Birthing Beautiful Ideas

We can call it “poor communication skills.”

We can refer to things like “misinformation” and “misrepresentation” and “misguided intentions.”

We can even call out some of ‘em for what they really are: “lies.”

Yes, when some women discuss vaginal birth after cesarean (or VBAC) with their health care providers, the information they receive can be mangled by everything from poor communication to outright falsehoods.

You can take a look at my own VBAC Scare Tactics series, where each post has been “inspired” by actual misguided scare tactics that women have encountered in their quest to find a health care provider to attend their child’s birth.

You can scour My OB Said WHAT?!? to find some (outrageous) instances of this misinformation.

You can search any number of VBAC-relevant message or support boards to find women reporting the false or exaggerated or misguided claims that their OB/GYNs or midwives have made about VBAC.

You can also ask nearly any woman who has ever attempted to find a VBAC-supportive care provider, and most of them will probably have some VBAC-related whoppers to share.

Want some examples?

There are loads of women (and their friends, relatives, and other loved ones) who think that or who have been told that “VBAC only has a 70% success rate, so why would you want to risk your baby’s health like that?”

The truth is that the “70% success rate” means that (approximately) 70% of VBAC attempts will end in vaginal birth and 30% will end in a cesarean section.  This does not mean that 30% will end in uterine rupture–only .7% of women attempting VBAC experience uterine rupture, and the majority of those ruptures are not catastrophic.  Making an informed decision regarding VBAC and repeat cesarean involves receiving accurate, non-misleading information about the difference between VBAC success rates and uterine rupture rates.

There are women who have been told (or who have engaged in conversations that have implied) that VBAC carries an exhorbitantly large risk and that repeat cesarean carries little to no risk.  VBAC consent forms are generally good at “mis-communicating” this information.

The truth is that neither VBAC nor repeat cesarean is without risk.  The main risk associated with VBAC is uterine rupture, which occurs in approximately .7% of VBACs.  Repeat cesarean, however, is associated with a number of risks, including incision-site infection, hemorrhage, bowel obstruction, and an increased risk of placenta previa, accreta, and percreta in future pregnancies for the mother; and iatrogenic prematurity, respiratory problems, and lacerations for the baby.  Preserving patient autonomy regarding VBAC and repeat cesarean involves ensuring that women know the risks associated with both VBAC and repeat cesarean before they enter the hospital, regardless of their birthing choice.

Women have been told that VBAC is very unsafe for babies and that VBAC is downright silly since it is only about a woman seeking out a certain “experience” at the expense of her baby’s health and safety.

The truth is that current research concludes that babies born after a VBAC have lower NICU admission rates and fewer respiratory problems than babies born via elective repeat cesarean. And the truth is that VBAC is never just about a woman seeking a certain “birthing experience” at the expense of her baby’s health and safety–there are many other reasons that women choose VBAC over repeat cesarean.  VBAC is a safe and healthy option for many women, and actively discouraging VBAC might very well compromise maternal and neonatal health and safety when one takes into consideration the benefits of vaginal birth for moms and babies and the risks that repeat cesarean(s) pose to a woman’s future reproductive health.

My thoughts in a nutshell?

I think that care provider-initiated misinformation about VBAC eats away at informed consent and patient autonomy and maternal and neonatal health.

And I think that in many cases, health care providers need to be counseled on their counseling when it comes to VBAC.

This why I’d like to take these thoughts to the NIH Consensus Development Conference on VBAC in March.  And I’d like YOUR stories to help me do so!

Have you been lied to about vaginal birth after cesarean?

Did you face “VBAC scare tactics” during your pregnancy (or pregnancies)?

Were you misinformed about the relative risks (and benefits) of VBAC and repeat cesarean?

PLEASE SHARE YOUR STORY HERE SO THAT YOUR VOICE CAN BE HEARD AT THE NIH CONFERENCE!!!

Because advocating for women’s birthing choices isn’t just about making sure that health care providers are doing the right things–it’s also about making sure that health care providers learn and say the right things.

I think that a lot of people misunderstand what the concept of “birth trauma” is, and in misunderstanding it, they often dismiss it and/or its gravity.

I don’t think that these misunderstandings necessarily come from a place of callousness.  A lot of the time, I think the misunderstanding comes down to a matter of (incorrectly) universalizing what another woman says about her own experience–or even of forgetting that one’s own intimate, personal, and wholly unique experience of birth can be radically different from another’s intimate, personal, and wholly unique experience of birth.

When I say that people “incorrectly universalize” statements or sentiments about birth, I mean that they often say things like this:

Misunderstandings about birth trauma

• “All women who talk about their ‘birth traumas’ need to get over the fact that they ended up with a cesarean and not a vaginal birth.  Wallowing in the guilt over a birth experience is totally counterproductive, and it seems like a wasted effort to focus on feeling ‘robbed’ of an experience when you still get a baby at the end of the day!”

• “My own c-section wasn’t traumatic, and I find it highly offensive that anyone would suggest that all c-sections are inherently traumatic experiences.”

• “Here’s an example of a truly traumatic birth where the baby (and/or mom) was actually not healthy after the birth.  Any other woman who feel traumatized by her birth experience just need to focus on the fact that she has a healthy baby.”

• “‘I don’t care how traumatic a birth was, it wasn’t rape.  I had a c-section/I had a horrible vaginal birth/etc. and it certainly wasn’t rape, or even anything like rape.  All women should stop comparing their birth experiences to rape.”

