Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Study Finds That Memory of Labor Pain Is Influenced By A Woman’s Childbirth Experience March 30, 2009

A study recently published in the March 2009 issue of BJOG: An International Journal of Obstetrics and Gynaecology has found that for about half of women who give birth, memories of the intensity of labor pain decline over time, for some women, their recollection of pain does not seem to diminish, and for a minority of women, their memory of pain increases with time.

 

I could not access the original study online but I did find an article published by Reuters Health Stories that summarizes the study.

 

As a labor & delivery nurse, I have heard many a time a mom in the throws of her second, third, or forth labor yell out, “I don’t remember it hurting this much last time!!”  It doesn’t matter if “last time” was 18 months ago or 18 years ago, anecdotally I personally have found that women do tend to “forget” the pain of childbirth.  It is interesting that this study did find that for about 50% of women, this is true.

 

But what I found most interesting about this study were the following two things:

 

#1) The study found that a woman’s labor experience (positive vs. negative) was an influential factor. The study found that women who reported labor as a positive experience 2 months after childbirth had the lowest pain scores, and their memory of the intensity of pain had declined by 1 year and 5 years after giving birth.  However, the memory of labor pain did not decline during the observation period for women with a negative overall experience of childbirth.

 

#2) The researchers found that women who had epidural analgesia remembered pain as more intense than women who did not have an epidural, suggestive of these women remembering “peak pain.”

 

Reading this article reminded me of the book Birthing From Within by Pam England, CNM, MA.  In her book, England writes a lot about a woman’s prior labor/birth experience and how much it can affect her future pregnancies and labor/birth experiences…especially the negative ones.  She writes about how important it is for a woman’s birth preparation and prenatal care to not just include learning about tests and birth technologies, but to include talking and exploring a woman’s hopes, secret fears, unresolved grief, self-doubts, and visions of birth.  England’s “Birthing From Within” classes use birth art as one way to achieve these objectives. 

 

Regarding epidurals (and again, anecdotally speaking) there have been many times in my practice as a labor & delivery nurse that an epidural doesn’t provide the mother with the relief she was seeking.  The epidural could be one sided, there could be a “window” of pain, or it could provide no relief at all.  It had always seemed to me that if the epidural never worked or more so if it worked for only a while and then wore off, that the women seemed to have less ability to cope with the pain for a variety of reasons.  In an article for Mothering Magazine entitled Epidurals: risks and concerns for mother and baby author Dr. Sarah J. Buckley MD writes:

 

“Beta-endorphin is the stress hormone that builds up in a natural labor to help the laboring woman to transcend pain. Beta-endorphin is also associated with the altered state of consciousness that is normal in labor. Being “on another planet,” as some describe it, helps the mother-to-be to work instinctively with her body and her baby, often using movement and sounds. Epidurals reduce the laboring woman’s release of beta-endorphin. 

 

Obstetric care providers have assumed that control of pain is the foremost concern of laboring women, and that effective pain relief will ensure a positive birth experience. In fact, there is evidence that the opposite may be true. Several studies have shown that women who use no labor medication are the most satisfied with their birth experience at the time, at six weeks, and at one year after the birth.  In a UK survey of 1,000 women, those who had used epidurals reported the highest levels of pain relief but the lowest levels of satisfaction with the birth, probably because of the higher rates of intervention.”

 

Certainly some food for thought… 

 

Maternity Care In the News: A Breath of Fresh Air in the Berkshires March 28, 2009

I was recently forwarded an article entitled “C-section births fall” published in The Berkshire Eagle (a newspaper based out of Pittsfield, MA) that restored my confidence in good reporting J.  The article begins by citing the cesarean rate statistics for North Adams Regional Hospital in Massachusetts and highlights the fact that they perform significantly fewer c-sections than other hospitals around the state — an average of 18 percent of all births at the hospital compared to the state average of 34 percent. 

 

But what I really like about the article overall is that its tone is positive regarding the midwifery model of care and the whole article is not overly sensationalized just to score a headline.  My favorite quotes include:

 

“I think what is being reflected in our numbers is that we are taking a more ‘midwifery’ approach with our practice then before,” Robin Rivinus, a certified nurse midwife with Northern Berkshire Obstetrics & Gynecology at the hospital, said last week. “It means that we do fewer unnecessary interventions — inductions, Cesarean sections, episiotomies. We treat childbirth as the normal, natural thing that it is. We only step in when it’s medically necessary, which is much better for both the mother and the baby.”

 

And

 

“Recently there have been several high-profile studies done that conclude there is overuse of high-tech interventions,” Rivinus said. “The conclusions have been that all women should be offered a midwifery model, or a ‘back-to-basics’ approach to childbirth, where spontaneous, natural birth is the focus.”

 

An article like this is a breath of fresh air after reading some of the recent garbage that is being reported as “news” recently.  See: Why The Today Show Hurts America (or, Battling The Case Against Breastfeeding) 

 

Thanks Berkshire Eagle J

 

“I Needed to Know My Body Could Do It!”: A VBAC Story March 26, 2009

Last week I had the honor to be a part of one of the most beautiful VBAC (Vaginal Birth After Cesarean) hospital births I have ever witnessed. I would like to share that couple’s story with you today as both a feel-good tale of personal triumph and a story of inspiration for all those moms planning a VBAC out there that might stumble upon my blog. Since this is a blog about “a nurse’s view from the inside” this story is probably much different than any other birth story you might have read from the mother or father’s point of view. But then again, maybe that isn’t so bad! Enjoy!

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It was ten to 11 o’clock am as I walked through the lobby doors of the hospital I work at, rushing towards the elevator so I could punch in on time. As the elevator doors started to close, a hand shoved through the crack, forcing the doors back open. “Please make room!” said the woman, a phlebotomist who works in the hospital, in a shaky voice, “Woman in labor here!!” Following behind was a very pregnant woman, huffing and puffing as she waddled into the elevator, followed by what looked like her husband and her mother. “Don’t touch any buttons!” said the phlebotomist, “We’re going right up to labor & delivery!” Since that was where I was headed too, I smiled at the husband and said, “Don’t worry, you’re here now and she won’t have the baby in your car! I work up on L&D so I’ll show you were to register.” Something told me that if this woman was truly in labor then she would be assigned to me since I was just starting my shift. But she had to “pass” triage first, so after helping the family to the registration desk, I hurried into the locker room to change into my scrubs.

