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Maternal Death and the United States {Birth Without Fear}

Maternal Death and the United States {Birth Without Fear}

Maternal Death – the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. (WHO)

This is a subject no one really wants to talk about. Mothers die. Mothers die in pregnancy and childbirth and just after birth. The weight of that reality is just so heavy and heart breaking. In our current birth culture, fear reigns. However, fear reigns without reason or knowledge of what really needs fear. And of course – all of us hope to Birth Without Fear. And so, I approach this subject with a heavy heart but hope as well.

Samantha's Birth

Where Does It Happen?

In short, it happens everywhere. However, some areas are more prone than others. This can be due to lack of care – think of sub-Saharan Africa or rural villages in some undeveloped countries. Maternal death in those areas is an unfortunate fact of life (though organizations are striving to change this).

But apart from the “obvious” places, where do you suppose it happens? Perhaps war-stricken places, or those places without advanced medical facilities? Would it surprise you to know that the United States has one of the highest maternal mortality rates in the developed world?

Yes – you read that right. Our current maternal mortality rate is 21 deaths per 100,000 live births as of 2010 (WHO). This rate went up from 2005 (18/100,000). The 2010 “Healthy People” Goal for the United States was set at 4.3/100,000 – we grievously missed that by a large margin. The 2020 goal is 11.4/100,000, which would only be a 10% decrease from what the US considers to be its current statistic (the 12.7/100,000). I find it interesting that the government decided after they missed the 2010 goal that maybe they should try less to save mothers, since their efforts before had no effect and saw a rise in deaths.

The WHO number is adjusted from the number reported by the CDC (12.7/100,000) – this is because the United States does not have a universal system of reporting maternal deaths and the CDC admits that our numbers are drastically under reported due to this lack of uniformity in reporting (See this CDC publication, specifically page 20). Currently, only 25 states make it mandatory to state that a death was pregnancy related on the death certificate – and even this method is questionable due to lack of doctor training in filling out certificates and the great fear of litigation in the medical system. Ina May Gaskin writes about the lack of reporting here.

Other countries have much better standards of reporting. The “gold standard” is considered to the be reporting system in place in the United Kingdom. The UK ensures that not only is every death reported, but they also compile the deaths and reasons for them in a report every three years. This report is available to the public and the locations and names of the deaths remain confidential. This allows the nation and the nation’s health workers to look at the issues without fear of litigation – meaning they have no reason to hide maternal deaths.

To provide some perspective, here are the rates of some other countries:

  • Australia: 7/100,000
  • Brazil: 56/100,000
  • Denmark: 12/100,000
  • Germany: 7/100,000
  • Israel: 7/100,000
  • Japan: 5/100,000
  • Netherlands: 6/100,000 – note that about 30% of all births here are at home.
  • United Kingdom: 12/100,000

As you can see, we are rather behind many other countries – and don’t worry, I am going to come back to Brazil and why I included that statistic which is very high for an industrialized country (as is the USA’s number).

Why Are Mothers Dying?

This question is hard to answer since as mentioned above the reporting methods are varied and not always followed. We do know that some deaths are simply not preventable, this is just a fact of life. However, looking at the much lower numbers in other comparable nations we know that unpreventable deaths are not the reason for the very high numbers in the United States.

We know that it is not from lack of care in general – reports show that over 99% of all women in the United States receive prenatal care. However, we have to look at the level of care women are receiving. We have to ask, does a 5 minute rushed visit with your actual doctor count as adequate care? Does more diagnostic testing equal better care? Does spending more money equal quality care? (The numbers say no – we spend more than any other country in the world on birth).

We see a HUGE disparity in death rates in regards to ethnicity. An African-American woman is 3.3 times more likely to die in childbirth than a white woman. This is simply not acceptable in a country as advanced as ours, and one that is supposedly equal. Midwives such as Jennie Joseph are helping to implement ways to combat this disparity – her creation of The JJ Way is an example of how we can work to correct this travesty.

A big question that needs to be asked in the United States has to do with who is providing this care – care that is obviously not saving as many mothers as it should. In the United States women overwhelmingly see Obstetricians. While Obstetricians are amazing for complicated and high-risk pregnancies, they don’t have much training in plain old boring pregnancy and birth.

A majority of the time pregnancy will proceed in a normal fashion, and birth will follow in the normal fashion. When we use care providers who are trained to search for problems there tends to be a trend of finding problems whether they exist or not, or whether they are actually emergencies or not. As the saying goes, “Give a boy a hammer and he will find something which needs to be hammered.”

We can see that in countries were the majority of care is given by midwives (or that country’s equivalent care provider) the maternal mortality rate is lower (and the infant mortality rate is lower as well). The United Kingdom is a great example of this. They are comparable to us in many ways (general health and population structure), and yet consistently have better maternal outcomes. And they use the midwife model of care in which all women start with midwives and only transfer if problems arise. (Note that a woman can opt for an OB to start with, however most do not).

Now for the elephant in the room: the United States cesarean rate. Our current cesarean rate is 32.8% (CDC). Yes – basically 1/3 of all babies in the US are born through cesarean. So are 1/3 of all US women somehow “broken”? Unable to birth? Producing massive or stubborn babies? NO – of course not. If 1/3 of all women in the US were “broken” then those numbers would be reflected all over the world, and the statistics show this is not the case. In the same vein, we are not producing massive babies either – in fact the average birth weight has gone down as the cesarean rates have gone up (and is independent of that rise or that of induction).

Remember when I said I would come back to why I included Brazil? Brazil has a rather good medical system and is considered a developed country, so why the massive maternal death rate (56/100,000)? Take a look at their cesarean rate – 52.3%. Yes – over 50%. Brazil is an interesting case since most of these surgeries are elective, even for the first time mothers. The fear of childbirth is so deeply engrained in Brazilian culture that women jump at the opportunity to have a cesarean and avoid labor totally. A vaginal birth is seen, culturally, as something only poor women do because they can not afford a cesarean.

That mortality rate could be the United States’ future. We see a fear of birth in the US, and a huge cultural love of telling horror stories about labor and birth. We see more interest in elective cesareans (though elective first time cesareans are not significantly altering the rates). As VBACs are “allowed” in fewer and fewer places and malpractice issues continue to rise we see more and more women forced into surgeries they do not want or need. Our rates are heading right up to that of Brazil’s, and our maternal mortality rates will be sure to follow. A Cesarean increases the risk of death significantly in comparison to vaginal birth.

In comparison, the rate of cesarean in the UK is 25%, the Netherlands has a rate of 14%. As I stated before, the UK has 12/100,000 rate and the Netherlands 6/100,000 – rather interesting that as the rate of cesarean is almost half in the Netherlands and their rate of maternal death is also half that of the UK. While in some countries a higher cesarean rate does not correlate to a significantly higher mortality rate, those countries with very high rates of cesarean typically have higher (or rising) mortality rates.

We also cannot forget postnatal care. The postpartum period is one that needs care just as much as the prenatal time period. In the US, typically a woman is seen in the day or two after birth, at two weeks or so, and then at six weeks…and that is about it. This is simply not enough during this time of life when hormones are changing, the body is attempting to heal from creating another life, and things like retained placenta or clots can cause major issues. A much better plan of postpartum care must be put in place.

What Can We Do?

Be Educated. That is the number one thing you can do to not only help yourself have a safe pregnancy and birth, but also to help the women around you as well. When you learn, share the information. Break down the myths that pervade this culture – break down the assumption that VBACs are dangerous, or that “big babies” need surgical birth. Share the studies and articles you read.

Be Fearless. Help to eradicate fear of birth. Can birth end in tragedy? Yes. Unfortunately is does happen. But with proper and evidence-based care we give ourselves and our babies the best chance. Share the positive birth stories you hear. Share your positive birth. How does this help? It helps women to not fall into a fear based decision that increases her risks of complications – namely induction and cesarean. When a woman can start her pregnancy and birth journey from a positive place it gives her more space for growth and research. Absence of fear is not ignorance of risks – it is not being beholden to the fear of risk.

Those two things hand-in-hand – education and fearlessness – can go a long way towards helping this mortality rate go down. An educated woman is better able to avoid situations or care providers that increase her risks, and a fearless woman is better able to stand up for herself and decipher what is really in need of intervention and what is not without cultural fears clouding her view. Lets do our part to save mothers.

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Why Mothers Measure In Months

Why Mothers Measure In Months

So often, I see memes like this:

meme

And you know what, they bug me. A LOT. Normally these are posted by people who are not to the point of having children yet, which makes it even more annoying.

Basically any mother will tell you that from one month to the next, our children learn and change drastically. During the first year it is the most drastic, during which time it is still “acceptable” to refer to your child’s age in months. But for some reason after that first birthday people like to make fun of referring to a child’s age in months instead of years or “1/2” measurements. This especially comes up in reference to full-term breastfeeding.

