Thursday, May 30, 2013

What does it take to have an intervention-free birth?

(Laughing at 5cm)

According to a Perinatal Services BC report, in the first quarter of 2013 almost 1 in 3 (31.7%) women in BC gave birth by cesarean section, and 1 in 5 women (20.1%) were induced. These are the highest rates of cesarean and induced deliveries ever recorded in BC and it forces me to reflect on how things have changed over the past 26 years.

I just re-read the Statistics Canada paper (1996) "Declining Cesarean Rates: A Continuing Trend?" and felt a twinge of nostalgia. Take a look at the study. The cesarean rate in BC during my first year as a doula (1987) was 21.9%, and a few years later in 1992 and 1993 the rate was declining! At that time, there was hope that the overall cesarean rate would continue to drop, with the goal of reaching the World Health Organization's recommended "medically warranted" cesarean rate of 10-15%. One local study (Janssen, Klein and Soolsma, 2001) found that Burnaby Hospital had a cesarean rate of 10.3% in 1995, which was appreciably less than the BC Women's Hospital rate of 22.9% (less than half an hour's drive away). They concluded that "Differences in use of epidural analgesia may contribute to differences in institutional rates of cesarean delivery. Use of epidural analgesia may be related to use of ambulation, consistency of caregiver during labor, availability of epidural, and suggestion for its use by caregivers." What does this mean for birthing women? It means, as more recent studies suggest, that inductions and epidurals – technology that have become more and more common throughout my years of doula practice – are influencing the rising cesarean rate.

But why are inductions and epidurals more common now than two decades ago? What has shifted in the past 26 years in the general population? I'm currently working on compiling and analyzing the statistics for my first 1000 clients and it looks as though their intervention rates have been consistent over time. Just to give you a snapshot of recent births, of my 18 clients in the first quarter of 2013, the cesarean rate was 5.5% (1), the induction rate was 11.1% (2), and the rate of epidural use was 22% (4). Here’s what happened:
    • The lone client who gave birth by cesarean was over 40 and had been induced at 40 weeks. (Have you heard of the 40 at 40 trend? What are your thoughts?)
    • The second induced client had prolonged ruptured membranes and gave birth without any other interventions - almost birthing her baby in the bathroom!
    • Two of the four epidurals were planned in advance, due to non-pregnancy-related medical conditions.
    • Among other clients who used analgesia, one woman was given a shot of morphine and gravol (and gave birth without complications or any other medications) and two women used nitrous oxide gas after reaching 8cm dilation (and while remaining mobile).

Without an induction or epidural, how did 78% (14/18) of my clients manage the power of their labour? Are my stats low because my clients are highly motivated to avoid interventions? Do they all deliver at home or with midwifery care? Do they avoid cultural messages that describe birth as risky and dangerous?

Maybe the women in 2013 are totally different than in the 1980s. Twenty-six years ago, the average age of birthing women was much lower than today. So are the high cesarean, epidural, and induction rates in BC related to the increase in older first-time mothers? That could be true. But, the majority of my clients are well over age 30, with 22% over age 40. So that idea doesn't explain the low intervention rates among my clients (though I’m going to explore the influence of age and other potential sociodemographic confounders in my case series analysis).

And, yes, my clients would all love to avoid a cesarean. But, those who are planning a home birth are the first to acknowledge that they don't know what their body or their baby will need on the "birth day." My client can be motivated and keep calm, but if her baby is in face presentation or if her placenta is lying over the cervix, there’s no choice in the matter. Her only option is a cesarean. The baby and body like to play the wild card.

And while many of my clients plan a home delivery with midwives, I work equally as often with clients cared for by physicians. We can try to make the hospital environment as homelike and undisturbed as possible, but when there is only one available birthing room and 5 women in the assessment room, and all the nitrous oxide tanks in the hospital are empty... you will be disturbed, your labour will be disturbed, and your probability of having a cesarean will increase! (Yes, that scene was played out the other day at BC Women's.)  Each statistic has a real woman's story within it. 

