Are you gonna eat that?

Nurse (smiling): "You can't eat that."

Laboring mother (smiling): "It's a cracker."

Nurse (not smiling):  "You don't want to hurt your baby."

Laboring mother (smiling even bigger): "A cracker can hurt my baby?"

Nurse (actually frowning):  "Well, you can't eat that."

Ok then.  What's a laboring mother to do?  She's hungry, been in labor for hours, now at the hospital and she wants a cracker (or an apple, a burger, a piece of toast, a candy bar, you name it - she's still pregnant, remember?).

But if her hospital is like thousands of other hospitals in America she has an extremely restricted diet while in active labor (in some hospitals, any labor at all).  She can have artificial flavor, food coloring, artificial sweeteners, sugar, salt, some fruit juices, gelatin (and we all know where that comes from, boiled hooves are ok I guess), water and ice.  She can have it in the form of popsicles, juice (may actually be sugar water), diet soda, Jell-o or broth.  YUM!!  (Actually popsicles can be tasty in labor, but maybe something else sounds good after, say, 36 hours of "orange or grape?").  Did you notice the complete lack of protein in this diet?  Or any other nutrients at all?  What each item on this menu has in common is that you can see through it.  (Actually, you can't.  But hospital officials will say that if you boiled it down or melted it, you could see through it.  Are you following all this?  No protein and you can see through it.  I guess we could add snow to the list.)  

Would you feed this to your baby?  Or how about if you were running a marathon, would this sustain you?   I've had a few marathoners in my birth class or as doula clients.  Do you know what they say? Birth is WAY harder than running a marathon.  And marathoners eat whatever they want, including a lot of protein, simple and complex carbs, etc.  They have to in order to race well and not just lay down and die out there.

So what is going on?   Long long ago a doctor decided that because women in labor were at risk of a cesarean, which under rare conditions might be performed under general anesthesia, they should be treated as surgical patients.  Each and every one.  Even though the vast majority would not be having surgery (especially back then - today 1/3 of women will be having surgery, but we'll come back to that).

What will happen if that poor hungry mom I quoted above actually has to have a cesarean?  Not that unlikely since maternal exhaustion leads to fetal exhaustion, a common cause of cesarean (and I don't know about you, but I get tired when I'm running mile after mile on an empty stomach, especially when someone is jogging right along with me telling me "You can't eat that!").  So mom has to have surgery.  95% of cases will NOT require general.  She has a 5% chance of general.

If she's in the 5%, her anesthesiologist will intubate her (putting a tube down her throat to keep her airway open) JUST IN CASE.  In case of what, you ask?  The very thing that this doctor long long ago was so afraid of - that she would vomit, while out, and breathe the vomit into her lungs, possibly dying.  Death by cracker.  They didn't have intubation back then.  BUT WE DO NOW.  ( I just had surgery (knee) under general, I starved for more than 12 hours before, and guess what they did anyway, that's right - intubate me).

There is a huge problem with the logic that starving a mom in active labor will keep her safe from aspiration anyway (that's the complication).  I was in active labor all of 3 hours with my first baby. No way was the pizza I had for dinner was out of my stomach by the time I went to the hospital. General?  I would have needed intubated anyway.  And no anesthesiologist on the planet is going to risk taking a mother's word for it that she hasn't eaten in 12 hours.  ( I wouldn't - I see moms lie about eating all the time).  So they just intubate everyone who gets general to be safe (and remember it's only 5% of the 30% who even get general).

So why still no food for mom?  I don't have a clue.  It makes no sense.  It's like a triple, double, super, extra fail-safe.  Except that it's not a "safe" at all because starving mom has risks.

Now I'm going to get serious.  Very serious.  Have you ever spent time with a laboring mother who is being starved?  They are cranky. The don't like being out of control.  Sometimes they are downright angry.  Their blood sugar is a mess.  They vomit more.  They cry and scream more.  They need way more pain management (either natural measures or drugs).  Their babies are exposed to more drugs, to more stress, to longer labors.  Mothers and babies get depressed.  They are more likely to have that surgery, just from starving.  They suffer.  I am not a fan of suffering, just to give birth to your baby. Suffering is really obnoxious when there is a perfectly good cracker sitting right there, and there is NO GOOD REASON WHATSOEVER why she can't eat it.  (You might think all of the unpleasantness above is just what labor looks like - I have seen women eat, and women starve - the starving suffer far more, both physically and psychologically).

So, if you are a mom about to have a baby, or someone who is helping a woman do that hard work, what can you do?  

