Birthing Beautiful Ideas

I recently received a very thoughtful set of questions from reader Rachael N.:

I keep hearing this idea that women who have birth plans are women who end up having c-sections. I actually first heard it from my freestanding birthing center midwife, when I asked if she would recommend that I write a birth plan. On the one hand, I imagine that there may be some women who become so attached to their plan that they are unprepared for the unpredictability of labor itself. On the other hand, it sounds far more likely that the birth plan may be a convenient target for blame on those occasions when it was actually the system that did not serve the woman well. So my questions are: What’s up with this myth? Is there any actual research showing what the outcomes are when women have birth plans? And how should a woman build some flexibility into her birth plan, given that childbirth is an unpredictable process??

I’ve also heard and seen people express this sentiment before: namely, that women with birth plans (and, especially, long birth plans) are the ones who will end up with the most birth interventions.

Like many sweeping generalizations, I find that some of these sentiments gloss over a lot of much-needed nuance and sensitivity and attention to detail.  And this is troubling.  In fact, it does little, if not nothing, to empower or even help women who are preparing for the birth of their babies.

For instance, when Taffy Brodesser-Akner talked to Dr. Kimberly D. Gregory in an article in Self magazine, Dr. Gregory expressed the following reservations about birth plans:

“I think that birth should be a beautiful experience,” says obstetrician Kimberly D. Gregory, M.D. She’s the vice chair of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in L.A. “It should be exactly the way you want it, and doctors should intervene only to preserve the health or life of you or your baby.“

Naturally, one would assume that Dr. Gregory advocates birth plans. When I ask her this, she laughs. “We always say, ‘If you show up with a birth plan, just get the C-section room ready,’” she says. “You get everything on that list that you don’t want. It’s like a self-fulfilling prophecy.” Dr. Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan. The birth-plan group trended toward a higher C-section rate and more interventions. “There’s a certain personality type that tends to be more anxious. Maybe the anxiety hormones themselves put them at risk,” Dr. Gregory theorizes. “It seems that being open and honest and choosing the right doctor is probably a better option than writing everything down. Walking in with this list appears to set up an antagonistic relationship.”

For what it’s worth, I think that Dr. Gregory’s statements (which, to be fair,were probably edited for purposes of the article) include a mix of sweeping generalizations and helpful distinctions.

On the one hand, even if the hospital staff is joking when they claim that showing up with a birth plan entails a trip to the OR, the joke itself raises questions about just whose self-fulfilling prophesies are being fulfilled.  Not all birth plans are created equally–some are the result of an online, cookie-cutter checklist, and others are the result of careful research that a woman and her partner have discussed with their care provider, the hospital staff, and their pediatrician.

On the other hand, Dr. Gregory’s points about the relationship between anxiety and labor and the importance of finding a supportive care provider are spot on.  For if one envisions the hospital as a battle scene in which one must use a birth plan as a defensive shield, one might very well set oneself up for disappointment, and even the self-fulfilling prophesies to which Dr. Gregory alluded.

I was also able to dig up one published study that examined the disparities between patients’ and medical personnel’s perceptions of outcomes in women who use birth plan.  (Note that this is different from the actual outcomes of women who use birth plans.)  And the results were pretty fascinating:

Sixty-five percent of medical personnel vs. 2.4% of patients reported that patients with birth plans had overall worse obstetric outcomes than patients without a birth plan. There were 65.7% of health care providers vs, 8.7% of patients who reported that women with a birth plan had an increased rate of cesarean section. In addition, 53.4% of health care providers vs. 9.9% of antepartum patients reported a perceived increased rate of chorioamnionitis for women with birth plans. Statistically significant differences were also found between health care providers and patients in terms of their perceptions of the effect of birth plans on operative vaginal delivery, postpartum hemorrhage, episiotomy and length of hospital stay.

I do not doubt that these perceptions exist or that (as Dr. Gregory commented) birth plans created out of anxiety or antagonism can contribute to more complicated labors.  (Fear or anxiety-based stress effects everything from pregnancy to birth to breastfeeding negatively.)  But I also think that they/we need to make some clearer distinctions before drawing any hard and fast conclusions about the relative usefulness (or uselessness) of birth plans.

You see, I can understand why certain attitudes or expectations about birth plans might be more of a hindrance than a help to birthing women and their partners.  But this is entirely different from claiming that birth plans themselves are somehow responsible for a higher rate of complications and/or medical interventions.  And if this distinction (i.e. the one between attitudes and expectations about birth plans and birth plans themselves) is not made abundantly clear in the sort of statements described above, then women might be led to think that any and all articulation of their preferences for birth are counterproductive, useless, and even dangerous.

In my humble opinion, this thought is what is actually counterproductive, and even dangerous.

And that’s because there is a lot about birth plans that is a “good thing!”

Researching your birth preferences is a good thing.

(Who wants to find out the risks, benefits, and side effects of narcotic pain medication during a contraction, or, worse, while their baby is receiving medication because of the respiratory distress caused by the narcotic pain medication?)

Articulating your birth preferences is a good thing.

(How will your partner and/or the nurses know that you don’t want them to offer you pain medication unless you tell them so?)

And discussing these preferences (as early as possible) with your care provider, your hospital staff, and your pediatrician is an even better thing!

(Who wants to get to the hospital, in active labor, only to find out that their care provider doesn’t “allow” intermittent monitoring after all?  Or that the hospital doesn’t have tubs in every labor and delivery room?  Or that the staff will call Childrens Protective Services if parents refuse the erythromycin eye drops?)

But in order to create an effective birth plan–one that will communicate one’s wishes without working against one’s wishes–it is important to be mindful of the following:

1) A birth plan does not replace the need for birth preparation.

Going to an online “birth plan mill” and checking off a bunch of boxes (“yes” to the epidural!  “no” to the episiotomy!)  is not the same as preparing for birth.

A good childbirth education class can help you prepare for birth by helping you to discern what the protocols are in your chosen birth location, what the risks, benefits, and alternatives are of any birth intervention, and how you can cope with both the expected and unexpected during labor.