All my clients hear friends and family say, "Get an epidural!" at some point during pregnancy.  They have all heard other women recount horror stories (why must we do that???). And many have daily phone calls from those near and dear to them who inadvertently undermine their confidence. "Why would you think YOU could birth without drugs? I didn't.  Just book your cesarean!" Women’s motivation can be severely impacted by the daily onslaught of negative images.

But in trying to understand why my clients’ intervention rates are so low, there's one piece of the statistical puzzle that really compels me.  The average dilation upon admittance at hospital for the epidural and no-epidural groups. The two women who had unplanned epidurals arrived at hospital at an average of 3.5cm.  Those 14 who didn't have epidurals comprised of 7 successful homebirths (71% were having their first baby), and 7 hospital births (average arrival dilation upon arrival was 7cm). Does arriving at the hospital later in labour make a difference?

Now, I can't conclude that arrival at hospital at 7cm will never result in the need for an epidural or a cesarean.  But, it certainly increases your chances of having a smooth, intervention free birth if you arrive at hospital in active labour. Every client and their partner who birthed without an epidural or cesarean said that, if I hadn't been with them at home, they would have driven to the hospital hours and hours earlier.  Many women said their advanced dilation gave them incredible confidence - "I couldn't believe I was 9cm when I arrived! When I heard that number, I knew I could do it!"

So, my thought is that, taken together, these approaches account for my low epidural, induction, and cesarean rates: a positive attitude, low stress, low disturbance levels, late arrival at the hospital (as long as the woman is in contact with her caregiver, who is supportive of the plan), great support, as well as many other low-tech options – movement (walking, dancing, swaying, spiraling, lunging), position changes, water (shower, tub), sound (singing, toning, talking, music) as well as continuous physical and emotional support (from me and their partner and team). All of my clients who used those tools went on to have spontaneous "slow and simple" vaginal births. 

- Jacquie Munro

Wednesday, May 29, 2013

Texting: Trends in Doula Life

One more thing...she now officially hates being on her back. She will sleep so peacefully 
on us then the second we put her down she goes nuts. :) Oh the questions.
That is just one of the text messages that I've received this week. Day or night, weekday or weekend (as my husband will attest!) the messages flow in from clients who are pregnant, newly birthed, or even facing their first nursing strike at 6 months!

I quickly reply by text, which releases a flurry of iPhone alert sounds. Um...I'd better phone her.  My husband and I are good at taking long walks arm in arm, communicating by hand signals, while I'm calming a client on the phone. Forty-five minutes later, I hang up, confident that we have covered all of today's fears (at 41+ weeks, with no baby in sight, there's a lot to cover!) (p.s. She went into spontaneous labour the next day!)

Each morning, I check in with my clients who have just given birth. Many times, it's an opening move of an hour long phone chat.  Other times, my text "How was your night?" or "How's breastfeeding going today?" results in these responses from new mamas...
Breast feeding is pretty good, working on getting a better and more productive latch but overall she feeds great. She is already above her birth weight! (mama at 3 days)
Had a phenomenal night. 3 feeds each 3 hrs apart and she went straight back to sleep. It was bliss. (mama at 6 days)
She seems inconcolable at night she will feed well at 10 then sleep three hours then one hour naps I'm exhaused (mama at 13 days)

Some women need to see their midwife, family doctor, or lactation consultant, or they might need the name of a good postpartum doula service. Which one above do you think needed a referral? But most women just need to hear me say "I hear you".  Jacquie pep talks are famous!
 You've breastfed successfully before. Confidence (even if you fake it) is key, because your baby is a sponge for feelings. If you're calm, she'll be calm. If you're freaking out...well... (Day 1)
Trust your instincts and keep her skin to skin and nursing as much as humanly possible today and tonight. (Day 2) 
Anticipate another mega feeding (aka breastfeeding bootcamp) night. Try to beat 12 feeds in 24 hours then your milk should be in tomorrow. (Day 3)
Just a reminder that no baby will self-wean before 18 months. Anything that appears like rejection is probably a short-lived nursing strike. Is he teething? Please call me. (7 months)
But it's not just the women who send me text messages.  The dads, the partners, the grandmothers, the midwives, the lactation consultants and the family docs - they all check in. Because this is a team effort!
Hopefully she will feel good about the experience and her decision making. (Family doctor after a birth)
Sounds like still early labour but progressing... (snippet of long family doctor update about a client at home)
Or I will send an update to the client's caregiver (with their permission):
She's thrilled that something is happening. We had a good walk. I came home for dinner. I'll check in with her in a bit. I hope it's tonight! (41 weeks, and baby was born before breakfast.)
When one physician heard that I connect with postpartum clients and caregivers by text, he said, "I like to go the old-fashioned way and meet them face to face." Oh, absolutely! I agree that face to face is best, but is it practical on a daily basis? Does it meet the clients' needs? When a breastfeeding mama is curled up on a sofa and wants to know if she can bath her baby, is it really best to bundle up the baby into a carseat and take a trip across town for a 5 minute doctor visit?