First I have to ask the masses, why does it bother you if I refer to my toddler as “30 months” instead of “2 and 1/2 years old?” Are your math skills not up to par? Does it take too much brain power? Does my reference to months actually effect your life at all? Some commenters and meme makers like to take it a step further, insisting that referring to our babies in terms of months is just a way to cover up our inability to let go of them being a baby and rationalize our child still breastfeeding/sleeping in our bed/being carried/[insert parenting issue here].

I simply have to assume these cynics have never paid attention to the development of a child, especially when that child is your own. For instance – my son at 12 months could not walk – at 13 months he could. What a difference a month made! At 29 months my son was still breastfeeding, at 30 months he had self-weaned. Again – the difference a month makes! At 18 months he had learned to jump down off the sidewalk at the park without falling. That month he also chose to go down the slide on his own for the fist time. He was 32 months old when his baby brother was born, I will always remember him singing Twinkle Twinkle at their first meeting and his avid interest in the placenta.

stairs

These are all moments after the first year that are in my memory at a specific time and place. To me the month it happened is important. It is a milestone, a special moment. It is something scribbled down in a baby book or documented in a photo. In my mind he was not “2 and 1/2” or “almost 3” or “a year old”.

23 months

One day when I am not living in this moment, in this day-to-day rapidly changing world, I will probably tell him “You were 2 and a 1/2 when you weaned,” or “You walked just after your first birthday”. But today, those vague time periods are not specific enough. They are not important enough to describe that exact moment he learned something new, that moment he became his own person a little more than the day before.

32 months

So next time you hear a mother say “He is 22 months old” don’t roll your eyes. Smile and know that this mother is simply relishing in this fleeting time in her life as a mother. She is giving homage to the breakneck pace at which her children are growing and learning.

Prepping for Your Home Birth Without Fear {The Ultimate List}

Prepping for Your Home Birth Without Fear {The Ultimate List}

One of the most common questions about homebirth from those considering it is, “What do you need?” While the list of supplies varies from midwife to midwife, there are some basic things that almost everyone is going to need to gather in preparation for the birth. There will also be things you will (probably) want to do for your comfort and peace of mind before “go time”. This is meant to be an Ultimate (I hope I thought of everything) List, but please don’t stress yourself to cover all the little extras. Birth really is pretty basic. This list is long and detailed so that you have a chance to consider everything you might want to do, not everything you have to do.

Early Prep

While not everyone plans a homebirth from the start, many women do. If you can get a head start on a few things it makes the final months much more peaceful. After you have lined up your midwife, get a head start on your prep.

One of the first things you can do is to create a peaceful space. (Right about now mothers of small children are laughing). If you know which room/area you plan to use then work in the early months to slowly declutter and create your space. Your nesting urge will come in handy with this as well.

If you have older children, you will want to decide if you want them at the birth or not. If you do there are things you can do to prep your child for the birth. Some things will depend on their age – for instance a one year old won’t need the same prep as a 5 year old. Older children may be interested in the mechanics of birth and understand more. You know your children best. Birth can be a beautiful family event if you decide to have your children there. And if you don’t think you want them there – no guilt! Everyone labors differently.

For younger children helpful prep includes books, videos, and role playing. There are a few children’s books out there that discuss homebirth, one of my favorites is called Hello Baby by Jenni Overend. It is beautifully illustrated and is great for little ones. Birth videos are also great for prepping kids. I previewed many, many homebirth videos on youtube and created a little playlist of those I thought my son could see. I included water births, “land” births, quiet moms, loud moms, and especially videos that included the whole family.

Speaking of “loud” moms – this is where the role playing comes in. While I was a very quiet laborer with my first born, I wasn’t sure if I would be again. We never know how labor will go (and I wasn’t quiet the second time, by the way). So we discussed as we watched the videos that mommy may “Roar”. I talked about roaring like a dinosaur or a lion. We had a lot of fun roaring at each other and I explained that if mommy roars it is okay – I am not hurting and it just means the baby is coming soon. Apparently this worked really well since my two year old was not phased at all by my roaring at the birth – and I was loud!

Another opportunity for prep and role play with little ones can include your midwife visits. Many homebirth midwives do home visits for prenatals or have offices that are child friendly. I made my son a little midwife kit of his own, including a little plush placenta I whipped up with some felt. During my appointments in our home he “helped” my midwife and we talked about the baby. All of this helps children feel included in this life changing event.

plush placenta

Now whether you decide to have your children at the birth or not, I highly suggest lining up a support person for them. If they are going to be taken somewhere else for the birth be sure they are comfortable at the location and with the support person. Also try to pick someone with a flexible schedule who can be “on call” for the birth.

If they are going to be staying with you for the birth then you need to pick a special person. You need to pick a person who is there just for the child/children. This means that if they need to leave the house or room and miss the birth, they will be 100% okay with that. I would suggest clearing this specifically with them, since in some cases support people at home births might be signing up in the hopes of being a spectator. This isn’t the point of a support person for the older child. Be sure to acclimate them to your routines and places they can go with your kids. Discuss car seats if they need to drive the children anywhere. While this may seem over-kill it will give peace of mind in the last weeks and while in labor. It also clears up your support team to work just for you during the birth and not have to split their attention.

You will also want to consider if you want a doula for your home birth. Be sure to set up an interview and get someone who you feel is comfortable in your home and is preferably experienced or knowledgeable about home birth. Another part of your team to consider is a birth photographer. Again, interview them and be sure they make you feel comfortable. It also helps if they understand home birth or have shot one before, since they have different highlights and flow than a hospital birth.

Almost to the Finish Line!

Once you hit about 32 weeks, order your birth kit. This may seem a bit early, but some companies take a few weeks to ship. Or, if you are lucky like me, it will get lost in the mail because apparently your house is invisible to UPS. This also gives time to clear up any issues if the order is wrong or missing something. You don’t want to be stressed at the last minute!

There are many places to order birth kits and your midwife may have a custom kit set up with a particular company. You can also order kits of your own making or a basic kit from places such a In His Hands or Baby, Birth and Beyond. *

Basic Supplies Include:

Now that is just a starter list, and as I mentioned above some midwives will want more or less or different items. Some additional items might be an herbal after bath, different herbal items (for cord care or afterpains), Depends-type underwear, and a “birth certificate” and foot printing kit. You can also take off items from a premade kit on most sites, and substitute in your own items. For instance you may get your own postpartum pads and “depends” (hey, those are handy the first day or so!). The one thing I suggest not skimping on is the chux pads. Most births require a good amount of them, and they are handy after birth too. I tend to use them for a couple months under my sheets to protect the mattress from breastmilk leaks in the night.

Once you have ordered your birth kit it gets exciting! You have all these cool things ready to go, so what do you do with them until the big day? Enter the plastic tote.

boxes

I love “totes”. Really – my house is full of these lovely plastic boxes. It makes everything look organized, even if you really just threw stuff in there eight years ago when company was coming over. But I digress. Plastic totes are perfect for organizing your birth supplies. The above picture is actually my birth supplies from my second birth. The top tote has all the little stuff. Here was my personal list:

  • Everything from the basic list above, plus a few additional items from my midwife’s list
  • Several hair ties (in a small plastic baggie, taped to the inside of the box)
  • Chapstick (in the small plastic baggie as well)
  • A roll of paper towels
  • My heating pads, both the plug-in version and my rice heat pack
  • A bath robe

The bottom tote has all the linens I would need. For the bed I had a fitted sheet and flat sheet, a plastic bed protector (I actually scored that at the dollar store), and a really old holey fitted sheet. I gathered four or five old towels I didn’t mind getting dirty or stained (none of them ended up stained) as well as several wash cloths. I also threw in a few pairs of underwear and a pair of socks. This box wasn’t so much about needing things set aside for me, it was more about having it set aside for my birth team. This way I could just say “check the tote” instead of explaining where my sock drawer was.

A note about the bed, and more experienced homebirth moms will know this already – prepare the bed whether you want to birth there or not. Labor is a funny thing and may not go the way you planned (as I found out myself!). The most convenient way to prepare the bed in my opinion is to make what I think of as a bed sandwich. When you go into labor, have your partner strip the bed. Then put on a fitted sheet and flat sheet that are clean and nice. Over this, put the plastic mattress protector (or large plastic shower curtain liner). Then over this put the crappy/holey/old fitted sheet you don’t mind messing up.

If you birth on the bed or get anything on it, you simply strip off the old sheet and protector and VOILA you have a clean and ready made bed underneath! It may sound odd but this was one of the best things after the birth was over. I ran to shower off and when I came back the bed was totally ready with minimal effort for my birth team.

Another great place to store your birth supplies for easy access is the pack-n-play or crib:

tamara birth supplies

Okay – so that is your supplies covered! That was easy.