Fifteen minutes later the triage nurse came to the main desk, “I’ve got a term mom, 40 weeks 5 days, who’s five centimeters,” she said, “We’re gonna need to put her in a room…. And she’s a VBAC with a ‘birth plan’.” “I’ll take her!,” I said excitingly, knowing that I have my best days when I can assist a woman through labor, as opposed to getting stuck on the OR team or in the high risk ward running magnesium. (Not that those women don’t need a lot of TLC too, it’s just that I like labor the most!) Birth plans, natural unmedicated labor, and getting my patients out of bed…those are my specialties! I quickly set up the room across the hall as the resident finished the patient’s history and physical in the triage room. Then I quietly knocked on the triage room door and let myself in. The patient, Alyssa*, was standing by the bed, rocking her hips back and forth, as the continuous monitors strapped to her abdomen traced the baby’s heart rate and her contraction pattern. It looked like she was contracting every 3 minutes, and the baby’s heart rate was beautiful and reassuring. Her husband, Jared, was leaning nervously against the wall and her mom, Deb, was sitting quietly in the corner. I could really tell that Alyssa was lost in “Laborland” and I wanted to make the transition to her room as seamless as possible as to not break her rhythm and concentration too much. I quietly introduced myself and with the help of Jared and Deb, moved all of their belongings across the hall as Alyssa waddled behind.

I could tell that Alyssa was coping well with the contractions while standing but a quick glance at her prenatal summary revealed that she was Group B Strep positive and would need IV antibiotics (our hospital’s policy) and hence, and IV. Now I feel that I am pretty skilled at starting IVs, but I have not yet mastered starting an IV with the patient standing and swaying! So in the two minutes between the contractions, I explained to the Alyssa what I needed to do before the admission process was complete: get 5 more minutes of continuous monitoring on the baby (to equal the “20 minute strip” my hospital’s policy requires before we can switch to intermittent auscultation), take a set of vital signs, draw three tubes of blood, start an IV, and ask a few more questions. “Give me 8 minutes sitting on the bed,” I said, “and I can have everything but the interview done. The rest of the admission can be done with you standing up.” “Okay,” she said, “I can do eight minutes.” Eight minutes later the IV was in, antibiotic running, labs drawn and sent, vital signs done, monitors were removed, and the patient was helped out of bed (Phew!! That was close!! J). And it wasn’t a moment too soon because Alyssa was having a lot of back labor and sitting in bed was just making it worse!

Then there was a knock at the door. Here’s how the subsequent conversation went down…

Me: “Who is it?”

Med Student: “It’s just the medical student,” (said as he walked right into the room)

(I hadn’t yet gotten a chance to ask Alyssa if she was okay with medical students so I just kind of looked over at her and Jared and tried to judge their reaction.)

Med Student: “Hi I’m Michael. I have to ask you a few questions.”

(Have? How about “Is it okay if I ask you a few questions? Sheesh!!)

Med Student: “Are you being induced today?” (asked as he stared down at his paper)

Alyssa: “INDUCED! DOES IT LOOK LIKE I AM BEING INDUCED!”

Med Student: “Okaaaaay. Umm, any problems with this pregnancy?”

Jared: “Do you really need to ask these questions right now? The resident already asked her that stuff.”

Med Student: “Umm yeaaaah, I do. There is a lot of repetition but we have to ask again.”

Deb: “Doesn’t her prenatal summary tell you all of that?

Med Student: “Ummmmm….”

Me: “With all do respect, Michael. But I think they are trying to tell you that they do not want any medical students. Or anymore residents for that matter. Okay? So I think we are done here.”

Med Student: “Ummm, what am I supposed to tell the resident?”

Me: “Tell her I said that the next induction that comes in is all yours.”

As the med student left, Jared, Deb, and Alyssa all looked at me simultaneously and said “THANK YOU!” “I don’t think he was getting the hint,” said Jared. “Yeah,” I said, “I figured he needed it spelled out.” In hind sight, I think this was one of the moments that really helped me to bond with this family because after all, I understand how difficult it must be for families to come into the hospital and have to work with a nurse that they have even never met during one of the most intimate experiences of their lives!

I spent the next fifteen minutes finishing up the patient’s admission assessment as quickly as I could. I told Alyssa that if she was having a contraction to just ignore me, and asked Jared to help answer any questions he knew the answers to. (Unfortunately, our hospital’s pre-registration does not include performing an admission assessment and hence, it has to be done on arrival to the hospital. Usually, if a patient comes in for false/early labor a time or two, it gets done then but Alyssa had not been to the hospital her whole pregnancy, which is great, but it meant that I did have to bother her with some silly questions during labor. Kind of a bummer, but with the help of Jared, it went pretty smoothly.) It was during the admission interview that I found out some of the details of Alyssa’s pregnancy and prior cesarean section. Alyssa had an unremarkable health history and a normal, healthy, uncomplicated pregnancy. She was a G2P1, but since her first baby was born by cesarean section, she technically was considered to be a “primip” (healthcare slang a woman who is about to deliver her first baby) regarding a vaginal delivery.

Jared told me that when their son was born two years ago, Alyssa was persuaded into an induction at 39 weeks for “LGA” (a.k.a. large for gestational age, which by the way is NOT recognized as an appropriate indication for induction of labor by ACOG), was first given a few doses of misoprostol to “ripen” the cervix, followed by pitocin to stimulate contractions and continuous external fetal monitoring to monitor those contractions, then given a couple doses of Stadol and eventually an epidural for the pain, followed by artificial rupture of membranes to place a fetal scalp electrode after the epidural dropped Alyssa’s blood pressure and caused a prolonged fetal heart rate (FHR) deceleration, then an intrauterine pressure catheter to assess if the pitocin induced contractions were “adequate”, and eventually a cesarean section after 1 hour of pushing in a back-lying position for “failure to descent & cephalopelvic disproportion (CPD).” Thirty minutes later baby Kevin was born at approximately 2:00am, weighing in at 7lbs, 5 oz.