Many postpartum questions do not require a medical visit. Sometimes, just a woman to woman (aka doula) chat is needed. Often, postpartum women just need me to say, "It's a crazy ride, but it's normal!" Face to face is best, but I can also offer an immediate virtual hug via text before popping over for a home visit. Or if my answer to their question is, "I don't know the answer myself, but I know who does," I can recommend that the woman calls her caregiver to make an appointment. One of the reasons why midwifery care is so exemplary is that, in BC, midwives provide multiple postpartum home visits.   And the family practice doctors here are always waiting for a call. My text and phone messages (and Facetime chats) bridge the gap between my clients' visits with their caregivers (and myself)...and boy, do my clients appreciate that!

Wednesday, May 22, 2013

Conversations with babies

I was at a home birth many years ago. The new mother had nursed the baby, and was just drying off after showering (and chatting to her husband about what had just happened!), while I was quietly tidying the bedroom. As the parents came out of the bathroom, shining and clean, the midwife approached the baby, who was lying in a moses basket. With the parents' permission, the midwife was going to do the newborn exam. She leaned close to the baby, and said something like..."Hello - I'm Patti. I'd like to pick you up and weigh you and measure you." She waited a moment, then gently picked up the baby. Each movement during the newborn exam was preceded by an explanation of what she was doing. She moved slowly. She held the baby respectfully. "Babies are not fragile, but they are vulnerable," she explained to the new dad, as she moved her finger along the baby's spine. The baby was engaged, focused on Patti's words. The baby was content to be weighed and measured by these calm hands, washed by calm words.

I had always spoken to my own babies and clients' babies as people, as equals, but what Patti was doing took it to another level. "I'm going to put a diaper on you now (pause)..." She provided ample time for the baby to take in her request and respond. She was asking the baby to be a partner in a conversation, right from birth. She was also modeling a wonderful slow parenting method which the parents then continued with their baby as he grew.

When Jack and Finn were newborns, I didn't want to interrupt their time with their mum and dad by holding them too much (unless a parent had been "touched out" and needed a quiet moment in the bathroom!). Before picking one up, I would tell him what I was going to do and pause for a (then silent) response. I still go through a day with the boys, telling them what will happen next, what we've just done, and how our day will flow. The rhythm helps them to make sense of their world, and shows that we respect their need to understand the world. They are active, and now very vocal, participants in the conversation. "We'll go to grandmama's house, and then she will give us scones!" How we parent our babies at birth flows through the toddler, then preschool, then school years. Everything is connected.

Montessori teachers have practiced this for a long time. Michael Olaf says, "Gentle handling from birth on also builds trust in the world. Talk to the child gently, explaining what you are doing as you dress and change him. Provide soft clothing, peace, and soft lights, in the first days as the child is getting used to the world outside the womb. We can learn to listen to the sounds a baby makes, to watch quietly, observe, see what the child is trying to tell us, and to get to know this unique human, giving the message that the child is cherished and the world is a safe place." 

Rudolf Steiner stated that a newborn is a "sense-organ" (she is a sponge for touch and sound and movement and taste). Parents should pay close attention to the sensual input surrounding their newborn, limiting their time outside in loud traffic or having noisy toys in the first years. Babies take some time to "come into their body", so our words and movements and their environment should be respectful and calm. I especially love Rahima Baldwin's book, "You are Your Child's First Teacher", which points to practical ways to bring this gentle Waldorf approach into your home.  It was only after about two years that Jack and Finn were able to process the overwhelming sensory input of a crowded space. Slow and quiet outdoor green spaces were more their style, and we respected and honoured their needs by keeping the pace slow for a few years. 