The Last Weeks

Now there are just a few additional things you may want to do. One is a list. This list will be for your main birth partner. On this list include the steps you want them to take once labor starts. For me and my husband the list looked went something like this:

  • Call midwife (include number)
  • Call photographer (include number)
  • Call child care to give a “heads up” (include number)
  • Make bed
  • Empty washing machine
  • Hook up hose attachment for filling the birth tub, start to fill tub if in established labor

This list meant that I could concentrate on labor and not have to direct anything. I could get in “the zone”. I included the numbers on the paper just in case he couldn’t find them in my phone or his or if someone else was there doing the list instead. I didn’t include “call family” since we agreed we would not call family until the midwife had arrived and I gave the go-ahead. This was a lesson learned in our first birth that sometimes alerting family at the start of labor isn’t always the most peaceful thing to do if labor is long.

If you have a support person for your child, create a little cheat list for them of your child’s routine and favorite foods if they are not familiar with all of that. While the lists might seem over-kill, trust me that the less questions directed at you in labor the happier you will be. It also helps you avoid the little mini-panic that tends to happen in the last weeks when you realize that life is about change in a big way and you want to scream “I have no control” – yes, most pregnant mamas have been right there with you!

The next thing you will most likely want to do is a trial run on your birth tub, if you are using one. My friend and I both were very glad we did a dry run. For myself, we found out the tub had a slow leak and we created a plan for dealing with it. For my friend, she found this:

tamara tub hole

Yes – that is a giant hole. Apparently the plastic of the tub got brittle from the cold of the trunk it was stored in and it cracked. Since she looked at the tub around 36 weeks she had time to get a new tub from her midwife and do a dry run with that tub. Imagine if she had not inspected the tub until she was in labor! Doing a dry run also lets you see where you want to set it up and make space. Keep in mind you want room around the tub for your team to work and have access to you. Also figure out how you are going to fill the tub and think about how much hot water you will need. Some sinks may need an attachment to put a hose on it or may not have good water pressure. You can also fill your tub from the hot water heater or shower. If you are using your own built-in tub in your home, put some nesting skills to use and give it a good scrub down or have your partner do it (I vote for the partner).

tamara tub test

Another thing you may like to work on is affirmation cards. This would be a good activity for a quiet evening before baby comes or even as part of a baby shower or mother blessing. You can hang the cards around your birth space and even put some around the house where you will see them in the coming days (like on your bathroom mirror).

One of the final things you might want to do is be sure a space is clear for your midwife. Most midwives like to lay out their supplies if they have time before the birth is imminent. This can simply be a good patch of clean counter top or space on a bed in the birth area. If your kitchen looks like mine, a clear bit of counter space may mean moving your stand mixer under the cabinet or storing the blender or clearing the kitchen table (mine always ends up as a catch all). If you don’t have time to do this (or birth catches you by surprise) don’t worry, your midwife will find a good spot. Again, remember this is the Ultimate List – not the “stress about everything” list!

krystal midwife prep

You can also take a moment to set up all your postpartum supplies in the bathroom and by your bed. Myself and another friend I know created a breastfeeding station – nursing pads, nipple butter/lanolin, a good book, children’s books and small goodies (for the older child), and a nice water bottle. Some postpartum supplies you might like are a peri-bottle, pads in easy reach, herbal preparations (like those sold by Earth Mama Angel Baby), and over the counter pain medications for after pains (or herbal preparations). Always discuss medications or herbal options with your care provider.

krystal postpartum supplies

A small note about the cleaning that needs to be done. One midwife described it to me this way: “Clean like your Mother-in-Law is coming for a visit.” Basically, clean like you are having an overnight guest and then just take some extra care in a couple key places – your birth space and the tub/shower you may want to use. There is no need to over sanitize and totally tear apart your home in preparation for a home birth, just keep clean and neat. A great investment if you have it in the budget (or have an amazing friend) is to have someone come in and do a nice deep clean around 36 or 37 weeks.

Now you have all the preparation done. You have a peaceful birth space; you have your tub ready to blow up and know how you are going to fill it. You have your support team ready and affirmation cards made. Now you can relax and focus on that moment. That sweet, sweet moment when you hold your baby for the first time. Birth Blessings mamas! Did you do anything else to prep for your home birth? Let us know in the comments!

krystal home birth

*Please note Birth Without Fear does not have an affiliation with any birth supply companies and these are only suggestions.

**Last three photos credited to Aperture Grrl Photography.

Did you do anything else to prep for your home birth? Let us know in the comments!

VBAC: What ACOG Really Says {Birth Without Fear}

VBAC: What ACOG Really Says {Birth Without Fear}

VBAC – Vaginal Birth After Cesarean.

The term and action is wrought with political and emotional meaning in the birth world. Can  you have a VBAC? Does your doctor or hospital “allow” a VBAC? Under what conditions can you have a VBAC? Should it be called a TOLAC (trial of labor after cesarean)? What sort of prior birth history is preferred? Once I have one successful VBAC, will I still have to jump through hoops in subsequent pregnancies?

All these questions and more come up when we start to discuss the mine field that is VBAC in today’s world. But I wanted to know what ACOG really says. I am not talking about the public statements – which you can read HERE. I want to know what ACOG is saying to the doctors, what they put out in their practice guidelines.

vbacacog

The document I found is HERE. I encourage you to not only look at the document for yourself, but to also follow the many links I have scattered throughout this article.

At the opening of the document, ACOG has this to say:

Trial of labor after previous cesarean delivery (TOLAC)* provides women who desire a vaginal delivery with the possibility of achieving that goal––a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient’s preference for vaginal delivery, at an individual level VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies. At a population level, VBAC also is associated with a decrease in the overall cesarean delivery rate (1, 2). Although TOLAC is appropriate for many women with a history of a cesarean delivery, several factors increase the likelihood of a failed trial of labor, which compared with VBAC, is associated with increased maternal and perinatal morbidity (3–5). Assessment of individual risks and the likelihood of VBAC is, therefore, important in determining who are appropriate candidates for TOLAC. The purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and provide practical guidelines for managing and counseling patients who will give birth after a previous cesarean delivery.

Lets start with noticing that ACOG automatically terms all VBACs as TOLACs first. If you complete the trial with a vaginal birth, then it is a VBAC. The issue with this sort of wording (and thought process) is that it sets women up with doubt and it sets the doctor on the defense against the failure of the trial. I will use the term interchangeably only because the document that I am citing uses the term so often. But moving past this unfortunate wording we do see that they know VBACs are beneficial. They state that VBACs lower the maternal morbidity rate and risk of complications in future pregnancies and that as a whole they lower the cesarean rate. They do also point out that there are certain factors that make a TOLAC less likely to succeed, and that when they do “fail” you are more likely to have morbidity (which makes sense, as a major surgery is considered a morbidity to begin with).

In the “Background” section at the start of the Practice Bulletin we see several points that seem to be denied in the general obstetric community. First they state that the cesarean rate has increased rapidly since the 1970s, from 5% to more than 31% in 2007. They blame this increase on the introduction of electronic fetal monitoring, and the decrease in breech births and forceps births. I put emphasis on the EFM use, since we are often told that it is needed for a safe birth, even though research proves that it does not lower fetal morbidity or mortality. Again and again, research also shows that it increases the chances of a cesarean, which in turn increases the risks to mother and baby. Yet, ACOG still insists on the use of EFM as standard care.

They also state in this section that after the 1970’s VBACs gained popularity. By the mid 1990’s the rates of VBAC (28.3%) were such that it was actually reversing the cesarean rates. However, this increase in VBACs seemed to come with an increase in uterine rupture – though the literature does not state what sort of uterine scars were common (since certain types are known to have more risk, such as classical), whether induction was used, or what type of rupture occurred (most ruptures are not catastrophic but are instead considered a “dehiscence”). Due to this increase in ruptures, the case for VBACs was again set back to “once a cesarean, always a cesarean” in many practices. They finish this section by stating that it is known that liability is a large part of why VBAC is not offered to many women who are actually good candidates.

Now we get into the nitty-gritty of what they say about VBAC. I am going to take questions and statements from the document to break this down. All noted pages are from the Practice Bulletin unless otherwise stated or linked.