So can a good book (or set of books). (Please see my recommended reading list on the right sidebar.)

Or a good website (such as Childbirth Connection, Lamaze International, or Mother’s Advocate).

Or a good doula or other birth professional.

But a birth plan really doesn’t help all that much you if you haven’t yet determined why you want what you want–why you prefer intermittent monitoring over continuous monitoring, why you want to eat and drink during labor, why you want something different from your care provider’s or your hospital’s typical protocol.

2) A birth plan does not replace the need for a supportive care provider who is on board with your desires and preferences for your birth.

Even a well-researched birth plan will generally not stand up to a care provider who doesn’t allow anything stated on the birth plan.  And this is why it is crucial to discuss your birth preferences–and even get your list of preferences signed–with your care provider well before labor begins.

For instance, if you would prefer to tear rather than to undergo an episiotomy, but your care provider has an 85% episiotomy rate, then you might consider finding a care provider who has a much lower rate.

If your care provider does not “allow” some of your birth preferences (such as intermittent monitoring, eating and drinking during labor, etc.), then you might consider asking if s/he will make an exception in your case (and sign your birth plan!), or you might consider finding another care provider who does support these preferences.

In other words, a birth plan itself will not magically change the way your care provider practices when it comes to your birth!

And a care provider who is on board with your preferences is worth much more than a piece of paper expressing these preferences.

3) A birth plan cannot plan your birth–but it can help you to articulate and express your desires and preferences for your birth.

This is why I (and many others) like to refer to birth plans as “birth preference lists.”

Birth is inherently unpredictable, whether you have an unexpected unassisted birth at home or an elective cesarean section that you have planned for from the moment you knew you were pregnant.

Thus, you cannot plan the birth you want–you can only plan for the sort of birth that you would like and remain open to the possibility that your plans and preferences might need to change in light of the particular circumstances of your birth.

This is not to say that articulating your birth desires and preferences is useless.  To the contrary, this is an exceedingly useful exercise, one that can motivate you to research your options and to get a better feel for what you can expect from your care provider and from your birthing location.

But your attitudes about and expectations for your birth plan should reflect these sentiments: namely, that you cannot control your labor.  You cannot control birth itself.  But you can and even should empower yourself to make decisions about what you want for your birth, and how you would like others to accommodate your desires and preferences for your birth, and how you plan to remain flexible and open to the unpredictability of childbirth.

And care providers should be able to respect these sorts of preferences without pegging you as taking a one-way train to the operating room.

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If you’re looking for a helpful guide on writing a birth plan, Melissa, the L&D nurse blogger from Nursing Birth, wrote two fabulous posts on birth plans: one covering the general topic of birth plans, and the other offering more specific tips and pointers for writing a birth plan/preference list.

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I’m also interested in hearing your thoughts!  Have you heard that “the women with birth plans end up with the most interventions”?  Have you seen that in your experience as a birth professional?  What advice would you/do you give to women about birth plans based on your experience?

You can see more of this discussion over on my Facebook fan page!

Dear Alec,

Lately, I’ve been writing about our mother/child adventures as if they were battle scenes from World War Two-year-old.

I’ve compared your antics to “mashing my brain matter” as if it were a ripe banana.

I’ve compared you to a rabid howler monkey.

And I’ve documented just how much I’m drowning in (among other things) the trials and tribulations of parenting you and your brother.

And I won’t deny any of it.  It’s been hard.  It’s been so. hard.

But.

But.

I don’t want you to ever feel as if I have resented parenting you, or as if I have dreaded spending time with you, or as if I haven’t respected your astounding curiosity and ingenious resourcefulness.

And I don’t want you to think that I’m forgetting just how hard it is for you to be my child, or just to be two.

I know that it can be so. hard.

For instance, I know that you don’t yet appreciate the importance of a good night’s sleep.  You’re too young for that–”appreciating the importance of” is not even in your cognitive horizon right now.  And what you have in its place is this magical exuberance that tells you that climbing over your crib is what your little legs and arms were built to do and that the nighttime holds the promise of yet-unseen adventures and that sleep itself means missing out on all the mysteries that occur under the moon and stars and in our quiet house.

And I want you to know that in these still and silent moments–in the few minutes I have to sit and reflect–I appreciate the importance of that magical exuberance.  I want you to sleep, oh how I want you to sleep.  Both for selfish reasons (oh! how I need these still and silent moments) and for reasons of love and care and concern (oh! how you need this sleep to keep growing, to keep that smile on your face, my darling boy).

But I know, I do know, and I do love that you yearn to know what’s just beyond your little world, what lurks underneath the moon and stars and nighttime sky.  I’m secretly proud of your adventurousness, that frightening twinkle in your eyes.  You’ll scale mountains, both literal and figurative, some day.

But just remember (perhaps with my voice ringing in your ears) that you always need a good night’s sleep before you start climbing.

I know too that it’s frustrating to hear the word “no” over and over again.  And I know that I’m not always the best at choosing redirection or affirmation or patience over the word “no.”

But I also know that, no, you shouldn’t play with scissors, and no, the buttons on the oven are not for touching, and no, you shouldn’t spit on your brother when he makes you mad.  I’m just trying to keep you safe.  I’m trying to keep you healthy.  I’m trying to teach you respect and thoughtfulness and self-restraint.

Maybe, just maybe, I won’t have failed completely with all of my “nos,” and some day you’ll hear my “no” in the back of your mind when you decide not to join your friends in taunting that kid on the playground, or when you don’t pick up that cigarette, or when you don’t do that thing that’s unsafe or unhealthy or unkind.

And maybe, please maybe, you’ll hear my “yes” and “great job” and “wow” and “you’re amazing” too.

You’ll take all of that curiosity and find a way to supply everyone on the planet with clean water, or you’ll take that ingenious resourcefulness and build bridges or schools or sculptures, or you’ll fix leaks or cars or broken hearts.

