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A Lamaze Story

May 31st, 2011 by avatar

[Editor's note:  In this post, Lamaze Certified Chidbirth Educator, Doula and Lactation Consultant Jackie Levine answers the question: "How do you incorporate Best Evidence into your childbirth education program?]

A Perspective on Birth
The quick version of the trip that got us to where we are now is that birth moved from home to hospital.  Ann Oakley, sociologist, nails both the rationale for that move and its results: “…the significance of the hospital lay in the service it could do for the emergent profession of obstetrics.  It facilitated the restriction of competition from female midwives, established the principle of doctor control over client preferences, enabled clinical expertise to be taught to others, and set the stage for the depiction of childbirth as potentially pathological”1.

And Diana Scully, writer on women’s health, makes this breath-taking observation: “Of all professions, medicine has been among the most successful in achieving autonomy and establishing the freedom to work without regulation from outside its own community”2.  It’s not hard to understand that the intense socialization process caused by living inside that “community” for years of medical training shapes the ethics, the values, the very behavior of OBs.  The autonomy of this community allows the continuing use of practices and protocols that by now just about everyone knows are not based on best evidence. In her recent post on Healthy Birth Practice #5 Joni Nichols asks why best-evidence birthing positions are ignored. That’s a powerful word…ignored!

Pinning our hopes for sane and humane birth on it, we expect that, at any moment, best evidence care must surely begin to prevail, and we examine ways to foster and promote it.  But will best-evidence practices really ever begin to outweigh entrenched “opinion-based” care and become the norm? The Six Healthy Birth Practices are based on best-evidence.  The very latest Lamaze Webinar asks the question, ”Does evidence-based research guide your childbirth education?” We breathe the concept of best-evidence care as our oxygen.

And there is some slow improvement in intent, one recent and hopeful bit being the ACOG call “for evidenced-based practice and greater cooperation between obstetrician-gynecologists and certified nurse-midwives/certified midwives”, “recognizing the importance of options and preferences of women in their healthcare”.3 Another positive sign is the recommendation by ACOG that OBs actively include patients in the “planning of health services to reduce risk and improve outcomes” with “shared medical decision-making”.4

But we really can’t wait for the slow grind of the universe of medical planets to align properly, and for textbooks and training and institutions to change. How many hospitals still won’t allow anything but ice chips?  Why should the health and well-being of the individual come second to the entrenched needs of the institution?

Implementing Best Evidence into Childbirth Education
How could I counter the real-life, day-to-day “doctor control over client preferences” in healthy and natural birth? Credibility is the coin of the realm when women demand best–evidence care, and becomes a really perfect tool when paired with a thorough knowledge of one’s legal rights. Since birth is under the jurisdiction of this self-regulated medical community, birthing women must seem to be knowledgeable in “their” way to be recognized as credible. For the time being, then, perhaps we need to give women a different kind of “evidence,” by giving them a look into the medical community.  If women can know more of what goes on inside the profession, if they know a bit of what the docs know, they feel a different level of empowerment.  They feel a gravitas in the unfamiliar and sometimes hostile world of the hospital.  In Amy Romano’s interview on this blog with J.D. Kleinke, he says: “… providers still do what they always did – because that’s how they always did it. The best ways to realize the vision you’re asking about is to stop treating maternity care–all medical care actually–like a folk art, arm all providers with better information… the single best way to make all that happen is to arm pregnant women with the same information… no more excuses for paternalistic decision-making on behalf of passive patients.”

About two years ago, I had a realization about teaching best-evidence care so that it satisfied the needs of the women in my classes in a more powerful way. I teach Lamaze classes to the maternity clients at a Planned Parenthood Center, and they are, in the main, an under-served population. Since I can follow many of them though their births as their doula, I’m aware that they are often treated with less politeness, shall we say, than are private patients. For them, as for many women, the Healthy Birth Practices could be warnings, for example: “Labor begins on its own” becomes “don’t let them induce you!” I couldn’t help but feel that I must somehow keep them from harm.