In my opinion, Alyssa was a victim of the “cascade of interventions.” Many maternity interventions, including elective induction, pain medication, artificial rupture of membranes, epidural anesthesia, back-lying positions for labor or for birth, etc. have unintended effects. Often these effects are new problems that are “solved” with further intervention causing a domino effect that ends up creating yet more problems. This chain of events has been called the “cascade of intervention” and unfortunately often leads to vacuum extraction/ forceps delivery, episiotomies or 3rd or 4th degree tears, and even cesarean section. Many of these women are often also then mislabeled with diagnoses like “CPD,” “failure to progress,” “failure to descent,” and at the end of it all, the obstetricians turn around and say, “Thank God we were in a hospital; look at all the technology we needed! So when will your repeat cesarean be??”

This time, however, things were different. After the birth of their son, Alyssa and Jared started to research more about labor and birth, VBAC, and natural birth. They interviewed and chose a doctor (Dr. Z) that was supportive of natural birth and VBACs, with the statistics to prove it! And here they were now, at my hospital, ready and rearing to go! Alyssa said that for the past few days she had been having contractions “on and off” but that they really started to get going at 8:00 am. When the resident had checked her on admission, her water spontaneously broke during the vaginal exam at 11:15am. It was now 11:45am and Dr. Z’s midwife entered the room. Although it had only been 30 minutes since her last vaginal exam, the midwife decided she would check Alyssa again since she seemed pretty active. And boy was she ever! The midwife’s exam showed that Alyssa had progressed to 7-8 centimeters! “I don’t think I can do this anymore,” Alyssa softly whimpered to the midwife. We all reassured her that she was doing so well and that things were getting more intense for a reason and to stick with it!!

The midwife then offered to help Alyssa into the shower to help alleviate her back pain. Alyssa seemed skeptical at first but we assured her that if it wasn’t helping, that we could get her right back out. So Alyssa agreed and the midwife and I, along with Jared, helped the patient into the shower. What happened for the next hour was one of the most beautiful displays of love, perseverance, hard work, and dedication I have ever witnessed. Alyssa turned her back to us and rested her hands on the grab bar on the shower and her head on the shower wall. Her cadence was this: Between contractions she would sway side to side, as if she was slow dancing. During contractions she would squat up and down, up and down, moaning in a low tone as she carried out her ritual. She just moved with the rhythm of her labor, listening so instinctively to what her baby and her body were telling her to do. Jared used the hand held shower head to spray Alyssa gently with a stream of warm water up and down her body, concentrating mostly on her lower back. I quietly entered the bathroom a few times that hour to check the baby’s heart rate with the portable doptone, trying hard not to disturb Alyssa’s concentration. Mostly, however, the midwife, her mother, and I stayed outside the bathroom door as to give Alyssa & Jared the privacy they needed to facilitate the progress of her labor.

At 12:35pm Alyssa told me that she was starting to feel a strong urge to push. The midwife entered the room and as Alyssa knelt in a hands and knees position in the tub, the midwife checked her cervix. To everyone’s surprise Alyssa only had an anterior lip of cervix left to go (this means she was about 9 ½ centimeters dilated)! After the next contraction, Jared and I helped Alyssa out of the shower to the toilet where we both used warm towels to dry her off. Then Alyssa walked over to the bed, “Can I kneel on my hands and knees?” she asked. “Sure!” we all said in unison, as we helped her up onto the bed. “I feel like I have to push!” Alyssa said convincingly and when the midwife checked her cervix, the anterior lip was gone…Alyssa was fully dilated at 12:45pm, only 1 hour and 55 minutes after arriving at the hospital! “You can start to push anytime,” said the midwife.

One of the best things about being a part of this experience was the fact that it was one of the only times that I have been present at a delivery where that a birth attendant has allowed the mother to use spontaneous or mother-directed pushing, as opposed to directed pushing. I knew that Alyssa was interested in using a variety of pushing positions for the second stage of labor from her birth plan and for the next hour and a half the midwife, Jared, Deb, and I helped Alyssa get into a variety of positions including right/left side lying, squatting, hands and knees, and kneeling.

(Side Note: I would like to digress for a moment to point out how important it is to be physically fit during your pregnancy whether you are planning for a natural birth or not. Many a woman I take care of blindly fills out a “birth plan” they find online where they can click on the boxes for options that sound “good” to them, without actually researching or thinking over what they are writing down. For example, they say that they want to try squatting during labor and birth, but couldn’t even do a squat at the gym pre-pregnancy. Although it is definitely true that a woman can sum up and realize an incredible amount of strength during labor and birth related to not only hormones but also sheer will power, it should also be known that labor is HARD WORK and pushing out a baby is HARD WORK which both require a great deal of physical strength and stamina. This is yet another reason why it is so important to follow a modified exercise plan and eat a healthy well balanced diet rich in protein and omega-3 fatty acids before, during, and even after your pregnancy.) Let’s continue with Alyssa’s story…

What was so amazing was that although there were plenty of times during the labor and pushing phase that Alyssa would doubt her ability to go on (“I can’t do this anymore!” “The baby isn’t moving?” “Is the baby moving?” “I am so tired!”), she never gave up on herself. Each time she made a comment like that, we all took it as a request for more support. And every time we gave her more encouragement, cheers, and reminders of her progress and goals, (“Keep going!”, “You are doing so well!”, “We can see so much more of the baby’s head!”, “She has lots of hair!”, “Just a few pushes more”, “You are so strong, you are going to do this!”, “You can do this!”), she found the ability to keep going! Towards the end of the pushing stage Alyssa was (understandably) exhausted and was pushing in a modified lithotomy position while Jared and I supported both of her legs. Then all of a sudden Alyssa popped up and said (and I quote) “I need GRAVITY! I need to be UP!” as she sat upright into a full squat and pushed her baby’s head out with one gigantic roar! “Whoa, whoa!” the midwife and I said almost simultaneously, “Easy, easy, baby pushes.” “Blow like you are blowing out birthday candles,” I said. The midwife checked for a cord around the neck (which there was none) and cleared the baby’s mouth and nose. And with only a few more “baby pushes” Addison Joy was born at 2:27pm!