Maybe you’ll take that frightening adventurousness and fight fires or crime or injustice, or maybe you’ll just take that magical exuberance and be the best damn person that you can be.

And I’ll be right there, right there, shouting “Hell yeah!  That’s my kid!  That’s my kid!!!  The one with the curiosity and the resourcefulness and the adventure and the exuberance!  He’s my boy!“

And I hope you’re able to appreciate the importance of my appreciation then.  Because it will be enormous, and it will be immense.

And it will always have been here, right here, all along.

the climber of cribs (and mountains) and his mother

Love,

Mom

Sometimes I whine.  Sometimes I cry.  Sometimes I whine and cry.  And sometimes I whine and cry and gaze at my navel when I write on this blog.

And by “sometimes,” I mean right now.

What can I say?  I’ve had one of those weeks.

Lately, it seems that I’m flailing about in a sea of problems that, when looked at individually, are just a bunch of small potatoes–just a bunch of little things that, on their own, don’t really warrant cries of “WOE IS ME!” and “SAVE ME, I’M DROWNING!”

But when you add enough small potatoes together, you can end up with a 50 pound bag of spuds–a bag that you might need a little help toting around town.

And what, you might ask, is in my giant sack o’ small potatoes?

What about seven consecutive nights of sleeplessnes, thanks to my overactive (because, strangely, he’s overtired) toddler?

Or the morning that said toddler rubbed crushed chili peppers in his eyes?

Or perhaps the major meltdowns that ensued?

Or the fact that I can’t deal with hearing about yet another sick family member?  That I’m far more prepared to confront my own mortality than theirs?

What about the fact that Tim and I just learned that we are now stuck with paying over $1300 in deductibles and rental car fees because a drunken, unlicensed, and uninsured kid smashed up both of our cars, and his parents’ insurance won’t cover him (because he’s not on their policy) and the insurance company won’t cover the car owner (who is the kid’s girlfriend’s grandfather–UH HUH) since the driver supposedly didn’t have permission to drive the car, even though the owners never filed a stolen vehicle report?  (Have I lost you?  Don’t worry–I feel lost too.)

What about the fact that we’re probably going to have to resort to litigation in order to get this substantial amount of money paid not by us but by the person who is unequivocally responsible for the smashing up of the cars?

Or the fire?  What about that bedtime-obliterating electrical fire?

What about the fact that I threw out my neck and back for the first time ever this past Sunday (and subsequently learned to appreciate just how much we humans use our necks and backs each day)?

Or how about the fact that on the night that my back began to feel better, M (4) came down with a cold?  And I was up with him throughout the night, (lovingly, though still tiredly) rubbing his back and propping up his pillows each time he woke up?

And on the night that Tim went away for a business trip (i.e. Thursday night), A (2) came down with a cold?  Except I didn’t know that he was coming down with a cold, and in my haze of fatigue and pain and stress, I yelled when he kept M and me up until 3:30 a.m. with his constant screaming and flailing and kicking?  And I yelled again when M started whining?

What about the fact that I feel like a horrible parent now?  For all of the yelling, for my short temper, for the way I’ve been gritting my teeth each time one of my children asks me for food or for help turning on the light or to “LOOK AT THIS, MOMMY” for the seven-thousandth time?

The small potatoes–they’re weighing me down.

(You think I could whip them up into a giant, greasy, ranch dressing-slathered batch of potato skins?  Because then I could eat them, and the problems would disappear….into my hips and thighs and butt.)

These weeks are what make sanity a truly precarious beast.

They are what make the difference between asking your partner to be “a little more careful next time” or acting as if he and Beelzebub conspired to destroy you and all of humanity by messing up the garden hose when he used the power washer to clean the siding on the house.

And on these days or weeks or (GOD HELP YOU) months, I think that we parents (and we human beings, because these trying time aren’t just unique to those with children) need a “reset button.”

We need a little life preserver thrown our way.

A bone.  A helping hand.  An offer to take all of those small potatoes and make them into that greasy batch of potato skins (with the reassurance that they are the nutritional equivalent of a heaping bowl of spring greens).

We need a moment to close our eyes, take a deep breath, and begin again anew, afresh.

Sometimes, I make my own reset button when I need one.  Like the days where, if both boys are napping, I tell myself that the work and the cleaning and the responsibilities can wait, and I settle down with a homemade latte and a couple episodes of Sex and the City.

Other times, I’m lucky enough–blessed enough–to have others hand me a reset button.  And sometimes, I need to hit that button over and over and over again.

This post is dedicated to all of those people who have recently showed up at my proverbial doorstep with a basket full of reset buttons.

To my fantastic in-laws and parents, who watched the kids for me last weekend so that I could spend some time with my long-lost girlfriends.  (RESET!)

To my fabulous college roommates, who spent a girls’ weekend with me in one of their fabulous apartments in Chicago’s South Loop.  (RESET!)

To various blog readers, who have sent me all sorts of kind comments and emails and tweets and Facebook replies, all of which make me smile, and some of which make me cry tears of joy and humility.  (RESET!)

To my husband, who brought home Chipotle on Wednesday night and pizza last night.  (RESET!)

And to my children, who gave each other the biggest smiles ever when they saw each other after their naps today, and who love me unconditionally, even when I’m a “bad mommy.”  (RESET!)

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Do you ever need to use a “reset button” in your life?  What do you do to fashion your own such button?  How have others given you one recently?

For what it’s worth, this post is also dedicated to all of you who are in need of a reset button.

As many people might have seen in the news, on press releases, or on blog posts, the American College of Obstetrics and Gynecology (ACOG) just released a revised version of its VBAC practice bulletin.

This is big news.  It’s huge news.  And it’s particularly big and huge in light of the fact that two previous practice bulletins on VBAC (from 1999 and 2004) were instrumental in leading to the decrease in VBAC access and the swath of VBAC bans across the United States. What’s more, this current bulletin has the potential to reverse some of the effects of the previous bulletins.

And this is not because it will effect any immediate policy changes but because it gives women a tool to help them facilitate discussions with their care providers and/or their local hospitals so that they can advocate for their birthing options.