Rectifying these misunderstandings takes an effort not only to point out that they are misguided but also why they are misguided (and why universalizing anyone’s experiences with or claims about birth is problematic):

Creating a better understanding about birth trauma

• Not all mothers are disappointed by their birth experience (whether vaginal or cesarean section), but this does not negate the possibility (and the reality) that some are.

• Not all mothers who are disappointed by their birth experiences would describe those experiences as traumatic, but this does not negate the possibility (and the reality) that some do.

• Not all c-sections are traumatic experiences for the mothers who have had them, but this does not negate the possibility (and the reality) that some are.

• All mothers who are disappointed by–and especially those who feel traumatized–by their birth experiences should be received with non-judgmental support. Validating a person’s feelings does not mean that one is allowing another to “wallow” in their “negativity.”

• Not all traumas involve life-or-death situations. And not all “traumatic” c-sections (or vaginal births, for that matter) are the result of life-or-death situations.

• Not all those who have experienced traumatic births would describe their experience as akin to rape. But some do.

• Not all those who describe their birth experiences as “birth rape” have had cesareans.  Some are describing vaginal births instead.

With the above points in mind, it would obviously be ludicrous (and even insulting) for someone to describe all c-sections as traumatic or as “birth rape” or even as disappointing.  This would be to engage in the same sort of “problematic universalizing” that I described above.

But it seems equally ludicrous and insulting to belittle or dismiss any mother who describes her birth(s) in this way.  And this might have something to do with the many ways in which “trauma” can manifest itself during a birth.

Sometimes, the trauma really does come down to a matter of life-or-death.  Sometimes, life (and medicine and all of the best efforts and intentions in the world) does not prevail over death.  And that is certainly not something that a person should be encouraged to “just get over.”

But other times, the trauma manifests itself when a person is “duped” into an early and unnecessary induction that leads to a c-section–a c-section that may have been prevented if (a healthy) labor had been allowed to start on its own, a c-section that may lead a woman to think that her body has failed her and her baby.

Even other times, this trauma manifests itself when (trigger warning) a woman is literally forced down onto the hospital bed so that her OB/GYN can insert an amniohook into her vagina, or when she is given a pudendal block against her will (neither of which are emergency obstetrical procedures).

And as far as I can tell, forcibly inserting instruments into a woman’s reproductive organs against her will is battery at the very least and, upon further interpretation, rape.

What’s more, the inherently sexual (which shouldn’t be confused with erotic) nature of childbirth can bring back past experiences with sexual abuse, and this in and of itself can lead to a traumatic birth experience.  (Trigger warning)  Repeated and/or rough vaginal exams, insensitive comments, having one’s arms “tethered” down during a cesarean, not being able to see the surgeons manipulating one’s reproductive organs–these can all be “triggering” and even re-traumatizing experiences for a woman.

So sometimes (if not many times) the traumas extend well beyond–far beyond, eons beyond–feeling “robbed” of an experience.

On that note, while I would agree that a healthy, living baby and a healthy, living mother are exceedingly important and should be the primary goal of any birth, these goals in no way cancel out the importance of a woman’s birth experience.  These goals in no way suggest that women cannot or should not have their own hopes and dreams for their birth experiences.  They in no way suggest that women cannot or should not regret their birth experiences, or even that they might never have the birth experience for which they hope and dream.

As I have pointed out elsewhere, we humans are complex creatures, and we can simultaneously feel overjoyed by our healthy babies and still feel devastated by the way those babies came into the world (or even by the effects their births have had on our sexual enjoyment).  Allowing this devastation to consume one’s life certainly is problematic and is probably a signal that one might want to seek out therapy and/or anti-depressants and/or a support group (such as Solace for Mothers or ICAN).  But simply feeling this devastation deeply does not seem to be indicative of a problem with one’s emotional life.

With this in mind, it is important to recognize because a woman’s birth experience is so profound and personal, and because trauma can manifest itself in so many ways during a birth, jokes about various birth experiences can be (unintentionally) insensitive.

For example, as a doula, I’ve attended two precipitous (or very fast) labors, and each woman experienced the birth radically differently: one was elated that her labor went by so quickly and without any complications, while the other was utterly traumatized by the speed of her labor, even though there were no complications for either her or her baby.  One would have laughed at a joke about “the ease of a fast labor,” and the other would have been deeply hurt by it (and actually expressed to me that she had been hurt by those jokes and didn’t know how to express herself to those presumably well-meaning people).

I’ve also had conversations with moms who have felt violated by their cesarean sections and those who were quite pleased with their c-section experience(s).  Many might bristle at and even be deeply hurt by a joke about their “tighter vaginas” or their “easy birth” while others might laugh right along with one of those jokes.

This is not to say that there is no place for humor in the healing process.  But it is to say that there are real times and places where jokes can end up hurting instead of humoring (and real times and places where even well-intentioned jokes warrant an apology).

In the end, I think it is always worth recognizing that birth is intimate and personal and can be the most empowering or the most traumatic experience of a woman’s life–but it is her experience to judge and process and celebrate and mourn.

And I hope that all birth advocates–and all people, for that matter–can ultimately push for these goals: for healthy moms and healthy babies, for care providers who give transparent and caring and sensitive advice to the women they encounter, for care providers who treat birthing women with dignity, for care providers who practice evidence-based medicine, and for women who can find a safe space to process their births, whether these births were exhilarating or disappointing, empowering or traumatic.