The room erupted into cheers of excitement and tears of happiness J! I put the baby skin to skin on mom as I dried her off with warm blankets and cleared her mouth and nose with the bulb suction. A quick palpation of the baby’s cord revealed that her heart rate was nice and strong and she was pinking right up! Jared and Alyssa kept hugging and kissing each other and talking to their new baby girl, “Hi Addison! Hi baby girl! I am so glad to finally meet you!” The midwife waited until the cord stopped pulsating before she cut it (per mom and dad’s birth plan) and checked Alyssa for any tears. Except for some swelling, she only had a small tear on her right labia that didn’t even require any stitches!! We kept mom and baby skin to skin for a full hour after birth and baby Addison nursed almost the whole time. When she was an hour old, I weighed her to satisfy mom’s curiosity and to everyone’s surprise the baby weighed 9 lbs 3 ozs!!! So much for “cephalopelvic disproportion” huh!!

And it was as I handed baby Addison back to Alyssa that she looked up at me and said softly, “I needed to know my body could do it. I knew my body could do it! I really needed this. Thank you.” So as you can imagine, I started to well up. I have never felt so honored to be a part of something so special. What a privilege to have a job where I witness the miracle of birth and the miracle of motherhood every week!

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So let’s recap shall we. Alyssa, after having a cesarean section for her 7 lb 5oz son two years earlier for “CPD” and “failure to descent”, pushed out a 9lb 3oz baby after a 6 hour and 27 minute labor, including 1 hour and 42 minute of mother-directed pushing, without any pain medications or an epidural, monitored by intermittent auscultation, needing not a single stitch to her perineum! Her tools included good and relevant labor & birth preparation, appropriate and helpful family support, sheer strength, determination, and will power. The midwife’s arsenal included extensive knowledge of and experience with natural birth and labor support, a doptone, a trust in birth, and a belief in Alyssa’s ability to do it! No medications, no vacuums, no scalpels, no scissors, and no doubt!

Boy how I love my job sometimes J

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*As always, names and any identifying information have been changed to protect privacy.

For more information on VBAC please visit: International Cesarean Awareness Network and Childbirth Connection

 

Why The Today Show Hurts America (or, Battling The Case Against Breastfeeding) March 18, 2009

The Today Show hurts America.  That’s right.  And while I’m at it, so does Good Morning America, The Early Show, Fox & Friends, and every other American morning “news” and talk show that propagates careless, partial research and half-truths.  And Monday, it got personal. 

 

The American media has been finding itself in a heap of trouble lately.  First it was the political media that failed us by not accurately and truthfully reporting the state of events leading up to the war in Iraq.  Then it was the economic press, failing to appropriately and honestly alert us to the foreseeable consequences to greedy and dishonest deeds on Wall Street and in corporate America.  And now it’s the morning news/talk show circuit (and I use “news” lightly) that is flooding American homes with irresponsible, half-assed, and poorly researched segments that can have a profoundly negative impact on the breastfeeding culture as we know it.

 

Case in point, Monday’s segment titled Is breast-feeding really best?: The case against breastfeeding, hosted by The Today Show’s Natalie Morales, advertised with the tag line, “Some women are questioning whether the health benefits are worth it.”  When I saw this segment and read the “supporting” article on www.today.msnbc.com I honestly started to cry; my entire being was deeply saddened by the potential negative consequences this garbage could have on impressionable gestating and new mothers all over this country.

 

The segment starts by citing the American Academy of Pediatrics recommendation that mothers breastfeed their children exclusively for the first 6 months and continue to breastfeed while introducing solid foods for the first year.  After this, the segment goes downhill fast.   Dr. Nancy Snyderman, NBC’s chief medical editor, continues by apathetically listing an incomplete inventory of the health benefits of breastfeeding for both babies and mothers and then states (and this is a direct quote), “But some challenge the science is not so strong.”  [I will get to that outrageous untruth in just a moment.]

 

Next to speak is Hanna Rosin, a breastfeeding (that’s right) mother of three who recently wrote an article for the current issue of The Atlantic magazine entitled The case against breastfeeding.  Morales prompts Rosin with the statement, “You are not anti-breastfeeding but you do talk about the society pressures.  Explain,” to which Rosin responds, “New moms are really vulnerable.  You go into the doctor’s office, you read the magazines, and they make you feel like you are putting your child in grave danger if you don’t breastfeed them.  And then you read the scientific literature and frankly, there isn’t the solid evidence you would expect to support this.”

 

Let’s take these outrageous statements one at a time shall we! 

 

Bogus Claim #1 I believe Rosin is right when she says that new moms are vulnerable and because of this, I feel like we should be using our resources and energy in this country to increase support for pregnant and postpartum moms instead of going on television and touting why one shouldn’t breastfeed!  In fact, pregnancy is a time when most women find themselves really starting to form a healthy obsession with researching everything they can about pregnancy, birth, and child rearing.  And that is good! We have come a long way from the 1950s when women were given hormone injections to dry up their milk, left alone as their babies were taken from them for hours or days after birth, told that their breasts were either “too big” or “too small” to breastfeed, or worse, that breastfeeding was only for “poor” or “uneducated” women.  It is sad that Rosin does not see how wonderful it is that magazines and physicians are finally on board with reporting on the benefits of breastfeeding and how to be successful at it!  And if those articles make women feel “bad” about choosing not to breastfeed, that doesn’t mean that these articles are bad, it might just mean that these particular women might need more education and support during pregnancy and postpartum.