So while the current document is not perfect, it’s an improvement.  And a possibly giant improvement at that.

Just consider the introductory paragraph from the 2004 practice bulletin:

A trial of labor after previous cesarean delivery has been accepted as a way to reduce the overall cesarean delivery rate.  Although vaginal birth after cesarean delivery (VBAC) is appropriate for most women with a history of low-transverse cesarean delivery, several factors increase the likelihood of a failed trial of labor, which in turn leads to increased maternal and perinatal morbidity.  The purpose of this document is to review the current risks and benefits of VBAC in various situations and provide practical management guidelines.

And now the introductory paragraph from the new practice bulletin:

Trial of labor after previous cesarean delivery (TOLAC)* provides women who desire a vaginal delivery with the possibility of achieving that goal––a vaginal birth after cesarean delivery (VBAC)†. In addition to fulfilling a patient’s preference for vaginal delivery, at an individual level VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies. At a population level, VBAC also is associated with a decrease in the overall cesarean delivery rate (1, 2). Although TOLAC is appropriate for many women with a history of a cesarean delivery, several factors increase the likelihood of a failed trial of labor, which compared with VBAC, is associated with increased maternal and perinatal morbidity (3–5). Assessment of individual risks and the likelihood of VBAC is, therefore, important in determining who are appropriate candidates for TOLAC. The purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and provide practical guidelines for managing and counseling patients who will give birth after a previous cesarean delivery.

While some people may find the “managing” language to be off-putting, I think that the changes in this paragraph signal both an acknowledgment of women’s birthing preferences and desires and some much-needed nuanced distinctions regarding VBAC and repeat cesarean outcomes.  And an increased attention to detail and to women’s choices is a welcome difference.

Below, I’ve listed some additional major changes that ACOG has made to their practice bulletin on VBAC between 2004 and 2010.  If you are are having a difficult time finding a VBAC-supportive care provider in your area, you might be able to draw her or his attention to these changes in order to advocate for the birth that you want!

*

On evaluating the risks and benefits of VBAC and elective repeat cesarean delivery

From the 2004 bulletin:

Neither elective repeat cesarean delivery nor VBAC is without risk.  Generally, successful VBAC is associated with shorter maternal hospitalizations, less blood loss and fewer transfusions, fewer infections, and fewer thromboembolic events than cesarean delivery.  However, a failed trial of labor may be associated with major maternal complications, such as uterine rupture, hysterectomy, and operative injury, as well as increased maternal infection and the need for transfusion.  Neonatal morbidity is also increased with a failed trial of labor, as evidenced by the increased incidence of arterial umbilical cord blood gas pH levels below 7, 5-minute Apgar scores below 7, and infection.  However, multiple cesarean deliveries also carry maternal risks, including an increased risk of placenta previa and accreta.

From the 2010 bulletin:

Neither elective repeat cesarean delivery nor TOLAC are without maternal or neonatal risk.  The risks of either approach include maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death. Most maternal morbidity that occurs during TOLAC occurs when repeat cesarean delivery becomes necessary.  Thus, VBAC is associated with fewer complications, and a failed TOLAC is associated with more complications, than elective repeat cesarean delivery. Consequently, risk for maternal morbidity is integrally related to a woman’s probability of achieving VBAC…

…In addition to providing an option for those who want the experience of a vaginal birth, VBAC has several potential health advantages for women. Women who achieve VBAC avoid major abdominal surgery, resulting in lower rates of hemorrhage, infection, and a shorter recovery period compared with elective repeat cesarean delivery. Additionally, for those considering larger families, VBAC may avoid potential future maternal consequences of multiple cesarean deliveries such as hysterectomy, bowel or bladder injury, transfusion, infection, and abnormal placentation such as placenta previa and placenta accreta.

*

On VBAC after multiple cesareans (or VBAmC)

From the 2004 bulletin:

Women who have had 2 previous low-transverse cesarean deliveries have traditionally been considered candidates for a trial of labor.  However, the few studies that address this issue report a risk of uterine rupture ranging between 1% and 3.7%.  In the only study that controlled for other potential confounding variables, the risk of uterine rupture during labor was nearly 5 times greater for women with 2 previous cesarean deliveries when compared with women who had 1 previous cesarean delivery.  Women with a previous vaginal delivery followed by a cesarean delivery were only approximately one fourth as likely to sustain uterine rupture during a trial of labor.  Therefore, for women with 2 prior cesarean deliveries, only those with a prior vaginal delivery should be considered candidates for a spontaneous trial of labor.

From the 2010 bulletin:

Studies addressing the risks and benefits of TOLAC in women with more than one cesarean delivery have
reported a risk of uterine rupture between 0.9% and 3.7%, but have not reached consistent conclusions regarding how this risk compares with women with only one prior uterine incision.  Two large studies, with sufficient size to control for confounding variables, reported on the risks for women with two previous cesarean deliveries undergoing TOLAC. One study found no increased risk of uterine rupture (0.9% versus 0.7%) in women with one versus multiple prior cesarean deliveries (66), whereas the other noted a risk of uterine rupture that increased from 0.9% to 1.8% in women with one versus two prior cesarean deliveries. Both studies reported some increased risk in morbidity among women with more than one prior cesarean delivery, although the absolute magnitude of the difference in these risks was relatively small (eg, 2.1% versus 3.2% composite major morbidity in one study).  Additionally, the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited.

*

On suspected macrosomia (or “big baby”)

From the 2004 bulletin:

Although macrosomia (usually birth weight greater than 4000 g or 4500 g, regardless of gestational age) is associated with a lower likelihood of successful VBAC, 60-90% of women attempting a trial of labor who give birth to infants with macrosomia are successful.  The rate of uterine rupture appears to be increased only in those women without a previous vaginal delivery.