  • What are the risks and benefits associated with TOLAC? (p2)
    • Neither an Elective Repeat Cesarean (ERC) or a TOLAC are without risks.
    • Most maternal morbidity that occurs during TOLAC is related to a failed attempt when a cesarean becomes necessary.
    • VBAC is associated with fewer complications than an ERC.
    • Thus, the risk of a VBAC really comes down to whether it is achieved. If it is a “failed” TOLAC it has more risk than an ERC, but if it succeeds, it has lower risk than a ERC.
    • The main risk of TOLAC/VBAC is a uterine rupture. However, as stated in the background, some studies do not give background information about what type of ruptures are occurring nor on what type of prior incision or induction methods.
    • They include a chart of maternal risk in this section and it is interesting to note that maternal death risk can be almost double (0.2%-0.4%) with a ERC compared to a TOLAC after one prior cesarean (0.2%), and that TOLAC with more than one prior cesarean had no death risk within those studies. It is also noted that a ERC also comes with the risk of uterine rupture (0.4%-0.5%).
    • It is noted that for families wanting several children a successful VBAC takes away the risks of multiple surgeries which includes hysterectomy, bowel or bladder injury, transfusion, infection, and abnormal placentation such as previa and accreta.
    • They include a chart of neonatal risk factors when comparing ERC to TOLAC. It should be noted that there is no significant increase in neonatal death or neonatal admission (NICU admission). We see a much higher rate of respiratory distress (1%-5% vs. 0.1%-1.8%), transient tachypnea (too much fluid in the lungs which causes breathing issues) (6.2% vs. 3.5%) and hyperbillirubinemia (jaundice) (5.8% vs. 2.2%) in babies who go through an ERC.
  • What is the vaginal delivery rate of women who have a TOLAC? (p3)
    • Most studies show a 60-80% success rate.
    • Studies show a decrease in success if the same circumstances happen again, such as stalled labor, which lead to the first cesarean  (however, I will note that the definition of “stalled labor” is more likely the issue than anything else).
    • The chances of success are increased if the mother has spontaneous labor with no augmentation.
    • One VERY interesting note is that being “non-white ethnicity” lowers your chances of success. This speaks to the huge disparity in maternity care in ethnic groups in this country. Simply taking one look at the maternal mortality rate in non-whites gives a clear and horrible picture of this undercurrent in our maternity care system.
  • Who is a candidate for VBAC? (p4)
    • The best candidate is one in whom the risks and benefits balance out in a way acceptable to the client and care provider, this may be different for each woman and there is no specific “formula” to come to this answer.
    • Decisions about the first VBAC should be considered with future pregnancies in mind. This is due to each subsequent cesarean increasing the risk for future pregnancies, and the inability in some areas to find care providers to attend a VBAC after multiple cesareans.
    • For most women with one prior cesarean and a low transverse incision VBAC is a good option and they should be counseled and offered a TOLAC. Women with other incisions (T-incision or classical) or with prior ruptures and surgeries of other sorts to the uterus should be evaluated more.
    • Individual factors should be considered in all cases (i.e. – no hard and fast decisions to ruling mothers out of VBAC), and in the case of women presenting in labor, VBAC should be strongly considered as spontaneous labor increases the success rate of a TOLAC.
    • More than One Prior Cesarean:
      • Studies addressing TOLAC in women with more than one prior cesarean find rupture rates ranging from o.9% to 3.7% – again, without specifying the type of prior incision or level of rupture. They also have not consistently compared these findings directly to women with only one prior cesarean.
      • One large study in particular found no significant increase in rupture between VBAC and VBAMC (vaginal birth after multiple cesarean) – o.7% vs. 0.9%. A second large study only found a slight increase – 0.9% vs. 1.8%. They also found no significant increase in morbidity.
      • The chances of success are similar to that of a VBAC after only one cesarean.
    • Macrosomia (Big Baby):
      • Some studies show a decreased chance of success with a baby larger than 4,000g, and posibily higher rupture rates. However, these studies are based on actual birth weights, and not the estimates given before birth. This is significant given the inability to accurately predict birth weight before the birth.
      • Suspected macrosomia alone should not rule out TOLAC.
    • Gestation of more than 40 weeks, according to the largest study done which looked at this factor, does not increase risk. There is evidence that after 40 weeks chances of success decrease but we must consider that induction of some sort may be common at that point (given current practice trends) and that lowers the chance of VBAC in general. Gestation of more than 40 weeks should not rule out TOLAC.
    • Previous Low Vertical Incision:
      • Studies show similar rates of success compared to low transverse incisions (the most common).
      • Studies do not show increased risk of rupture or morbidity for mother or baby.
      • Studies are limited, but a low vertical incision should not rule out VBAC given the current information.
    • “Unknown” previous uterine incision should not rule out VBAC. The two large studies done at large tertiary hospitals show that there is no increase in rupture rates or morbidity, and success rates are similar. Unless there is a high clinical suspicion of a complicated previous uterine incision TOLAC should not be ruled out.
    • Twins Gestation:
      • In all studies available it is shown that in women with a previous low transverse incision there is no increase in risk to VBAC a twin gestation.
      • Success rates are similar to those of singleton mothers. Twin gestation should not rule out TOLAC.
  • How does management of labor differ in a VBAC? (p5)
    • Induction of labor for maternal or fetal factors remains an option for TOLAC. However, the increased risk of rupture that comes with any induction and the decrease in success rates should be discussed.
    • One large study of over 20,000 women found that rupture rates increased slightly with induction. Spontaneous labor had a 0.52% rupture rate, non-prostaglandins induction with a 0.77% rate, and with prostaglandins a rate of 2.24%. However, again the types of rupture were not specified and the context of the inductions are not known (unfavorable cervix, need for multiple induction methods, etc).
    • Another study of over 33,000 women found a slight increase in rupture (o.4% for spontaneous labor, 0.9% for augmented labor, 1.1% for oxytocin alone, and 1.4% with the use of prostaglandins). An analysis of this same study noted an increase in rupture rates when the highest levels of pitocin were reached, however no upper level of dosing has been decided for VBACs.
    • Studies done on the risks of misoprostol (cytotec) show an increase risk of rupture and should not be used for TOLAC. (Actually, it increases risk of rupture in ANY mother so it should not be used for induction, period.)
    • Due to the small absolute risk found in several studies, ACOG notes that use of pitocin for labor augmentation is not ruled out for VBAC.
    • Mechanical cervical ripening (such as the foley bulb) are also considered acceptable for labor augmentation/induction in VBAC.
    • ECV (External Cephalic Version), such as to turn a breech baby, are not contraindicated in a woman who wishes to VBAC.
    • Epidural/Analgesia use is not contraindicated and studies show it does not effect success rates. However, epidural use in general is shown to increase the chances of cesarean in all mothers. (to view that study, right click and select “copy link location” and input into google)
    • Electronic Fetal Monitoring is suggested since the main sign of uterine rupture is abnormal fetal heart rate (up to 70% of cases). It is noted that internal monitoring does not help in diagnosing ruptures.
  • How should future pregnancies be managed after uterine ruptures? (p7)
    • If the rupture is in the lower segment of the uterus, the chance of another rupture is 6%. In the upper sections of the uterus it is around 32%.
    • ACOG suggests an elective cesarean for births after a rupture.
  • How should women be counseled about TOLAC/VBAC?
    • Each woman will weight the risks and benefits differently. Therefore, the options should be discussed at length and documented.
    • Counseling should always consider the future plans for more children and discuss the risks of multiple uterine surgeries. Women should also consider that family plans can change or there may be unexpected pregnancies.
    • After counseling the ultimate decision should be made by the client. Global mandates (aka – hospital wide) should not be made as they do not consider the individual factors and wishes of each client.
  • What resources should be available at a facility where a woman will VBAC?
    • The previous suggestion of ACOG was that VBAC should only be offered in facilities with “immediate” access to surgical facilities and staff. However, this severely limits the locations where women could VBAC.
    • ACOG now suggests that care providers and clients consider the facilities available, their individual risk factors, and the availability of other locations where more resources are available.
    • Health care providers and insurance companies should do all they can to facilitate women in achieving VBAC through transfer of care or co-management of care.
    • If there is no way to transfer care, a woman’s autonomy should be respected. If a woman wishes to VBAC in a hospital without immediate access to surgical facilities steps should be taken early in care to develop a plan of action in case of rupture.
    • It should be noted that coercion into a repeat cesarean is not appropriate. A policy of not allowing TOLAC at a facility should not be used to deny care or force a woman into a repeat cesarean. If appropriate, transfer of care should be arranged to a facility and care provider who is better able to support TOLAC.

Now I would like to take a moment to talk about the notion of only “allowing” VBACs in facilities with immediate access to surgical teams and facilities. Lets compare the risk of rupture, 0.7% in most studies, which is not always catastrophic, to the risk of other obstetric emergencies. Cord prolapse, a very dangerous situation in which the cord proceeds the baby down the birth canal and gets pinched, occurs in about 0.28% of births. This situation requires immediate access to a cesarean in most cases. Placental abruption, another very serious complication, occurs in about 0.7% of pregnancies. This also requires immediate access to cesarean in almost all cases. Notice that the risk of abruption and the risk of rupture are the same. The rate of shoulder dystocia, which is considered an emergency that may necessitate a cesarean (or an instrumental birth) is around 1.29% though some studies report it at higher rates in the current birth climate.