As we cover each Healthy Birth Practice, I gather every recent study I can find to demonstrate the huge divide between what best science shows, what they can expect in the way of “real-life” care, and in many cases, how practitioners reacted to the science and scientific news. Once I began to give actual studies, piling up the papers, they said that it felt like they were eavesdropping on conversations within the medical community.  It doesn’t matter whether they understand the medical language…very often the titles of studies in themselves are illuminating, and I just highlight the “good parts.”  It’s pretty eye-opening to read a chatty bit of a study about estimating late gestational age that says “Predictions of gestational age that are based on ultrasonography in the third trimester can be off by three weeks or more in each direction”5. Of course, no one ever tells that to the women being sent for sonograms at due date to assess for induction.  And how about the blog post sent out to the profession by an OB recommending that delayed cord clamping should be the standard of care, citing dozens of studies, and wondering why “we have not heeded the literature,” but understanding that one reason OBs just “ignore” the evidence is that the practice was “championed” by midwives.6 Reading this communication has saddened many a class of mine. It made them want to own their births. It made them aware of how much harm can be done to mothers and babies when the culture fosters a prejudice based on ego and insularity and a continuing but profitless battle for turf in the world of birth.

Having access to what the docs themselves see (and ignore) seems to give real ammunition to the mothers I teach.  They have found it super-empowering to know for example, that fetal blood sampling in early labor raises the risk of cesareans, as does continuous monitoring, and that episiotomy for shoulder dystocia is not helpful and should be discontinued, despite its longtime use.  They have a solid way to challenge hospital policies. A little role-play and rehearsal rounds out their skills. Not only do they know that the evidence exists somewhere out there…they see it; they own copies of the studies. They feel trusted with special information that they would never otherwise have access to. In addition to learning to trust their bodies, in addition to knowing how birth works, in addition to practicing comfort measures, they learn about what goes on behind the scenes.  It expands their sense of control and choice.

These women have little in the way of status when it comes to their stay in the hospital, and I have seen them treated in uncaring ways by imperious staff, but I have also seen them able to counter bullying or threats, implied or otherwise, even as they are vulnerable in labor.  They feel confidence in the principle of informed refusal and have amazing natural births.  They ask for and they get what is their right; they ask with tact and finesse from a position of knowledge, and most importantly, with confidence. They engage with the reality of what birth is now. They are tigers.

Posted by:  Jackie Levine, LCCE, FACCE, CD(DONA), CLC

References

1-The Captured Womb, Basil Blackwell Inc., NY, 1986 p.29.

2- Diana Scully Men Who Control women’s Health Houghton Mifflin 1980, p.13

3-Joint Statement of Practice Relations between Obstetrician-Gynecologists and Certified Nurse-Midwives/Certified Midwives,” released April 1.

4-ACOG Recommends Partnering With Patients to Improve Safety, Obstet Gynecol. 2011;117:1247-1249 Extract

5-Amniotic Fluid Spectroscopy Assesses Late Gestational Age http://www.ajog.org/article/S0002-9378(10)000076-1/abstract

6-http://academicobgyn.com2009/12/3delayed-cord-clamping-should-be-standard-practice

7- Episiotomy for Shoulder Dystocia Does Not Reduce Nerve Injury Rates, Am J Obstet Gynecol 2011. : http://bit.ly/kE3Gvq

Uncategorized

Making the Case for VBAC: A Three-Part Interview with Dr. Hélène Vadeboncoeur (3)

May 27th, 2011 by avatar

[Editor's note:  This is Part Three of our in-depth interview with childbirth researcher  Hélène Vadeboncoeur, author of the recently released in English book, Birthing Normally After a Cesarean or Two. To read Parts One and Two, of this interview, go here.]

Science & Sensibility: How much does the issue of VBAC get discussed when a woman is facing a C-section during her present pregnancy/birth?

Hélène: Our society (and several care providers) is biased towards repeat cesareans, which sure has an impact on how it’s talked about. Risks of cesareans are not necessarily talked about as much as the lesser risks of VBACs. Women are asked to sign an informed consent for VBAC, without having the same information about cesareans. And there is a lot of false information circulating, like if the baby is presumably ‘too big’ you can’t have a VBAC, or if you had a cesarean for cephalopelvic disproportion, or for ‘failure to progress’, you can’t either, or if you are expecting twins, if you’re ‘too old’, etc.