From the 2010 bulletin:

Women undergoing TOLAC with a macrosomic fetus (defined variously as birth weight greater than 4,000–4,500 g) have a lower likelihood of VBAC than women attempting TOLAC who have a nonmacrosomic fetus. Similarly, women with a history of past cesarean delivery performed for the indication of dystocia, have a lower likelihood of VBAC if the current birth weight is greater than that of the index pregnancy with dystocia. Some limited evidence also suggests that the uterine rupture rate is increased (relative risk 2.3, P <.001) for women undergoing TOLAC without a prior vaginal delivery and neonatal birth weights greater than 4,000 g . These studies used actual birth weight as opposed to estimated fetal weight thus limiting the applicability of these data when making decisions regarding mode of delivery antenatally.  Despite this limitation, it remains appropriate for health care providers and patients to consider past and predicted birth weights when making decisions regarding TOLAC, but suspected macrosomia alone should not preclude the possibility of TOLAC.

*

On the “immediately availability” of obstetrical and surgical teams during a VBAC

From the 2004 bulletin:

Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

From the 2010 bulletin:

A trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries.  Because of the risks associated with TOLAC and that uterine rupture and other
complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care. When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.

I’m writing this post under a virtual clear plastic tarp in hopes that it will protect me from all of the rotten tomatoes, Similac-filled water balloons, and laser beams of disgust that are about to get hurled my way.

You see, I’ve been wondering about something deep inside the dark and labyrinthine confines of my mind lately–something about which I have some basic thoughts and intuitions, but nothing all that substantial.  And now, I’d like to wonder about it out loud:

What is the “right way” for a breastfeeding advocate/lactivist/what-have-you to mention or even suggest continued supplemental feedings/part-time breastfeeding/what-have-you to a mother who has been bamboozled by “booby traps” and appears to be on the verge of giving up breastfeeding altogether?  Is there ever (or never) a “right way” or “right time” for any self-respecting lactivist to do this?

(Please email me to let me know where I can pick up my award for the “world’s most convoluted question.”)

Now before someone cries, “BUT THIS SUGGESTION IN AND OF ITSELF IS A BOOBY TRAP AND UNDERMINES THAT MOTHER’S BREASTFEEDING RELATIONSHIP WITH HER BABY,” let me say two things:  I know this.  And I worry about it.  But allow me to go over a few of the qualifiers in my question:

1. I’m not talking about women who are at the very beginning (i.e. the first few days or even weeks) of their breastfeeding journeys.
2. I’m not talking about women who are just beginning to seek out breastfeeding advice.
3. I’m not talking about women who are currently and actively committed to maintaining (or even achieving) exclusive breastfeeding.
4. I’m not even talking about women who are currently and actively committed to maintaining part-time nursing.

I’m talking about women who have tried, and tried, and tried to breastfeed exclusively: who have seen or spoken to lactation consultants (including, one hopes, an IBCLC), who have sought out peer-to-peer support (from nursing friends or at La Leche League meetings), and who have scoured books and online resources (such as Kellymom) for breastfeeding advice.

I’m talking about women who were “booby trapped” at the hospital (“you’re not making enough milk!”) or at home (“why don’t you just feed the baby a bottle and get some sleep?”) or among friends (“um, gross, can you do that somewhere else?!”).

I’m talking about women who were coerced or misled into offering their babies formula and who now must fight tooth and nail (and nipple!) to re-establish an exclusive breastfeeding relationship.

I’m talking about women who might not prioritize breastfeeding the way a breastfeeding advocate like myself would, and those who might also have health or financial or family or personal issues that I never had to face in my challenging yet still relatively smooth efforts to exclusively breastfeed both of my babies.

I’m talking about women who, for whatever reason, might not have the time, or the energy, or the resources, or even the desire to follow all of the advice and instructions that their lactation consultants and/or breastfeeding support groups have given them.

I’m talking about women who are this close to giving up breastfeeding entirely.

And I’m talking about meeting women “where they are”–not in the place that I want them to be, not in the place that they could be if they had started with better nursing support in the hospital or the doctor’s office or at home, but where they are.

I’m talking about saying to them, “Hey!  If part-time breastfeeding is the way you need to go, then GO FOR IT!  Do what you CAN!  You are AMAZING for all of the efforts you’ve made to feed your baby!”

Sure, their milk supplies will dwindle if they don’t maintain their efforts to achieve exclusive breastfeeding.  But maybe they and their babies will enjoy the small comforts (and even benefits) of a couple nursing sessions each day, even if nursing only lasts for a few more weeks than they were planning.

Maybe they’ll even start enjoying breastfeeding for the first time ever.

Maybe they’ll learn to enjoy these small comforts so much that they’ll approach breastfeeding the next time (if there is another child some day) with more (or at least a different sort of) confidence in themselves and their bodies.

Maybe they’ll talk to their friends about breastfeeding in a way that is not entirely negative.

Maybe instead of saying, “I couldn’t do it,” they’ll say, “This is what I can do.”

These all seem like possibilities–ones that might not be part of a perfect world of universal (and socially and culturally supported) exclusive breastfeeding, but ones that might be the best possibilities that some women can hope for in the booby trap-ridden world in which many of us live.

What do you think?  Is there ever a time and place to suggest to a new mother who is about to quit breastfeeding, to whom you have given all your best books, resources, and IBCLC recommendations, and who has tried her damndest to work her way out of whatever booby traps she has come across, “You know,  you can still breastfeed part of the time and supplement with formula the rest of the time.  Your milk supply will ultimately dwindle, and you might and your baby might not get all the same benefits that exclusive breastfeeding offers, but you both would still get some benefits!“

If you are a mother who switched to exclusive formula-feeding early on in your child’s infancy, do you wish that you would have heard something like this from a breastfeeding supporter before you stopped nursing?  Did you ever hear anything like this?  Did you ever entertain the option of attempting part-time breastfeeding for the long-run (or as long as you could)?

Or is my out-loud wondering (gulp) just doing even more to booby trap new mothers?

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If you are a nursing mother who is at the end of her nursing-rope, please consider seeking out these resources before stopping breastfeeding entirely.  You might find that the breastfeeding support you need is right around the corner–or just a click away!