*Much of what was written here was inspired by two thoughtful and provocative blog posts (and my replies to those posts), one from Her Bad Mother, the other from Adjunct Mom.  I might not agree with all of their claims, but I appreciate their thought-provoking discussions nonetheless.

If you or someone you love has experienced birth trauma (or if they are experiencing signs of post-traumatic stress disorder following a birth), a tremendous source of online support for many women is Solace for Mothers. Birth Cut also has an online space where women can safely express their “cesarean rage“.

“Why does it matter what this snarky sex-advice book says about epidurals, or how this prime time drama portrays natural childbirth, or how films tend to make birth into a super-crisis?  It’s POP CULTURE!  Women listen to their doctors and their books on pregnancy and labor when they want to make decisions about pregnancy and labor.  They don’t go to to these other books or television shows or movies for that sort of advice!  Why should you even CARE about what they say?!“

Yep.  I’ve heard that a lot.  And even though statements like these really irk me, I can sympathize with the sentiment behind it.

I mean, I don’t think I’m over-generalizing when I say that most reasonable people turn to trusted sources or experts on topic x when they are making decisions regarding x.  So when most pregnant women want to know more about pregnancy and labor, they read a book or a website or talk to a midwife or an OB/GYN or a doula or even a friend or family member who has given birth before.  They don’t always get good advice, mind you, but at least they’re generally going to the right sorts of sources.

But I also think it’s pretty foolish to dismiss the effects that popular culture has on a woman’s beliefs and decisions about pregnancy and childbirth.

In fact, I would venture to say that these effects are pretty widespread.

Of course, I’m not saying many of us literally turn to pop culture when we’re deciding whether or not to consent to an episiotomy or to request pain medication in labor or to choose one care provider over another.  That would be stupid, right?  It would be ridiculous for someone to say, “Well, my OB/GYN reminds me of that chick on Private Practice, so I think she’s the best one for me and my baby!”

But that doesn’t mean that what we see on television or read in a (non-birth-related) book or watch in a movie has no effect at all on our thoughts about pregnancy and childbirth.

Quite the contrary, in fact.

Because every a woman reads that she “won’t be able to make it without an epidural”…

…every time she sees natural childbirth portrayed as something only for hippies and freaks…

…every time she sees a movie in which birth is a crisis or a catastrophe or a comedy of errors in which the mom is a crazed, expletive-hurling woman who is seriously out of control…

…those images and words start to affect the way she thinks about birth in general, and they may even have an effect on her specific beliefs about birth.

Instead of rambling on about the general effect that pop culture can have on a woman’s beliefs about birth, however, perhaps it’s better that I give a real-life example: my own real-life example.

And it’s even a positive example!

You see, long before the thought of even trying to get pregnant was ever on my radar, I was a big Sex and the City fan.  A huge fan.  I owned the entire series on DVD, I cried into my Cosmo during the series finale, and I even went to see the first movie in the theaters a mere four days after giving birth to A.  (Judge me all you want for my messed up new-mom priorities, I know.)

I love Carrie, Miranda, Samantha, and Charlotte forever with a big, sparkly pink heart.

And one of my most-loved SATC episodes is the one where Miranda gives birth.

Before Miranda actually goes into labor, there’s this scene where she and Carrie are walking down the street, and Miranda is telling Carrie what she does and doesn’t want in the delivery room.

She wants Carrie there.

And when it’s time to push, she doesn’t want everybody getting all “cheerleader-y” on her and shouting “PUSH!  PUSH! and shit like that.”

Call me silly, but when I first saw that scene, it signaled a major change in the way I thought about how I was going to give birth some day.

I literally turned to Tim and said, “YES!  Yes!  When we have a kid some day, I do NOT want people getting cheerleader-y on ME!  Just let me do my thing.  I’ve NEVER liked that cheerleader stuff when I’m trying to concentrate on something!  [OMG, I'm so much like Miranda!  Teehee!  Pink, sparkly hearts for everyone!]”

Seriously, though, the moment was very exciting for me because all I had ever seen at that point in my life were women flat on their backs in hospital beds, pushing out a baby while everyone around them shouted “PUSH! PUSH!” and shit like that.

It was my entire paradigm for birth.

And to know that this paradigm could shift (and eventually shatter, as it did during A’s birth)?  To know that I could request otherwise?

Who knows, maybe the good ladies of Sex and the City helped to send me on the path that I’m taking this very day.

Pink, sparkly hearts and all.

*Although there are certainly silly components of Miranda’s labor–correct me if I’m wrong, but can you actually break your bag of waters by pushing it out in active labor?–I love how the writers had her walking around in labor and stating that her doctor said that natural membrane ruptures were “better” than amniotomies.  And what a tender moment when she meets Brady–not ooey-gooey sentimental, but weird, and strange, and lovely.

If you haven’t yet figured out, I tend to analyze and over-analyze a lot.  And I’m pretty damn verbose, especially when it comes to the written word.  (Case in point?  I left an 800+ word comment on a blog this past weekend.)

My tendencies toward over-analysis and verbosity seem to be part of my nature, and these tendencies have only been enhanced by my tenure as a philosophy graduate student.

But I also think it’s nice just to slow down, quiet down, and let certain things speak for themselves every once in a while.

Which is why I’m going to devote one post every week or so to “words for thought.”  Words that I find inspiring or provocative or just downright cool.  Words-without-Kristen’s-analysis-and-verbosity for y’all to ponder (and even comment on).