Now looking at the rates of these complications, which are on par with the risk level of rupture, we have to wonder why ALL hospitals offering birth services are not required to have immediate access to a cesarean. After all, placental abruption happens with the same frequency and can happen in any pregnancy and ACOG does not seem to be concerned that EVERY pregnant mother does not have access to immediate surgical care. At the end of the day, the risk/benefit analysis needs to be decided by the mother and what she feels comfortable with since the rate of rupture is comparable to the risks of any pregnancy and birth.

The point of this article is not to suggest any particular course of action for every mother. This is about giving you the facts to make your own decision. This is about looking at what ACOG really says about VBAC/TOLAC and not just what your doctor tells you they suggest. Arm yourself with information and consider your own personal factors and Birth Without Fear, no matter how you choose to birth.

Breastfeeding Rights: On Being Asked to ‘Cover Up’ By a Home Depot Employee

Breastfeeding Rights: On Being Asked to ‘Cover Up’ By a Home Depot Employee

I noticed how polished she was. Flirting with a guy who was loitering around the taco truck and asking her again when she got off work. She said, “Nine.” I considered complimenting her on her perfect ankle boots.

I sat down on the gray wooden box that probably holds pylons or road salt (but wait – it’s California – no ice here) and put my shopping bags beside me. Baby Evie wasn’t in her carrier because we had taken the car. My husband and son had gone to Home Depot, and baby and I to my preferred big box store. It’s a craft emporium and sells such craft-making necessities as “Christmas scent” and “One hundred things you might need someday”.

I waited. We were supposed to meet at the Home Depot checkout but I needed to nurse Evie. She had been patiently smacking her lips and making occasional lowing noises since half-way down the Mod-podge aisle. In the thousands of square feet of the craft store, patronized mostly by women, there was nowhere to nurse her. Outside in the new evening there were some wire-frame benches at the bus stop but to reach them I would have had to cross a busy parking-lot street with a baby, a purse, and two full shopping bags in my arms. I’m always scared of being hit by a car anyway.

So I sat on that gray box outside the Home Depot exit and cuddled baby up. I wasn’t wearing a nursing top, just a v-neck sweater and a tank-top underneath. I pulled them both down and latched her on. She nursed contentedly. I found I couldn’t meet the eyes of the well-dressed security woman checking receipts at the door. I found I had already known she would disapprove. Much to my chagrin, I found that I cared. I didn’t want to, but I did.

She asked me to cover up.

In my two-and-a-half years of nursing I have breastfed in public places across Canada and in parts of the US. I have breastfed in front of friends, family, strangers, public officials, flight attendants, doctors, my husband’s boss, and at least one family pet. Nobody has ever asked me to cover up.

She said people were staring.

I asked who. I looked around. I saw no one. I shrugged. She rolled her eyes and huffed. Like, if I want to be a slut, that’s my problem. Which it is. I mean, which it would be.

My heart was pounding. But my baby is hungry. She has been so patient. She doesn’t nurse with a cover and would inevitably pull it off. Why would I have to cover, anyway? I’m not doing anything wrong. My right to do this is protected by law, dammit! And breastfeeding in public won’t become culturally accepted until women start breastfeeding in public. 

Kristie Robin I

As if on cue, Evie felt the (immense) milk letdown coming and pulled off. So now my nipple, spraying like a geyser, was exposed. I pulled her close so it would just spray onto her onesie (babies are supposed to smell like milk, right?). Under the stare of the security worker, I let her latch back on. We nursed for a few more minutes. I stopped it early and gathered my things, walking around to the entrance of the store so I could look for my husband. I just didn’t feel safe.

The moment of breastfeeding is more than just a soft, intimate act. It’s also a moment of vulnerability. It feels primal to me. No female ancestor could fight off a saber-toothed tiger while holding a baby to her breast.* While only I can decide whether or not I want to breastfeed, my success in breastfeeding requires consideration from other people. When I sit down to nurse Evie, I depend on other people not to insult me, ostracize me, sexualize my actions, or invade my space. You know, to take a turn battling those saber-toothed tigers – not to come running at me shouting caveman obscenities.

boobs gif

*It’s reflected in the biology of breastfeeding – for most women, stress inhibits their ejection reflex (instead, I have an ejection reflex like those bullet-shooting ta-tas in Austin Powers, but that’s another GIF altogether).

Because let’s face it: I’m human and if people told me to leave or cover up everywhere I went, I would stop nursing in public. If my husband acted grossed out or jealous when I nursed at home, I would stop nursing there, too (or just get a divorce, but then who would take our kids to Home Depot every week?).

In a culture that fetishizes female bodies, their exposure is not inert. Maybe some people were staring, just as they would stare at a woman wearing a revealing shirt. But I can’t imagine an employee asking a woman who was baring her breasts in that way to cover up. In fact, she might even receive better service. In any case, it’s up to me whether or not I am concerned about people ‘staring’ at me.

I don’t give a rat’s ass about people staring at me. I’m just that kind of gal. I do care about having society’s shame thrust upon me when I am feeding my baby. It was the Home Depot employee who felt uncomfortable and it was wrong for her to project her discomfort onto me. I’m starting a correspondence with the store manager the moment this post goes live. Stay tuned for a follow-up.

Home Depot, you messed with the wrong mama.

Kristie Robin II
Have you ever been told to cover up? What did you do? How did you feel about it?

**Images of breastfeeding at Home Depot by Kristie Robin of Kristie Robin Photography.

Grief And Guilt {The Birth Trauma Experience}

Grief And Guilt {The Birth Trauma Experience}

Trauma after the birth of a baby is a ‘special’ kind of trauma.

It’s a bittersweet kind of trauma. It’s a silent kind of trauma. It’s an invisible kind of trauma.

And if your baby is healthy, it is usually considered an unjustified kind of trauma.

I suffered from birth trauma. It was agonising, painful, and heartbreaking. I was alone, and misunderstood. It began the first night, a few short hours after the birth of my first daughter, from the moment my partner went home for the night. I was alone in the dark in my single room with this tiny little newborn. I held this chubby baby girl in my arms, and felt nothing but sadness at the experience we had gone through together to bring her into this world. I’d feel a stab of shame every now and then, and scold myself for being so ungrateful – my baby was here, wriggling in my arms, and I had the nerve to even consider mourning the experience that brought her to me. I would quickly go back to the sadness, mourning the loss of a dream – a beautiful and empowering birth experience. That night was the beginning of a four year battle with birth trauma.

My grief was deep, and some days I felt I was drowning in it. I floundered, being hit by waves of sadness, disappointment, and anger. I replayed the labour over and over in my head. I beat myself up with ‘what if’ and ‘if only’. I felt responsible; I blamed myself. I felt cheated, let down; I blamed my partner, I blamed the midwife, I blamed everyone. I tried to pinpoint where it went ‘wrong’, where I  went wrong. News about new babies had me sobbing, even watching birth scenes in movies was painful. A phone call from my sister, hours after the birth of her son, left me feeling like I’d been hit by a truck, and I hid behind shelves in the department store I was in and I just cried and cried. I bitterly wished for every woman to have a horrifying experience, and I felt an unimaginable hurt when I saw women emerging from birth empowered and ecstatic. It wasn’t that I wanted every woman to experience the pain of birth trauma, but I just wanted to them to know my pain.

 

I suffered terrible postnatal depression and post-traumatic stress disorder, even though my trauma largely went unacknowledged. Where it was acknowledged, it was usually deemed unwarranted. My experienced was pushed away and minimised by well-meaning but hurtful comments from others…

 “Years ago, you both would have died. Thank goodness for modern medicine.”

“It’s just one day in your life.”

“You were probably never going to give birth naturally anyway.”

“It’s probably because of your birth plan. You can’t control birth, you know. If you didn’t have such high expectations, you wouldn’t be so disappointed.”

“At least you are both alive and healthy, that’s what really matters.”

The comments were so hurtful. I felt like very few people understood. What about me? I would think. How can you say I am healthy? I feel like I am falling apart. Does my mental health not matter? I should have been overwhelmed with love for this tiny little bundle of joy, but instead I would hold her, look at her, and wish that I felt something. I was numb.

Sometimes I retold my birth story. I rarely came across anyone who had a story like mine, and people would cringe and exclaim “oh my goodness that’s terrible”, and then tell me their story. Sometimes they would have their own war story to tell, and I would listen and we would joke about never doing that again… But that wasn’t what I wanted.

I craved validation. I craved acknowledgement. I just wanted to tell someone my story, have them hold me as I cry, and look me in the eye and say: “I’m so sorry. You were cheated. You deserved better. You should have been able to birth the way you wanted. Your pain is justified. You have every right to grieve, without guilt.”