Kellymom – information and articles on nearly every topic related to breastfeeding, and online forums supporting all nursing mothers

Best for Babes - articles and public service campaigns devoted to helping moms avoid “booby traps” and working to break down the social, cultural, and institutional barriers to breastfeeding

La Leche League International - information and support for breastfeeding, with links local peer support groups and meetings

Yes, I know how lucky I am to have my darling children.  I love them more than I can fully express, even when they keep me awake at all hours of the night.

And I realize how lucky my family is to have a roof over our heads.  To have food in the refrigerator and jobs and running water and a safe place to live.  And I’m not forgetting all of that luck for one second.

But COME ON universe!  What is UP?!

Yep, that’s the kind of night I had last night.

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Something truly magical happened on Wednesday night.  Something so magical and wonderful and exquisitely beautiful that I almost couldn’t believe it when it happened:

Both boys slept from about 8 p.m. until 6 yesterday morning.  Without any fights, or meltdowns, or freak-outs, or early morning wanderings to snag some spicy banana muffins.

It was a glorious night.

And because of this glorious night, I woke up yesterday feeling like a new woman.  A calm woman.  A still-fatigued woman, but a woman who was beginning to see a little more rest and a little less “attack-of-the-overtired-children” in her future.

So yesterday evening, as Tim was putting A (2) to bed and M (4) was resting peacefully in our bed until A fell asleep (our latest sleep strategy!), I decided to get in a little exercise, a little shower, and then an early bedtime.

It was a good plan.  A wise plan.  I was, after all, taking the kids (by myself) to Chicago to visit their grandparents the next day.  A good night’s sleep was on the agenda.  It was a totally reasonable and magnificent plan, people!

But oh, those wise plans.  How they mock me.  How they ridicule me.  How they tease me like a seventh grade bully.  ON CRACK COCAINE.

‘Cause those plans were about to be demolished.

During my post-exercise shower, I heard what sounded like someone pounding really, really hard over and over and freakin’-over-again on the front door.

And because I have a one-track mind right now (and on that track is a freight train riding to OH MY GOD, WILL MY KIDS EVER SLEEP town), my first thought was “WHO THE F#&K IS KNOCKING ON THE DOOR WHEN WE’RE F#&KING TRYING TO PUT THE KIDS TO BED?!?!”

My mind.  It curses like a sailor.  Especially when I’m exhausted.

Once the knocking of doom stopped, I prayed that the salesperson or the survey-taker or the neighbor-kid or WHOEVER IT WAS THAT WAS TRYING TO DESTROY BEDTIME would just go away.  Quietly.  Quickly.

But then M ran into the bathroom to let me know that he was going to check on who was “knocking at our [second-story bedroom] window.”

Duh, WHA?!?!

I screamed, “NO!  WAIT!  DON’T GO NEAR IT!” and then hopped out of the shower.

Oh my god, what was I going to find?  A mutant squirrel?  A serial killer?  My two-year-old, who had now learned how to climb out the window and swing from the tree branches like a real howler monkey?

So with my hair sopping wet, water dripping all over the carpet, and a towel draped over the front of my body, I tip-toed out of the bathroom to see what was making all of that sleep-obliterating noise.

No hulking rodents.  No serial killers.  No two-year-old.

But there were a handful of neighbors in the alley behind our house.  They were looking up at something.  And there were some flashing red lights a block or two away from us.  Oh, look!  Those lights were coming from a fire engine.  And hey, LOOK!  THE WIRES ON THE TRANSFORMER BOX BEHIND OUR HOUSE WERE SMOLDERING.  They were on FIRE!

FIRE!

MOTHERHUMPING FIRE!!!

Boobs, meet neighbors.  Neighbors, boobs.

I threw that towel down, yelled for Tim to gather the kids, and then told him to run out into the front yard because OH MY GOD THERE WAS AN ELECTRICAL FIRE!

Tim later informed that the room looked like a scene from one of those ’80s sorority films, what with the bouncing boobs and the “FIRE! FIRE!” shrieks.

Which, you know, had to have looked awesome.  To the neighbors.

So Tim scurried outside with both kids as I scrambled to get my clothes on, and then I made a mad dash out the front door.  You see, WITH OUR LUCK that burning wire could have flown across the yard, landed on our gas grill, and then sent the whole house up to the moon.  It’s not outside the realm of possibility when it comes to our lives. And I didn’t want to be near the house when it happened.

Once I got to the front yard (with a lovely case of “raccoon eyes” and, hey neighbors!, shirt on!), Tim and I learned that the transformer box had exploded while I was in the shower.  Like exploded, exploded.  Flames shooting up into the air and everything.  And that’s where the noise came from.  THE KNOCKING, BOOM-BOOM, POUNDING SOUNDS WERE FROM AN EXPLOSION!

AT BEDTIME! (Seriously, couldn’t the fire have been a little more considerate of my family’s needs?)

Hours later, after the fire department put out the fire, after the power company had fixed the box, after both boys were in bed, and after the electricity came back on in the house, Tim and I snuggled on the couch with a couple glasses of wine, way past my hoped-for early bedtime.

And we realized that it’s got to be one hell of a week when you tell each other, “HEY!  AT LEAST THE HOUSE DIDN’T EXPLODE TODAY!”

I realize how potentially dangerous and frightening the following situation is, and how frighteningly dangerous one or more of the soon-to-be-described events could have been.  Everyone is safe, so I think it’s permissible to write about it all here and use humor as my motherhood-catharsis.

Yes, that’s the sort of week I’m having.

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If you follow me on Facebook or Twitter, you may have heard me say a thing or twelve about the obscenely chaotic time we’ve been having in our house, courtesy of our resident two-year-old Houdini-howler-monkey, A.

It all started last Friday night after Tim and I had put the boys to bed.  First I heard a thud, and then a thumping, and then a constant pitter-pattering.

When I went upstairs to see what the ruckus was all about, I discovered that my dear, sweet A had managed to clamber out of his crib and sweep tornado-style through the room and all of its contents in the moments between my hearing the thud-thumping pitter-pattering and my doing something about it.

