Tuesday, March 31, 2009

Choices in Childbirth

Many people ask me why Jack and I have chosen to work with a midwife for our prenatal care and birth.  While I am, of course, particularly biased due to the amount of information I know I do make it a point of stressing that I support any decision an expectant mother makes as long as she feels completely confident and safe in that decision.  Some people feel safest with OBs even if they know they are not guaranteed to have that doctor with them at the birth of their child.  It doesn't really matter, I suppose, who is there; the baby knows who it wants to have in the room.  But ever since I was little, I have not been okay with the strange concept of doctors and nurses coming and going in shifts during my labor while I would be constantly having to readjust myself to the environment in the events of those changes.  It was good that I did not understand this protocol at such a young age as it prompted me to explore other options.  And boy, there are so many.
I will spend much of this post quoting the book Jack and I are currently reading for our birthing class, "Natural Childbirth the Bradley Way."  I could write an exhaustingly long post about how this approach is different from the 'famed' Lamaze approach, but this post is merely about why we chose to work with a midwife instead of an OB.  In the Bradley Method, we are taught to preface everything with 'as long as everything is okay.'  This is where the CNM (certified nurse midwife) excels.  She is way m ore of an expert in natural normal pregnancy and childbirth than an obstetrician any day and she is also privy to a larger range of normalcy than the average OB so she can help the woman's body naturally deal with labor much more effectively without need for intervention.  It is only in the face of abnormality (which she will catch during the prenatal care) that she refers her patients to be exclusively cared for by an obstetrician.  A lot of people mention to me that they feel more comfortable with a doctor 'in case anything should go wrong.'  What they may not realize is that a midwife is trained to recognize early warning signs of emergencies BETTER than the average OB, often with hours to spare.  The labor, to the midwife, is innocent until proven guilty.  Unfortunately, the opposite applies in the minds of many an obstetrician simply because they are trained to look for pathology.  A good midwife spends much time getting to know her patients and makes the proper measurements throughout the prenatal care to ensure that these women are candidates for normal natural birth.  A good healthy pregnancy has a very very good chance at culminating in a good healthy normal birth.  It pains me to realize that women in this country are taught from the get-go that inevitably something should be wrong with their beautiful bodies.  We are told this in so many ways other than just pregnancy and childbirth; it is just one of the burdens we must bear as the females species.  It can do one of two things:  cripple us under the guise of the amused 'experts' or make us stronger and more adamant at finding answers to our questions of 'WHY shouldn't I trust my body the whole way through?  Why must we WAIT and see what might go wrong?'  With this distorted mindset, the woman is set up for so many birth complications already such as prolonged labors due to fear or early intervention by medical staff who deem them 'unfit' to give birth normally even though their pregnancy has been problem-free.  Don't get me wrong.  I love doctors.  They are necessary and important and work wonders in emergencies.  But there are other avenues for a more natural approach to the NON-pathological function of childbirth.  A lot of women who are under the care of OBs are simply not taught to trust their bodies.  They are more often taught to fear them and trust the doctors more than nature.  This is apparent mainly in the due date calculation and weight gain estimation.  Due dates are averages.  The apex of a bell curve.  Normal gestations RANGE from 38 to 42 weeks.  Some midwives use the range of 37 to 43 weeks.  Essentially, the body and the baby know when it's time to be birthed and most often in a normal pregnancy the baby will not grow too large for its mother.  When a woman is tagged with a due date she already stresses herself out as soon as that due date lurks around her and as soon as she 'goes past it.'  She loses faith in her body and offers herself more strongly into the arms of the medical establishment to 'rectify the situation' and fix her subpar body.  This concrete due date nonsense should be obliterated, especially with the amount of ultrasounds doctors due nowadays.  Instead, women should be told the range of time during which their child can be normally and healthfully born.  As far as weight gain goes, it's different for everyone.  The BMI should also be obliterated as it is only based on averages and does not take muscle mass into account.  It is this BMI which tells the health practitioner the 'proper' amount of weight to gain for that body type.  It is this which leads to much confusion, depression, and loss of faith in mothers who feel like they are just 'getting too heavy.'  Dr. Brewer says that a woman's body will gain what it needs to and to restrict a mother's diet (particularly in the third trimester when the fear of gaining too much weight takes center stage) can actually INCREASE her risk of developing toxemia which can be life threatening.  So doctors are humans, too.  they are often wrong and it's important to understand that.  Midwifes can be wrong also.  Therein lies the importance of being physiologically and emotionally aware of one's own body and how it reacts in the face of challenges.  This, to me, was a core difference between my midwife and other OBOs in that at the end of the day she teaches me that my body knows the answers more than she.  She has enough humility to let my body do the work and just monitor my progress to make sure I am moving in a healthy direction in my pregnancy.  Women's bodies are wise.  And unborn babies are wise.  They know what to do and how to do it; it is their first choreographed dance with their mother as the two work in unison for this mystery we call life.  