 

Bogus Claim #2 As far as there not being enough scientific literature supporting the benefits of breastfeeding, how about this: a meta analysis published by the U.S. Department of Health and Human Services (AHRQ) in 2007 entitled “Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries,” which reviewed over 9,000 abstracts, 43 preliminary studies, 43 primary studies on maternal health outcomes, and 29 systematic reviews or meta-analyses that covered approximately 400 individual studies on breastfeeding concluded with the following:

“A history of breastfeeding was associated with a reduction in the risk of acute otitis media, non-specific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma (young children), obesity, type 1 and 2 diabetes, childhood leukemia, sudden infant death syndrome (SIDS), and necrotizing enterocolitis [for the child].  For maternal outcomes, a history of lactation was associated with a reduced risk of type 2 diabetes, breast, and ovarian cancer…Early cessation of breastfeeding or not breastfeeding was associated with an increased risk of maternal postpartum depression.”

An article posted yesterday on Motherwear’s Breastfeeding Blog originally referenced this study and I highly recommend reading the post as it is both informative and extremely well put!  As far as Rosin’s article, she only cites 2, that’s right…two research articles to support her argument that there isn’t enough evidence that “Breast is Best.”

 

 

Bogus Claim #3 The segment continues with Rosin stating, “I feel like many people do feel like they’ve failed, if they can’t breastfeed or have trouble breastfeeding, or if they want to stop breastfeeding.  They just feel like ‘I’m giving my kid poison if I give them formula’, and it really isn’t like that.”  In Rosin’s article she also gaffs at the idea of a “lactation consultant” by writing “(note to the childless: yes, this is an actual profession, and it’s thriving).  

 

What Rosin fails to realize is that lactation consultants are a woman’s ally, not enemy.  Their training and purpose is not to make women feel bad about not being able to or having trouble with breastfeeding, but rather to assist them in anyway so that they can become successful at breastfeeding!  And if after their help a woman still cannot breastfeed (for whatever reason), then at least she can rest assured that gave it her best. Should other mothers now judge this mother?  Of course not!  But that doesn’t mean that the information and support about breastfeeding should not be provided to that mother first!  Rosin alludes to the fact that in this country, women do not have enough postpartum support and yet she degrades one profession that seeks to do just that!  And furthermore I’d like to shout, Hey NBC!!!  How about next time you put together a panel to speak about breastfeeding issues, you include someone who actually is an expert in breastfeeding or breastfeeding education, like a lactation counselor, La Leche League leader, pediatrician, nurse, midwife, or obstetrician, instead of an Otolaryngologist (a head and neck surgeron) who specializes in head and neck cancer.  (That’s right, Dr. Nancy Snyderman is an otolaryngologist).  To me, that’s downright irresponsible journalism. 

 

Bogus Claim #4  Both Snyderman and Rosin stress the inconveniences of breastfeeding throughout the segment as well as pointing out the societal pressures against it.  “If you want to clear a zone of inhibition around your lunch table [at work], breastfeed your baby in public,” squawks Snyderman. By this point in the show, I began to think to myself, what is this segment’s main argument?  Is it that some mothers know the benefits of breastfeeding, but question whether the benefits are worth it to them?  OR Is it that breastfeeding does not offer health advantages for both mother and baby over formula feeding?  I hate to break it to the Today Show, but the former statement, although very saddening, is probably true…but the later statement is just blatantly FALSE! 

 

Is it that mothers should support each other, even if situations beyond their control arise that prevent their ability or shorten the length of time they’re able to breastfeed? OR Is it that formula is just as good as breast milk and therefore breastfeeding isn’t worth the “bother and inconvenience?”  Because again the former statement is true…but the later statement is blatantly FALSE!  Sadly, the Today Show automatically promotes both of the later statements with its sensationalized hooks and trailers for the segment, which were repeated before every commercial break for 30 minutes before the piece aired.  Oh, and by the way Snyderman, formula might not be poison, but I certainly don’t think it is conscientious to go on national television and call it “wonderful” and as healthy of an alternative.”

 

 

Bogus Claim #5  On www.today.msnbc.com, Mike Celizic recaps the segment by writing, “After decades of indoctrination delivered with evangelical fervor, American women have come to take it as an article of faith that if they don’t breast-feed their children, they’ll grow up to be underachievers plagued with health problems and lacking a bond with their mother.”  Oh the drama! (…Give me a break!!)

 

In reality, if an organization or health care provider details and promotes the benefits of breastfeeding it does NOT mean that they are telling women that not breastfeeding their child will result in harm and danger.  It’s about RISK REDUCTION.  The truth is, research supports the belief that breastfeeding might lower your child’s risk for a variety of illnesses and reduce a mother’s risk for things like postpartum hemorrhage and postpartum depression.  That doesn’t mean that every woman who bottle feeds will get postpartum depression and her baby is guaranteed to be plagued with frequent diarrhea and ear infections.  It just helps decrease their risk!

 

Furthermore, when I go to the dentist and the dentist looks at my teeth and says to me, “Have you been flossing twice a day?” and I say “No…” and then he goes over the benefits of flossing and the risks of not flossing, what is wrong about that interaction?  True, I might be a bit embarrassed and feel a bit guilty about not flossing, but that doesn’t mean that the dentist should NOT tell me about the benefits of flossing!  It would be irresponsible of him as a health care provider to not at least make sure I knew all the risks and benefits and then if I still decide that flossing isn’t something that’s “worth the time”, then I have the right to make that decision for myself as an adult.  But throughout her article, time and time again, Rosin writes negatively about providing women with counsel and educational information regarding breastfeeding, NOT just about the unfortunate judgment that some women might face from their peers if they make the decision not breastfeed.  When I ask a patient if she is going to breast or bottle feed during my admission interview as a labor & delivery nurse, and she tells me she is going to bottle feed, it is my responsibility as a health care provider to ask her about her reasons and provide her with educational breastfeeding materials so that I know in the end, if she decides breastfeeding is not for her, it is not because of misinformation, old wives tales, misguided pressures from family, or a lack of education, but because it is just her decision.   

 

Bogus Claim #6 As for the time commitment argument, on the show Rosin stated “…and we all know what a time commitment breastfeeding is… I mean it’s a pretty serious commitment to breastfeed.  It’s not like taking a prenatal vitamin.”  She elaborates on this position in her article by writing, “[Breast-feeding]is a serious time commitment that pretty much guarantees that you will not work in any meaningful way. This is why, when people say that breast-feeding is “free,” I want to hit them with a two-by-four. It’s only free if a woman’s time is worth nothing.” 