I had figured this day would arrive sooner or later–he is quite the climber, after all–so I wasn’t entirely shocked by what I saw.  I very calmly rocked him, read him one more book, sang him one more song, and snuggled him under his blankets for a good night’s sleep.

Minutes later, the thud-thumping started up again.  And then again.  And then again.  And for the next three hours, Tim and I took turns placing A back in his crib.

It’s an understatement when I say that our patience had been whittled down to a nub by the night’s end.

At one point, we did have the bright idea to place a baby gate at A’s doorway.  But then he took a half-filled box of diapers, turned it upside down, and scaled the gate.

We removed the diaper box, but then he found a canvas toy bin, turned it upside down, and hopped the gate yet again.

And after we removed everything remotely resembling a box, A took to climbing up and over the gate all on his own.

Oh A, how I admire your determination.  All. That. Freakin’. Determination.

I know what some of you are thinking right now: what’s a little climbing?  He was excited!  Thrilled with his new-found freedom!  Let’s celebrate his curiosity!

But let me just put his brand of excitement into perspective for you.

Did you guys ever see that after-school special in which the main character (played by Academy Award winner Helen Hunt!) tries PCP or angel dust (or are they the same thing?) and then FA-REAKS out and plunges out the second story window at her school?

(Hey look, someone uploaded the video on YouTube!)

A looked a lot like Helen-Hunt-on-drugs that night.  And to that, I ask WHO THE HELL GAVE MY BABY DRUGS?!?!

Oh wait.  He was high on the sweet taste of freedom.  WHO THE HELL TOLD MY KID TO CRUSH HIS FREEDOM AND THEN SNORT IT UP HIS NOSE?!?!

Tim and I gave up somewhere around midnight.  And A gave up (in a pile of utter, wild-induced exhaustion) around 12:30 a.m.  And he started back up again at 6 the next morning.

If A were a child who didn’t need much sleep, I wouldn’t have been all that worried.  (Join hands with me and celebrate his beautiful, sparkling curiosity and lust for life!)  But both of my boys are 12-14 hour sleepers.  They are “high energy” kids, both physically and intellectually, and if they don’t get enough sleep in any given 24-hour period, they begin to melt into puddles of whiny frustration.

Isn’t that what all people do when they don’t get enough sleep?

In any case, somewhere in the midst of trying to sidestep the puddles of whiny frustration scattered about the house, Tim and I had the scintillatingly brilliant idea to transition A into the “big kid bed” that was waiting for him in his brother’s room.

That’s exactly what they needed!  The crib-climbing was a sign!  It was so obviously time for them to begin sharing a room!

Someone?  Get me a drink.  And a magic “DUDE, you gotta start seeing things more clearly” device.

Trying to get the two of them to sleep in the same room was like trying to dress a bunch of feral cats in baby-doll clothes and sit them around a teeny tiny table for a tea party.  Ain’t gonna happen.

Soon, naptime was shot to hell.  (M, who’s four, generally doesn’t sleep during “quiet time,” but he does often benefit from a quiet hour or two in his room while his brother is sleeping.)  And sooner, bedtime was completely obliterated.

And much to our dismay, the kids were averaging a total of seven hours of sleep per day.

If you are a parent (or even if you’re not), you know that this is not. good.

So, geniuses that we are, we began getting A (2) to sleep first, and then letting M (4) stay up until A was in a deep sleep.  And it was working.  It was really, truly working for a couple of naptimes and bedtimes.

Until A woke up at four this morning and started getting his groove thang on once he spied M in the bed next to his.  (“M!  M!  Wake up!  WANT TO PLAY?!“)

And then it took us nearly two hours to get him and his tired, tiny, grooving butt back to sleep.

And then?  THEN?

People, I was in a deep, deep sleep.  It was the deep, deep sleep of sleep-deprivation.

And that’s why I didn’t hear A wake up and climb over the baby gate in his doorway.

That’s why I didn’t hear him walk downstairs, saunter over to the kitchen, and scoot a kitchen chair over to the counter so that he could grab and eat one of the banana muffins that we had made yesterday in my attempt to do something low-key yet fun with the kids–you know, something where A could mash something (i.e. bananas) other than my brain matter.

That’s why I didn’t hear him as he spilled a container of Milakai Pudi (I.E. “FRESHLY GROUND PEPPERS WITH HOUSE SPICES” FROM A LOCAL INDIAN RESTAURANT) all over the banana muffins, all over the counter, all over (and inside) my purse, all over the chair, and all over the floor.

That’s why I didn’t hear him when he scooted the chair across the entire kitchen and over to the pantry to search for more food.  (I sweartogod, we feed him.)

But I did hear him as he let out a blood-curdling scream after he RUBBED HIS EYES WITH HIS SPICE-COVERED HANDS.

A couple of eye-flushes later, he was ready to take on the world just as he had been for the past five days: wearing his new-found independence like a gold lame’ jumpsuit.

And I’m just begging that he soon learns that the entire family (A included) is ready to take on the world with just a little more sleep.

nothing like milakai pudi and banana muffins to perk up your morning.

it's amazing that i've been able to construct complete sentences today.

Come September, I might not be able to say that I’ve learned how to parent two overtired and feral children without losing my mind.

I probably won’t be able to say that I’ve learned how to change the oil in my car or how to sing opera or how to throw a football in a perfect spiral (although as the daughter of a former college quarterback, I can say that my spiral is pretty freakin’ good).

But I will be able to say that I’ve learned how to make granola.

And, surprise of all surprises, I’ve learned that it’s a pretty easy thing to do too!

I don’t know why I always thought that making granola would be some sort of Herculean task.  I imagined you would need a special oven or a special gadget or a special $15.99-per-pound ingredient to pull it off.

But at least with the recipe that I’ve been using, granola-making is fairly simple and even fairly inexpensive.

