Crunchy

A video went around facebook recently:  “Sh*t Crunchy Mamas Say”…. I’ve said most of them.  Nathan often teases me that I’m a hippy in disguise.  I use family cloth, breastfeed, cloth diaper, practice elimination communication, baby-wear, am delaying vaccinations, use homeopathics & herbal medicine, & bed-share.  I had a homebirth with a doula and midwives, and encapsulated my placenta. I’m studying the use of herbs and aromatherapy. I know how to make bread and soft cheeses at home, although I don’t do either as often as I’d like. We use coconut oil for all sorts of things. We have a “bug out kit” in the front porch so that if we needed to evacuate in a hurry we’d have the basics we need to survive on for a while. We eat about 2/3 vegetarian, and most of the meat we use is purchased locally from a farmer-friend we trust. We only use household & personal care products that are both planet and human friendly - I make as many of those products as I can.

Before I start sounding too virtuous though, I ate Chocolate Cheerios for breakfast, and polished off a couple hot dogs for lunch yesterday.  I don’t eat enough fresh fruits and vegetables.  I like the *idea* of exercise but more often than not I spend the time watching tv instead. I have a sweet tooth and would gladly eat sugary stuff at every meal of the day and snacks in between (ahem – I’m eating Chocolate Cheerios straight out of the box while I type).   I have black thumbs so don’t garden – the only thing I’ve managed to keep alive is an aloe vera and a few potted tomatoes.  Nathan & I both own cars which we drive regularly.   I don’t rinse out my jars when I recycle. I really enjoy a long hot shower, and I still shave.  I own a smartphone & can’t imagine giving up that piece of technology.  I’m pretty much addicted to facebook.  I know how to can/preserve things but am totally envious of how much food my friends Lesley & Suzanne put up each year. I’m kind of a hippy… kind of in disguise.

All that being said, there is a constant tug-of-war between my desire to live in a way that is human and planet friendly, our need to live frugally, and how much effort I want to put into these things.  We’re certainly not poor, but if we had to purchase ready-made all the household & personal things that I make, we wouldn’t be able to afford to live as eco-consciously. When you make it yourself you have full control over the ingredients, and you save both money and plastic packaging.  But sometimes I just feel lazy and so I don’t make the effort that I should.  I mostly skip canning/preserving because it means I have to wash more dishes in the process.  I hate dishes.

Anyhow - one of the products which has eluded me is Shampoo/Conditioner.  I’ve tried a variety of recipes and never been happy with the results, so I buy either Prairie Naturals or Nature Clean Herbal.  Both are good products IMO and are the most reasonably priced shampoo/conditioner I’ve been able to find.  Still, $13.99 for a 500mL bottle (60¢ per use) rubs the wrong way when you know  you can buy a bottle of cheap ordinary shampoo for less than $5 for 1000mL (10¢  per use)   So about a month ago I started something I never thought I’d do…. I went shampoo free.  Apparently we don’t really need shampoo, and we only need conditioner because we use shampoo.  I made a mix  of 15mL baking soda to 250mL water to wash with (I used about 1/3 of it on my shoulder length layered curly hair) and did the same ratio for an Apple Cider Vinegar rinse.  I’ve been told that it can take a few weeks for your hair & scalp to adjust to this new regime but so far so good.  I bought a boar bristle hair brush for $10, and that helps too as it distributes the oil from your scalp. My hair looks a little different, but I’m still comfortable going out of the house with it.  The baking soda/ACV regime works out to a measly 6¢ per use, so I'm hopeful that the good results will continue.

Cementing The Memory

A friend of mine recently expressed disappointment over the lack of pictures from her most recent child’s birth.  Her midwife encouraged her to really envision her birth experience so that its place was cemented in her memory. This resonated with me deeply.  Let me explain.

When I was pregnant with Levi I made 3 birth plans:  1 for a homebirth, 1 for a hospital birth, and 1 for a caesarean birth.  I had no intention of giving birth in a hospital, let alone surgically, but I wanted a plan in place if necessary. There were a few common elements between my 3 plans – a set of beads I had received from friends, a collection of music I’d listened to throughout my pregnancy, and a candleholder from Ghana.  These were the objects that would keep me grounded. These were the tangible reminders that I could do it, and that I was not alone.  Seeing the candleholder, smelling the sweet purifying beeswax candle if at home, feeling the weight of  the beads, hearing the music - - all would serve as signposts on the road, indicating that many other woman had also walked this path before me, and were in fact walking this road with me.  These signposts would bring me strength, courage, and joy.