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Maybe your birth trauma hit you straight away, or maybe it slowly grew, beginning as a nagging feeling you didn’t quite understand and growing into a deeper pain. Maybe your plan for birth went way off course, or maybe you didn’t have a birth plan but you wished that you had. Maybe you sometimes think that you weren’t informed about your choices, or maybe you think your pain could have been eased if you knew, and expected, less.

Maybe you had a caesarean. Maybe you had an instrumental vaginal birth. Maybe you had an unmedicated birth. Maybe you birthed in a hospital. Maybe you didn’t make it to hospital. Maybe you birthed in a birth centre. Maybe you had a planned homebirth. Maybe you asked for pain medication, and didn’t get any. Maybe you asked for support in a drug-free birth but was pressured into using medication. Maybe you had an unexpectedly fast labour, or an unexpectedly slow labour. Maybe you refused a procedure, but it happened anyway. Maybe you wanted a certain procedure, but no one listened…

Or maybe, none of this happened. Maybe it’s not about how you birthed. Maybe you birthed exactly as planned – but your trauma relates to how the nurse spoke to you or looked at you or ignored you…

Maybe you feel unsupported, alone, unjustified, silly, or even selfish. Maybe you’re sad. Disappointed. Angry. Hurt. Jealous. Afraid. Ashamed. Guilty. Responsible. Maybe you don’t feel any of those things…

Birth trauma can happen to anyone, in any situation. Birth trauma can happen to you, and even to your partner. Your experience is totally unique, and it doesn’t matter how anyone else feels about their birth or what anyone else would have done. Birth trauma is about how YOU feel about YOUR birth. Birth trauma is about YOU and YOU alone.

But make no mistake, you aren’t alone. Right now, thousands are alongside you, silent in their trauma and suffering.

Birth trauma is real. And needs real support.

To the mothers out there, dealing with birth trauma, I want to offer you my empathy, and my deepest condolences. Birth trauma is real. Your pain is real. Your pain is justified. You deserved a wonderful birth experience, and it is unfair that you didn’t get that. You deserve support. You have the right to grieve without guilt.

To the partners, friends, family, midwives, doulas, doctors, nurses, acquaintances… offer your empathy, and your deepest condolences. Birth trauma is real. Their pain is real. Their pain is justified. They deserved a wonderful birth experience, and it is unfair that they didn’t get that. They deserve support. They have the right to grieve without guilt.

 

Circumcision Doesn’t Beget Circumcision {One of These Things is Not Like the Other}

Circumcision Doesn’t Beget Circumcision {One of These Things is Not Like the Other}

Yes, you read that right, we’re going to talk AGAIN about circumcision, but this post is a little different. I’m not writing this to try to tell you what to do. In fact, this post is actually going to start off with a confession; the day after my first baby was born I had him circumcised.

Whew. Okay. We got that part out of the way!

When I was pregnant with my oldest child, I must have read everything that I could get my hands on. I was very strict with myself and did everything that I could to maintain my weight, to avoid every item on that list of no-no foods (deli meats, sushi), and struggled through headaches and pains to avoid using medications like Tylenol even though my OB said it was fine. I started a pregnancy journal and had the baby’s full name picked out by 14 weeks along.

pregnancy second baby

When I got to the chapter in my pregnancy how-to book about circumcision, we had just found out that the baby was going to be a boy and I remember reading about the detailed procedure and cringing, picturing them doing this to my tiny, new baby. I had never really read anything about circumcision before, and not only that, but I literally knew NOTHING about foreskin. Like many new moms-to-be, I decided to leave that decision up to his father, figuring, “Well, Dad’s got a penis and I don’t, so he will know the correct decision to make here.”

Well, it turns out that my husband was reading FAR less about this baby than I was and without researching any part of it, or even reading the chapters I had so nicely bookmarked for him, he told me that we would have it done because “that’s just what you do” and “we don’t want him to look different.” Even though the description had made the hairs on the back of my neck stand up, I didn’t argue with him.

I ended up being (unnecessarily) induced and after 12 hours of Pitocin, our perfectly healthy baby boy came torpedoing into this world. The circumcision was performed the following day and we listened closely as all of the aftercare instructions were explained to us. They even sent us home with a whole packet of information about how to care for it and danger signs to look out for in case he got an infection. (Whoa, wait… an infection?? Isn’t that what we were trying to avoid? We’ll get back to that.)

Have you ever seen a freshly circumcised penis? It’s basically an open, raw wound that you smother with Vaseline and hope that it keeps it moist enough to not stick to the diaper. Have you ever skinned your knee open? Imagine the feeling of peeling a gauze bandage off of it when it gets stuck. Now imagine someone pouring warm, acidic liquid all over it; because that’s what’s happening to this brand new, little person every time they urinate. Then that wetness gets to just sit there. You ever wear a moist Band-Aid over a cut?

Every time our new baby wet his diaper we immediately had to change him because it hurt him so badly. And when he would poop, well, that was a whole different ball of wax! Cleaning poop off of a penis and a set of testicles (especially when it’s a learning experience with a less than one week old) is one thing, but having to do it while your child is screaming bloody murder in your face because he has feces covering his raw, sensitive glans is quite another.

Fast forward a few years and now he is almost five. We are constantly reminding him to clean himself and have had to teach him to be sure to tug on his “foreskin” (basically just the remaining bit of skin that was leftover) and pull it away from the glans because it is constantly trying to reattach itself. As our son has gotten older, we have had issues with the “foreskin” trying to reconnect and also teaching him how to keep himself clean.

So when we got pregnant with our second child, I was in a different spot with the medical side of birth. I had not had a good experience with my first delivery and therefore spent a lot of time reading more than just baby books and fear-mongering websites. I started to look into the facts about birth, the facts about induction, and even the facts about circumcision. We found out that we were having another boy and the decision of circumcision came up after a prompting from our care provider.

Like I have already stated, my husband was not into researching everything pregnancy like I was and so it wasn’t something that he was concerned with. He had automatically assumed that because we had circumcised the first boy that of course we would be doing the same with the second. All those complications involved with the first baby? Yeah, those weren’t necessarily complications at all! They were just snags that happened when you leave the glans open and raw like that. Those issues we had with our first baby in the first several weeks we were all learning how to be a family were totally “normal” and were all listed in our handy little info packet that was sent home with us.

In reading up about circumcision I was very surprised to learn that, with the exception of Israel, the United States has the highest rate of circumcision. Most countries don’t practice it, in fact many have had the procedure banned. In some cases, circumcisions are botched, leaving men with noticeable scarring or sexual dysfunctions – and that is in mild cases: baby boys sometimes die from the complications of circumcision.

I also took the time to learn about the many functions of the foreskin and how having one intact would benefit my child. It might be tough to think of it like this, but the foreskin can easily be likened to an eyelid or a pair of lips. One of its main functions is to protect the sensitive skin underneath and to keep that area clean and moist.

Along with keeping the area underneath clean and moist, the foreskin is actually adhered to the glans and won’t even start to detach until around age three! So all that stuff we had heard before about it being “cleaner” to cut that part off was total BS! It’s attached! That means when your baby has one of those really big poo-splosions and craps up the back of his onesie, you won’t have to also deal with carefully and calmly wiping poop off of a swollen and painful wound. With a baby who is NOT circumcised the foreskin does a fantastic job of keeping everything covered, so you don’t have to worry about it getting inside at all! You just clean it off like a finger (likely how you’ll clean up your own finger after checking for poop) and go about trying to remove said onesie without resorting to scissors.

Then there came the whole deal with him not only looking different from his Daddy, but also looking different from his older brother. Well, when you really get down to it, they’re already going to look different in so many more obvious ways, does it really matter? For instance, our oldest boy has green eyes and his younger brother ended up with blue ones. His older brother has light brown hair while his head is covered in pale, blonde locks. They are different heights, different weights, and have vastly different personalities, so why in the world would anyone be worried about their penises looking the same, which they probably wouldn’t anyway.

circumcision decision

I was asked about what we would do when he was teased about his foreskin in the locker room at school and I honestly had to laugh at that one. First of all, adolescent boys are going to tease one another about SOMETHING, so for me to be worried about that NOW seems a bit pointless. Secondly, the circumcision rate in America is going down every year, so chances are he will not be the only boy with foreskin. And lastly, because I will explain to him why we left him intact when he is old enough to understand, he will be able to educate his friends and tell them how when he’s older, having a foreskin will make sex feel better for both himself and his partner, allow him to masturbate without needing lotion, and add girth to his penis. What adolescent boy wouldn’t want that?

And while we’re on the topic of sex we may as well just get it all out there right now: “Anteater”, “turtleneck”, “Water Snake”; the list of horrible, sex-shaming nicknames goes on. It’s a disgrace that we would alter a baby’s body so drastically just to make it more aesthetically pleasing for ourselves. Yet if someone wanted to start trimming the labia from the genitals of baby girls I am positive that people would be totally up in arms. Has it ever occurred to anyone that the basic function should override the supposed aesthetics?