Midwifery care is so much different than obstetrical care and is based around the previous sentence.  Instead of seeing 6 patients an hour, my midwife sees 1.  We have her full attention and she gives us proper advice that will help us to avoid any unnecessary medical interventions.  She educates us on nutrition and exercise physiology and informs us that many psychological things arise during pregnancy and birth while providing us with many resources to combat anything we might be facing.  She implores us to delve deeply into our spirits, connect with our baby, thank it, talk to it, dream with it, walk with it.  After all, we are parents already.  We don't just suddenly become parents when the baby is born.  She asks us to speak to our own mothers about OUR births and how WE were brought into the world because often a woman in labor can be caught off-guard by a snapshot of a memory from her own birth that had been buried in her mind since day one of life and the same goes for fathers.  Yes, babies DO remember how they were brought into this world.  With this guidance, it is impossible for me to explore any other avenue of prenatal care.  As Susan McCutcheon puts it in the book we are reading, "Study after study has shown that the quality of care by the certified nurse-midwife is superior to the average doctor's care.  The CNM is a registered nurse (RN) who has continued her education to study nurse-midwifery.  When she finishes her training she has more experience than most obstetricians in normal childbirth.  An obstetrician's training focuses on abnormal childbirth, which requires intervention.  In their training, many obstetricians never see a woman give birth naturally without an episiotomy, the use of forceps, or a vacuum extractor...In fact, during labor a midwife can often spot problems more quickly than the OB.  This is simply because the midwife spends hours with the laboring woman, while the average busy OB may manage labor over the telephone, checking with the labor-and-delivery nurse to see how you are doing.  The ordinary RN on duty has less training than the nurse-midwife in spotting problems.  We know that many obstetricians leave standing orders with nurses not to call them to attend a birth until the baby's head is showing.  Then the woman often has to wait for the doctor to get there before she is allowed to push.  this makes for an unnecessarily hard pushing stage for the mother.  The nurse-midwife, however, is there all along, waiting to take her cue from the mother.  Delaying birth is definitely NOT in the interest of the infant's health or the mother's."  To me, as long as things are progressing normally, there is no WAY I would prefer an obstetrician over a midwife.  And God help the person who is demanding that I WAIT to push!!
So this is sort of my beef about the whole process.  I was a little reluctant to post this entry as there are so many of our family members involved in the medical establishment who may differ in opinion but then I remembered, I TOO am involved in this establishment, am entitled to my own educated opinion and choices, and I appreciate the opportunity to make my voice heard and understood.  Again, and I can't stress this enough:  I am happy to support any woman's decision as long as she has thought long and researched hard on that decision.  Many women spend a lot of time reading about how to be healthy during pregnancy, and how to keep their kids healthy after birth (therein lies the vaccine debate) but not many women take the time to research their options about HOW this child's birth can be the best birth possible for that child and that mother, often because our society does not teach women that they have so many options.  Importance is not stressed on how strongly the method in which the baby is brought into this world affects the long term health of that child.  This is a realm I hope to change in our society because it does not serve us and, as the rest of the world shows us (the US has the highest rate of infant mortality in the developed world and we spend the most amount of money on maternity care), it does not have to be this way.  My favorite quote about birth is from the film "The Business of Being Born," where it states that "People spend more time and energy researching a camera, a car, a stereo system, than they do at checking out what their options are for birth!"  There are so many.  So many.  Just a few off the top include:  doctors' personal c-section rates (an OB with a 3% c-section rate is a god in the midst of a hospital with an overall 40% rate), the choice to avoid silver nitrate eye ointment (which is ONLY needed if the mother has an active gonorrheal or chlamydia infection but is still routinely given to all or most infants as a means of precaution and has even caused a few babies to go blind), the choice to decline a routine episiotomy (which has been shown more and more to contribute to incontinence and postpartum fistulas moreso than a natural tear and has been a culprit of the unchanging rate of maternal mortality, a subject that is rarely discussed but very real in the US), the option for assuming any position during labor AND pushing (for instance, most women squat on the floor when they are being attended by either of my backup OBs at Cedars), skin to skin contact IMMEDIATELY after birth (not just 20 minutes after the baby is 'cleaned and disinfected.'), delayed cutting of the cord, avoidance of separation of mother and baby, immediate breastfeeding initialization (which releases more oxytocin in the body and naturally contracts the uterus to help expel the placenta).  The list is vast and I will probably expand on it in future posts.  I often wonder what would happen if childbirth choices were ranked in Consumer Reports.  I encourage you to read up and question question question your caregivers.  Know your caregiver, know his or her intervention rates and policies, and what routine interventions he or she demands.  Know what is and is not okay with you.  It is YOUR child.  It is YOUR body.  It is YOUR choice.  A woman in labor does not need to be rescued.  She must be held and supported and told that she CAN do this, that no one will do it for her and that her body is a perfect mechanism of miraculous mystery.

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