 

First I personally know women who work in offices, restaurants, schools, parks, and hospitals, in white collar jobs and blue collar jobs, as doctors, nurses, teachers, farmers, bus drivers, waitresses, and stay-at-home moms, who would like Rosin to know that they believe, as well as myself and many others, that their work IS meaningful.  And if you are a mom who feels differently, who feels “miserable, stressed out, or alienated by nursing, or who feels her marriage is under stress and breast-feeding is making things worse”, then perhaps you are right.  Perhaps you shouldn’t be breastfeeding and perhaps you should also honestly consider obtaining counseling or joining a support group for new mothers because breastfeeding probably isn’t the root of all of your problems.  But for goodness’ sake, for Rosin to go around writing and stating on national television that “the actual health benefits of breast-feeding are surprisingly thin” and that breastfeeding is just “instrument of misery that mostly just keeps women down” [both direct quotes] is untrue, misleading, and hurtful to gestating and new mothers everywhere, both planning and not planning to breastfeed.

 

Second, I would like Rosin to know that MANY healthy practices in life take a time commitment.  Our primary care physicians and cardiologists often tell us Americans about the health benefits of eating a well balanced diet low in saturated fat as well as the benefits of exercising regularly.  Everything we do in our lives to better our health takes time, but that doesn’t mean that our doctors and other health care providers shouldn’t continue to educate people on these healthy practices just because people might feel “guilty” if they don’t do them!  And it also doesn’t mean that if you don’t exercise three times a week and eat a balanced diet that you are guaranteed to die of a heart attack.  It just helps to reduce your risk!

 

In conclusion, the state of maternity care and postpartum support in this country is in a crisis, and if we don’t even have the media reporting good research and promoting healthy living for ourselves and our children, it is only going to continue to get worse.  Shame on NBC for being so irresponsible; it’s one thing for The Atlantic to publish an opinion piece (no matter how outrageous), but it is another thing to put this woman and her bogus research on national television and try to pass it off as news.  The unfortunate thing is that for some people, shows like Today are their only source of news!  As a society, we should be focusing our energy towards making things better for new mothers by using the power of the media for good, like airing segments on breastfeeding/new parent support groups and tools for breastfeeding success or helping to pass legislation that makes appropriate break time, a clean & quiet place to pump, and an adequate place to store milk something that is available to ALL working mothers!  But instead the Today show decided to throw their hands up and agree that things are never going to change by providing unchallenged air time to this sorely misled mother.  And if shows like Today continue to propagate and support such astounding untruths on national television, they are going to continue to hurt America. 

 

Top 10 DOs & DON’Ts of Pooping During Labor & Birth March 15, 2009

On February 8th, 2009 I wrote a post entitled Top Ten Things Women Say/Do During Labor (And trust me… they are totally normal!).  This piece has been the most popular post on my blog yet, which is pretty exciting!  When I originally thought of the piece, I figured that most women would stumble upon it by searching for something like “Things to do in labor” or “Things women say in labor”.  However, upon reviewing the top searches of February/March for this blog, I was surprised to find that they didn’t include those phrases at all!  Instead they all had one simple thing in common: POOP.  That is right… poop! 

 

Here are the top 7 searches for NursingBirth in the last two months:  (Note: The wording is not altered at all…these phrases were actually typed into a search box and searched for!):

 

#1 Pooping in labor

#2 Will I poop while I push?

#3 How many women poop during delivery?

#4 Labor and delivery nurse poop

#5 L&D nurses and bowel movement during delivery

#6 Woman in labor thinks she has to poop

#7 What will happen if I poop during delivery?

 

Since I am a labor & delivery nurse, I am naturally inclined to jump on any opportunity to talk about bodily functions (especially during awkward times like dinner or outings with the in-laws J) and consequently, I have been inspired to write a post about, what seems to be, the number one thing on every pregnant woman’s mind…POOP!

 

So here they are:  The Top 10 DOs & DON’Ts of Pooping During Labor & Birth

 

#1 DON’T forget that life does go on after an embarrassing moment.  How many of you have accidentally passed gas during sex?  You’re all “hot and heavy” with you man (or woman) and you’re both getting into it and then…whoops!  If he/she happened to make a big deal out of it, hopefully you kicked him/her to the curb!  Let’s face it, the people that are closest to us often see us in embarrassing situations at one point or another in our lives: bowing down to the porcelain god after a night of partying, passing gas during lovemaking, runny nosed and hacking up a lung during a bout with the flu, squatting to pee in the woods during an outdoor sporting event etc. etc. etc.  And if those things happened in the company of someone who really loves you, they probably still loved you just as much, or even more, afterwards.  Cuz hey, you’re human!  (By the way, I have personally experienced all of those things so if you are laughing and thinking the same thing…you are not alone!  And for the record, the guy that I passed gas on during sex ended up marrying me this summer so it couldn’t have scared him that much!)

 

#2 DO understand that the vast majority of women poop during the birth of their babies and that this phenomenon is NORMAL.  If you think about it, when your birth attendant tells you to “bear down and push” they are really telling you to “push like you have to poop!”  It is the exact same motion.  And if you do poop, your nurse, midwife, or doctor is usually reassured that you are pushing correctly!!  In fact, the WORST thing you can do is not push right because you are afraid to poop!  I have seen it happen before and it is such a shame because these women just end up pushing for way longer than they should have all because they let their fear of embarrassment overcome them.  As a labor & delivery nurse, I do not keep records of exactly how many women poop during birth (can you imagine pooping statistics!  haha! J) but you can rest assured that it is the VAST MAJORITY of women.  If someone you know tells you they didn’t poop during childbirth they either are: #1) part of the very small minority of women who actually don’t, or #2) just didn’t realize they did.  And to be honest, #2 is way more likely!