Having been to homebirths as a doula, I knew what practical things would make it easier for my support team to be in my space.  A large trash bag – labelled.  A large laundry hamper for birth laundry – labelled.   Easy healthy snacks ready. Crockpot of corn chowder warming.  Dishes, cutlery, & napkins out on the counter.  A variety of portable beverages in the fridge.  Tea & coffee ready. Antiseptic handsoap and a stack of fresh hand towels at every sink.  I had an ‘early labour to do list’ pinned to the bassinet in our bedroom which ensured that all these things would be in place by the time our doula and midwives arrived.  I figured that being a first-time Mom I’d have lots of time to fill in early labour and that getting the house ready would be a good way to occupy all that early labour time.  When my support team walked into my birth space, I wanted everything to be ready.  I envisioned myself leaning on Nathan through contractions, my body supported against his bare chest - drawing strength from his strength.  Music playing.  Candle burning.  Birth beads around my neck. I did not want there to be any sense of panic, or chaos, or frantic urgency in my space.  Calm.  Open.  Surrender.  

As it turns out, there was no time to occupy or fill. There wasn’t even time to catch our breath.  I woke up at 5am with contractions that came every five minutes, lasting a minute.  There was no time to play music, light a candle, put on a fresh nightgown and birthing bead necklace.   Birthing day food stayed in the freezer. Antiseptic soap and towels stayed in the birth supplies bin. Dishes were piled up in the sink.  I wore the undershirt, boxer briefs, and hazelwood necklace I’d slept in.   Just before 6am I woke up Nathan who made the decision for us to call our doula.  By 7am our doula had arrived and Nathan had made the decision to call our midwife.  By 8am, just as our primary midwife was arriving, we realized that the birth was imminent and called for the second midwife to come too.  At 8:19am Levi made his appearance.  Before my body and mind had really come to grips with being “in labour”, labour was done and the baby was on my chest in our bed.  What?!  How did that happen?  Labour was so fast that, in some ways, I feel like I missed it. Like my friend who missed having pictures as a reminder of what had happened, I felt as though I missed the time I needed to process what was happening. I certainly didn’t have time for the things that I thought would be important to me like music and candles and a necklace. Despite the absence of the ‘signposts’ though, there was no panic or chaos. There was still a sense of calm in the space.  But it has taken me 10 months of processing and reflecting to see that.  

Penny Simkin is well-known in natural birth circles for her research which shows that how a woman recalls her birth experience in the months immediately postpartum, is almost word for word how she remembers it decades later.  A few years ago I went to visit my grandmother in the nursing home where she lived.  Taped to the door of her room was a small note which said: “Please leave this door open at all times”.  She told me the story of my father’s birth, 60 years prior, in which she was locked - alone - in a cold, dark basement room of the hospital.  It was a traumatic experience, and for the rest of her life she couldn’t bear to be alone in a closed room.  The memory which was cemented for her, was one of trauma and fear.

One of my goals as a doula is to help women look back on their birth experience, and see their own moments of strength, courage, and joy.  I used to believe that this was only important for me to do when the labour or birth were difficult. I would often talk through a clients (difficult birth) experience with them, and listen for where they were proud of themselves; where they were especially happy.  If I didn’t hear it, I would be sure to plant a seed of encouragement into their story – mentioning where I had seen them be amazing. If you’d had a good birth though, then of course you would form a good memory right? Not necessarily.

I had a lovely homebirth – just like I hoped for – but I quickly realized that I didn’t see any moments of strength, courage, or joy in it.  I felt as though I had merely done my job as a birthing woman and there was nothing special about it at all. I wasn’t proud of myself.  I didn't feel joy. It all just ‘was’, without any particular emotion attached to it. Which brings me back to the beginning of this post.  As I’ve worked to cement my own experience in my memory, I have been sure to look for my own moments of strength, courage, and joy.  Because how I remember Levi's birth now, how I choose to cement it in my mind, is how I'll remember it years from now.  Someday, when I am old, and I can't remember what I had for breakfast or where I put my false teeth - the memory of Levi's arrival will still be with me.  And I want it to be a good one.

Making Concessions

Last week I wrote about night laundry.  Our dryer had broken, so even though it’s February I was hanging laundry on the line to dry.  The weather was clear and mild.  I was putting laundry on the line in the evening either while Nathan was watching Levi or after they’d both gone to bed.  I was excited to be saving electricity – good for the planet and our bank account. I loved the winter fresh smell when our laundry came in, and the whitening power of sunlight.

And then it rained.  I couldn’t hang the laundry outside. I ran out of room to hang laundry inside. I ran out of fitted cloth diapers because they were so slow to dry indoors.  (I pulled some prefolds out of storage to tide us over) Nathan took a second look at the dryer and discovered a small connection had been missed.  Voila! We had a dryer again. Hanging laundry outside works when the weather is clear at the times I have available to go hang it outside and we’re not expecting rain or snow before I’ll have time to bring it in again. So I’m making  concessions.  The diapers are in the dryer; the load of whites are out on the line.  I’ll take it ‘one load at a time’ and do what’s necessary to keep us all clean and dry.

