The Four Preventative P's

I was reading a blog called Academic OBGYN and found a fascinating article about handling slow labor. After the article, I always read the comments....sometimes just a handful of opinions since a lot of these blogs will boast hundreds of comments. Near the top I found a comment by Amy Romano, who is a pretty well known and respected midwife who writes a blog for Lamaze International called Science and Sensibility. In her comment she took a moment to talk about what she calls "The Four Preventative P's":

I give a talk on optimizing labor progress and talk about “Four Preventive P’s” rather than the 3 P’s and other variations, all of which I think address how to treat rather than prevent dystocia.

Briefly, the four P’s are:

Permission – freedom of movement, autonomy in decision making, freedom to vocalize, throw up, ask for help, or whatever it is the woman needs to do to get her baby out.

Physical environment – there are some intriguing pilot studies showing beneficial effect of simple alterations like removing the labor bed and/or giving women freedom to rearrange furniture and props in her own room.

People – continuous support from a doula or other trained labor companion has many documented benefits and should be the standard of care.

Practices – avoid routine use of interventions that slow labor down. Avoid arbitrary time limits, etc.

Of course, you don’t get the Four Preventive P’s in most hospital environments.

I had a thought after reading this that this could be a birth plan for any mother planning a natural childbirth. Its short, easy to read and gets right to the point. If her doctor or midwife has problems with any of these four things, it would be a good indication that she isn't going to get the birth she wants and should look for a new provider. Also, I like how it simplifies the requuests to four items. Sure, there are a lot more than four things asked for here, but since it basically bullet-points four things, it doesn't look like such a long laundry list of requests.

What do you think? Would this work as a birth plan?

Is the Birth Battle of Today Similar to the Breastfeeding Battle of Yesterday?

I was talking to my mom yesterday and the conversation turned to birth and breastfeeding. She said something about how I am so passionate about birth and yet her passion is still for breastfeeding. Now, of course I am pro-breastfeeding, but it got me thinking about why I am *so passionate* about birth while she remains much more passionate about breastfeeding, even years after she nursed her kids. I'm wondering if it because I am able to reap the rewards of the battles that she and her generation fought for breastfeeding, while I am fighting the battles of my generation over birth.

By today's standards, no one doubts the superiority of breastmilk over baby formula. Ask any pediatrician who follows the American Academy of Pediatrics recommendations on what is the best food for your newborn baby and they will quote verbatim "the AAP recommends that breastmilk is the best food for your baby through the first year of life." Of course, they get less supportive once you've hit that first birthday, but that's another topic for another day. However, that supportive position towards breastfeeding wasn't always there.

Imagine with me. A young woman learns she is expecting. Although she and all of her siblings were fed formula, she has heard from friends that breastmilk is actually better for her baby. She does lots of research which completely supports this position and she continues reading everything she can get her hands on to do everything possible to ensure breastfeeding gets off to a good start. When she informs her doctor of her plans to breastfeed, a patronizing look comes over his face. "Oh this silly girl," his eyes seem to say, "why doesn't she realize that medical technology has created a better milk?" He may even try to convince her of all the reasons why feeding a baby formula is so much more convenient and easy. "Just think," he says, "you'll be able to go out with your friends and not be tied down at home to that baby......it's liberation! Isn't that what the girls these days want anyway?" Imagine if that woman tries to breastfeed, but with no support from anyone she knows, when problems arise she has nowhere to turn and after shedding some tears, reaches for the can of formula. As that woman grieves the loss of her body's ability to make milk and nourish her baby, well-meaning friends and family try to cheer her up by saying things like, "look at that baby......she's completely perfect and healthy......why get all upset over what type of food to give to her; just be glad you have a healthy baby....." Is any of this starting to sound familiar?

I have no idea if those were actual arguments used in support of formula-feeding. Because I live in a time when breastfeeding is generally supported, its hard to imagine a time when "the professionals" were spouting advice that is 180 degrees opposite of what it is now.