I have also been asked about what I will say to my oldest son if he should ever ask me why I decided to have his foreskin removed and not his brother. Well, I plan on telling him the truth. I thought that I had read all of the right information and, at the time, I thought I was doing what was in his best interest. However, if I am truly honest with myself, reading about the procedure made my stomach turn. That feeling was human instinct and I plum ignored it. I thought I knew what I was doing and I was wrong. I felt in my heart that going through with the procedure was a bad idea but did not feel like it was truly up to me to make that decision.

And truth be told, it wasn’t. It wasn’t up to me and it shouldn’t be up to the Daddy either “just because he has a penis”.

So, okay, they say that circumcision is “cleaner” and “healthier” and will keep your child from “being made fun of.” Well let’s just say you believe all of that (which is fine, and it might be what your care provider has told you); where does it say that this procedure HAS to be done within the first week of your child’s new life outside of the womb? Isn’t there already enough going on? Chances are you’ve got a birth you’re healing from, other children to care for, breastfeeding (which can be quite stressful for some) to learn, and you’re probably hungry and sleep deprived. WHY in the WORLD would you want to add in “caring for an open wound”?

Where does it say that the offer to be circumcised will expire after the first two days? Why can’t it just be left up to the person whose penis status is being questioned to decide? A lot of people will get a child’s foreskin removed because of the possible risk of infection. But what about tonsils? Appendix? TOENAILS? All of these things can become infected yet we make no mention about having them removed at birth. Many people will research more about their newest cell phone upgrade than they will about their own pregnancy and labor, and even fewer will research about circumcision.

brothers

If I were to wish one thing for you, it would be for you to read, read, read about circumcision. Don’t just read about it in the US, check out what they say about circumcision in other countries, where it is seen as a barbaric practice. Or do your baby a solid and watch the procedure being done on YouTube. Arm yourself with knowledge and if anything, wait until the child is old enough to be given proper pain management for such a painful procedure. Even better, leave them intact and allow them to decide it for themselves.

It makes me sad when I think about what I have taken from my oldest son by having him circumcised, but I feel like I have all the opportunity in the world to help make it better by passing on what I have learned to others. Hopefully, with the correct information, they will make better choices than I did. I have looked into the information on foreskin restoration so that I may pass it on to my son should he be interested in it one day.

Having circumcised one child does not mean that you have to circumcise them all. Even if you have FIVE boys that were circumcised you can TOTALLY leave the next intact! None of our children will be exactly like the next. Even if their genitals don’t match Daddy’s or each other’s they will always be brothers and that is what’s important. I leave you with a quote that has always resonated with me about our decisions regarding circumcision:

forgiveyourself

Forgive yourself for not knowing what you didn’t know before you learned it.” – Anonymous

Photography Credit: http://earthmamaphotography.com

Further reading:
http://www.thewholenetwork.org/index.html

http://www.cirp.org/library/

http://www.catholicsagainstcircumcision.org/

http://www.doctorsopposingcircumcision.org/

http://www.jewsagainstcircumcision.org/

http://www.mothersagainstcirc.org/

http://circumcisionresources.org/

http://uncutting.tumblr.com/compilation

http://www.publichealthinafrica.org/index.php/jphia/article/view/jphia.2011.e4/html_9

http://www.noharmm.org/anatomy.htm

http://www.icgi.org/2010/04/infant-circumcision-causes-100-deaths-each-year-in-us/

http://www.psychologytoday.com/blog/moral-landscapes/201109/myths-about-circumcision-you-likely-believe

Beautiful Breastfeeding while Pregnant Moment

Beautiful Breastfeeding while Pregnant Moment

Yes, it was removed from Facebook, but really we just want to share this gorgeous picture of a mother breastfeeding her child while pregnant with another. This is real life folks. #peaceloveboobs #normalizebreastfeeding.

IMG_7985

I had my first breastfeeding image removed from my personal FB page today.  This photo is so special to me because of 2 things, first, my son whom I never thought I would be able to breastfeed is 2.5 years old and going strong and second, because I am 26 weeks pregnant with my 4th son and am thrilled to have kept nursing through this pregnancy and really look forward to the amazing bond my kids will have through tandem nursing.  {Whitney Hempsey}

My Fearless Birth {Home birth turned hospital}

My Fearless Birth {Home birth turned hospital}

My wife, Jenny, and I tried for two years getting pregnant, so when we found out on our 2 year anniversary trip that I was pregnant we were more than excited! I had known since we started trying that I wanted a home birth. I educated myself as best I could. I started taking a Hypnobabies class, hired a midwife and a doula, and soaked in any and all information my fellow home birth moms had to offer.

Since the day we had come back home after finding out, spiritual things started happening in our home. We chalked it up to being my wife’s father, who passed away. Our midwife, Susan, and doula, April, were so very kind to hear us out and not make us sound crazy. Actually they helped us come to terms with it. After that things settled down until around November. We were all sitting there talking about the new things that were occurring in the house and new feelings surfacing when I started telling them that I had always had a feeling the baby was going to come early. Jenny kept saying the date December 5th kept sticking out in a big way. This so happened to be the same day her father died. We talked to the spirits (assuming it was her father) letting him know Dec. 5th was too early and we wouldn’t be able to have a home birth.

December 5th came around and sure enough I went into early labor. The only thing that kept me from going into full labor was that I put myself on bed rest for the next couple weeks. All was well.

Friday, January 4th at 3:00PM labor starts again (Due date was Janurary 3rd). Our 10 year old son, Quenton, came home from school and saw me practicing my Hypnobabies and getting super excited. It had been planed for him to be leaving that day for the weekend but he didn’t want to go. We told him it was OK, he had to go, but he was going to be a big brother when he got back. He went on his way. I tried keeping myself occupied by working on the baby book and a calendar project with friends and families guesses when they thought I’d have the baby. I was getting restless by the evening and we went and rented movies.

That night my sister came over to help out. I was stressing out with getting the room and bathroom ready since pressure waves (contractions) were getting closer and stronger. I was also obsessing about who was going to take pictures that I couldn’t focus on Hypnobabies. When she came things started progressing even more. We focused hard with Hypnobabies and used the yoga ball a lot. Later that night April and Susan came over after waves started getting closer. Jenny and I did very well through each wave. We were all very excited to meet our baby boy. We talked and laughed through each of my waves. I felt good. I felt on top of each one, progressing nicely. Since it seemed like it was going to be soon we all thought it’d be a good idea to get some rest. Even though I knew I needed the rest, once I laid down my waves slowed down. Around 8:00am (Jan. 5th) I asked Jenny to go make everyone some breakfast. I was upset and wanted to be alone for a little while. I was so sure this was going to happen and I felt bad for calling April and Susan over (since they lived 30 mins away and both had kids). They assured me it was OK but that they were both going to go home and to call them when things picked up again. I liked that idea because I was ready to do this on my own again and concentrate on what I was doing.

home birth

(Saturday, January 5th)
Jenny and I decided to go rent a couple more movies around 11:00am to help me relax again. I remember breaking down while in the aisle at the rental place because the waves were getting so strong. We took the day to work through the waves that were quickly intensifying again. I could tell they were getting stronger than the ones I had the day before but I did not want to call April and Susan until I felt like we were really ready (in my mind I wanted to call when I felt like I wanted to go to the hospital). I did not want to take the chance of calling them and labor slowing down again. My brother came over to borrow some stuff and I remember working through the waves with breathing techniques. He was surprised to see I was that calm while in labor (although I personally felt like I was going outta my mind). We used different techniques of Hypnobabies. I tried walking up and down the road which didn’t work too well for me because it was just hurting too much. I got in the bath a lot. I rolled around on the yoga ball, also. I couldn’t put my finger on it, but I was falling out of rhythm with Hypnobabies and I could feel EVERYTHING. I would cry and the hospital kept crossing my mind. We were so sleep deprived at this point. Even though we would rest, we would get woke up every 5-10 minutes by a strong wave.

Around 10:00pm we felt we were ready for April and Susan to come. It was like deja vu, yet waves were definitely longer and stronger than Friday nights. My mom was now there since we just “knew” this was it. I got in the tub with candles and my wife. She’d rub me down with oils and we had finally gotten back into a fabulous Hypnobabies rhythm. Jenny would chant the cue words in such calming and comforting ways that she ended up putting my mom to sleep. When my mom would wake up, the vibe around the room was so different. Like a warm blanket being put on you coming in from the cold. I’m still cold, but the comfort was there. She was so brave and strong for me. Always telling me how proud she was of me. That was a big moment in my life as we had not had a close relationship growing up.

Early morning came (Sunday) and when I laid down again waves slowed down. Again, April and Susan went home. I was so upset. I cried and cried and kept saying I just can’t keep doing this. I had been working so hard at this point to stay in the zone of Hypnobabies. I didn’t know how much more of this I could take.