The other concession I’ve had to make lately is in the area of sleep and night weaning.  Levi was a great sleeper until a growth spurt, teething, and the time change collided on the same weekend when he was 6 months old.  He was up every couple hours all night long.  To preserve our sanity, Levi started sleeping in bed with Nathan & I so that he could nurse as needed through the night while I at least rested.  3 months of this came and went.  I was supposed to go on-call in late February. Nathan could manage to distract Levi with solids and a bottle during the day, but if I got called out to a birth and Nathan had to feed Levi in the middle of the night – that would be a whole different matter.  I made the decision to night-wean, and Levi would go back to sleeping in his crib next to our bed.  I would hold, rock, bounce, jiggle, and sing to him as needed – but no milk. And no bed-sharing either because then Levi gets desperate looking for the milk.  Not that he’s hungry, he mostly likes to twiddle and play.  Let me tell you – that’s a little distracting to sleep through!  It’s been going reasonably well.  He’s still awake a few times a night.  If it’s a good night I can pat his bottom and he’s back to sleep. On the hard nights I’m up bouncing him multiple times. I said from the beginning that if he cried or was obviously hungry then *of course* I would feed him. That hasn’t happened… until this weekend.  Thursday he slept from 10:30pm to 6:30am.  I was overjoyed.  I thought we’d finally turned the sleep corner.  Yeah right.  Friday night he nursed to sleep at 10:15 but woke up for more milk just as I was going to lay him down.  He went to bed at 11, I came to bed at 11:30, he was up at 12:30.  I patted him back to sleep.  12:40 he woke up;  I patted him back to sleep.  12:50 he woke up;  I patted him back to sleep.  1:00am he woke up; I finally get out of bed to bounce him back to sleep – that usually works in less than 5 minutes.  Not this time.  After 45 minutes of trying, Nathan got up to take a turn while I rested.  After 45 minutes of Nathan trying it was my turn again. It’s now 2:30 in the morning.  I really get desperate and turn the tv on to watch a movie in the hope he’ll be mesmerized to sleep.  Not the healthiest choice I know, but desperate times call for desperate measures.  Uh huh.  That didn’t work either.  By now it’s 3am and Levi is wide awake and irritable.  As am I.  I manage to find a moment of clarity though in which I realize the only reason I was night-weaning was because of going on-call in March.  I’m not on-call after all.  Forget it then!  Let’s feed this kid some milk and call it a night.  3:30am I tuck him into his crib and burrow down for a few good hours myself.  You guessed it.  4:30am he’s awake again.  But it’s okay.  This time he’s just coming to bed with me.  I don’t go on-call again until the end of April.  By then he’ll be pretty much a year old and Nathan won’t have to mess with defrosting breastmilk to feed him.  Let’s just go to sleep.

I had been determined to hold firm.  On using the laundry line, on night-weaning, on so many things.  But life is too complex to hold firm.  Sometimes you have to make concessions, let go, change your mind.  For sanity’s sake.

Night Laundry

I've noticed lately that it's been taking our dryer longer and longer to get things dry.  An average size load takes over two hours, and sometimes even that isn't enough.  We mostly line dry in the summer, but it's February.  Seriously?!  What kind of nut line dries in February?  Apparently me.

Our dryer died this week, the same day our electricity bill arrived: 

5 kilowat hours/day during On-Peak time

5 kilowat hours/day during Mid-Peak time

33 kilowat hours/day duing Off-Peak time.

Yes, it's great that we've managed to arrange our lives so that over 75% of our electricity usage is during the lowest-cost Off-Peak period.  But 33 kW?!  That's a lot of electricity compared to the rest of the day.  The main thing we do during Off-Peak hours is laundry, especially drying.

I put two and two together (broken dryer we can't really afford to replace + electricity bill which shows the dryer is our biggest energy hog) and decided that we'd try going without a dryer.

11pm laundry under a skiff of snow.

What can I say?  I'm frugal.  It does take a bit more time, but so far it hasn't been too much of an inconvenience.  I wash one medium load of laundry in the evening, hang it on the line for overnight through till the next day sometime, then bring it in and hang it on a rack under a furnace vent in the basement to finish.  I do the same with a small load of diapers each night.  If its snowing or raining, clothes go directly to the indoor rack.  If we are due for a multi-day stretch of clear weather, then I do towels & bedding. Strictly speaking the outdoor step isn't necessary, but it makes our clothes smell great (winter fresh!) and it allows me to have multiple loads going at once.

I thought I'd hate it.  I thought I didn't have time. I thought only crazy environmental frugalistas line-dried in the dead of winter. Nathan immediately dismantled the whole thing to find what was broken and repair it if possible.  When it started blowing the breaker each time we tried using it, he was willing to buy a replacement (used) dryer by the end of the week if needed.  But if we don't have a dryer, we can't use it, and that means a lower electricity bill.  Yep, I'm that kinda crazy.