1. Don't have your baby in a hospital.  Birth centers and homebirths have no restrictions whatsoever on what you eat.  They have a much lower cesarean rate and among their cesarean transfers, there is no higher risk of aspiration (obviously women who've been eating through labor).
2. Tell your doctors or nurses you are going to eat whatever you darn well want, and show them the evidence to support your choice.  A doctor or hospital's policy is not the LAW ladies.  If the doctor or nurse tries to pass the buck to the anesthesiologist, ask to speak to her and show her the evidence.  Ask for proof to back their refusal to let you eat.  And if you are not convinced, eat.
3. Eat whatever you want whenever no one's looking.
4. Or starve yourself and hope for the best.

The mom I quoted above did #3.  She ate that cracker as soon as the nurse left, and several more.  She also ate a couple bananas later on and some homemade cookies, with peanut butter, oats and nuts. She had a long labor, first time mom, and she had been vomiting in early labor.  But she stopped as she found her groove, ate something she wanted, and she went on to have a completely natural labor, all on her own power.  Her baby was great throughout the whole labor.

I encourage you to read the evidence and decide for yourself.  Take responsibility for your birth, your baby and your body.

Blog post comparing your risk of aspiration to dying in a plane crash or from complications from an elective cesarean.  (Eating can prevent cesareans).  8X more like to die in plane crash, 900 X more likely to die from a cesarean, than from aspiration from general anesthesia during a cesarean.

WebMD - Researchers Say Eating And Drinking Don't Pose Risk for Delivery

Unnecesarean on British Medical Journal's reassessment of eating during labor

Citizens for Midwifery - great review of the Cochrane Review on eating during labor

Favorite labor foods:

• whole grain cookies
• nut butter
• apples
• grapes
• pears
• yogurt
• smoothies - yogurt, banana, nut butter
• real fruit juice
• turkey
• bananas
• Luna bars
• cheese
• crackers (with or without a frowning nurse)
• and yes, popsicles.  I like orange best.

"Natural Cesareans"

This post is being re-purposed by MCC member, Kimmelin Hull, who initially published the article on Lamaze International’s Science & Sensibility blog site (May 18, 2011).  

Kimmelin Hull was originally trained as a Physician’s Assistant and worked in clinical medicine for 5+ years before turning her attention toward community health education.  She began teaching childbirth preparation classes as a Lamaze instructor in 2005 and took on the role of Lamaze International’s Science & Sensibility blog Community Manager in 2010.  Kimmelin is now pursuing her Master of Public Health~ Maternal & Child Health from University of Minnesota.  Following her program completion, she hopes to work on promotion of family health and well-being by targeting women and mothers.

Introducing….the concept of the “natural” cesarean… I have struggled with whether or not to post on this YouTube video for some time. The title, in and of itself, is aggravating. And I don’t mean from a judgmental standpoint, but simply from a realistic standpoint: cesarean birth—whether positively, clinically indicated or not—is not “natural.” It is an alternative method to birth compared to how nature originally designed it.

I have heard many others refer to the practices described in the video as “gentle cesarean.” This, at least, seems to be a bit more accurate—except for the cutting, pushing, tugging, pulling, suctioning, cauterizing, and externalizing of the uterus that goes on. (In a former career life, I used to surgically assist on cesareans, so I’m pretty familiar with what the procedure looks like.)

A list serve I’m a member of has recently spent a lot of time debating practices that surround cesarean births: should hospital policy allow for placement of baby skin-to-skin with mother directly following birth? Should breastfeeding be allowed in the OR while mom is still being sewn up? Should separation of mom and baby in the minutes and hours be avoided following a C-section in the same way this practice has taken hold in the vaginal birth setting?

Other questions about cesarean birth discussed frequently in my own local birth network include: Should birth plan elements such as low lighting, quiet music and delayed cord clamping be integrated into the C-section setting? Should doulas be allowed into the operating room to provide the emotional support the mother/parents hired her for? (An aside here: the most common argument against allowing doulas into the OR at my local hospital is that, “the OR is too small to have an extra person in there.” Every time I hear this I nearly explode: the OR seems to be large enough to admit medical and nursing students at-will, along with the various OR staff coming and going from the room throughout the procedure. And yet the presence of a doula sitting quietly and still beside the birthing woman/couple seems to take up WAY too much space!)

The “Natural C-Section” video encourages many of the issues discussed above. It follows a second-time-mama into the OR for her second cesarean birth and features obstetrician, anesthesiologist and midwife talking heads who all describe this version of a cesarean birth in a universally positive light. In fact, mood lighting does seem to be implemented. The sterile drape separating mom’s head and the rest of her body is dropped in time for her to see her baby being pulled from the incision in her belly. The doctor holds the baby up, legs spread, so mom and partner can “discover” the baby’s sex on their own, as the OB narrates, “…it’s one of them.” Baby is placed right away, vernix, fluid, blood and all, on mom’s chest. Dad cuts the cord following a delayed cord clamping. In this video, the midwife’s job following the baby’s birth is explained as being focused on facilitating bonding measures like skin-to-skin contact and early breastfeeding, while also assessing baby’s well-being.

