Wednesday, September 26, 2007

Making Change in Florida

Got the time to call and make a difference? Let us know if you do!

From ICAN of Orlando:

If you only make one call in the next 24 hours, MAKE THIS CALL!

LOCH HAVEN OB/GYN: 407-303-1444

webmaster@lochhavenobgyn.com
235 E Princeton St - Ste 200
Orlando, FL 32804


Hello Ladies,

We have it on good authority that the doctors at Loch Haven OB/GYN will be having a meeting on Friday to discuss whether they will go back to doing VBACs now that Florida Hospital has lifted their ban. Loch Haven is a major obstetrical group at Florida Hospital. If they start doing VBACs, other OB's might follow.

Please, please, please! Call, write letters, or send emails to them, (or do all 3!). EVEN IF YOU DIDN'T HAVE A C/S, PLEASE HELP OUT! Please let them know that you will support them in their decision to protect a woman's right to choose how to birth. Encourage them, in whatever way moves you, to give women the option of VBAC. It is our hope that if they see that there is a market for VBACs, they will be more likely to go back to supporting them. (If they ask why you care if you didn't have a c/s, just say "Any pregnancy in the future may cause me to have to go under the knife. I want to know this option is available to me." Or something like that.)

**If you were a Loch Haven client in the past, or are now, it would be especially helpful for you to call.** If you avoided them because they wouldn't do a VBAC, please tell them so.

Letters must be in the mail by tomorrow AM to make it by Friday, but that may already be too late. I would recommend calls and emails just because we have so little time. Michelle is posting the letter she is sending, that would be a great starting point if you are not feeling very articulate about the topic at the moment. Make your calls/emails/letters personal, brief, and to the point. And, you could also point out that their own Dr. Hill was once a VBAC supporter, and you are excited for him to be again! Do it now, while you are thinking about it! :-) Call me if you need help!

Thanks Everyone!

Friday, September 14, 2007

Epidurals vs Narcotics. Klein on the Meta-Analysis.

Dr. Klein speaking on the Cochrane meta-analysis of the Epidural vs Narcotics issue.

*in the past, these meta analyses showed a 10% increase in Cxion (his word again..sigh) with epidurals. This one doesn't..hmm.

*Quoting him "It is not the fault of the RCT as a methodology!!! It is the fault of the inclusion in the meta-analysis of studies that ought not to be there - or the studies need to be grouped or stratified according to their settings or approaches so one can know if the results apply to one's own setting."

THIS IS IMPORTANT. Cochrane is trusted, so we don't realize that the data is being SPUN!

*There was an inclusion of one study with a LARGE population that gave their epidurals late in labor, only in active labor. Without Sharma, there is a 4.3 hour increase with epidurals, with Sharma, it's only 1 hour increase (1st stage of labor); cesareans were higher, perineal trauma was higher, infant consequences higher. The book for this is very blurry, so I am hoping that Dr. Klein will forward me his slides so I can actually use this information with real stats.

Throwing the Mother out with the Bathwater

Nope, not my Title. I attended this session at Lamaze with Dr. Michael Klein. I was taking notes on his speech, I bought the CD and I'm still not sure I'm getting all of the nuances, but I wanted to point some things out before time passed...and I'm in an airport at 6:48am.

This session was a talk on Randomized Controlled Studies and how they are misused.
*In a matched cohort of healthy women, one hospital had a 8% cesarean rate, the other a 20% rate (early 1990's...don't we wish that was now!)
Cesarean rates with women having epidurals: 15.4% in the one low hospital and 67.2% in the other. The odds were 3.4x higher. In the low risk hospital, epidurals weren't given until later in labor, typically. The interesting thing is that with women having NO epidural in both hospitals, the cesarean rate was about the same and the women having an epidural in both hospitals, the risk of a cesarean was about the same. Dr Klein states that we don't know that it's causal, but it's a dang good coincidence, eh?

(Janssen P, Klein MC Differences in Institutional Cesarean Rates: The role of Pain Management. J Fam Pract 2001, 50(3) 217-223)

*His research survey also showed some correlation with epidurals and newborn outcomes. The higher the epidural rate, the lower the apgars in newborns and the more newborns in the NICU.
Interestingly, he notes that physicians who spent more time with their patients, even though their patients were in the hospital for a shorter period of time and used epidurals later..had better outcomes.

*universiality cannot be conferred by an RCT, even if done WELL. A small hospital with three doctors ad 1000 births per year is not going to have the same type of situation as a hospital with 30 physicians and 25K births per year. (my numbers, pulled out of my hat.)