Their story is not my story

As a doula I attended births right up until I was 34 weeks pregnant.  I needed to sit more, eat more, and take more frequent bathroom breaks, but other than that it felt normal.  Thankfully no one was due during that exhausting and nauseating first trimester.

During my pregnancy I had the opportunity to work with local midwives quite a bit, and felt like I was really developing a professional rapport with them. I was busier than I had ever been as a birth doula and I turned down as many births as I attended. Some of the last births I attended before giving birth to Levi were intense, but thankfully the very last birth I attended was a calm and beautiful homebirth. Either way - positive or negative - I reminded myself often that 'their birth story is not my birth story'.  I wanted to remain open to whatever our story was going to be, and not spend my last days of pregnancy wondering if my birth would be just like those of the women I knew.  Our story would be our story, with its own struggles, wonders, and discoveries.

I haven't been at a birth since April 2011.  I've done some private childbirth education in the meantime, brewed up some herbal infusions, creams, and tinctures, and even helped catch 10 miniature goldendoodle puppies last week.  None of those carry with them the same pressures and joys as a birth though.

I go on-call a week today for my first 'post-Levi' clients, and may have a second couple due around the same time.  I've never been this kind of nervous about attending births.  I love it.  I miss it.  I believe that what I do makes a significant difference in the lives of women, babies, and their families. I'm looking forward to providing doula care once again.  And yet, I'm nervous - that Levi won't cope well without me;  that my family won't cope well with a potentially hungry & unhappy Levi. The sort of things any mother returning to work is nervous about I think.

I tell myself that I could just wait - refer clients out to other fabulous doulas in the area and take more time with Levi before returning to birth work.  But I know myself.  I know there will always be a reason for me not to do it, even though I want to do it, so I may as well jump in now as later.

I know that the nervous butterflies aren't ever going to leave me now.  No matter where I am, or what I'm doing - thoughts of Levi will flit about the edges of my consciousness, and even wiggle their way to the forefront of my mind.  I'll see the sweat and effort of a mother pushing her baby into the world, and remember what those final moments before Levi emerged were like. I'll see a new baby and remember how it felt to hold Levi the first time.  I'll help a new mother bring her baby to the breast, and my own body will remind me that Levi hasn't nursed for a while.

Their story is not my story.... and yet they are the same story: struggle and emergence; joy and heartache; becoming and loving.... All women who have carried life within, even for a brief moment; all women who have wished and prayed and hoped for that spark within to take life but haven't yet had it catch, share this story.  
We each have our own story, and we're all part of the same story.

In going back to births, I feel like I'm journeying into something that is both comfortingly familiar, and scarily unknown. Only time will tell how it all unfolds.

Where Did My Mind Go?

I forgot a rather important task at work last week.  I was supposed to pick up the Annual Reports from the local printers so they could be distributed on Sunday.  At 10:30pm Saturday night I realized I hadn't done it.  Don't get me wrong - I love being a mother - and please don't be offended if you're one of those moms who has it all together - but I kinda feel like becoming a mom has made me 'stoopid'.

There is so much more whirring around in my brain now, and less sleep, and I can't resort to caffeine or ginseng to keep me alert....  Just when I'm about to return that phone call, Levi needs a diaper change.  When I'm about to place that order of herbal supplies, Levi needs to eat. When I'm supposed to pick up the report at the printer, Levi falls asleep in the carseat so I opt to drive straight home so as not to disturb him - completely forgetting that I was supposed to stop at the printers on the way home from a client meeting. And on it goes.  I've heard that being a mother doesn't actually make you stoopid - your brain just re-prioritizes what information is important and mother-baby stuff trumps everything else. I think I'm gonna stick with that theory.  ;) It makes me feel better.

(Re) Joining The Club

Once upon a time my room-mate convinced me that I should blog.  She said I would become addicted to sharing my thoughts with the world.  She also convinced me to join facebook.  I  became addicted to both. ;)  After a few years my blog started to grow more recognizable than I was comfortable with. I tried to keep it anonymous but that was harder and harder to maintain.  I didn't want the people in my life to feel like their trust had been in any way compromised, so I took down my blog.  I intended to sort through it all - removing the birth stories for my own records only, reposting the eductational and informative stuff.  But as it turns out I accidentally deleted the whole thing.  All 5 years disappeared in one inadvertent keystroke.  *sigh*

Well, what's done is done.  I left the world of blogging altogether.  I married Nathan.  Moved from Cobourg to Brighton.  Quit my job at Northumberland  YFC.   Started doing postpartum doula work and teaching private childbirth education alongside being a birth doula. Gave birth to Levi Nathaniel. Began studying the use of herbs and aromatherapy more formally through Birth Arts International.  Let go of my birth doula certification with DONA International and began certifying through Birth Arts International instead. Was offered the opportunity to guest post on a colleagues blog. Realized I really missed having my own blog.  Started thinking about what my new blog could look like.....