(Sunday, January 6th)
First and foremost- I’m not above admitting that by this point I had gone through enough and was ready to go to the hospital. The thing that stopped me was the simple fact that I had went on and on about how much I wanted this home birth and I did not want to disappoint everyone who rooted me on.

Jenny and I were left alone again, and although the waves slowed down in length they, by no means, slowed down in intensity. To be perfectly blunt- I was pissed. I was annoyed. What the heck was I doing wrong? Why wasn’t this baby out? I was doing everything I learned, everything I was taught. I never read this in the books. I had never listened to anyone tell their story of being in labor for three days, dilating back and forth. What was going on? I was ashamed in thinking I was not giving birth the right way. I kept thinking to myself, “I’m so bad at this. April and Susan are so annoyed with me. Jenny probably thinks I’m not trying my best.” But no way would I voice these things out loud. I had to be strong. I had to put my game face on and not let anyone know how different this was becoming to me, how increasingly hard it was to keep it together.

It seemed like as soon as I started thinking all this April had arrived, and Susan soon followed after picking up our son. I put a brave smile on for my son, my sister Justice (who was the same age as my son), and my mom. Soon after, my father came downstairs to give me a huge hug. I remember this moment like it was yesterday. I didn’t want him to see how much pain I was in and I knew since the waves were really close together it’d have to be a quick hug and he would need to go. Once he got down there and I fell into his arms, I didn’t have a single wave. I felt so much peace. I wanted him to stay. He told me he loved me and off her went out of town for a job.

midwife birth story

My family stayed upstairs as I continued to moan, sway, and breathe through each wave. “I can’t give up now! I can’t give up now!” Susan and April insisted me sit on the toilet to help keep me dilating. I hated it. No- I LOATHED IT! They sure were right though. It wasn’t long after going to and from the toilet to the bed that my water broke. I remember I was on the bed with the yoga ball asking for the bed pads because with this next contraction I’m pretty sure I’m going to pee. There it went. “DeAnna- it’s not pee. Your water broke!” Another contraction. “I’m sorry guys I’m peeing again!” “DeAnna- I promise it would be OK if you were even peeing, but you’re not. It’s your water.” I was not convinced it was not my pee until it was prob the 10th time I had a contraction and was still feeling gushes come out. Once my water broke I could not stop the urges to push. Now it all seemed so surreal. It’s official. I’m about to have my baby! My mom, sister, and son came down and sat on our bed waiting for the cue to come in and watch little baby boy Sebastian come out. An hour of uncontrollable pushes came and went. Two hours. Three hours. They fell asleep on my bed. Four. Five. ‘OMG, WHY ISN’T THIS BABY COMING OUT! Stay strong, DeAnna. They’re all here for you. Ahhhhh! Please Lord help me!’

I couldn’t stand the water anymore. I sent my family away as I was to the point that I didn’t want them to hear me cuss, I didn’t want to scare my son any more than he had already been, I didn’t want to scare my sister into never wanting children. By this time though, laying in bed, I hated everyone. I felt like every birth story, birth movie, birth show I ever watched were all lies. Every time anyone would tell me I was close I didn’t believe them anymore. Everyone was a liar. I’m NOT close. I’m NOT doing a good job (otherwise the baby would be here by now). I’m NOT about to have my baby.

I kept being checked and told that I was close. I would cry and losing all faith in Hypnobabies. Although I felt like I wasn’t doing Hypnobabies anymore, I was told they would catch me not saying much and chanting through some tough waves without even giving it a second thought. I just wished I could get a break- just for an hour. I need sleep. But nope- those urges to push just wouldn’t let up.

(Monday, January 7th)
I pushed all night. Begging and pleading for someone to do something. Everyone was so encouraging. April tried so hard to keep me calm. I remember crying as she rubbed my head looking into her tear filled eyes. Jenny was so sick as this time- really feeling the effects of everything I was going through, still sticking by my side like the amazing wife she truly is. Susan was the perfect midwife, encouraging me that I was the toughest person she’d ever met.

April needed to get home to her little girl. Everyone thought a new person in the picture to help with the support would be a good idea. So they called up Megan- a close friend and our Hypnobabies instructor. She arrived around 9am. I cried in her arms allowing every fear and angry feeling come out. “I’m trying so hard Megan. I’m doing everything you told me to do. I’m doing everything everyone is telling me to do. I can’t do this anymore. They’re lying to me or something.” She smiled this beautiful, angelic smile and told me I was amazing. She helped me get back into the groove of Hypnobabies. She helped me back into the tub with Jenny. We began to breathe, chant, laugh, and chit chat. Susan insured us that this was great and would allow that last bit of cervix to move out of the way. I felt confident at this point.

About an hour later, after the water was cold and I was ready to try pushing him out, I got out and laid on the bed. Everything intensified again. I made it clear at this point that I was way too tired to do this anymore. I wasn’t going to push him out. I got hysterical all over again as these uncontrollable waves took over my body over and over. Susan said she was going to check me. Megan held my hand on one side as Jenny stroked my head and held my other hand. That’s when I let them know that if there is no change we have to go to the hospital. I saw the look on Susan’s face. No… no change. Still a 9. “NOOOOOOOOOOO,” I cried, “Ok. Let’s go. NOW! I want the epidural and I want it now! If you don’t take me right now I’m going to go out there half naked and make someone driving by take me.”

At that point my mother came down to try and calm me down because even though I had it set in my mind that I was going, I was even more hysterical because of how disappointed I was in myself. I couldn’t stop telling her that everyone who doubted me and was negative about my birth plan is going to say “I told you so.” Everyone was so comforting at that point telling me how great I had done and that they understand and think it’s a wise choice to go ahead and go in.

We pulled up to the ER entrance and I told my wife to please go in there and tell them to have me a room ready before I get in there because there was no way I was going to scream through my waves and pushes in the middle of a waiting room. I can laugh about it now, but it was so funny getting into the hospital. The look on their faces! Those people rushed around so fast. I felt like I was in one of those really dramatic movies. I mean, no joke, the guy pushing me in the wheelchair was swerving around corners so fast I thought I was going to tip over. The woman in front of him was running yelling for people to get out of the way. I couldn’t tell them to chill out because I was busy “hoooo-hooo-haaaa-haaa-ing” but inside I really felt like I was in a movie.

I was checked once I got situated in the room. I slipped back to a 6 from a 9 since we left home. (This is what was happened at home. I would go back and forth in dilation). Another mind boggling thing? My water broke… AGAIN! Right there in the bed. I had no idea this was possible… having your bag break multiple times? Yep- it’s a real thing.

It was a couple hours later that I finally got the epidural. Oh sweet loving Lord above. Thank you! At least now I can still have a vaginal birth. I’m not gonna lie- I see why women are so quick to get those things. My wife, son, mother, sister, and Hypnobabies instructor and friend, Megan, were all there. At 8:30p.m. it was time to push. I got scared because I could feel my legs. I THOUGHT I WASN’T SUPPOSE TO FEEL ANYTHING! It was too late. I was pushing. OMG I FEEL IT! WOW! I began feeling sick and started vomiting. This is was the BEST pushing tactic haha. As I was puking the force of it was really shooting him out.

home birth turned hospital birth

“Look down DeAnna! Look down!! Baby born at 8:57p.m.”

“OMG! Look at my baby. Is he not the most beautiful baby in the world,” I said with tears just rolling down my cheeks.  My wife went with the baby and my son instantly came from my feet (watching his baby brother come out) to my head. As he rubbed my head, grabbed my hand, bawling his eyes out he managed to give me a kiss on my forehead and said, “Oh mom I am so proud of you. I can’t believe you did it. You did such a good job. I can’t believe this baby isn’t dead and we finally get to take one home.” I had never known that the loss of one baby made him think that every failed attempt of trying to conceive meant it died too. I had never known he was crushed every time (for two years) we’d have to tell him, “Nope, bud. It didn’t work this time.” My big brave son finally let it out and he was proud. Proud of ME. What an emotion. An emotion I don’t think I will ever experience again. An emotion nothing else can replace. The bond that happened in that moment made me want to be the best mother in the world not only to him, but new baby Sebastian.

birth story

I look back at how hard this labor was. I had never had a kid before so I did not know that what I was going through was rare and not a typical birth. When everyone would tell me all that happened I started to realize how strong I was. I just went FOUR DAYS in labor! There was nothing in my life that made me feel so amazing. Nothing that made me feel so powerful. I wanted to yell, “I AM WOMAN! HEAR ME ROAR!” Even though this was a very hard birth, there is no doubt in my mind I would do it all over again. In fact, I can’t wait to get pregnant again because I will try the home birth without a second thought. It’s funny because I actually hear myself thinking, “You can do even better next time!”

hospital birth

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