Easter weekend was great. I thought Conference had a whole lotta talks about parenting and motherhood, and let me tell you, it is easy to feel that you are doing your duty as a mother when you are pregnant. That duty is burning up my esophagus as we speak, so “motherhood” = check.
Before the first session on Saturday (and leaking a little over the first speaker, because we were a bit fired up), my dad and I talked labor stuff. My dad said that doctors have always had reasons for the things they do, even if those reasons are not the best, and even if those reasons turn out to be unsupported, they do things because they think there’s some benefit to the baby and the mom. Which I’m willing to grant, though the more I learn, about both the history of childbirth and contemporary medical practice, the more I think that at least a non-malicious misogyny has pervaded much of the perspective of male-dominated (even today) obstetrics. (“You poor dears shouldn’t have to do something as hard as childbirth. You’re too delicate and dignified for all that pain and possible poop!”)
I have been talking to my sister-in-law about natural and home birth (she is planning a homebirth; I think I would if I lived 30 minutes closer to the hospital). She read about lotus birth the other day, and I had just read about some of the benefits of delayed cord cutting (that blood volume and iron levels are better in babies six months after birth if their cords were not immediately cut).
My dad said that when he was learning obstetrics thirty years ago (he delivered around 1000 babies as a family practice doctor), there was much debate over things like whether to do an episiotomy or not and whether to cut the cord immediately or to milk it towards the baby. I pointed out that both of those cord options were things that doctors do: neither of them is similar in perspective to a third option: allowing the cord to pulsate as it will. Both imply that there is something to be done, that a doctor, and his unique learning, are needed in order to fix something that is wrong.
The midwifery model of prenatal care and passive management in labor is a different perspective entirely, that childbirth is something that is going to happen, and that it will most likely happen without negative incidence, and that there is little need to be doing things to the process, that in fact the process will be hindered and harmed by a lot of doing.
Incidentally, (one of) the reason(s) for cutting the cord immediately was a fear of polycythemia, a condition of high blood volume, which occurs in .4-12% of infants, and in which delayed cord cutting has been thought by some to contribute, though trials show this is not the case.
(I still don’t know what I want to do about cord cutting. I’ll probably read some more, talk to my midwife, ask about the hospital policy — about this and other things like silver nitrate or erythromycin in the eyes (seeing as I do not have gonorrhea OR chlamydia) — and make a decision from there. I’ll probably end up somewhere in the middle, with cord cutting (no milking) in 1-3 minutes or so after birth, though from a natural/homebirth/historical perspective this is still really early, so maybe I will wait until after the placenta is born, especially since I experienced troublesome placental delivery with Susan.)
Today I read an article about palliative care and a young doctor who had to face her own death from cancer as she counseled others about their options for end-of-life care. It’s a sad story about how hard it is to face and accept one’s own death even when death is something one understands and respects, intellectually. But the part about palliative care struck me:
Over the last decade, palliative care has become standard practice in hospitals across the country. Born out of a backlash against the highly medicalized death that had become prevalent in American hospitals, it stresses the relief of pain; thinking realistically about goals; and recognizing that, after a certain point, aggressive treatment may prevent patients from enjoying what life they had left . . .
I’m not sure what all the parallels here are, or where the comparison would break down, but it’s intriguing that our end-of-life is recognized as needing a de-medicalization, just as most of our beginnings-of-life do. Palliative care emphasizes presenting a patient with all of the options, finding out their priorities, and then helping them die in the way that is least distressing (most appealing?) to them. It is not a way to prolong life at all costs with ever-more aggressive medical treatments, but a way of coming to terms with an inevitable process, though this seems more poignant (tragic) when the death is coming to someone who has not yet “lived a long, full life.”
Even the meaning of the word palliate would seem to apply to a midwifery model: to relieve or lessen without curing; mitigate; alleviate, since pregnancy and childbirth are usually the desired state/outcome, not things that need curing. And this highlights one significant parallel — how difficult it must be for doctors, who become doctors in order to actively help people (often at the sacrifice of their own time, sleep, earning power — I’m thinking especially of the non-sexy specialties like family practice), to admit/accept/embrace that at certain times, in certain instances, the best thing they can do is the least.
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When I read your posts on pregnancy and childbirth I feel like I am (was) not as educated as I should be (have been). I do feel like I made the best decision–one which worked perfectly for me and felt “right.” My labor and deliveries were relatively easy so natural childbirth was an easy option, and I was never really comfortable with a home birth (too paranoid) so giving birth at a hospital was also an easy decision. I’m totally for whatever a birth mom chooses to do as long as it feels like the best option for her and her baby.
Even though I did what felt right to me and I wouldn’t go back and change a thing (and might not even change a thing if I’d had more children), I still feel like I had no idea what I was doing compared to all the research you’ve given the issue. You’re amazing (in a really, really awesome way)!
