she got into her car to head home after the shower, she happened to mention that she would really like to avoid drugs while she's in labor. I tried to restrain myself, though that inner radar detector started beeping like mad. I did my best in those few minutes to encourage her and give her a positive take-home message that might (just maybe, I really hope) help her make it through labor. But it's hard to make a huge difference in three minutes. I told her she could do it, that I love giving birth, that I'm practically addicted to it, and that I wouldn't do it any other way than au naturale.

I'll never forget the conversation I had that was the spark for my interest in natural childbirth. An acquaintance was pregnant with her first child and had some books from the library. I asked her about the books. I don't even remember what the books were. But she ended up mentioning that she would be giving birth without drugs. It floored me. What?! People still do that?! I couldn't believe it! But she explained that her mom had all her children that way and she planned to as well. She said there were lots of benefits, but didn't go into them much 'cause there wasn't time. But that little exchange is what started it all for me. It got me thinking and wondering and intrigued. So when I entered my first pregnancy, I went to the library and checked out some books and I was never the same.

So I guess I hope that even if my two pregnant friends don't have wonderful birth experiences THIS time, maybe our conversations will have been the spark that will intrigue them and inspire them to check out some books and prepare themselves in the future to have the kind of birth experiences their bodies were intended to have. I really do hope so.

In the meantime, I'll enjoy the natural buzz/high that follows a few good conversations about birth.

I know where I'm having my next baby!

Well, not really, but I wish... Check out Jennifer Block's article--"Childbirth in England--It's Shocking!"

Childbirth Mortality Rate is Rising in the U.S.

"Valerie Scythes, a 35-year-old elementary school teacher, died in March at a hospital in New Jersey -- the state with the highest caesarean section rate. She had had a C-section, as did another teacher at the same school who died after giving birth at the same hospital two weeks later."

It's all over the news this weekend. See these links:
Experts: U.S. childbirth deaths on rise
Rate of death in childbirth rising in the U.S.
Rate of U.S. women dying in childbirth rising
US childbirth mortality rate increases

More and more women are dying! Do we really need any more evidence that maternity care in the U.S. needs an overhaul?! Raise an uproar, write a letter to the editor, spread the word, do whatever you can! Let's stop this madness!