Science & Sensibility: Based on your research, can you describe for us the picture of an optimally favorable candidate for VBAC?  Considering this picture of favorability, what barriers is this woman still likely to face in achieving a vaginal birth?

Hélène: It’s possible to estimate the level of risks that individual women wanting a VBAC entails. Research has shown that these factors are the most favorable, from the ‘risk’ point of view:

  • Having had one cesarean (as opposed to 2 or more)
  • An interval of at least 18 to 24 months (ideally 24 months and more) between the moment  the cesarean was done and the VBAC due date
  • Double layer sutures, for the uterine incision
  • Labour starts spontaneously
  • Having already given birth vaginally (before the cesarean)
  • And maybe a uterine scar of at least 2.3 to 2.5 mm in width (research results are contradictory at the moment)

Regarding the chances of completing the VBAC, these factors are most favorable :

  • Being younger than 30 or 35 years old (older women end up having more cesareans)
  • Having had  a cesarean for breech, fetal distress, i-e a reason that has nothing to do with the ‘functioning’ of the uterus
  • Being healthy (some studies show that being diabetic (Type 1), asthmatic, having high blood pressure, being obese*, for instance, lessen the likelihood of completing the VBAC.)
  • Expecting a baby whose estimated weight is under 4 kg.
  • Entering in labour before 41 completed weeks
  • Giving birth with a midwife

There are other factors, listed in Chapter 3 of my book. The barriers even these women are likely to face:

  • Not finding a caregiver that will accept to support her choice of a VBAC, or a hospital.
  • Not being supported by her entourage, because of the atmosphere of fear that surrounds birth in general, and VBAC in particular
  • Her own lack of confidence in her ability to give birth, linked with the increasing and quite generalized lack of confidence that women feel in our society towards their capacity to give birth.

Science & Sensibility: In Chapters 4 and 5 of Birthing Normally after a Cesarean or Two you spend a lot of time discussing the emotional and psychological aspects of planning/achieving a VBAC.  Why is this element so important?

Hélène:

  • Because women’s suffering around having had a cesarean needs to be addressed
  • Because it can be helpful for a woman to advance in the ‘healing’ of her cesarean experience (if need be) before preparing for a VBAC
  • Because a woman that had a cesarean often lacks confidence in her ability to give birth, so the psychological aspects (and mental aspects) of preparing for a VBAC needs to be addressed
  • Because achieving a VBAC can have quite a positive impact on the psychological well-being and self-esteem of a woman, as can have a vaginal birth per se.

Science & Sensibility: The end of each chapter concludes with several “Birth frames”—personal depictions of birth stories that do (and sometimes don’t) include successful VBACs.  Why spend so much time in your book offering these anecdotal experiences?

Hélène:

  • First because I’ve had lots of comments by women on how they love reading birth stories
  • Second because it helps women realize that it’s possible, that other women achieved it
  • Because it’s a form of sharing between women and they learn from each other
  • Because it can validate women’s feelings about their cesarean (reading how others experienced it)
  • Since some quote men (new fathers), it can also help some men realize that it’s possible
  • Because if offers qualitative data, instead of mainly quantitative information
  • Because it helps to balance out the more scientific parts of the book, giving it a more ‘human’ side

Science & Sensibility: Given the history and present circumstances pertaining to VBAC, where do we go from here?  More specifically, what do you envision happening in the coming decade in terms of women achieving vaginal births after cesareans?

Hélène:

  • I hope that the trend we’re in will change, because right now it’s not very encouraging. One woman at a time, let’s hope more and more women will be tempted to have a VBAC, and especially will be supported by caregivers and institutions in preparing for it and in doing it. What is encouraging for me, as a researcher, is that more and more attention has been given in recent years to birth as a normal event, that has many more dimensions than the biomedical one : there is more research on normal birth,  there are more conferences, more research centers in different parts of the world. There is now an Initiative that completes the Baby-Friendly Initiative : the International MotherBaby Childbirth Initiative, centered on the respect of women’s rights during labour and birth, on the physiology of labour and birth, on  evidence-based care, on the importance of non-separation of the mother and her baby, etc.  So this recent focus on the importance of normal birth and on the mother-baby unit adds weight to the importance of VBAC.

Science & Sensibility: What else would you like to share with our readers, not already discussed here?