This week’s “words for thought” comes from Sylvia Plath’s novel, The Bell Jar (a favorite of mine).

In this passage, Esther (The Bell Jar’s narrator) sneaks into a hospital maternity unit with her boyfriend, Buddy, a medical student.  And I think what she has to say is brilliant and insightful and all-the-more haunting given the fact that The Bell Jar was published after Plath herself had given birth to her two children:

I was so struck by the sight of the table where they were lifting the woman I didn’t say a word.  It looked like some awful torture table, with these metal stirrups sticking up in mid-air at one end and all sorts of instruments with wires and tubes I couldn’t make out properly at the other…

…The woman’s stomach stuck up so high I couldn’t see her face or the upper part of her body at all.  She seemed to have nothing but an enormous spider-fat stomach and two little ugly spindly legs propped in the high stirrups, and all the time the baby was being born she never stopped  making this unhuman whooing noise.

Later Buddy told me the woman was on a drug that would make her forget she’d had any pain and that when she swore and groaned she really didn’t know what she was doing because she was in a kind of twilight sleep.

I thought it sounded just like the sort of drug a man would invent.

From the news that 27% of first-time, low-risk moms in the state of Ohio had cesarean sections in 2008 to the World Health Organization’s findings that elective cesareans are riskier than vaginal birth for both mothers and babies, cesarean sections have been a fairly frequent topic of discussion in the news over the past few days.

While I’m glad that word about the risks of unnecessary c-sections (and of high c-section rates in general) is getting out, I more than a little dismayed by the fact that most of these articles (and the health professionals interviewed in them) engage in some serious (though perhaps unintentional) mother-blaming when it comes to explaining the reasons for the climbing c-section rates throughout the world.

In fact, reading these articles might make it seem as if the c-section rate can be blamed on the ”facts” that we birthing women are all too fat and too old, carry too many babies, are too scared of labor, and are too stuck on the idea of picking our babies’ birth dates.

Don’t believe me?  Just read this report from the Newark Advocate:

Dr. Elizabeth Koffler, an obstetrician at [Licking Memorial Hospital], said the increase in the national rate, which is at 32 percent, has to deal with more women having twins or triplets and maternal obesity.

Women who request a C-section tend to have a fear of labor and also a fear of future complications, Koffler said.

I’ve said it before, and I’ll say it again, but that 27% c-section rate reported by the Ohio Department of Health DOES NOT INCLUDE BREECH BIRTHS, MULTIPLE BIRTHS, REPEAT CESAREANS, OR PRE-TERM BIRTHS. 

So all of those twins and triplets births cannot be blamed for the state’s inordinately high c-section rate.

What’s more, while it may be true that women who request cesarean sections harbor certain fears about complications from a vaginal delivery, maternal-request cesareans (which should not be conflated with elective cesareans in general) only account for an exceedingly small proportion of all c-sections performed in the United States. 

So maternal-request cesareans cannot be blamed for the state’s (or the nation’s) inordinately high c-section rate.

Adding fuel to the mother-blaming fire, a recent MSNBC article on the WHO’s findings on the risks elective cesareans reports that:

In the U.S., where C-sections are at an all-time high of 31 percent, the surgery is often performed on older expectant mothers, during multiple births or simply because patients request it or doctors fear malpractice lawsuits. A government panel warned against elective C-sections in 2006.

Oh, so birthing women are also too old and too sue-happy?  Got it.  Now I know why the nation has such an inordinately (and unhealthily) high c-section rate.

Perhaps you think that my reaction to these articles is more fittingly an overreaction.  Do I really think that the people interviewed for these articles come right out and say that women themselves are to blame for the c-section rate in this country?

What’s more, it shouldn’t go without saying that the article from the Newark Advocate (along with a similarly-themed article in the Mansfield News Journal) does make some worthwhile points about the importance of necessary c-sections, including those performed for “fetal hemorrhaging” or breech birth (with a birth attendant unskilled in breech birth, I might add).  So shouldn’t we be thankful for these necessary c-sections?

And my answers to these questions would be: No, the interviewees don’t directly blame mothers, and yes, we should be extremely thankful for these necessary c-sections.

But.

BUT.

If medical professionals continue to omit and/or neglect to mention the ways in which certain obstetrical practices may also be responsible for the cesarean epidemic in this and other countries, then they are inadvertently (or perhaps blatantly) placing the blame for the c-section rate squarely on the shoulders of birthing women.

And this is simply not the case.

What about failed inductions?

And forced repeat cesareans?

Inordinate standards for adequate labor progression?

The care provider who has a dinner or a golf game or a meeting to attend (which, I hope beyond hope, is just as rare as those maternal-request cesareans that have been blamed for the rising cesarean rate in the past)?

These (and other) problems are also significant contributors to the climbing cesarean rate.

But instead of playing the blame game, I think that it would be far more productive to carefully and critically examine those issues that contribute to unnecessary c-sections and to remedy those issues where possible.

Instead of blaming the rising c-section rate on obese mothers, let’s try examining (and fixing) the ways in which the modern maternity system mistreats obese mothers.

Instead of blaming the c-section rate on high-risk births, let’s look at the birth practices of Miami Valley Hospital in Dayton, OH, which not only specializes in high-risk births but also has the lowest c-section rate in for first-time, low-risk moms in the state of Ohio and has hospital representatives who know that “some hospitals are too quick to do C-sections” and that “there is a lower rate of admission to the neonatology critical care unit due to low rates of respiratory problems … and [that babies are] more likely to successfully breast-feed” after a vaginal birth.