Jane Reply:
April 6th, 2010 at 8:29 pm
I think if more women felt supported and encouraged in natural/unmedicated birth in the hospital there would be fewer homebirths, though of course there are some (many?) who are philosophically opposed to the idea of giving birth there no matter what the care atmosphere/perspective is.
And interestingly, the more I learn, the more it kind of seems that there is that I could study. And I hope to be able to support my daughters in their future choices, because otherwise, this is a lot of work for one birth.
Jane,
I agree w your characterizations, and w your comparisons to end-of-life situations.
Interestingly, I feel strongly that the main impetus for intervention at the end of life has been the family’s stong urging. Many is the time that I have tried to prepare a dying pt and fam about what to expect near the end, and how it would be best for them to use Hospice, and let the pt die peacefully at home. Then when a terminal or near-terminal event arises (notice I didn’t call it a *crisis*, though that is how it is viewed) then the family members fall apart, and rush Granny to the ER and demands that the doctors “DO SOMETHING!” There is an urgent emotional need to intervene. It almost seems that some of the general populace lags behind the more avant guarde doctors, in impelementing new ideas. As you once said, there is a 7 year lag-time for a new idea to become part of general practice.
Is there a parallel to beginning of life scenarios?
Jane Reply:
April 6th, 2010 at 8:26 pm
Yes, I concede that it is often the family of the dying (or the woman scared because she doesn’t understand birth) who demands intervention. I was that woman three times before, asking for an epidural, asking/acquiescing to an induction, unaware/uneducated/uncaring about the different routine procedures my baby and I would be subject to both as a matter of course and as a consequence of my initial desires/decisions.
Which is why I feel so passionately about getting it right (-er) this time.
(Also, this makes me wonder about Sarah Palin’s motives for characterizing the end-of-life discussion provision in the HCR as “death panels.” I don’t want to argue whether the government should have oversight over any facet of insurance, but since it does, it seems like an end-of-life discussion would be as conducive to quality of life as any other procedure.)
Oi vey…too deep for me today. You know I love you….but this post kind of makes me not want to have another baby.
Too much work all around.
But really, it’s just this weather making me so dang tired.
I agree with much of what you’re saying here.
I think “non-malicious misogyny,” however, is a convoluted description. In your examples you’re describing someone who values beneficence over autonomy. Or perhaps paternalism? Or do you really think practitioners encouraging pain relief are motivated by hatred or contempt of women? Maybe I’m not quite grasping your meaning; I’m trying to think of something nontrivial that I hate in a non-malicious way.
I think that the fact that the OB field has been dominated by males is a moot point; the female OB’s I’ve worked with exhibit the attitudes you describe just as much (if not more) than the males. Perhaps “western/modern/traditional medicine” should feel your wrath rather than men.
Lastly, just because something is physiologic does not mean that it is without risk. Pregnancy and delivery are normal. Uncontrolled uterine hemorrhage is not normal. Chorioamnionitis is not normal. Cord prolapse, placenta previa, and shoulder dystocia are not normal. Shoulder presentation and premature labor are not normal.
My point is that I agree with you–just as you’ve mentioned multiple times in recent posts–that each mother (and I would like to emphatically add, father, or even better, couple) should decide how much risk they are willing to take with what will hopefully be a normal delivery. There are risks and benefits of a home birth vs. hospital birth. There are risks and benefits of delivering with the assistance of someone who is trained in normal births vs. someone who has been trained to deal with complications.
I agree with you that these decisions have to be decided on a couple-by-couple basis since 1) they are risk/benefit decisions, 2) it’s hard to get evidence-based, unbiased information, and 3) each family is unique. I think it’s unfortunate that both camps (natural? vs. modern? for a lack of better descriptions) are so stigmatized.
Jane Reply:
April 6th, 2010 at 8:15 pm
Though misogyny literally means “woman hate” I don’t think that’s the common connotation. I did mean something more like paternalism. And yes of course often female OB’s (I’ve had 3) are even more entrenched in an active-management mode of practice.
If we’re going to talk semantics, the origin of the two words obstetric and midwife is enlightening. Obstetrician = one who stands opposite; Midwife = with woman. You can be upset all you like that I have metonymied these into obstetrician = male, midwife = female, but on average and historically and perspective-wise, I don’t think this is an unfair characterization.
I absolutely agree that it comes down to a risk-analysis (wish I could get the Freaknonomics guys to tease it out). But, so often the perspective of “normal birth” versus “high risk” seems to be a self-fulfilling prophecy. For (a small) e.g. high-risk specialists will do a vaginal exam at every appointment, and often there are twice as many appts as usual. Then the mom gets a bacterial infection from all these vaginal exams, goes into premature labor, and the baby has to be delivered by c-section because it is still transverse.
If both camps are subject to self-fulfilling prophecy (which I think more and more that they are), guess which type of practitioner I prefer?
And finally, amen completely on the tragedy really of having both camps so polarized, so diametrically unreconciliable. (sp?)