And so here we are.  I begin again.  Posting about whatever things cross my path, that catch my eye.  Mostly things related to the world of birth, natural health, herbs, being a wife & mother.

In the meantime, to get things started, I've moved over a few work-related posts from my website. I'm excited to be back.

When In Doubt - Breathe

My experience as a doula has shown me that birth is natural, normal, beautifully intricate, and a force of nature worthy of our respect. My experience as a doula has also shown me that birth plans and birth reality rarely cross paths. The preparation of a birth plan can be a useful learning and communication tool, but making a plan and handing it to your caregiver doesn’t mean that your plan will be realized.

Preparing a birth plan can help you sort out what you really want, and whether or not your desires are compatible with the practices of your chosen caregiver and birthing location. If what you want is already the standard of care, there is no need to write it in a birth plan. If what you want is NOT the standard of care, just writing it down is not sufficient. You will need to communicate with your care provider and negotiate for your desires in light of their policies, procedures, and preferences.

It is important to think about what things are most important to you, which things are not important at all, and WHY. If you know WHY something is important, then you can look for alternate opportunities to creatively integrate those important things, if necessary.

Working through a birth plan allows you to explore the pros and cons of all the options. Then, if you have to make a choice you weren’t expecting - a choice that deviates from your expectations and plans of birth - you will already know what your options are and be more prepared to make choices that are right for you.

And sometimes, no matter how carefully we plan, prepare, and negotiate for birth - - things may take an unexpected turn.

No matter what happens though…. No matter how quickly or slowly your birth unfolds…. No matter how small or large a change you have to make in your expectations and hopes for your desired birth experience…. Whatever happens…. When in doubt…. You can breathe.

You can choose to relax your body, and you can choose to breathe in a way that nourishes and sustains you and your baby. You can find a rhythm and a ritual that are meaningful and helpful to you in the moment. Your breath is literally the breath of life to your child, and it is a gift you can continue to give your baby, no matter how your birth experience unfolds.

Your rhythm, your ritual, your ability to relax, and your very breath, can carry you through.

Preparing For Emergency Childbirth

Many expecting parents worry that they won't make it to the hospital in time, and will deliver their baby alone at home or in the back of their car on the shoulder of the highway. While we all have plans for birth, sometimes birth takes an unexpected turn. Sometimes traffic is bad, the weather slows you down, a natural disaster strikes, or the hospital closes. When you give place somewhere other than where you planned, and without the professional help you were counting on, we usually hear this called "emergency" childbirth.

When prospective clients are interviewing me, one of the questions I'm often asked is "Have you ever delivered a baby? If things happened fast would you know what to do?"

I explain that while catching their baby is outside my scope of practice as a doula, I have done it before (under the supervision of a midwife), and I maintain current first aid & CPR skills so if it came right down to it, and there was no way around it, I would take off my doula hat, put on my "first aider" hat, and do the best I could for them.

The thing is, birth is normal. Healthy. Generally safe here in Canada. Even if you do find yourself unexpectedly giving birth without a dr/nurse/midwife at your side to help - - it's not likely an emergency.

The first thing to do is take a big breath and say "This isn't an emergency. I just need to stay calm and take things one step at a time." Despite the yelling and drama you see on tv, childbirth is a process that is designed to work. While there are exceptions to every rule, if the labouring woman has safety, privacy, and warmth, and her labour is unhindered, she & baby will be just fine in the VAST majority of cases. Keeping all that in mind....

The second thing to do, after you've taken your deep calming breath, is pull out this fabulous handout from the American College of Nurse Midwives. Follow the instructions there, and you'll be off to a good start.  The ACNM also offer this handout which is an expansion of the one above and includes information on how to deal with a few common complications of birth.

I recommend you read through the handouts sometime early in your third trimester. Gather the supplies. Put a print out of the pages with your birth supplies, and put it all somewhere that is both safe AND easily accessible.

"Emergency childbirth" doesn't have to be feared, if you've taken some time to prepare!

Birth Matters

Many women and couples today find it difficult to fit childbirth education classes into their busy schedules. They might watch an episode of Baby Story, or read "What To Expect..." At most, they manage a short crash course at their local hospital or health unit. From my clients’ point of view, the health unit courses tend to focus on healthy prenatal nutrition; the hospital courses tend to focus on being a good patient; and the vast majority of mainstream media portrayals of birth breed fear not confidence. My clients were coming to me and saying they needed “more”. They had attended classes hoping to learn about the birth process, but came out feeling anxious and less prepared than ever. That's why I began offering private teaching sessions for my clients, and for other couples in the community as well. We spend a solid hour per topic – in the comfort of your home and at times that fit your schedule – talking through and practicing and exploring the areas that YOU want to know about. If you do not have access to a high-quality independent childbirth education class, I encourage you to check out www.ibirthapp.com It is an inexpensive (ie less than $5!) application you can download for your iphone or access online, which takes you through positions and comfort measures and checklists etc, for birth. It’s not a real live person giving you continuous hands-on support, knowledge & encouragement – but it’s better than nothing! It's also a great 'on the fly' teaching tool for doulas.