Instead of blaming the 31.8% c-section rate in the US on maternal-request cesareans, let’s look at the ways in which many women are forced to undergo repeat cesareans when they would prefer to attempt a vaginal birth after cesarean.

Instead of insinuating that many women are too old, too big, too small, and too scared to birth their babies vaginally, let’s make sure that our labor inductions are not performed too early and too frequently, thereby leading to a slew of failed inductions and cesarean sections.

Let’s not blame the mothers.  Let’s just fix the system.

Every single one of them.

Whether they’re asking difficult questions or making difficult decisions or planning for their birth or coping beautifully with contractions or showing unimaginable strength in an unexpected birth situation, they continue to astound and inspire me.

And one of my current clients recently did something that makes me so proud that I feel the need to share it here.

J* (my client) is expecting her first child in late spring.  She is very well-informed about childbirth and has chosen to give birth at an in-hospital birth center that offers (and routinely does) water births.  Although she has already toured the birth center, she and her husband made the decision to tour the hospital’s Labor and Delivery Unit as well so that she could get a better sense of what to expect there just in case unforeseen circumstances prevent her from birthing at the birth center.

This is what she wrote to me about her experience during the hospital tour:

So we went on our tour of [the hospital's Labor & Delivery Unit] last night.  We had been to the Birthing Center [tour]which focuses solely on the birthing center but I wanted to check out the rest in case the Birthing Center ends up not being an option for us. 

 

Anyways, we were in the labor and delivery room and one of the husbands asked if “all the horror stories about epidurals are true?”  The nurse said that the epidural is safe but like any intervention there are risks associated with them.  And that was all she said.  So I asked her if they had any information available about the risks associated with epidural use and she said “well the Anesthesiologist would go over it that day.”  SO I replied, “Well the thing is I don’t think I will be able to make an informed decision while in the middle of labor about the benefits and risks of this procedure so it would be nice if there were a way for people to find out the risks associated before hand.”  I was mainly asking for the benefit of the other couples because I know how to find the information and will do the research in advance….I was hoping that helping them find the resources and encouraging them to read up before hand would help them make an informed decision.  Although the other couples may have thought I was a bit nuts – I was asking about intermittent monitoring, freedom of movement during labor, ability to eat and drink at will, and need for IV’s.   The nurse knew i wanted to do [the in-hospital birth center] so she kept saying “well at [the Birth Center] things are different” and I said “I realize this but if I don’t end up in [the Birth Center] I want to know what my options are here.”

 

1. She set a great example by following up on the one father’s particular question which asked about the potential risks and benefits of routine hospital interventions.  In other words, she did not allow an overly general answer about the risks of a major intervention to suffice.  And while some of the parents on the tour may have dismissed her as “one of those natural childbirth freaks,” I would bet that there was at least one parent (and perhaps more) who may have been inspired to ask similar questions or to research their birth options in more detail.
2. She shed light on the issue of informed consent.  As she rightly pointed out, in order to give truly informed consent, one must be apprised of the potential benefits and risks of any suggested or recommended procedure.  And as J also pointed out, active labor is not the best time to weigh the pros and cons of any particular birth intervention.  Thus, her questions were in no way intended to convey the idea that epidurals are “bad.”  Instead, they were intended to convey the idea that not giving women and their partners accurate and thorough information about epidurals is “bad.”
3. In that same vein, J illuminated the fact that it is very difficult to give truly informed consent when one is in the midst of active labor, especially when one is at the point of really wanting an epidural.  (For what it’s worth, even though I had an unmedicated birth, there were a couple of times during my labor where if I hadn’t a) prepared for a natural childbirth, b) had access to some non-pharmeceutical comfort measures to help cope with contractions, and c) known the risks of epidurals ahead of time, I would have likely shouted, “YEAH, YEAH, I DON’T CARE IF THAT EPIDURAL TURNS MY EYEBALLS INTO WALNUTS, JUST GIVE ME THE DRUGS!”)  In other words, in order to best honor the concept of informed consent, one should strive to educate others (and oneself) about the pros and cons of birth interventions before and not during labor.

The March of Dimes has designated November as “Prematurity Awareness Month.”  As part of their campaign to increase awareness about prematurity and its serious risks to newborns, they have called for bloggers to write posts about premature awareness and to publish those posts today, November 17.

Hundreds of bloggers have already written insightful, informative, and moving pieces about prematurity awareness, and many of them have dedicated their posts to those who have been affected by prematurity.

And while some of these bloggers have already touched on the point I am about to make–one that I have addressed briefly in other previous posts–I feel compelled to reiterate one small but important point: namely, that  labor induction and cesarean section performed prior to 39 weeks have been shown to contribute to serious neonatal complications, including (but not limited to) late prematurity and the many problems that accompany it.

In fact, a study published earlier this year in the New England Journal of Medicine concluded that:

As compared with [elective repeat cesarean] births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend <0.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks.

What’s more, a recent article published by MSNBC noted that many hospitals are limiting their birth attendants’ abilities to perform unnecessary inductions prior to 39 weeks because of the extra risks presented to babies (including iatrogenic, or doctor-caused, prematurity).