Today we don't have to fight the breastfeeding battles of yesterday, but we do have almost the same battles in childbirth. Women who want to have a natural childbirth, do their research and present it to their doctor often times are laughed at, ridiculed and patronized. Who am *I* to question the decision-making ability of someone who went to medical school and has delivered babies for "x" number of years? Do I think I'm *better* than someone else for wanting something different? If it was good enough for so-and-so, why isn't it good enough for me? When our desires to avoid inductions, drugs and machines are compromised and we end up with much more of a medicalized birth than what we had hoped for and dreamed of we are (in essence) told we are selfish to mourn our natural childbirth.....after all, our baby is healthy.....isn't that all that matters?

Looking to the future, I hope history repeats itself and the next generation will look to us with thankful hearts for the battles we fought (and won!) for them. I hope my daughter (and my sons' wives) have more choices in childbirth. I hope they look back at women who were refused food, refused a tub to ease labor pain, drugged up and were hooked up with wires to machines and think "wow! how archaic! I'm glad I don't have to go through that!" Even if they take their birthing freedoms for granted, I'll be happy, knowing I was part of the generation that paved the way!

I heart Lindsey Meehleis!

This video is inspiring! Watching it, I wonder....is this my path? I don't know if I yet have the courage to go forward toward being a doula, childbirth educator or whatever God has in store for me, but its exciting to watch other women achieving that goal and I love living vicariously through them.

My Journey to a VBAC from Lindsey Meehleis on Vimeo.

Your Body is *Not* Broken

I found this blog post by Birthkeeper over at Midwifery Ramblings and wanted to share it. The post is a bit old, but the advice will never be so. I think this is so wonderful because I know so many women who have a "failed induction" and they feel like a failure....like their body doesn't work right. They may even sign up for a cesarean next time since they don't believe their body knows how to go into labor. Isn't it great to know that your body isn't broken? Your body is doing exactly what it is supposed to.....exactly the way God made it to work. I just love it!

Depending on Christ through Childbirth....aka....You gave birth with no drugs??? Are You Crazy???

So, the short answer is "Yes, I gave birth without pain relieving drugs (twice actually) and no I am not crazy." I actually have three beautiful children and in order to explain why I will have to tell you a story that will probably end up being very long but hopefully you'll begin to see how this really has been a journey for me. Just as a disclaimer, I get very detailed about my births in this post, including my cesarean and the complications that followed. If you are pregnant or at a place where reading scary birth stories might not be a good idea, you may not want to read further.

I was 24 years old when I became pregnant for the first time. I had been married about a year and it just seemed like the right time to start a family. During that first pregnancy, I did everything right....ate the right foods, avoided all the things I was told to avoid. I had a very uncomplicated pregnancy (except for all the "normal" stuff like horrible nausea, fatigue and pretty bad swelling in my feet toward the end). We knew we were having a boy and had decided on the name Gavin Dean. Gavin was simply a name we liked and Dean is my father's middle name. We attended a local childbirth education class and got your run-of-the-mill typical hospital class. We made a birth plan, but since I really didn't know what I wanted, it was pretty standard to the hospital's policies. I was open to getting an epidural....I guess I assumed I'd need one since I have such a low pain tolerance. However, I don't know why, maybe I wanted to see what my body was capable of, but I didn't want to get it right away. I wanted to wait as long as I could....heck! Maybe I wouldn't even need one at all!

On July 12, 2002 my husband and I went out to dinner to celebrate after having a very successful day at work. We went to a steakhouse and I ate *so much* that night, possibly forgetting that I was 9 months pregnant.....4 days short of my due date. Later that evening I felt so sick and wondered why I ate so much. Chad had early morning plans to go waterskiing with my dad the next day (which was a Saturday) and I didn't want to disturb him, so I layed on the couch and was back and forth to the bathroom for several hours. It never crossed my mind that I might go into labor that night. I had just had an appt. with my OB that morning and I remembered her saying, "you aren't dilated at all. I can't make any predictions, but I think I can safely say you won't go into labor today. After that, I can't make any promises." Plus, this was my first baby and I had heard over and over again that first time moms *always* go passed their due date. The more time that passed, the worse I felt. It got so bad that I started to think I shouldn't wait until morning. Even though it was close to 2:00 a.m., I started thinking maybe I should call the on-call doctor. I woke Chad up and told him I wasn't feeling well and maybe we should call the doctor. There was a long pause (he later admitted that he was trying to think of a way to lovingly assure me that I was fine and to just come to bed). Then it happened! GUUUUSSSSHHHHHHH! Wet everywhere! I said, "Ummmm, either I just peed myself or my water just broke." That got him out of bed!