Magda Gerber, one of the founders of RIE, the new "hot" (and slow parenting) approach, said “We not only respect babies, we demonstrate our respect every time we interact with them. Respecting a child means treating even the youngest infant as a unique human being, not as an object.”   Talking to our babies about what will happen next helps them to feel safe in the world, and helps parents develop a sense of rhythm.  Describing what you will do next, calmly and slowly, will also ensure that you remain connected with your baby, and reminds you to slow down. You don't need swings or bouncers or extra props. With the RIE approach, a lot of pressure is taken off the parent.  You can let the baby lie on the floor watching a sunbeam or the geometric line of a table leg. You can slow down and see the world from your baby's perspective. This is the start of child-led learning. For more info on the basics of RIE, take a look at Janet Lansbury's blog and see if her posts resonate with you. 

Explore the ideas in the Waldorf, Attachment Parenting, Montessori, RIE and Slow parenting approaches and see what makes sense to you and your family.  Each will offer you some great parenting tools...and, to quote one client, "There are some ideas that I just want to throw a book at!"  Take what you like and throw a book at the rest.

Through these conversations with your baby, you will start to develop your own family philosophy, "the big picture", that will lead you through all the years of parenting. Our own slow family philosophy includes a lot of "Cs". I see us as caring for our children, with conversation, connection, consideration and consistency. Our children do not belong to us, they belong to themselves, but we're in this together.  What's your family's philosophy? Or are you still pregnant and waiting to hear what your baby says?

Respect for our child's autonomy starts with our first conversation. "Here's my breast. This side is the appetizer. The next side is the entree. I think you're going to like it!" Wait...listen with your heart...and your baby will answer.

Saturday, May 18, 2013

The Lumineers playing...

A woman spiraling
a partner drawing
a woman in the shower
a cat watching
a doula holding
a fan blowing
a strong woman
a boy crying
a midwife whispering
a bird singing
a grandma helping
a boy in the rain
a lost cat
a push
a pant
a baby at home!

(Photo courtesy of dad Chad Smith. Extra love always to mum Carie. Love to midwives Gillian and Carolyn and Patti. Hugs to grandma Smith and big brother Bruce, the boy in the rain...and the cats. And kisses to bonny Alice.)

Friday, May 10, 2013

Cascade of interventions in first-time mothers with term births who experienced labour

Today, the report "Listening to Mothers III: Pregnancy and Birth" was released. I saw that the data suggested that the highest percentage of cesareans came from the induction group. Their chart is below:

I looked at my own data from the past 12 months (N=30) for first-time mothers at term who experienced labour (so gone are the multip births, the scheduled cesareans for placenta previa, the premature births, etc.) Of the 87% of clients who did not have an induction, there were NO cesareans. Of the 13% of clients who had inductions, 100% of them had epidurals and 50% of those women had cesareans. Overall, of the 30 clients who fit the criteria (two were at home), the epidural rate was 40% and the overall cesarean rate was 13%. The numbers are small, but they still closely mirror the large study. Interesting stuff.

I will publish my complete stats for the past few years soon, and will tease out some more of the interesting results, including VBACs (I believe the past year's VBAC success rate was 100%), home birth stats, and more.


"I see someone has been food shopping!"

“I see someone has been food shopping!”

One little sentence spoken by one little boy,
In an epic pose,
Hand on hip,
Peering into my fridge.

We just looked at each other
Eyes shining
And we laughed!

It was a simple statement.

At three years old, Finn knows that his Dagum (Grandad) and I (Deecy) keep quite an empty fridge. We tend to do European-style daily shopping for our meals - whatever we can carry home in baskets or on my bike. We eat very well. He was just genuinely surprised to see that we’d filled the fridge before he (and Jack, of course) arrived for a sleepover.

But, what if an adult had said that to me? Would those words have been interpreted as a comment on my (lack of) organizational skills? If I had just announced a pregnancy, or embarked on a postpartum weight loss challenge, think of the potential impact. My confidence would have been shaken. I might even remember the comment for a lifetime.