So if you are planning a repeat cesarean, or if you are considering an induction, and if there are no medical indications for an early c-section or induction, please consider waiting to schedule your baby’s birth until after 39 weeks.  (Or, if possible, consider waiting for labor to begin spontaneously!)

You will do your baby so much good just by waiting those few extra days until s/he is ready to be born.

(To learn more about prematurity in the United States, please visit the March of Dimes’s website.)

And now for a continuation of my responses to the Birthing from Within “wise mother” interview questions, this time applied to my second son’s birth–a hospital VBAC waterbirth.

What helped you most when you gave birth?

My labor support team–my husband, my mother, and my doula–all of whom provided me the right sort of encouragement and comfort and the right amount of space and privacy when I needed it.

My OB/GYN, who is truly what Ina May Gaskin refers to as an MD–a “midwife in disguise.”  Even though he had only met me once before, I knew that he believed not only in my body’s ability to birth my baby but also in birth itself.  It’s no wonder, then, that he supported my waterbirth (and the hospital’s first waterbirth) and used the second stage of my labor as an opportunity to teach the nurse about the benefits of mother-directed pushing.

My mother-to-mother support networks, which included both the women of my local ICAN chapter and the women on the Babycenter VBAC Support Board.  Their invaluable knowledge and inspiring stories and unwavering support accompanied me not only throughout my pregnancy but also throughout my labor.  In fact, I was reading their encouraging messages to me in between contractions while laboring at home!

And finally–and perhaps most importantly–the wealth of knowledge about birth and VBAC that I had gained by the time I felt that first gush of fluid that let me know my baby was coming.  I certainly wasn’t as knowledgeable about birth then as I am now (as a trained and nearly-certified doula), but I did know enough to let me feel absolutely confident in my birthing decisions.  I poured over books and websites on pregnancy and childbirth.  I researched the various risks and benefits associated with VBAC and repeat cesarean.  I hired a doula.  I investigated a multitude of comfort and coping measures for labor.  I read positive birth stories.  I practiced prenatal yoga and hypnobirthing and tried to eat a well-balanced diet (while fitting in a few french fries along the way, of course).

And the more I learned, the less I feared.

And somewhere along the way, the more I learned, the more I enabled myself to experience my birth joyfully, and with trust in myself and in my abilities.

What was your spiritual experience of giving birth?

It was, to be quite honest, shocking.  At least to me.

I’ve never felt quite comfortable discussing my thoughts on God and spirituality with people other than my husband and my very, very close friends.  I am a skeptical, snarky, philosophically-trained egghead who is in no hurry to be the object of proselytizing from believers or of sneering disdain from non-believers.

But.

If there is a God, I’ve never felt closer to her than I did after A’s birth.

For a few crystalline moments after A was born, the rest of the room melted away and it was just me, A, and the entire brilliance and beauty of the world.  And the moment was holy and pure, holier than anything I’ve ever experienced in a church or a synagogue or any other traditional place of worship I’ve attended.

And if there is a God, I hope s/he doesn’t mind me saying this:

Oxytocin is the shit, man. 

If you could do it over again, what would you do the same?

The preparation for his birth–the yoga, the research, the hypnobirthing, the meetings with my doula, the ICAN support meetings, the VBAC support boards–would remain the same, exactly the same.

The progression of my labor–from that gush of amniotic fluid to the gradually intensifying contractions at home to the requiring-all-of-my-focus contractions in the hospital to the wavering and quavering contractions in the water to the moment my baby boy was in my arms–would also remain the same, exactly the same.

And what my labor taught me–the power and confidence that it bequeathed to me–would certainly remain exactly the same.  (I almost wrote in the previous paragraph that I would settle for a couple fewer contractions, or maybe even one or two fewer hours in my labor, but I must admit that each contraction and each hour both took and gave me an added strength that I still carry with me today.  And I wouldn’t want to change that one bit.)

Is there anything you would do differently?

I would have switched to the OB/GYN who attended A’s birth well before I was even pregnant with A.

I would have spared myself the agony of fearing that I would need an unnecessary repeat cesarean, and of fearing that 36 weeks was far too late to change care providers.

I would have spent my entire pregnancy with a group of midwives and a doctor who trusted in birth, who believed in the safety of VBAC, and who did not doubt my ability to birth my baby.

I would have had an empowered prenatal experience in addition to having an empowered birth. 

What do you wish you had known beforehand?

I wish I would have had a better knowledge about “progress” during labor.  I wish that I had liberated my mind from the idea that cervical dilatation is apotheosis of labor progression.

When I arrived at the hospital and discovered that I was “only” 1-2 cm. dilated after laboring for nearly nine hours, I became very discouraged.  In my mind, nine hours of contractions that were now 3-4 minutes apart and that demanded every ounce of my attention should have dilated my cervix much more than a measly 1-2 centimeters.

But what I didn’t know is that those nine hours were certainly not “wasted hours” of contractions.

Because my cervix was almost 100% effaced upon arrival at the hospital.  A far, far cry from the 0% effacement at my prenatal appointment earlier in the week.  Those contractions were thinning out my cervix!

And the baby was now at -1 station instead of -3 station, as he was at my prenatal appointment.  Those nine hours of labor were moving my baby down!

And, from what I can tell, my baby was also rotating from a posterior to an anterior position.  My body was working hard to rotate my baby into an optimal position for birth!

Cervical effacement.  Changes in the station of the baby.  Rotation of the baby.

In my opinion, these forms of progression are just as important and worthy of celebration as cervical dilatation.