More on the Next Blog Entry. :)

Thursday, September 13, 2007

Away.

I'm at work this weekend, hoping to create change. Working to create change. Leaving my family for the priviledge of fighting for our rights. My daughter says "but you're the mommy" when I say I'm just going to work like daddy does all the time. I agree, I'm just the mommy.

But I have three daughters and they stand to lose so much. Their faith in themselves. Their health. Their future fertility. Their choices.
Giving birth in today's climate means that I have to pick one of them to have all of those risks thrown to the wind. And if things continue or they wind up with an obstetrician...their risks go to 1 in 2.

I'm the mommy and if you don't care enough to be doing something, I do. I'm the only one standing between my daughters and that future. Cesareans if necessary, fine, but otherwise, keep your non-evidence based defensive medicine away from my daughters or you will find yourself dealing with me. You may anyway.

Wednesday, September 12, 2007

Autonomy

Autonomy.
Freedom to be able to move, make your own decisions.
How does autonomy play into the cesarean epidemic?
A homebirth midwife in many states is required to practice under a law which requires her to follow protocols established by the medical community standards, many times being excluded (Arizona) from seeing VBAC clients.
A CNM in a hospital setting is required to have her protocols reviewed by her "supervising" OB. In order to do so, she compromises on things that are expendable, many times excluding VBAC's from any care or making VBAC's do a variety of hoops such as continuous EFM (non-evidence based care), induction, refusal to allow a woman to continue past 40 or 41 weeks...the list goes on and on.
A Childbirth Educator has to watch what she says in order to keep her job because she might be encouraging women to ask questions, refuse interventions.
A doula is a private practitioner who can be removed from a hospital or banned from a particular practice's patients.
As Henci Goer reminded me this weekend, one particular individual at the NIH's meeting on Maternal Choice Cesarean stated that he was simply a good soldier doing his job, taking orders.

We are all taking orders from the American College of Obstetrics and Gynecology in a trickle down of morbidity and mortality that will touch generations to come. None of us have our hands clean in this debacle. This is not fear of malpractice, though that makes a nice excuse for obstetricians to bring to the table. "We don't want to get sued." Well, I'm not sure who believes this any longer and if they did... let us ask ourselves:
Are we simply taking orders? Are we the bystanders saying "Oh My God. That woman just died due to an elective induction." (the wife of a local arena football player) or "Her boggy uterus wouldn't come back, so she lost her uterus due to an ERCS." (a mom in New Jersey) or "my baby spent 3 weeks in the NICU for an unnecessary cesarean"...are we simply recounting the tales?
Are we standing in horror, unable to move? Are we the resistance?
Or are we the Germans....crawling back into our homes to hide in case that they next come for us?

Tuesday, September 11, 2007

Activism

I was so excited to learn that the CPM's where I live do VBAC's. They don't just do VBAC's.
Thirty percent of all births in Florida done by CPM's were VBAC's.
And I just put all of them at risk by posting that. I was asked not to publicize or publish it because almost all of them are under review or investigation, either across the board or surreptiously. The climate of fear is palpable and protocols control birth at every level, even if you aren't an OB because the OB's set the standard for protocols with their trade union, ACOG. If you are a homebirth midwife, you will be hunted.

What is truly evil, however, is that other midwives, childbirth educators and moms will hunt you as well. If you do VBAC's, you "put the others at risk." At risk for what? For losing their licenses, for being investigated, for being lied about, for losing the right to attend "normal" women. In other words, they are forced to choose who to support and VBAC mothers are not who they choose, even when they still attend them. VBAC mothers are expected to step back for the "good of the many" and to walk a line of obeisance to all other women and care providers. When an OB states HIS policies, we are supposed to be grateful he even takes VBAC patients. When they state (without evidence) that we should be continually monitored, have epidural catheters placed, or birth in the OR "in case" we should be GRATEFUL. We should be quiet. We should thank our lucky stars that a surgeon is willing to waste his time to come watch by our bedside. Hell, some OB's charge $1000 up front, no insurance, for this priviledge. We aren't allowed in water to help ease the pains of labor and we should be grateful for them taking away this coping mechanism. And others will back them up, too. If we complain too loudly, they might stop doing VBAC's all together! Well, I disagree.