“Does she think I bought the wrong stuff? Is she going to critique me on my fruit purchases? Do I have too much dairy? Too much carbs? I shouldn’t be eating meat…or maybe I should? So glad she didn’t open the freezer! She just eats nuts and seeds.”

Yes, Finn’s innocent comment started me thinking about how much we read into what other people say to us, especially when we are pregnant. “What was she implying when she said that?” “Was he judging me?” The resulting guilt and loss of confidence can really shake us to the core.

I still remember the sleepless nights spent thinking about my weight gain (or lack thereof) and eating habits (or urges) during my pregnancies, just as clearly as if it was yesterday.

At 16 weeks in my first pregnancy, I had a nutritional consultation at our local health unit. I’d had to record my food intake for a week.  “Not enough cheese, I see,” said the nutritionist, shaking her head. “Not enough crackers. You’ll have to add more snacks throughout the day – cheese and crackers.” She looked me in the eye. I’m sure she would have been fine if I ate something different, but I spent the rest of my pregnancy scouting out different cheeses and something other than Carr’s water biscuits.

I had an obstetrician (for no particular reason). At 35 weeks, he said, “Let’s see if you’ve grown this week.” Yes, there were italics in his voice. All I could think was, “Didn’t I grow last week? What’s with the emphasis?” I went home and worried. At 38 weeks, I was sent for an ultrasound "for suspected IUGR"...growth RETARDATION???, and told to expect a baby under six pounds at birth, and told to eat more.

At 40 weeks, I stood on the scale so the nurse could weigh me. I had gained fifteen pounds in a week! “Oh, my!” said the nurse. “You’ve been eating some good meals this week!” I looked down, shocked, but then I started laughing. I was holding heavy shopping bags in each hand! It wasn’t until I was home that I felt the true absurdity of the situation. If I had been able to weigh myself (or even been given the right to NOT be weighed) like an autonomous healthy adult, I certainly wouldn’t be recalling this event 26 years later!

No one ever asked about our food habits. No one knew that we rode our bikes to Granville Island to buy our food, cooked wonderful meals, and grew our own summer vegetables.

Just to let you know…at birth, my daughter was a happy chunky 8.5 pounds…cheese or no cheese.

In contrast, during my second pregnancy, I was in charge of my chart. I wrote down my weight (if I liked) and checked my urine myself before each prenatal visit.  I was treated as an adult. I was trusted. We talked about nutrition, sharing recipes and ideas and laughing about the comedy of pregnancy. No judgment. No pronouncements. All the comments were positive. “Oh, what a bonny baby!” didn’t make me worry that I was eating the wrong food. It filled me with pride and confidence. I’d made a bonny baby! The experienced hands palpating my uterus belonged to Sheena Mavis. She described my pelvis as “cavernous,” so I could easily imagine birthing my baby (who, after a joyful labour, turned out to be a slippery 9.5 pounds).

What astonishes me is that my clients still describe similar critiques of their weight gain or food intake.  “It makes me feel like a child,” said one client recently. “I can’t even be trusted to weigh myself or eat properly. I have a CSA and my caregiver has no clue!” (We laughed together!) Don't think that one caregiver type or another make these comments - it's across the board. We all say these things. Thoughtless comments (without any implied meaning) can have such a negative impact.  Rather than expecting people to stop making these comments, we must become more informed and increase our confidence in our bodies.

We need to arm ourselves with the best evidence, so these comments won’t touch us. I love how the current BC Maternity Care Pathway comments on the practice of weighing a woman in pregnancy, “Some women may not wish to be weighed regularly. Since the evidence for any benefit is not strong, the woman’s preference should be a consideration.” It recommends that caregivers “advise women to refer to Healthy Pregnancy BC, a BC online resource for women related to healthy eating and healthy weight gain.” It expects that women can be trusted to educate themselves about healthy eating and weight regulation in pregnancy.