So even though the early hours of my labor did not follow the textbook-style “1 centimeter every one-to-two hours” dilatation that most obstetrical care providers refer to when assessing a woman’s progress during labor, this did not mean that my body was dysfunctional or inadequate.

My body was not following a textbook. 

And thankfully, no one tried to force a textbook-style labor upon my body.

Because five hours after I discovered that my cervix was “only” 1-2 cm. dilated, I was holding my baby in my arms.

In one of the early chapters in Birthing From Within, the authors suggest that pregnant women should interview the “wise mothers” in their lives in order to gain a better understanding of the birth experience–to get a peek at other women’s insights into birth, to see how they have coped with the physical and emotional intensity of birthing.  The authors provide a list of questions that women can ask other mothers in their lives, questions asking what helped them most during the birth, what their spiritual experience of birth was, what they would do differently, what they would do the same, what they wish they had known beforehand.

Although I would not go so far as to consider myself a “wise mother” (and all that the term connotes), I do think that my birth experiences imparted some wisdom to me.  Or at least they made me wiser.  And, maybe on some level, the ways in which I was made wiser are worth sharing.

In the context of M’s birth–my first birth, which was an unplanned, pre-labor cesarean section–I answered the Birthing from Within questions as follows:

What helped you most when you gave birth?

Sheer willpower and the uncanny ability to remain cool, calm, and collected on the outside when there’s a storm raging on the inside.

I had planned (oh, those dear, sweet plans) on a spontaneous, drug-free, hypnobirthing-assisted labor.  I had planned on laboring with my husband, my mother, and my mother-in-law by my side.  And by the time I was nearing the end of my pregnancy, I was even excitedly anticipating those first few contractions.

But when a non-stress test revealed variable decelerations into the 60-70 beats-per-minute range, and when an ultrasound also confirmed these decelerations, and when the decelerations not only continued but also worsened during an oxytocin challenge test, my doctor determined that M would probably not tolerate labor well once it started.  So it was decided that M would arrive via cesarean section.

I had four hours from the start of my prenatal appointment to the first incision to get used to the idea that all of my plans for M’s birth were evaporating into the sterility of what was to become my–and his–birth experience.  And the shift in plans wasn’t made any less dramatic by the fact that M’s c-section was, by most stretches of the imagination, a necessary one.

So, as Ani DiFranco once sang, I learned like the trees how to bend, how to sway.

Flexibility.  It’s a mighty good tool to take to the birth of one’s child.

Surprisingly, my doctor even provided one of the most helpful aids in my emotional recovery from the cesarean.

For although he was patronizing and misleading and haughty with me as he tried to talk me into unnecessary repeat cesarean in the 36th week of my second pregnancy, I can still say that I appreciate him for “slowing down” my first son’s birth so that my husband could take pictures as my son was born. 

The doctor moved away the surgical instruments and the surgical team’s hands so that Tim could snap a quick shot of M’s head just as it emerged from my belly.  Just his head, just my belly, nothing else. 

Perhaps a grotesque photograph for some.

But for me, it was and is my one tangible link to M’s birth.  I was numb and paralyzed and scared and sick and anxious when he was born, and I could literally do nothing to actively bring him into the world.  I could not even see him being born.  So to have that photograph–to have that document of the moment of his birth–helped and still helps me to feel a deeper connection to his birth.

And finally: breastfeeding.  Breastfeeding is what helped me the most.  Hands down.

Admittedly, breastfeeding was a struggle in the recovery room.  The spinal medication had worn off.  I was groggy and tired.  My baby had been rooting for my breast while we were still in the operating room, and he didn’t even get to my arms until he was over one hour old.  He was so distraught, and I was in so much pain, that we had trouble getting that first latch.

But we persevered.  (And we persevered for weeks, through cracked nipples and colic and all.)  I told him that if I couldn’t give him the perfect birth, I would give him this.

It was what I could actively, happily, and empoweringly do for him.

And it helped me to become a more active, happy, and empowered mother. 

What was your spiritual experience of giving birth? 

It was a humbling experience.

The change of plans, the awesome flexibility required of me, and the tenacity I needed just to feed my child in those first weeks of physical recovery all humbled me in a powerful way.  It was not the spiritual journey that I had envisioned whenever I imagined M’s birth when I was pregnant, and it took time for me to accept the spiritual journey that had actually occurred.

What’s more, combined with some traumatic events following M’s birth, the circumstances of his arrival into the world contributed to months and months of spiritual bankruptcy (otherwise known as post-partum depression).  I am lucky to have come out of that darkness–to have emerged “on the other side” with my spirit intact.  And stronger.

But M’s birth also set me on the path toward one of the most spiritually powerful experiences of my life–my second son’s birth.  And if it weren’t for what M’s birth taught me–if it weren’t for those dark, cavernous places I had to confront within my soul–I’m not sure that I could have experienced the triumph of A’s birth with the level of depth that I did.  In some strange way, I am eternally grateful for M’s birth for that.

If you could do it over again, what would you do the same?

I would still offer my breast to my baby as soon as he was placed in my arms, and I would still fight just as hard as I did to develop and maintain a good breastfeeding relationship.

And, of course, I would want him to be just as healthy as he was (with 9/9 Apgars) from the moment he emerged from my body.

Is there anything you would do differently?

I would insist upon holding my baby in the operating room.  Skin-to-skin contact.  Earlier breastfeeding.  Just something so that it would not have felt as if they were placing a complete stranger in my arms when I first “met” him in the recovery room.