 

#3 DON’T invite anyone to be present at your birth that you are not totally and completely comfortable with them seeing you in your most vulnerable and trying moments.  Let’s be honest, even in the closest of relationships not many women are comfortable going to the bathroom and pooping in front of their significant other or family members but it is important to understand that the circumstances of childbirth are way different than just your daily morning bowel movement.  My mother doesn’t prefer to be there when my grandmother is bathing, dressing, and going to the bathroom but when my grandmother broke her arm this past winter and needed surgery, that is exactly what my mother did because she needed her.  And I would do the same thing for my mother as I know she would (and has) done for me!  Passing a bowel movement or gas during labor & birth are normal bodily functions that happen during normal labor (as is burping, throwing up, grunting, groaning, crying, etc).  Labor and birth are NOT spectator sports and you are NOT a “hostess” and therefore if you are going to be too preoccupied with the thought of how embarrassing it will be to poop in front of your mother or sister or best friend, then perhaps you should think more carefully about who you invite to your birth.  Just because a family member loves you and “really wants to be there” at your birth, it doesn’t automatically make them a fitting labor companion.  Remember, excessive worry and fear during labor releases hormones that can physically slow or stop your progress!

 

#4 DO go to the bathroom and empty your bowels (only if you feel the urge) in early labor.  Feeling like you have to “poop” during active labor or transition is almost always the baby putting pressure on your rectum.  Even if you end up passing some stool during the pushing stage, the rectal pressure you were feeling right before was NOT poop, it was the BABY and therefore you would have STILL felt intense rectal pressure even if you had emptied your bowels earlier!  However, if you are in early labor and you feel like you have to poop and you can easily pass stool without straining, then go ahead.  In early labor, it won’t hurt the baby or your cervix.  That being said…

 

#5 DON’T try to go into the bathroom during active labor or transition and “try” to have a bowel movement right before the pushing stage just because you are afraid of pooping during birth.  If you are in active labor/transition and you feel rectal pressure, please know that it is the BABY pressing on your rectum that is giving you that sensation.  Therefore straining to have a bowel movement during this time could at best, worsen your hemorrhoids and at worst, injure your cervix by causing it to swell or tear.  There is an appropriate time to start pushing, and many women tell me it is the best part (because they can actually do something about all that pressure!) but it is only time to push when your birth attendant gives you the okay. 

 

#6 DO make a pact with your labor companions (husband, partner, mother, sister, etc.) to NOT tell you that you are or did poop during your baby’s birth if you happen to be really self conscious about it.  The vast majority of the time the mother doesn’t even know that they did poop because the nurse, midwife, or doctor quickly wiped it away.  Trust me, as a nurse, you see it all the time and if vomit, pee, spit, poop, or blood bothered us, we wouldn’t be nurses, midwives, or doctors!

 

#7 DON’T ask for an enema/accept an enema before or during labor.  Please!  Given enemas to women in labor is an outdated and unnecessary practice.  Birthingnaturally.com writes:

“A substantial portion of women in labor will have bowel movements, whether or not enemas are given,” especially during both early labor and pushing (Mahan and McKay 1983:247). Available evidence indicates that enemas do not in fact decrease the chances of elimination during birth nor the incidence of fecal contamination during labor, whereas they do often cause considerable pain and distress to the laboring mother (Romney and Gordon 1981; Whitley and Mack 1980). Moreover, the expulsion of feces during labor does not seem to increase infection rates: in a study of 274 birthing women randomly assigned to enema or no enema groups, no difference in infection rates was found (Romney 1981), and the risk of neonatal infection was very remote (seven babies from each group showed signs of infection which may or may not have had to do with bowel organisms). Another finding of this study was that the two groups had similar durations of labor, contradicting the notion that enemas shorten labor.”

Also as a side note, please don’t take Immodium AD before labor to “prevent” pooping!  It will at best, not work and at worst, make you constipated.

 

#8 DO remember that your body will probably “cleanse” itself out during “pre-labor”.  After all, mild diarrhea or loose stools can be a sign of “pre” or “early” labor.  And even if you do experience “pre labor diarrhea” you might still poop during delivery and that is okay!

 

#9 DON’T limit your food intake during labor if you are hungry because you are afraid that you will poop (or throw up for that matter).  A runner does not prepare for a marathon by starving themselves and you shouldn’t prepare for birth by starving yourself either.  Both you and your baby need energy to have the endurance for a successful vaginal birth.  If you aren’t hungry, well then that is different, and you should still be encouraged to drink at least 4 oz of water, juice, or Gatorade every hour.  If you are preparing for a normal vaginal delivery, even if you are being induced, you should not have to follow a “clears only” or “nothing by mouth” diet.  Good prenatal nutrition recommends women eat 6 small meals per day with frequent healthy snacks so why should we starve women during labor?  The answer is: we shouldn’t!!

 

If after reading all of the above you are still worried about pooping during delivery, then:

 

#10 DO realize that “WORRY is the WORK of pregnancy!”  In her book Birthing From Within, certified nurse midwife Pam England tells the story about a patient of hers (Hannah) that worried a lot about having a natural birth experience after having had a highly medicalized birth with her first baby.  She writes that Hannah longed to hear her say things like “Don’t worry” and “Everything will be alright” but instead England encouraged her to face her fears.  She instructed Hannah to write down all of her worries and explore each of them with questions like “What, if anything, can you do to prepare for what you are worrying about?” and “If there is nothing you can do to prevent it, how would you like to handle the situation?” 

 

England lists the “Ten Common Worries” of Pregnancy as:

1)      Not being able to stand the pain

2)      Not being able to relax

3)      Feeling rushed, or fear of taking too long

4)      My pelvis not big enough

5)      My cervix won’t open

6)      Lack of privacy

7)      Being judged for making noise

8.)      Being separated from the baby

9)      Having to fight for my wishes to be respected

10)  Having intervention and not knowing if it is necessary or what else to do

 

I would like to add #11:

            11) Fear of pooping in labor/Fear of embarrassment regarding bodily functions

 

In summary, if you are a pregnant mom reading this post, please know you are not alone in your worries!  Please use these next few months, weeks, or days, preparing not only physically, but mentally and emotionally for the amazing journey you are about to embark upon.  Please understand that getting ready for labor doesn’t just mean a tour of the hospital or learning about birth technology/interventions, but also means acknowledging and talking about your worries and fears with people you trust, especially your birth attendant!  No mother can give birth if she feels unsafe, senses danger, or has never explored her fears, even if they seem “trivial.”  Please know that although the thought of it might be “mortifyingly embarrassing,” when you actually are working hard to push out your baby, anyone that really cares about you and loves you will not be bothered by a little poop and most likely, you will not even notice it!  Please know that although birth might be one of the messiest experiences of your life, no amount of fluids, cursing, farting, vomiting, striping naked, howling, crying, peeing, bleeding, or pooping will take away from how honestly empowering, mind blowing, and touching this experience can be for you and your family J.