The UK NICE guidelines (which I love for its simplicity and clarity) lists “antenatal interventions not routinely recommended”, which include:
  •            Repeated maternal weighing 
  •       Iron or vitamin A supplements 
  •       Ultrasound estimation of fetal size for suspected large-for-gestational age unborn babies 
  •       Routine ultrasound scanning after 24 weeks 
  •       Gestational diabetes screening using fasting plasma glucose, random blood glucose, glucose challenge test or urinalysis for glucose

      For more information, go to Eating Well, BMI Calculator, Healthy Eating, have fun walking to the Farm Markets, and, if you really need to enter a supermarket, make it as organic as you can, and cruise the outer rim of the store (where the unprocessed foods are), and keep your armour on when anyone says, "I see someone has been food shopping!"

Thursday, May 09, 2013

The Garden and the Family

When I joined my husband's family, I found that I had to learn a new language...latin! All his sisters seemed to be avid gardeners and would chatter about moving the pieris japonica, or the joys of alchemilla mollis (I love showing children how the rain drops glisten on this plant, also known as Lady's Mantle). Three of us were pregnant at the same time, and we would dig and plant flowers and vegetables at the family cabin as our bellies grew, after our babies were born, and as our extended family expanded. Pregnancy strengthened our need to nurture the gardens.

As my love of birth grew, so did my bookshelves fill with gardening books that linked women's bodies and plants, from Herbal Healing for Women to Susun Weed's Wise Woman's Herbal, The Complete Book of Herbs, Plants of Coastal British Columbia (great on car trips!) and Michael Pollan's books, the first of which was my favourite, Second Nature.  I discovered that the Lady's Mantle that I loved has been used since medieval times as a medicinal herb, and rainwater collected in the leaves was used for its alleged magical powers. I never tested its use as a tea to reduce excessive period bleeding, but I like knowing that women in the past had used this plant for that purpose.

Crawling on hands and knees, digging and dividing in the perennial garden, helped me to turn my son from posterior to anterior.  Squatting and weeding between the vegetable rows helped prepare me for my daughter's birth. There's no sitting still when you have a growing garden! Sheila Kitzinger's daughter laboured in her garden and held trees as she pushed. My own clients have laboured on hillsides in the dark, in Queen Elizabeth Park by the flowers, leaning on trees, and squatting on the grass. Many birthing centres in warm climates encourage women to labour in gardens specifically landscaped for labour and birth. This "Birth in Nature" video shows a woman whose labour is entirely outdoors.

One Master Gardener, Donna Guillemin, opened my eyes to the "art" of gardening, and the world of Plant Spirit Medicine. While I would work in my garden, raising my children and attending births, she would (seemingly magically) help clients of mine to conceive, or cure their PUPPS, or relieve their anxiety. She would send them (or me) to Finlandia Pharmacy or Gaia Garden for tinctures and teas, if her own tinctures and teas weren't quite what was needed.

Fast forward to today - and we have two more helpers, Jack and Finn, in the garden. They have changed the soundscape of my mother's garden - windchimes, stellar's jays and shrieks of laughter are now heard over the sound of the sprinkler. They are also learning to ask if they're pulling out a weed or a plant, or if the berry they hold in their hands is a "bird berry" or a "people berry". We pull and squat and crawl in the dirt and work hard and play hard together. From age 3 to 89, our family work together in the garden, connecting to the earth and each other.

Do we garden safely? Pregnant or not, we try to remember to wear our gloves (or at least have a good soap and water wash at the end of a gardening session), and take precautions to avoid toxoplasmosis or chemicals, and avoid strains or sprains. But any potential risks of gardening during pregnancy (or postpartum or otherwise) are far outweighed by the positive emotional, physical and spiritual benefits (check out the Canadian Horticultural Therapy Association for more). 

Our gardens in Point Roberts, Tsawwassen, and Vancouver have nurtured four generations of our family. They have helped our babies turn into the perfect position, strengthened our legs for labour, watched us nurse our babies on the grass, calmed our minds when we've been anxious, and cleared our heads when the 21st century has been going too fast. Sure, we buy our vegetables most years (yes, we must connect more with the Urban Farmer)...but we try to buy local and ride our bikes or walk to the local farmers markets. This year's markets open this weekend!

So, if you're starting to grow a baby, try adding a garden to your family.  There you will find joy for a lifetime (and you might just be able to avoid a posterior labour, too!)