Hélène:

  • First I would like to point out that for a woman, wanting to give birth herself is something totally valid, and that a woman choosing to have a VBAC is not endangering her baby. It should be an informed choice. It’s, as the NIH VBAC consensus development conference underlines it in its final report, a reasonable option. Giving birth is not only something that can be very empowering and deeply transforming for the woman, it’s something, as science increasingly shows, that benefits the baby too (going through labour prepares him or her to have an easier transition to life outside  of the uterus).
  • Then I would add that giving birth to a baby and being in total and close contact with him or her right from the first seconds after the birth helps the mother and the baby bond together. Increasingly, research also shows the benefits of this first contact that no woman ever forgets. Mother and baby belong together, and what’s happening during labour and birth has an impact on how things are afterwards. Take for instance breastfeeding and bottle-feeding : we now know that although babies can develop normally if bottle-fed, breastfeeding is not the same, and brings to both mother and baby something that bottle-feeding will never be able to give them, including protection against some diseases. For me, the same idea applies to giving birth oneself as opposed to having a cesarean. There is something in the act of giving birth, especially if the environment is supportive, that you can’t experience if you have a cesarean. We’re starting to understand it with the help of science (how hormones are at play during a birth and how they work), and research is beginning to show the possible impact of giving birth on personal growth.

[Thank you to Dr. Hélène Vadeboncoeur for the time she took out of her busy schedule to give us an excellent representation of the ground she covers in her book, Birthing Normally After a Cesarean or Two.  Go here to access the original, French version of the book.]

*Next month, Science & Sensibility will take a close look at the topic of obesity during pregnancy, including an assessment of the studies associating maternal overweight with cesarean delivery and the controversy that surrounds them.

Posted by:  Kimmelin Hull, PA, LCCE

Series: Birthing Normally After a C/S or Two, Uncategorized , , , , ,

Making the Case for VBAC: A Three-Part Interview with Dr. Hélène Vadeboncoeur (2)

May 26th, 2011 by avatar

[Editor's note:  Today presents Part Two of the three-part interview with childbirth researcher  Hélène Vadeboncoeur, author of the recently released in English book, Birthing Normally After a Cesarean or Two. To read Part One of this interview, go here.]

Science & Sensibility: Help us to understand a woman’s chances of undergoing a VBAC, based on where and with whom she chooses to give birth.

Hélène: Let’s say first that most women can give birth vaginally, and that on average, 3 women out of 4 complete a VBAC after they begin labour. True contraindications to VBAC are rare. Having a ‘classical’ incision (its name is misleading, it’s not done very often), i-e a vertical uterine incision done in the upper part of the uterus, is considered as being a contraindication by most medical associations, as is a previous uterine rupture. ACOG also includes extensive transfundal uterine surgery. Factors related to a woman’s chances of undergoing a VBAC have a lot to do with the ‘environment’ in which it’s prepared and done. Finding a doctor or a midwife who is supportive of their choice, finding a place of birth where people are not scared by VBAC, is important (and if all factors are not there, the woman’s determination and support from a doula is crucial), as is giving birth in a place where the physiology of birth is supported, where it’s considered a multi-dimensional event (familial, social, cultural, and, for some, spiritual event). The presence of a doula can be very important, for a woman that previously gave birth by cesarean, because she may lack confidence in her capacities to give birth (notwithstanding the fact that as shown by multiple studies, the presence of a doula has beneficial effects on labour). Statistics also show that a woman’s chances of completing a VBAC increases if her caregiver is a midwife, for instance (up to 97 %).

Science & Sensibility: You attended the March 2010 National Institutes of Health Conference on VBAC.  Do you feel the recommendations coming from that conference were ultimately helpful, or harmful to women interested in achieving a vaginal birth after cesarean?

Hélène: I have mixed feelings about this conference. While it was very good to review the scientific literature on VBAC and related issues, the group of invited experts did not include women who had cesareans/VBAC nor grassroots organizations like ICAN, for instance. Happily though, the conference was open to the public, so individuals and organizations could comment or question what they heard from the invited experts (either in person at the conference or via the Internet). Another element of the conclusions of the final report was their saying that with regards to VBAC and repeat cesarean “benefit for the woman may come at the price of increased risk for the fetus and vice versa.”  I don’t agree with this point of view. Although risks vary for the women, their babies, in vaginal births and in cesareans, it does not make sense to oppose the interests of the mother and of her baby. And a cesarean presents a higher number of risks than a vaginal birth, as Childbirth Connection showed.