The right to choose a VBAC should have women lined up outside of hospitals protesting. Demanding. The media should be writing about the non-evidence based care and assault on these women, the stealing of their civil rights. Midwives, childbirth educators, doulas, mothers, and OB's should all be agreeing on this. And if they don't, it's simply fear at being caught out of the pack and being taken down. The fact that they are allowing women to BE isolated out of the pack and hunted says so much all ready.

Shut up? Sit down? I don't think so. I'm still writing letters and making calls. I may not change things, but I am tired of women being forced to give birth at home without any trained care or agreeing to care that is cruel and uncalled for in the name of appeasing those with the power or those who shudder in fear.

Distortion of Normal

I wrote this on a late night recently, so I will probably review this post and come back to it. Your thoughts are appreciated.

Lately, I've seen a variety of things that have disturbed me. I've come to call the phenomenon "Distortion of Normal".
For instance: The average size of a newborn infant.
We measure this by comparing all newborns. In fact, we should only be counting newborns who are unmedicated and uninduced, non-cesarean in order to get "real" numbers. But in this day and age, even that number would be distorted. We've come so far into an induction/augmentation culture that most babies are not allowed to reach their potential birth weight nor their potential birth dates. In a world of scheduled birth or scheduled surgery, how do you define the "day most babies are born" or the "average" gestation.
Even a mom choosing an uninduced birth is encouraged to use a variety of methods to "get ready" and hurry the birth along.
Then, to add insult to injury, these numbers are used against mothers who are out of "norm." Full term used to mean 37-42 weeks but now, no mothers are "allowed" to go past 40 or they are over due. Twin and other multiple mothers are reduced to full term at 36 weeks, or less, encouraged to believe that their infants are in fact done.
In less than fifty years, we have so distorted the birth picture with our interference, we have lost our norms. If one out of three babies are being surgically removed, how can we even know how a normal infant responds to birth? We've removed 1/3 of the population, seriously skewing our view.

Monday, September 10, 2007

Your Rates. Your County. What are You Doing?

http://209.217.72.34/VitalStats/ReportFolders/reportFolders.aspx

This is the CDC's Vital Stats page for cesareans. Do you know your county's risk?

My county had 21 VBAC's in 2004. Twenty-one healthy vaginal births after cesarean.
My county had 520 Repeat Cesareans.
If (being conservative) 70% of all trial of labor would result in a VBAC...that means that 364 women were potentially VBAC mothers and only TWENTY-ONE escaped being cut.

And my county has a 34.89% rate of cesarean and a 23.58% for all first time mothers having cesareans.
I'm going to scream now. I want you to hear this as a scream. I want you to hear it as the same visceral sound as if your mother caught you stealing and you are looking in her shocked face as she says "what the hell are you doing?"

WHAT ARE CARE PROVIDERS DOING TO NORMAL WOMEN IF ONE OUT OF FOUR NEW MOTHERS ARE BEING CUT AND MORE THAN ONE OUT OF THREE TOTAL MOTHERS ARE GOING HOME WITH MAJOR ABDOMINAL SURGERY AND LIFELONG COMPLICATIONS!

They are coming in pregnant and going out high risk. What is happening in the process?
The sad part is..this was three years ago. I guess the hospitals are damn lucky the rates aren't kept real-time, huh?

So what is your county doing to women and what are you doing to change it?

Sunday, September 9, 2007

Guess What...there is a Normal....And you get Awards for it!

I've often thought that it was insane to be giving out awards to people for normal things. It's not like they INVENTED it, at best, they've only recognized it or given it a different term for the world to use it. Let's face it, fire was invented a long time ago and the only reason we like those long lighters is because they keep us from getting too close when we light the grill. But cavemen were using long sticks and they were at least biodegradable .

So...Dr James McKenna, the uberdude of co-sleeping and normal infant sleeping behavior stands up at the Lamaze Conference after being given an award and comments on the ridiculousness of receiving an award for the simple acts of a baby simply sleeping with it's mother! I could have hugged him!
Then he does one better.
"The only authority over parents that these professionals have is what the parents choose to give to them."
If only parents believed that and worked with the intuition and assumption that babies deserve to be with their mothers and that parents should be willing to lay down their lives rather than allow the treatment that these so-called professionals of the world regularly and pervasively assault them and their babies with.

The Legacy of a Cxion Baby.

Ok, so why did I write Cxion? or C-xion? Because the speaker this weekend, Dr. Michael Klein, used it in all his research presentations. I'm assuming it was born of his need to abbreviate for studies. I mostly hope this does not catch on in trade publications, however...it seriously looks "too posh to push" kind of media hip.
So back to the Legacy.
Dr. Klein shared that he was born by Cesarean section and I found that to be unique in and of itself. How many children will be leaving legacies born of a generation of surgical births? I'm probably going to update this post several times in the process, but here are some highlights I found from listening to him.