Let’s fast forward a few months to labour though shall we? If you’ve hired a doula, you don’t actually have to remember every detail of your classes because your doula knows that stuff like the back of her hand and will refresh you on the fly. Your doula will help you explore your options prenatally, and will be your real-life cheat sheet during labour and birth.

What if you didn’t attend classes though AND you don’t have a doula**? Or you attended a basic class but didn’t think about it again and certainly didn't practice what you learned on a regular basis? It’s kinda like attending the first day of math class, leaving your textbook in your backpack all semester, then showing up for the final exam three months later and expecting to pass. Yes, birth is a natural process, and if all you do is show up at the hospital doors, chances are good that you will be holding your baby in your arms within 24 hours….. but birth is about so much more than just having a baby. Every birth experience transforms you. Your experience of giving birth – how you were treated and how you felt – changes how you relate to your family and to your child; it changes how you see yourself.

Women who have some distance from their childbearing years – women generally who are 50+ - have told me – WITHOUT EXCEPTION – that they wish they had a doula with them when they gave birth. They tell me that when they were pregnant they thought it would all 'just happen' and that the only thing that mattered was a healthy mom and a healthy baby. They tell me that even after baby #1, they were so engulfed by the responsibilities of new parenthood that they didn't make time to think about what their options were for the next baby - "we'll just do it the same as last time". But then time passes, their children grow, and they start to realize that the experience of giving birth 25 years ago still affects them every day. They realize now, that there is so much more to birth than just a healthy mom and a healthy baby. And so they say to me, in parking lots, and at checkout counters, and in the farmers market:

"I wish I had known enough 25 years ago, to have someone like you with me. How you give birth matters so much more than I thought it did at the time."

I know that despite all this, many women today still believe that the only thing that matters is a healthy mom and a healthy baby. Of course we want everyone to be healthy. But there is so much more to life than just basic health. There is beauty and freedom and confidence and joy and power and... and... and...

How you give birth matters. That is why I am so passionate about women having the support they need to navigate the waters of birth in Canada. I want every new parent to come out of their birth experience feeling confident and prepared for the road before them. I want every new parent to be able to look back on their birth experience and find their moments of strength, courage, and joy. The reality is, if you just show up at the hospital doors - under-prepared and ill-informed like the vast majority of Canadian women unknowingly do - you will still likely walk out (relatively) healthy, but you might not walk out happy and that affects your well-being too. It affects you, it affects your child, and it affects you forever.

You research what stroller you want. You research the car seat and the breast pump and the diapers.... please take some time to research the experience of birth itself, and what it takes to have a good birth experience. I think you'll discover for yourself, that birth really does matter.

** "One study found doula support without childbirth classes to be more helpful than childbirth classes alone, as measured by levels of emotional distress and self-esteem evaluated at an interview four months after birth. In particular, it was noted that women in the doula-supported group reported their infants as less fussy than the group attending childbirth class without any doula support. - - Manning-Orenstein, Grace, "A birth intervention: the thereapeutic effects of doula support versus Lamaze preparation on first-time mothers' working models of caregiving." Alternative Therapies, July 1998, Vol. 4, No. 4, pp. 73-81.

To learn more about common practices in birth, and how they affect you, and your baby, please see:

Mothers Advocate – If you want to make informed choices about your pregnancy and birth, but are concerned that you might get overwhelmed by too much information, or don’t want to read, start here. Mothers Advocate gives you the bottom line on the most important things you need to know, in short video clips.

Science & Sensibility - A Research Blog About Healthy Pregnancy, Birth & Beyond from Lamaze International.

Thinking Woman’s Guide To A Better Birth by Henci Goer. This book “puts the power of the latest scientific research on childbirth into the hands of women to help them discern the facts from the myths and make informed decisions about their maternity care."

Gentle Birth, Gentle Mothering by Dr. Sarah J. Buckley. “This book gives you the WHOLE story to help you with your most important decisions in birth and mothering.”

A Guide to Effective Care in Pregnancy and Childbirth - This is an online overview of results of the best available research about effects of specific maternity practices today. LOTS of detail!!

What You Need To Know About Fetal Monitoring

While doing my daily ‘tour’ of birth-related blogs today, this April 2010 headline caught my eye: “Common Intervention Leads To Needless C-Sections”

What the author Alex Friedman is referring to, is continuous electronic fetal monitoring (efm).