The conference was helpful though in the following ways: by pointing out gaps in research, by saying  that, “given the available evidence, TOL (I don’t like that term, ‘trial-of-labor’) is a reasonable option for many pregnant women with a prior low transverse incision” and that one of their major goals is to support pregnant women… to make informed decisions about TOL versus ERCD. They also urged providers to incorporate an evidence-based approach into the decision-making process.

So I would conclude by saying that this conference was more than necessary (it was the first consensus development conference on VBAC), that it helped look at the situation and understand it, but that it did not position itself unequivocally in favor of  VBAC (the position of the earlier consensus conferences in the 80s on cesarean about VBAC was clearer).

Science & Sensibility:  In Chapter Two of your book, you review the risk assessment of various types of childbirth.  With increasing rates of labor induction occurring in many developed nations, can you help our readers understand the comparative risk of uterine rupture for women undergoing labor induction with synthetic oxytocin, with prostaglandin gels and during a VBAC?

Hélène: In my book, I center on VBAC and cesarean. What the research has shown, is that induction presents increased risks for a uterine rupture during VBAC (separation of the uterine incision), especially the use of prostaglandin gels. It seems that oxytocin use is not as risky, as concluded the NIH VBAC Conference (some studies have shown than its use can increase the risk of uterine rupture and others not). And regarding the use of oxytocin for acceleration of labour, it’s not contraindicated but it should at the least be used with caution.

Science & Sensibility: You mention that 90% of cesareans are prompted by controversial indicators for operative surgery.  What are the top three controversial reasons C-sections are performed?

Hélène: The top ? I don’t know. The more frequent ? Maybe.

Dystocia: is a category frequently mentioned as the reason to do a cesarean (failure to progress, cephalopelvic disproportion). It’s quite a vague category (lots has been put under that name), and often the approach to birth in hospitals leads to malfunctioning of labour–like preventing women to move, having them lay in bed on their back, withholding nourishment, breaking the waters or administering oxytocin which leads to a cascade of interventions (contractions more painful, epidural or Demerol, stimulation of labor, continuous monitoring, etc.). Epidurals can also affect labour.

Fetal distress : EFM readings and interpretations are not always right (mistakes), and cesareans are performed without the baby being necessarily in danger

Breech baby : A cesarean is not necessarily better for all babies that are breech, as research in recent years has shown

[Tomorrow, during Part Three of this interview, Dr. Vadeboncoeur discusses informed consent prior to cesarean delivery, in terms of future VBAC, optimal candidacy for achieving a VBAC and the barriers that make it more difficult, as well as the emotional and psychological aspects of vaginal birth after cesarean and more...]

 

Posted by:  Kimmelin Hull, PA, LCCE

Series: Birthing Normally After a C/S or Two, Uncategorized , , , , ,

Making the Case for VBAC: A Three-Part Interview with Dr. Hélène Vadeboncoeur (1)

May 25th, 2011 by avatar

[Editor's note:  For the remainder of this week on Science & Sensibility, we will feature an in-depth, three-part interview with childbirth researcher  Hélène Vadeboncoeur, author of the recently released in English book, Birthing Normally After a Cesarean or Two. You will find the dialogue contained in this interview (and the contents of Vadeboncoeur’s book) both informing to childbirth professionals, as well as to the women we serve.]


Science & Sensibility: Tell us about what inspired you to write this book.

Hélène: I wrote this book to let women who had a cesarean know about the possibility that they could give birth themselves, afterwards. In this era of ever-increasing cesarean rates, and of less and less access to VBAC, it’s important that women know about this possibility so they can ask for it, if they wish to have one. I personally had my first child by cesarean, and the second one was born naturally. These experiences changed my whole life, and led me to work for humanization of childbirth and to get a PhD in order to do research in this area.

Science & Sensibility: Based on your research and experience, what are the compelling reasons we can share with our expectant clients as to why a woman should consider VBAC and why clinicians should support them?