1. He's still a doctor. Medical model/statistical significance, those things matter to him so it's a bit like having a spy on the "inside".
2. His statement on the conflict of interest inherent in "informed consent":
"Counseling over the mode of birth should not be in the hands of those who benefit the most from it."
3. He was explaining some data and compared it to cesarean birth, then changed his wording and stated, "See, even I get caught in that trap. I shouldn't be saying cesarean birth. The term is cesarean section."

High points from the Research commentary:
*He stated that the epidemic of placenta accreta has parallelled the rise in cesarean section.
*He emphasized looking at the totality of the environment when assessing research. You can't transfer the results of an optimal environment with excellent care onto the vast audience of women getting substandard medical care in the United States, just as you can't take a midwifery driven program in Israel and transfer those results onto OB care populations in the US. You will not get results that apply to your life, your environment, your hospital.
*Nulliparas (first time moms) should never be compared to multiparas due to the differences that arise in how birth happens the first time vs subsequent pregnancies. Totally different animals. "You have to be a very bad doctor to screw up multiparas"
*Acknowledgement that nurses are not looking at the mother, but watching the machinery.
*He emphasized using both sides of your brain. You can not take only the left-sided thinking of 'this action equals this outcome' without taking into account the larger picture and impact on a variety of consequences. The global approach is necessary if you don't want to cause more problems than you are trying to prevent.

Refusing to Buy IN to the Myth.

Several times this weekend, the idea has been broached of not buying into the medical model with our language. When I listened to two presenters talk about reframing the conclusions of the studies, it reminded me that how we talk becomes an impacted belief.
It's not simply renormalizing birth (walking in labor is NOT an intervention, it's the NORM biologically for our species) it's also learning how to turn conversations away from defending natural or normal birth and towards proving the assumptions of non-evidence based care.

How do you prove that vaginal birth is normal? How many studies does it take to explain that what happens after an non-interfered (oh isn't this a wishful thought!) with birth is species normal?

ICAN and Childbirth Education

Once you latch on to a worthy cause, you can never be sure if you are honest and unbiased about it.

That's how I feel about ICAN (www.ican-online.org) and VBAC.

However, at a conference like Lamaze, the split was at least fifty/fifty on who knew about ICAN. The International Cesarean Awareness Network has existed for 25 years as a grassroots entity helping mothers prevent cesarean, recover from the surgery, plan for indicated surgeries and promoting VBAC as a healthy, safe way to birth. With 100 chapters in existence, how can so many mainstream educators not be aware of it? What resources are they giving their mothers to deal with the cesarean rate? To deal with the aftermath in a 1 in three society that is in reality 50% in so many places. How are these mothers being supported after a birth goes in that direction? These are questions to be asked because these are the women helping them prepare for birth.

Sign Language as a Part of Birth

At Lamaze International's Conference, there was a unique session on using sign language at hearing births. Much of the information and most of the signs was based on the principles that we all sign and we all should know sign, even basically, to help ourselves communicate with one another and help our babies communicate earlier and well. There was an interesting moment when our instructor had us write down words we wanted to know signs for and the first request was for "how is your scar healing". The room broke up in laughter, that slightly manic release of frustration that says "yeah, I know what you mean". The thing is... I wanted to know that sign and even after the session when I asked, there was some discussion about scar healing but the comments from one woman floored me.
"Oh, that area is numb, you can't feel it."
"Oh YES you can"
"I had a cesarean, I didn't feel any pain on my scar"
Wow. Just wow. How many mothers walk away from the hospital still feeling pain? My roommate at the conference still has pain in her scar THREE YEARS LATER. We can be experts in our own situation with a cesarean, but other mothers out there are feeling more or less than we are and we cannot even begin to express totalities. I resisted the urge to ask her how long ago her surgery was and if she wasn't extrapolating her current reality onto what happened in the first few postpartum weeks.
If it doesn't hurt, why are some cesarean moms hooked on oxycodone?

Blogging from Lamaze.

As previously suspected, childbirth education is not dead. It's alive and well and being graciously attended by vast numbers of caring women. The choir is filled with lovely angels.

So what can we take back from the choir and sing to the masses?

Testing...

...beginnings are interesting. WHO knows what will happen?