For the record, SOGC’s position on fetal monitoring/surveillance can be found here. They recommend intermittent monitoring in low risk women, and specify what situations might warrant a move to continuous monitoring instead. I have been unable to find Canadian statistics on efm use. In the 2006 Listening to Mothers Survery, 94% of (US) women reported that they had continuous efm. In 2001, 20% of labours in Canada were induced, and as of 2008-2009 the epidural rate in Ontario was 60%, and the caesarean rate was about 25% (27.7% in Canada). www.cihi.ca

While continuous monitoring is considered necessary during inductions, epidurals, and in other ‘high-risk’ situations, this necessity does not change the risk of the mother having a caesarean section as a result of the data obtained through continuous efm.

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When you check in to the hospital to give birth, they generally hook you up to “the monitors”. To hook up the monitors, a stretchy band is wrapped around your contracting belly, which holds two round discs in place – the disc at the top of your belly (a tocometer) measures the frequency (how often they come) and duration (how long they last) of your contractions, and the disc lower down on your belly is an ultrasound device that measures the baby’s heart rate. It’s important to know that the “Tocometer” (aka tocodynamometer) measures how much force your belly puts against the toco disc as a way of measuring your uterine contractions – so if you carry extra weight around your mid-section, the toco might not pick up the real strength of your contractions. If you sneeze, shift, bend etc - all that movement is picked up by the toco too. 

If for some reason your caregivers feel like the external devices aren’t recording accurately enough, they may want to place an internal monitor instead. A thin wire is passed through Mom’s opening cervix, and threaded into babies scalp. This gives doctors a direct reading of the fetal heart rate, and if they have placed an IUPC (intra-uterine pressure catheter) at the same time, they’ll have a more accurate reading of contraction pressure too. If they don’t place an IUPC, you might find yourself with both an internal monitor for baby AND an external monitor for you (I’ve seen it happen). 

Once you’re all hooked up and ready to go, the monitors will give a printout of what they are recording – you’ll see this as two squiggly lines either on a long piece of paper, or on a computer monitor. The top line is baby’s heart rate, and the bottom line is your contractions. Interpreting what these squiggly lines mean, and then interpreting what to DO about it, is as much art and personal judgement, as it is science. What one caregiver sees as an emergency, another caregiver may very well see as normal. (I’ve seen this happen too)

Which brings me to the article by Alex Friedman. I’ve interspersed key portions of the article with my own thoughts.

“Fetal heart-rate monitoring is a screening test. Good tests get several things right; they are cheap, detect a possible problem when there is still time to act, and minimize unnecessary follow-up tests.”

I would also add that in my opinion, a good screening test has an appropriate risk-benefit ratio. If the risks are high but the benefits are low, and even if the risks are low but the results aren’t reliable (false positives and/or false negatives), that doesn’t seem like a very good screening tool to me – why go through a procedure that isn’t going to give you meaningful information for your decision-making process?

“The Pap smear is an excellent screening test: By examining a few cells brushed from the cervix - where the vagina opens into the uterus - doctors catch precancerous changes - or even early cancer - when it is easy to treat.

But fetal heart monitoring is an appallingly poor test. The test misses the majority of babies with cerebral palsy, the condition researchers hoped it would prevent. It causes increased rates of a painful and invasive surgery: cesarean section. Even worse, almost all women undergo continuous heart monitoring during labor, not just those at highest risk.

… A study in the New England Journal of Medicine found that only 1 of 500 babies with a bad strip had cerebral palsy. Moreover, it remained unclear if the condition had developed before labor, in which case cesarean couldn't prevent it.

A 2006 analysis by the British Cochrane Collaboration, evaluating all available research, found that fetal heart monitoring failed to reduce perinatal mortality - the risk of a baby's dying late in pregnancy, during birth, or shortly after birth - and increased cesarean section rates and forceps deliveries, compared with listening to a baby's heart rate intermittently.”

Yep, you read that last sentence correctly.

Continuous electronic fetal monitoring does NOT reduce the risk of your baby dying, and does NOT catch the very condition it was designed to prevent (cerebral palsy) but it DOES increase your risk of having a surgical birth.

Everyone wants a healthy baby and a healthy mother. You might hear caregivers tell you that they have to monitor continuously for the safety of baby. Some will go so far as to say that Mom is being selfish when she doesn’t want to be continuously monitored, and they say this isn’t about her comfort, or her ‘nice experience’, but about making sure her baby is born alive and healthy. Just remember, if you are a healthy low-risk woman with a normal pregnancy, the evidence says that continuous efm isn’t ‘safer’ at all! “Even for high-risk fetuses, evidence of the benefit of electronic monitoring… is lacking.” - quoted in “The Thinking Woman’s Guide To Birth” by H. Goer

“Steven Clark and Gary Hankins, two prominent obstetricians, voiced my (the author Alex Friedman’s) frustration. “A test leading to an unnecessary major abdominal operation in more than 99.5 percent of cases should be regarded by the medical community as absurd at best,” they wrote in the American Journal of Obstetrics and Gynecology. "Electronic fetal heart rate monitoring has probably done more harm than good."