Here’s the “base recipe” that I’ve been using (which I’ve adapted from a recipe that appeared in Martha Stewart Living):

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3 cups rolled oats

1 cup dried shredded coconut

1 cup pecans, walnuts, or almonds

1/2 cup pure maple syrup

1/2 cup extra-virgin olive oil

1/4 – 1/2 cup packed light-brown sugar (depending on how sweet you want your granola)

1 tsp. coarse salt  (I’ve been using shaved sea salt.)

3/4 tsp. ground nutmeg

1/2 cup raisins, dried cherries, or other dried fruit

Optional:

1/4 cup white chocolate chips

1/4 cup sesame seeds

1/4 cup dark chocolate chips

Preheat oven to 300 degrees.  Mix together oats, coconut, nuts, syrup, oil, sugar, sesame seeds (if desired), salt, and nutmeg.  Spread granola in an even layer on a rimmed baking sheet or casserole dish.  Bake, stirring every 10 minutes, for 40 minutes.  Add raisins or other dried fruit, and bake until granola is toasted, about 10 minutes or more.  Let cool completely, then add chocolate chips (if desired).

I’ve made one batch with pecans and raisins, and it was delicious–chewy yet crunchy, sweet yet salty, and altogether lovely.

Last night, I made a batch with almonds, cherries, and white chocolate chips, and it too was mighty tasty.  (For what it’s worth, I’d probably try dark chocolate chips instead of white chocolate ones next time.)

And, as my entire family will agree, both batches were absolutely wonderful on top of vanilla yogurt, ice cream, or just all by themselves!

cherry-chocolate maple granola

in a little more-or-less than a year, this will be me.

At some unspecified time between now and January, Tim and I will be trying for our third and final child.

Yes, we will be adding to our brood.  Trying to conceive.  “TTC-ing.”  Having marvelously unprotected sex.

(Oh, pull your fingers out of your ears, family members.  You know where our other babies came from, right?)

And perhaps not like other parents planning to add to their family, I’m excited and nervous and prematurely nostalgic for this next chapter in our parenting adventures.

The excitement has really been building ever since I got that subtle intuition, that deep-seated feeling that we were ready to try to add another person to our family–that there was a space for another person in our family.  And I love dwelling on the mystery of it all: will we have a boy or a girl?  Will s/he be due to arrive in winter, spring, summer, or fall?  Will my pregnancy be difficult?  Will I breeze right through it?  What will my baby’s birth be like?  What will s/he be like?  How will s/he be different from or similar to his/her brothers?  How strange is it that I don’t even know this person who will some day hold one of the dearest and deepest places in my heart?

But Tim and I both have raging nerves about our decision too: Are we really ready for another baby?  Can we really afford another child (and potentially another college education)?  Do we have enough energy for one?  Good lord, will I ever finish my dissertation?  Can we make it through that first year again?  Are we trying too soon?  Will I have a healthy pregnancy and birth?  Where and with whom will I give birth?  Will our baby be healthy?  Will we have more than one baby?  (Twins run in my family!)

Despite these nervous wonderings and second guesses, I still feel that the time is right, and that we are ready.  And knowing that this will likely be my last adventure through pregnancy, birth, babyhood, and breastfeeding makes me nostalgic for all of the “last times” that Tim and I are about to experience: the last time I feel a baby kick for the first time.  The last time that Tim and I get to feel those baby kicks together.  The last time that I birth a baby, and the last time that I nourish a baby just with my own body.  The last time that I smell my new baby’s smells, and see my baby smile for the first time, and listen as my baby coos, oohs, ahhs, and slowly builds those first words.  The last time for sleepless nights and tiny onesies and little feet and first steps.

It’s all thrills and nerves and hellos and goodbyes and final chapters and new beginnings all wrapped into one, giant, transforming experience.

For what it’s worth, I’m not sure how much of our TTC journey I’ll actually share here on the blog.  I’m all for publishing the ins and outs of my birth stories, and I’m going to blog the hell out of my pregnancy (for the free therapy and commiseration and cheering squad), but I feel strangely protective of those moments (weeks? months?) that precede pregnancy and birth.

On the one hand, I’m just not sure I have the stamina to go through months and months of TTC-ing in public.  On the other hand, I’m also not sure I want to rub an easy-peasy “pregnancy on the first try” in other people’s faces–especially those who have been trying for months and/or are struggling with infertility.

Nonetheless, we will be trying at some “secret” time within the next six months.  And the moment I spot those pink lines, I’ll make sure to start documenting the whole journey here.

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Did you or do you have the same feelings about trying to conceive a(nother) child?  How did you know when the time was right to “TTC”?  Did you or would you document your TTC journey, your pregnancy, and/or your birth on your blog?  Or did you/would you feel protective about one or more of those experiences?

six years of marriage, six years of laughter

Dear Tim,

Six years ago today, you stood next to me as we affirmed to our family and friends that we would be journeying through the rest of our lives together–officially, legally, and blissfully together.

Six years ago today, I had no doubts, no worries, no fears.  We held hands and uttered words like “forever” and “home” and “husband” and “wife,” and I felt at peace because I knew that my forever and home and husband would be you.

Six years ago today, we held the promise of our sweet Miles and Alec.  We didn’t know them, but we knew we wanted them.  We weren’t ready for them, but we knew we would be ready for them some day.  And we certainly didn’t know how much they’d expand our hearts and transform our love for one another.

Six years ago, we were in flux: between our single life and our married life, between Chicago and Syracuse, between youth and adulthood, between our known past and our unknown future.

Six years ago today, we were silly: we danced and sang and ate and drank and laughed, and you even had the bright idea to shove chocolate cake so far up my nose that it was stuck in my nostrils for weeks–an act for which I forgave you minutes later, once I was able to breathe again.

Six years ago today, we were humbled: to have friends and family who loved us to much, to have a celebration that expressed our love for them and that mirrored our love for one another.

Six years ago today, we had fights and fun and sex and life-changing moments to anticipate.

And six years ago, we were as we are today: best friends, admiring, adoring, and in love.

I love you ever more, six years later.

*

Yours,

Kristen