I’m in my ninth month and have been considering some variation of delayed clamping. One additional consideration I read that you have not mentioned is there is an increase in the occurrence of jaundice in delayed-cord-cut babies since their total number of red blood cells is obviously higher than it would be otherwise. I don’t know yet– it’s an interesting decision.
Jane Reply:
April 6th, 2010 at 7:58 pm
Jaundice is mentioned (and dismissed as a concern) in the same study that said trials showed polycythemia to not be caused by delayed cord cutting — the fourth link in my post.
Interesting (to me, and not very significant bec. it’s just anecdotal) — my only baby with jaundice was Susan, who had immediate cord clamping, and also the “stubborn” uterus that the doctor had to reach up and pull on for 30+ minutes to get it out. That means nothing for anybody but me, and for me, it makes me interested to see what if any difference a delayed cord cutting has on the placental delivery. Some argue (seemingly logically) that the placenta is more easily born when still attached to the cord.
Whew! I’m so glad I came to visit here today because this post has given me so much to think about regarding how I can take a more active role in my future deliveries (should I be lucky enough to have the 2-3 more children we hope for). I’m always so focused on caring for myself/baby during pregnancy and after the birth – I rarely ponder much on all the small decisions that could possibly amount to a big difference in mine and my baby’s birth experience.
I too had placental-delivery troubles with my first and because of that have been advised to always take the epidural during labor, just in case the condition is once again present and measure have to be taken to save my life. With the epidural decision out of the way, I’ve sat back and let everyone else make the calls on all the other aspects of my labor and delivery. This time around I know I’ll be more deliberate. I appreciate your example.
A word on palliative care: I believe most doctors tend to focus on taking any measures possible to prolong life not because they are disconnected from their patients’ needs/desires or afraid of death or apathetic towards what they put their patients through – but because that’s their JOB. Most doctors feel that they were put on this earth to be doctors – to heal and to save and to repair and to help their patient’s walk away whole. It must go against every fiber of who they are to say “ok – it’s time to give up and let your body fail.” And my concern is that we’re not only too hard on the doctors that encourage their patients to fight until their final breath, but that this palliative approach could easily be abused and turn towards issues of assisted suicide or neglect. In a perfect world, all doctors would present all options and all patients would be perfectly able to make the right decision based on their particular situations, free of emotional manipulation or temporary exhaustion or financial concerns, etc. In the imperfect world in which we live, I want a doctor that will always encourage me to fight with every fiber of my being, that will exhaust every single option and then hunt for new ones. I want a doctor that will never every give up on the miracle that is the human body.
Jane Reply:
April 15th, 2010 at 8:41 am
That’s a stirring view of the human body, and I agree that it is miraculous, and that most doctors are good-intentioned, but I disagree about taking “any and all” measures. For example, I would not want to be on a mechanical ventilator or feeding tube for years. I wouldn’t want to be so sick from chemotherapy and radiation in the last years of my life if there were a miniscule chance of being “cured.”
I think issues of quality of life (not just prolongation) are significant. And I cannot discount the fact that too often we (as a society, as individuals) cannot afford the extreme lengths to which some patients/families/doctors want to go.
I know you didn’t ask my advice, but if you are truly interested in being more involved/participatory in your deliveries, I would definitely get second and third opinions on your placenta issues (from, for e.g., a midwife who has a “birth is normal” perspective and from reputable literature), esp if they were not present with subsequent delivery(s). It doesn’t take long at all to put someone under general anesthesia (I’ve been under a couple times for shoulder surgery) — much shorter than an epidural, and epidurals can cause so many other problems, that it’s hard for me to imagine a situation where one would be indicated for reasons like in your case.
I wrote about The Trouble with Epidurals here: http://www.seagullfountain.com/wp-admin/post.php
And there was a great article about the breastfeeding implications of hospital culture http://www.huffingtonpost.com/melissa-bartick/ipeaceful-revolutioni-mot_b_536659.html This gives a really good description of how different two births can be. What she doesn’t mention is that having an epidural can make the baby sluggish and inhibit immediate establishment of breastfeeding too. I didn’t experience this (at least, I didn’t notice) with my 3 births, but I’m interested to see if not having an epidural will make a difference in how alert my baby is.
It seems like we never get to see the whole picture (whether it is birth or death). I know a lady who had 3 c-sections and an emergency hysterectomy. She doesn’t know why she had to have the 1st c-section (they never told her) and she only knows she had to have the others c-section bec. VBAC was not an option at her hospital. One reason she acquiesed w/o questioning was because both her mother and a sister had c-sections; she assumed there must be some genetic thing. Then she found out the sister had a c-section because she had an STD. This is just an example of how unspoken things (no one ever told her there was a genetic component to her c-sections, but it was a logical assumption) influence our decisions/desires/perceptions.
With birth, especially, it’s impossible to go back and determine what would have been the outcome if we’d done this or that differently, but there is quite a bit of research out there that allows us to predict what will (or can) happen based on our choices.
(Sorry, I know this is long. Hope it isn’t *too* pompous.:P)