 

Pregnant In America: A (Brief) Review March 13, 2009

I recently was sent a link to a website that lets you watch the 2008 documentary entitled Pregnant in America: A Nation’s Miscarriage for free.  The catch is that it will only let you watch 72 minutes of the movie, and then it makes you wait an hour to watch the rest (unless you sign up for their program which costs money). So if you don’t mind watching half the movie before dinner and then the other half after dinner, it’s worth it to just wait watch it for free!

 

The synopsis posted on the documentary’s website reads:

 

“Pregnant in America is a motivational and inspirational documentary made by film maker Steve Buonagurio about the birth of his daughter Bella. Shocked by the greed of U.S. hospitals, insurance companies and medical organizations, Steve and his wife Mandy set out to create a natural home birth in a world where everything is anything but natural. The film is as much educational as it is entertaining and prepares excepting parent for their uncertain journey of being pregnant and having their baby.”

 

My overall impression of the movie was good, as it is very empowering to see “ordinary” people (that is, couples who are not already in the birth advocacy community) honestly researching all their options once they become pregnant as opposed to buying into the medicalized culture of fear that so many of us grew up to believe is the only way.  I have been meaning to watch the movie a second time so that I may give it a more thorough review but just haven’t found the time.  Check back soon for an update!

 

My only criticism of the movie is that it seems a bit scatterbrained and “all over the place” at times and when I finished watching the movie, part of me felt like there was no real cohesive message but instead, a bunch of scattered messages throughout.  Other than that I feel it is a documentary worth watching.  I am also interested in hearing all of your impressions too J!  What do you think?!

 

The Scope of Practice for Midwifery in America (or, Why Physicians Are Shaking in Their Boots) March 11, 2009

I recently read an article published on amednews.com (a publication of the American Medical Association) entitled Scope of practice expansions fuel legal battles by Amy Lynn Sorrel. The article reports on the increasing number of physicians and professional medical associations bringing forth court cases against state boards of health on what they refer to as “scope of practice expansions” by a growing number of health care professionals.  Two examples of this phenomenon that are highlighted in the article include the right of nurse anesthetists to provide interventional pain management services to their patients and the right of certified professional midwives to practice independently (as was passed in the State of Missouri in 2007).  If you have 10 minutes, the article is pretty short can be found at the link above.

 

This article immediately caught my eye as the main initiative behind these recent physician led court cases happens to be one of the greatest hurdles that both Direct-Entry Midwives and Certified Nurse Midwives find themselves trying to overcome in many states around this country every day.  This hurdle is played out in a battle waged by physicians to protect their own interests (including the “business” of medicine) by fighting to legally prevent other health care professionals from their right to practice independently and within their scope of practice. 

 

Attorney Timothy Miller, the Federation of State Medical Boards’ senior director of government relations and policy, states in the article that, “There is this overall push by allied health professionals to try to increase their scope of practice, and what’s landing people in the courts is when they actually meander outside of their scope into areas considered the practice of medicine.”  What is particularly frustrating about this statement is that throughout the relatively brief history of modern medicine, it is physicians who have defined the “scope of medicine” which really is just a fancy term for “anything that physicians want complete monopolized control over”.  Talk about job security…if you lobby for legislation to make it illegal for any other healthcare professional to perform any service that you perform as a physician, then every consumer by default has to come to you to receive the service…Cha Ching!

 

Author Sorrel continues by stating the physicians’ side of the story, which is that “in many cases physicians warn that allied professionals are overstepping their bounds without appropriate medical expertise,” and AMA Board of Trustees Chair Joseph M. Heyman, MD states “Nonphysician health care providers serve a vital role on a physician-led health care delivery team but [scope of practice expansions] put patients at risk.”  Not only do these statements skew the facts, but they promote a gross misconception of what these healthcare professionals are actually fighting for. 

 

In truth these allied health professionals are fighting to gain legal support for what they feel they ARE appropriately educated to do and are not just trying to “skip medical school”!  In regards to the fight for the legalization and independent practice of both Direct-Entry and Certified Nurse Midwives, these professions aren’t just fighting for legal support to perform services they have the education, expertise, and authority to do as well and as safe as physicians, they are fighting for the legal support to perform services they have the education, expertise, and authority research has proven they do BETTER and SAFER that physicians (i.e. attending the prenatal care and normal vaginal deliveries of low risk, healthy pregnant women in any venue they see appropriate, including the home, out of hospital birthing center, and hospital.)

 

 

Furthermore calling allied health providers part of “physician-led” health care delivery teams automatically puts them in a subordinate role which is an antiquated and borderline offensive school of thought.  More appropriately, research has found that patients get the best results, both in and out of the hospital, when cared for by an interdisciplinary health care team that combines the expertise and experience of many health care professionals (including nursing, nutrition, physical therapy, complimentary medicine, management, pharmacy, etc.) to attain a more holistic delivery of care.  The physician might be the one writing the final “orders,” but the best patient outcomes are obtained when all member of the team are considered to be professional “equals.” 

 

Len Finnocchio, DrPH, a senior program officer at the California Health Care Foundation states, “These battles are not going away, and the challenge for professions is to accept that we are going to have overlapping scopes in some practices.”  He states, “We should be using every resource to its optimum to provide health care to everyone possible at the lowest cost possible. And it boils down to: If a professional can demonstrate they have the judgment, competence and skill to provide certain services, they should be able to do that.”

 

And in today’s world with today’s economy, who in their right mind can argue with that!?