Interestingly, the anesthesiologist included in the video describes the birthing woman as ‘awake and participating in her baby’s birth.’ I have a hard time agreeing with his sentiment. While it is certainly preferable for the mother to be awake and aware the moment her baby exits the womb, I’m not sure how much ‘participating’ she is doing when strapped down with 2/3 of her body numb and immobile.

For women who must deliver via cesarean—I can definitely see the appeal in this version of a surgical delivery. It attempts to come up to speed in so many ways. There is no hour-long separation between mom and baby. When mom goes to the PACU (Post Anesthesia Care Unit), so does baby. The midwife in the video even acknowledges the associations between postpartum depression and cesarean rates as well as decreased breastfeeding initiation rates amongst women who have undergone a cesarean birth.  She then goes on to imply that this gentler approach to the C-section might just ameliorate some of this association.

Criticism Against the “Natural Cesarean”
Here is the cause of my hesitation: does this promotional video of the “Natural C-Section” run the risk of making surgical birth look so enticing that the risks of C-section get pushed under the table?

Dr. Andrew Kotaska, an obstetrician in Yellowknife, NT, Canada describes his concern over the “Gentle Cesarean” this way:

“It is admirable to minimize the necessary disruption of normal early maternal- neonatal contact associated with NECESSARY cesarean section. The gentle measures employed will not, however, reduce the maternal risk of amniotic fluid embolism, pulmonary embolism, operative injury, infection, severe hemorrhage, and death - all several times higher with C/S than vaginal birth. They also will not help achieve the neonate's normal immune system activation during labour, perhaps leaving it more vulnerable to autoimmune disease later in life.

“In no way can the "gentle cesarean" be construed as making C/S safer. In the best quality prospective data set on elective C/S, 1/2300 women died. Soft, family-centered window dressing does not change the cold, hard risks; it is important practitioners and women keep this in mind.” (Landon; NEJM 2004)

In the United States, we are struggling against an ever-increasing cesarean rate. Readers of this blog are well-aware of the ~ 33% C-section rate that doesn’t seem to be decreasing any time soon. In an age when we should be working to reduce the C-section rate to somewhere at least close to that which the WHO recommends, the promise of a gentler, naturalish surgical birth could threaten the work many maternity care professionals and normal birth advocates, alike, are doing to properly inform women (and some providers) of the true risks associated with cesarean birth.

On the same list serve I mentioned above, another related thread developed: should we “allow” post-cesarean moms to initiate breastfeeding while still in recovery? The meat of the debate was whether or not women with anesthesia levels up to the nipple line will suffer nipple damage from incorrect infant latches, if they cannot feel the latch. Hospitals apparently have policies on this: when a mother is and is not allowed to nurse her baby, depending on the type of birth they have experienced (and the resultant side effects—such as prolonged numbness). Since when did it become reasonable for maternity care facilities to dictate when a woman is and is not “allowed” to feed her own child? 

This is exactly the type of down-stream effect of surgical birth that
1) likely does not get discussed prior to consenting for a cesarean and
2) is not erased by a gentler approach to the procedure and
3) involves the institution of policies that certainly are not evidence-based.

A Wolf in Sheep’s Clothing
I will never become the person who denies the importance of C-section as an option in a few, particular cases: umbilical cord prolapse, placenta previa, abruptia or accreta to name a few. The cesarean
method of birth was, after all, developed to be a life-saving measure and, to this day, continues to be just that in a handful of circumstances. And when a C-section is truly indicated (but not emergent) then, YES, incorporating gentle, respectful, best-practices elements into the cesarean experience should be done. To me, this should quickly cease to be a point of debate at all. But for the remainder of women who find themselves in the position of contemplating the type of birth they’d like to experience—those who might be considering an elective C-section; those who have had a previous cesarean and are toying with whether or not to go for a VBAC—the promise of a “Natural C-Section” may turn out to be a wolf in sheep’s clothing.

As one participant on the list serve summarized:

“Can we work to make cesareans less common and also kinder--

at the same time?”

Kimmelin can be reached at kimmelin@adozeninvisiblepieces.com

Freedom for Birth

Birth as a Human Right?