So why do doctors still use continuous fetal monitoring, if the research shows that it probably does more harm than good? Most often you’ll hear an answer along the lines of “better safe than sorry.” Whether it is expressed as a fear of being sued, as insurance company requirements, or as a genuine belief on the part of obstetricians that it is in the baby’s best interest for the mother to undergo major abdominal surgery, these are all variations on the “better safe than sorry” theme. (I won’t get into the whole discussion here about how we currently weigh out baby’s best interest versus mother’s best interest)

I think there might be more to it than “better safe than sorry”. Obstetricians in North America must have malpractice insurance. If they get sued, their insurance rates go up, and this has the potential to force them out of practice. Their livelihood, and the wellbeing of their families is at stake. How motivated would YOU be to change the way you work, if you knew that doing so might result in you losing your job? Try not to forget that OB’s have to pay the bills just like the rest of us.

So let’s put some pieces together:

Research shows that continuous efm in low-risk situations does more harm than good.

Doctors, who are rarely in medicine ‘just for the money’, but are there because they want to somehow help people, are worried about being sued because it puts both their livelihood and their ability to help people, on the line.

IF doctors make the switch from continuous to intermittent efm on the grounds that continuous efm is harmful, suddenly the door swings wide open for women who underwent caesarean surgery due to “a bad strip”, to sue doctors for causing them harm.

The OB is now damned if they “do” AND doomed if they “don’t”. What’s an obstetrician to do?

I’m not making excuses, and I’m not trying to downplay the pain of women who underwent un-necesareans, I’m just trying to walk a mile in the OB’s shoes. You have to know where people are coming from, before you have a chance at making a change.

Aside from the money issue, obstetrics has a history of being slow to make changes based on available research. Doctors knew that hand-washing would slow the spread of infection and decrease maternal mortality rates for years, before they finally started washing their hands. DES continued to be prescribed even after it was shown to do at best, nothing beneficial. Cytotec is still in use on L&D units, even though its own manufacturer says that use is off-label. Why should we be surprised that - in an age where we want a paper-trail for everything; where science trumps intuition; where the one with the best lawyer wins – doctors continue to require continuous efm for low-risk women? I don’t think we should be surprised at all… but we should be motivated to protect ourselves; we should be prepared to work for change.

The Bottom Line:

If you are a healthy and low-risk pregnant woman (which is the vast majority of you), one of the best things you can do to protect yourself against an un-necessarean, is to NOT CONSENT to continuous efm in your healthy low-risk labour.

Intermittent efm (listening before and after a few contractions, every 30-60 minutes) gives the caregiver just as much useful data as continuous efm, but without an increased surgical risk for Mom. And there is risk for Mom. Cesarean surgery is major abdominal surgery and the more of them you have, the higher the risks become. Visit Childbirth Connection to learn more about caesarean surgery risks.

If your doctor and hospital include continuous efm in their low-risk birth policies, saying no to continuous efm the day you arrive at the hospital is not usually enough. If you want to protect yourself against an unnecessary surgery, talk to your doctor in advance of your labour day, about your monitoring options. If you’re lucky, your doctor and hospital use intermittent monitoring whenever possible and so you are already one step closer to a safe vaginal birth. Either way, have them write in your file that as long as you remain low-risk (and have your doctor be specific about how they define low-risk) you can have intermittent rather than continuous monitoring. That way if a different doctor is on-call or your nurse doesn’t agree, you can refer them to the written orders in your file.

Please know that if your labour is induced (20% of Canadian women), or if you have an epidural (60% of Ontario women), these interventions both move you into a category which SOGC says require continuous monitoring, and come with their own substantial list of risks and benefits that will need to be weighed out. I’ll write about those things soon.

To learn more about common practices in birth, and how they affect you, and your baby, please see:

Mothers Advocate – If you want to make informed choices about your pregnancy and birth, but are concerned that you might get overwhelmed by too much information, or don’t want to read, start here. Mothers Advocate gives you the bottom line on the most important things you need to know, in short video clips.

Science & Sensibility - A Research Blog About Healthy Pregnancy, Birth & Beyond from Lamaze International.

Thinking Woman’s Guide To A Better Birth by Henci Goer. This book “puts the power of the latest scientific research on childbirth into the hands of women to help them discern the facts from the myths and make informed decisions about their maternity care."

Gentle Birth, Gentle Mothering by Dr. Sarah J. Buckley. “This book gives you the WHOLE story to help you with your most important decisions in birth and mothering.”

A Guide to Effective Care in Pregnancy and Childbirth - This is an online overview of results of the best available research about effects of specific maternity practices today. LOTS of detail!!