Hélène: Because a VBAC is safer for the woman and it helps the baby adapt to extra-uterine life, lessening the risks for him or her to suffer from respiratory distress (some studies point out a smaller risk of death also for the baby).

Because most women can have their baby vaginally.

Because a VBAC facilitates mother-baby contact right after the birth, facilitating bonding.

Because giving birth can be for the woman an empowering, transformative and fulfilling experience that can have a positive impact on her, on her relationship with her baby, and on the rest of her life.

Science & Sensibility: In the Introduction, you mention this book as being for pregnant women who’ve had a cesarean section before, and for their partners.  Are there other people out there who should read this book as well?

Hélène: I have many times realized that caregivers don’t always have a good knowledge of VBAC, which hampers women’s access to it or desire to have one. Often this lack of information on their part can make them say scary things to pregnant women. I had lots of comments by readers (doctors, nurses, midwives), that health care professionals should also read my book!

Science & Sensibility: In your introductory “birth frame,” you describe your own experiences with both a traumatic cesarean section, as well as a vaginal birth after cesarean.  You depict your efforts to find a consultant (obstetrician) who would, in fact, be willing to attend a VBAC as harrowing.  Why does this type of difficulty so often still exist today for most women seeking a VBAC?

Hélène: Since the middle of the 90s, after a climbing rate of VBAC following two consensus conferences on cesarean (in USA and in Canada), VBAC rates started to decline. There are many reasons that could explain why:

  • One is that inductions became more and more common, in general, and medical milieu were not aware of the increased risks of this intervention for VBAC. More uterine ruptures followed. We had to wait until 2001 before a large-scale study warned about the risks of induction, in particular of the use of prostaglandins (Lydon-Rochelle et al, 2001). Caregivers got scared of VBAC uterine ruptures, without realizing the role of induction in it. And even if induction was seen to be the risk factor, the results of this study (and others) were communicated either by editorials in journals (NEJM) or by newspaper journalists in the following way “VBAC is dangerous.”  Medical associations, who had initially been supportive of VBAC, became more and more cautious in their recommendations. However, the basic risk of VBAC (uterine rupture) has not changed : it’s small, being between 0.2 or 0.6 % (NIH says between 0.3 and 0.7 %).
  • Lawsuits happened following VBAC that did not turn out good.
  • Cesarean is becoming so common that it’s considered a ‘normal’ way to have a baby, and its risks are forgotten or not talked about much.
  • The atmosphere of fear that surrounds childbirth in general has also an impact on VBAC. We all live in this culture of fear : the caregivers, the women, their partners, etc. It’s one of the biggest roadblocks to want – and obtain – a VBAC.
  • Cesareans are seen as ‘perfect care’ or as ‘better for the baby’ (neither of this is necessarily true) and women can be considered selfish because they want to have a VBAC for the sake of it, ‘forgetting’ their baby’s well-being.

Science & Sensibility: Many people believe birth options are only a “big deal” to birthing women and yet, you beautifully included your husband Steven’s memories about the births of your children in this book.  Why was this an integral part of your manuscript?

Hélène: Because when I wrote the first edition of my book, in French, I did it as a woman helping other women who were in the situation I found myself in. So it was natural for me to include my birth stories. And since men experience emotions around the birth of their child, it seemed important to include my husband’s views. Having a baby concerns both, the pregnant women and her partner/husband.

Science & Sensibility: Chapter One begins with a depiction of the current situation surrounding VBAC.  Can you give us a primer on what this looks like?

Hélène: VBAC is now only happening for a small minority of women, because lots of hospitals banned access to it, because caregivers became afraid of it, so did women. It’s a lot more convenient for doctors to do a cesarean than to wait until labor starts… And in a private health care system, it also pays more.

Also, as is summarized at the end of the chapter, “our modern view of childbirth is linked to our deep-seated values, particularly in relation to the emphasis on technology, the control of our lives in every aspect, the avoidance of pain and our frenetic lifestyles, etc.”

[Stay tuned:  In Part Two of this interview, Dr. Vadeboncoeur addresses success and risk assessment associated with VBAC, non-evidence-based reasons for moratoriums on VBAC, the March 2010 NIH Conference on Vaginal Birth After Cesarean and top controversial reasons c-sections are performed.]