I would also have hired a doula.  Especially so that she could have stayed with me as my incisions were being repaired in the operating room.  At this point, Tim had gone with M to the nursery, so I was then separated from everyone I loved most in the world.  And there’s nothing like being in an operating room while having your uterus sutured and hearing the OR team make small talk and being separated from the one person with whom you have been as intimate as is humanly possible for the past nine months to make you feel like one of the loneliest people in the world.

I also would have been a better (and snarkier) advocate for myself.  To the pregnant nurse in the operating room who exclaimed to the rest of the surgical team, ”Gosh, I hope that I don’t have to have a c-section,” I would have said, “HELLO.  I am not a slab of meat on the operating table.  I am awake.  I am alive.  And when I woke up this morning, I was also hoping that I didn’t have to have a c-section!” 

Instead, I remained silent.  Afraid to talk, because I was afraid that I would start crying.  And that’s because I was all alone, save for the OR team.

What do you wish you had known beforehand?

I wish I had known that I could have asked to bring M closer to me in the operating room, especially as Tim was holding him.  I wish I had known that I might have been able to offer M the breast sooner after his birth.  That I could have nuzzled him closer, and maybe even had Tim bring him closer to me for some (even minimal) skin-to-skin contact.

In that same respect, I wish I had known that preparing for birth should not involve simply preparing for a vaginal delivery.  I wish I had known that I could make some personal requests for a cesarean section.  That I should have discussed my doctor’s c-section protocol with him and his partners well before M’s birth.

I wish I had known to attend my local ICAN meetings soon after M was born.

But I also wish I had known just how much M’s birth would transform me.  I wish I could go back to myself, as I lay on the table, and whisper in my ear, “This will make you stronger.  And you are already amazingly strong.”

In fact, I think that any woman who brings a child into the world should know this beforehand. 

Whether she has a vaginal birth or a c-section, a drug-free birth or an epidural-assisted birth, a spontaneous labor or an induced birth, a hospital birth or a homebirth, a birth after months of carrying a baby in her womb or a homecoming after months of carrying love for an adopted baby, she is amazingly strong.

I will be neither the first nor the last person to draw comparisons between birth and marathons.

And I will certainly not be the first nor last blogger to address this analogy.

Rixa Freeze at Stand and Deliver, for instance, offers a beautiful and inspiring metaphorical story documenting the physical, mental, and emotional preparation that the story’s character “Ann” undertakes before running a marathon.  It’s the sort of a preparation that leaves her proclaiming, ”I can do it. I am strong. I am ready” as she stretches before the race. 

Just the sorts of affirmations that any birthing woman should be able to say to herself before welcoming her child into the world.

And then the blogger at Raising My Boychick gives a compelling account of both the misogynistic implications of comparing birth to athletics and the potentially empowering implications this comparison could have if the needs and autonomy of birthing women were respected just as much as the needs and autonomy of certain athletes.

Just the sort of respect that birthing women deserve.

But despite the fact that both bloggers (and many others) have pursued the birth/marathon analogy with remarkable depth, critique, and insight, I would like to add my perspective–a doula’s perspective–to the multitude of analyses and musings on this issue.

Because after witnessing my husband complete his first marathon last week, and after watching hundreds of other people sometimes triumphantly, other times agonizingly, and always inspirationally cross the finish line, my “doula’s attention” was drawn immediately to birth–and not necessarily toward how the physical, mental, and emotional work of a marathon is comparable to labor (although I’m sure in many ways it is) but instead toward what good labor support can offer to birthing women.

In the hours after the race, Tim told me how at all the major mile markers–the half-marathon mark, the 18 mile mark, the 26 mile mark (before the last .2 miles) and so on–there were volunteers whose primary job was to cheer on the runners.  And this was even in addition to the loved ones and general public who were there to see their friends and family run.

They’d remind the runners of how far they’d already come.  They’d remind the runners of how far (or how little) they had to go.  They’d share feelings of pride and excitement and awe with, for the most part, complete strangers running past them.  People they neither knew nor would likely see again.

Of course, I’m sure some runners may have “tuned” out the cheers, either with iPods or with their own internalized focus and awareness–that is, the internal tools they used to accomplish their goal.  (Must like hypnobirthing, I might add!)

But I’m also pretty sure their encouragement carried some runners right through those last strenuous miles.

Tim experienced this particularly in those last few tenths of a mile, where the volunteers were strategically placed to exclaim, “The finish line is just right past that hill up there!  Just run over that hill, and you’ll be there!  You can do it!  We’re so proud of you!  Just keep going!”

It’s what I’ve said to a woman in the throes of transition.  Or at least it’s remarkably close to what I’ve said.  (Without the shouting, of course!)

The pride and awe and encouragement is what doulas and other labor support people all over the world offer to women as they give birth.

And as my eyes welled with tears–as I felt the deepest awe and respect not only for my husband and the runners there that day but also for every woman who has welcomed a child into the world, no matter how she has done it–I said:

“Every woman deserves that sort of support during labor.  I want every birthing woman to experience the sort of encouragement and awe and celebration that you and the other runners received today.”

Really.

We deserve it.

You deserve it.

Whether it’s from a partner or a midwife or a nurse or a friend or family member or, yes, a doula, all birthing woman deserve the encouragement and awe and excitement and celebration that I witnessed at that marathon.