On September 20th, Improving Birth National Rally for Change, ICAN of Bozeman, MT and the Montana Childbirth Collective hosted a showing of Freedom for Birth, "a new 60 minute campaigning film that re-frames Human Rights as the most pressing issue in childbirth today."  This film shows how choosing the way in which she births is a fundamental human right for all women, and how this right is routinely violated, all across the world.  The film is amazing and we highly recommend you view it, and show it to others, especially women.  We had a lively and thought-provoking discussion afterward, about birth as a human right (something many of us had not pondered before), about the violations in the film and about birth in our own community.

This got me thinking about what we are doing right - and what still needs improvement - in our own community.  One of MCC's members at the film premiere said "We are so lucky to live here - we have so many choices other women do not have."  Absolutely.  In Bozeman (and surrounding towns) you might choose a homebirth midwife - we have several with great reputations and many many years of experience.  They will attend you in your own home with kindness and compassion and a high level of care.  We have two beautiful birth centers, The Bozeman Birth Center and The Birth Place, each staffed by highly trained, experienced and well-regarded midwives.  Both offer a lovely facility as well as compassionate and safe care.  These are all excellent choices for VBAC moms, or other moms who've had traumatic previous births.  About 10% of families choose either home or center births, the highest in the state, and Montana has the highest rate of out of hospital birth in the country.

Home or center choices here give women the choice of a low to no intervention birth, a family centered birth, a birth where the mother is firmly in control of her experience.  And we know from years of research studies that these are safe choices, the most recent from the Cochrane Review, concluding "Observational studies of increasingly better quality and in different settings suggest that planned home birth in many places can be as safe as planned hospital birth and with less intervention and fewer complications."  Less interventions and fewer complications mean fewer cesareans, less separation of mother and baby, fewer problems with nursing, less tearing of the perineum, less induction, less pain medications and much happier birthing experiences for families.

What are the problems?  Some insurers still won't pay for these choices, or will pay for only some.  Women deserve for their insurance to cover all the choices.  And this makes good sense for society too, as these choices are tremendously cheaper than even natural hospital births (and since they result in so many fewer interventions and complications, they are obviously cheaper than highly interventive births).

Not enough women know that home or birth center births are safe.  Not enough women know that they probably wouldn't need pain medications (like epidurals, which are not available outside of a hospital) if they didn't birth in a hospital.  And not enough women have trust in the birth process to take total responsibility for their births, which one must do to birth out of hospital.

Finally, we have a small choice of hospitals, Bozeman Deaconess, St. Peter's Hospital in Helena (about 1 1/2 hours away), Livingston Community Hospital (1/2 hour away) and St. Vincent's or Billings Clinic, (Billings, 2 hours away).  Most women in Bozeman choose our local hospital.

What are they doing right?  Moving in the right direction - toward a gentler and more patient centered kind of birth.  Bozeman is becoming Baby Friendly, which means a huge step toward better breastfeeding rates and help for mothers who want to breastfeed.  Some mothers are now able to keep their babies with them when they have cesareans and nurse right away, rather than have the newborn and partner whisked off to the nursery for hours.  Mothers who want low intervention births are more likely to be met with encouragement and support.  Doulas are warmly welcomed.  Two nurse midwives are now on staff at Billings Clinic's Bozeman OB practice, offering a level of care more based in midwifery.  Women choosing them would have one of two midwives attend them (instead of one of very many doctors, whomever is on call).  This makes a big difference to many women.  The maternity care nurses are well-trained to help mothers who want a low intervention birth and happy to support that with compassion.  VBACs (although called TOLACs - trial of labor after cesarean) are now "allowed," at least for some mothers.  Women transported from out of hospital births are generally treated kindly and with respect.  There are a number of doctors who are patient and support natural birth and who refrain from intervention.  This is all cause for celebration.

What still needs to be done?

• All mothers who have cesareans need to keep their babies (except the very rare baby who needs intensive neonatal care) for the duration of their surgery and have help latching on right away.  Separation needs to be as close to zero as possible.
• The cesarean rate is too high - the hospital reports a rate at the national average - about 30%.  This is at least 15% too high.
• VBACs need to be openly celebrated and encouraged, not treated as train wreck waiting to happen.  The research just doesn't support this panicked mentality.  VBACs are very safe.
• Far fewer inductions.
• A doctor/patient system that puts the patient first.  Birthing women need to birth with the caregiver they've seen for 9 months, not the stranger who happens to be on call.
• A return of breech births for the majority of those cases.  Again the research supports this as a safe practice (and can help lower the cesarean rate).

Our community can continue to support women's choices about birth, as a human right.  We can all respect the value of mothers by letting them choose what they know is best for their families.  And we can encourage our community hospital to continue taking steps toward improving its care of mothers and babies.