Posted by:  Kimmelin Hull, PA, LCCE

Series: Birthing Normally After a C/S or Two , , , ,

Teacher Turned Student: Childbirth Education Class, Week Five

May 22nd, 2011 by avatar

Last week, I attended the final session of one of our local childbirth education classes.  Beyond the hour-for-hour alternate credit I was able to log toward my Lamaze Continuing Education, I learned a heck of a lot along the way.

Last week’s session was broken into two separate parts:  a lengthy (and very good) discussion about breast feeding, and a tour of the hospital’s L&D department.  During the breastfeeding primer, we watched a great video, The Real Deal on Breastfeeding, which featured the expertise of IBCLC, Heather Kelly, as well as real moms discussing their challenges and achievements with breastfeeding.  The hip, thorough and factual video did a great job describing the importance of achieving a good (perfect!) latch, sharing the benefits of breastfeeding for mom and baby, answering common questions and deconstructing certain myths about breastfeeding.  Our class instructor followed the video with more discussion on latch, breastfeeding position, and the importance of getting the latch right “from the very first time.”

On my way home from this last class, I had a chance to visit with a childbirth educator friend of mine.  She asked me the same question that we’ve discussed between the two of us before:  “Do you think the hospital tour is helpful?”  I found myself waffling on the answer—as I felt ‘yes’ and ‘no’ were both legitimate responses.

By the time an expectant mom/couple is attending a labor & delivery department tour, they are most likely within a few weeks of greeting their baby.  They have (in most cases) firmly decided upon their location of labor and birth, as well as the provider (or provider group) with whom they will deliver.  According to Childbirth Connection’s Listening to Mothers I report, 88% of women who took childbirth classes attended them at a hospital, doctors’ of midwives’ office.  It just makes sense, then, when attending class at the same facility in which you will give birth, to head on over to the L&D department and take a look around.

In fact, I still remember quite clearly the hospital tour my husband and I took, while approaching the due date of our first child’s birth.  Similar to the L&D department tour I attended last week, we spent time in a labor and delivery room, ogling at the hospital bed that seemed almost gymnastic in its ability to move this way and that…the mound of pillows available in the fancy cupboards…the requisite birthing ball…the baby warmer, fetal monitor, IV stand and pain medication pump.  The dads were more likely to zero in on the buttons and switches—clearly tempted by the Up & Down buttons on the bed, and the volume controls on the monitor.  During the class I attended this week, we even received a demonstration of the “Star Wars” overhead lighting—surgical spot lights that can be zeroed in on mom’s perineum by a hand-held remote control.

As a first-time-expectant parent, I remember being ushered into the room of a second-time mother who’d given birth the day prior to our group’s tour.  I remember being in awe of her—sitting up in bed nice & comfy, calm and confident, discussing how well her baby’s birth had gone.  I recall making a mental note at that time:  “That’s how I want to look and feel after our baby’s birth.”  My own confidence was boosted.  My sense of calm: heightened.  It prompted me to recollect a birth I had witnessed, as a Physician Assistant student some years before:  a multiparous woman had come in from playing a round of tennis and delivered her baby a few hours later, medication-free and energized—rather than exhausted—from the experience.

During last week’s tour, we spent quite a bit of time in one of our hospital’s larger, fancier L&D rooms. One of the moms in the class—who’d reported a recent up-tick in her Braxton Hicks contractions—was utilized as a sample patient.  Our instructor invited her up onto the hospital bed and hooked her up to the monitor to demonstrate to the rest of the class how the fetal monitor worked and what each tracing represented.  For the next half hour, the woman remained in the bed, monitor beeping away, while the instructor continued to point out various aspects of the room.  I have to admit, it felt a little strange to be talking about a woman’s “freedom” to walk around during her labor—as long as she didn’t go beyond the confines of the L&D unit—while the twelve of us remained static in that singular room.  And, as the instructor admonished the class to “try not to focus too much on the monitor during your labor,” it was awfully hard not to do just that—with one of our classmates at front & center stage, pink & blue belts wrapped around her belly, baby’s heart beat echoing throughout the room.

As we left the L&D unit for the postpartum area, I glanced at the doors leading to the OR.  A computer printer sign was taped up on the door.  “Only ONE support person allowed into the OR with [the birthing woman.]  NO EXCEPTIONS.”  The twinge in my heart could have been heard in the next town over.  Our local birth network has been trying for years to achieve a universal acceptance of doulas into the OR, so that mom (and dad) can receive the continuous emotional support they opted for when signing on with a doula in the first place.  Myself included, several of us have achieved that goal in the past.  And in all circumstances, our presence was not only appreciated by the birthing woman/parents, but by the hospital staff as well.  Mom remained calmer—and not alone, after the baby was born and dad was across the room with his new son or daughter.  (I still recall the last birth I attended in the OR with an extremely anxious mother who demanded that both her husband and I be with her during her surgical delivery.  Silent tears streaming down her face, she continuously sought my eye contact and reassurance that ‘all would be ok.’)  I can’t help but believe that that type of emotional support has real consequences on things like blood pressure, pulse and oxygenation status—markers anesthesiologists are constantly monitoring during a Caesarean section.

The rest of the tour included a stop outside the nursery.  Looking in at the few babes present there, immediate post-birth procedures were reviewed again, with our instructor describing baby’s first bath, Vitamin K & Hep B injections, eventual circumcision & a hearing test and the like.  At some point she informed the class, “we now even allow you to walk around this hallway with your baby, if you want to—just as long as you don’t go past the unit secretaries’ desk at the end of the hall!”  I couldn’t help questioning in my own mind:  why shouldn’t new parents be “allowed” to walk around with their new child(ren)?

I really do think being able to visualize an up-coming event—including specifics of the surrounding atmosphere—is important.  It’s what athletes who subscribe to Sports Psychology practices are supposed to do in the days and hours leading up to an important sporting event.

But, again, I couldn’t help paying attention to the subversive messaging:  the baby warmer in the room was not countered by a discussion about the importance of skin-to-skin contact as being the “optimal” baby warmer.  (Thankfully, SSC was discussed as a beneficial tool in encouraging great breastfeeding from the very beginning.)  The high-tech gadgets in the room exuded a stronger suggestion than that which any previous discussion on normal birth, and comfort and pain-coping methods could completely debunk.

I actually birthed two of my babies at the hospital I toured last week.   Walking into one of the rooms in which I gave birth, brought back both visceral and surreal thoughts and feelings—many of which included my repeated actions to escape the confines of that environment (yes, in renegade fashion and still wearing my own clothing, I snuck outside the hospital doors on several occasions even after having been admitted in active labor—hiking a nearby hill in the August mid-day sun to progress my labor on my own!).  From my highly intervened second birth, my memories were isolated to beeping machines, unnatural lighting and lots, AND LOTS of hours in an uncomfortable bed.

As last week’s tour went on, I found myself hoping the expectant parents in the class would go home that evening and take a tour of their own familiar surroundings:  considering what aspects of their house, their apartment, the street or garden outside their home they would spend time in during the early hours of labor.  I hoped they would consider their kitchen in the same way our class passed by the water station and lollipop containers:  thinking about how they would fuel their bodies during the early hours of labor and in preparation for the marathon ahead.  I hoped they would consider their own beds, bathrooms and living rooms as equally fantastic environments to labor in—delaying their relocation to the hospital as long as possible.  (One couple kept asking about the food situation at the hospital, and why mom was limited to just “clear liquids” once at the hospital.)

Once a person has made an informed decision—such as where and with whom they will birth their baby—then feeling confident in that decision is important.  And if attending a hospital L&D department tour is helpful in that sense of confidence—then I endorse it wholeheartedly.  But I also think it’s ok to continue asking questions—and if those questions lead you to more questions, and your original decision suddenly seems to hold less water than it did before, that’s probably an acceptable process to follow through ‘til its end.

A colleague of mine recently told me of an expectant couple who attended the hospital L&D tour more than once, prior to the birth of their second baby.  It seems, they just really wanted to make sure it was the right setting for them.  I applaud that diligence in decision making.  If only everyone applied that much forethought and consideration to the ‘where and with whom’ pertaining to their up-coming birth experience.

After all, a baby is only born once.

Posted by:  Kimmelin Hull, PA, LCCE

Series: Teacher Turned Student, Uncategorized , ,