We raced around throwing things together. I called the on-call doctor (the same OB I had seen that morning). She was surprised to hear from me, but said I should probably go to the hospital and get checked out. Contractions started right away and they were pretty intense. In the car, we started timing them. It was hard for me to know when they were starting, so we timed them from the peak of one to the peak of the next. 3 minutes apart. Next one was 4 minutes apart. Next one was 2 minutes apart. Chad said, "You must not be doing this right....they are not supposed to be that close together this early." I practically yelled, "how am I supposed to know if I'm doing this right? I've never done this before!!" Looking back, it seems kind of funny, but it was incredibly intense at the time.

When we arrived at the hospital, there was a flurry of activity as the residents checked me out and my doctor was soon called. They kept telling me not to worry about them...just concentrate on my labor. I *was* concentrating on my labor, but of course as soon as they told me not to worry, I started worrying! They also offered me an epidural, but I declined at that point. The contractions were intense, no doubt! But they didn't seem overwhelming.....I felt like I could manage the pain. When my doctor came and saw that I was barely dilated to one cm and I was contracting like I was in active labor, she was concerned. She said, "there are two things that are concerning me. The first is that with each of your contractions, your baby's heartrate is going way below normal. The other is that you are contracting very actively, yet you are only dilated to one cm. We don't know how quickly you will dilate, but it probably will take many more hours and we don't know how much of this your baby can handle. We can wait a little while if you want, but we may need to talk about a cesarean section.

My. Heart. Stopped. Cesarean? I'm going to have a cesarean? The idea of having surgery was not even on my radar that night. All of a sudden, I thought of my mom. See, I was born by cesarean section.....my mother's first baby.....surgically removed from her womb. Fetal distress. Just like my baby boy. That's when I started to cry. My mom came into the room (she had been in the hallway calling my dad) and heard the news that I was being prepped for surgery. To be completely honest, I had mixed feelings about going in for the c-section. I had definitely not planned on going under the knife that night, but another part of me was excited that I was going to meet my baby much sooner than expected and relief that the incredible pain would be over within minutes.

Once the spinal took effect, they wheeled me into the OR. I remember having some creepy thoughts about it looking like one of those rooms where they take convicts on death row.....death by lethal injection. It also kind of reminded me of Jesus dying on the cross. (The table actually does look a bit like a cross, with your arms out to the sides, strapped down.) Kind of strange in a creepy sort of way that my only two thoughts were about death when I was about to bring new life into this world. The surgery itself was a bit surreal. Its hard to wrap your mind around what they are actually doing......and knowing you're awake the whole time! The one horrible side effect I remember was my entire body shaking. My teeth were chattering and I probably couldn't have kept my arms on the table if they hadn't been strapped down. My anesthesiologist was a grandfatherly sort of man. He sat by my head during the entire surgery and said, "I can give you something for the shaking if you want, but you need to know that it will probably make you very sleepy." I was so afraid of falling asleep. This was my big moment.....my baby was being born and I was NOT going to fall asleep! "No, I'll be ok," I said. However, after just a few more minutes of shaking, my arms started cramping and I knew I needed to take something. "Ok, give it to me....I can't take this anymore!" I still remember to this day the feeling of relief and rest as my muscles relaxed and the shaking stopped. I felt good......really, really good....and really tired. Maybe I could just close my eyes for a couple of minutes....NO! STAY AWAKE!!! Do not miss this! I remember them bringing Gavin to me and saying "here's your baby....congratulations mom" and I was like "oh, wow, thanks" and then conk! Out like a light! I awoke in recovery and at some point my doctor came to talk to me. I was told it was a good thing they did the c-section. My placenta had prematurely separated from my uterus (a rare condition called Placenta Abruption) cutting off the oxygen supply to my baby....this explained the heart rate drop.

Although Gavin seemed ok, they wanted to admit him to the NICU (Neonatal Intensive Care Unit) for observation. It took about 30 hours until he was released. I believe I saw him twice during that time. This part of the story is hard for me because I believe mistakes were made and no one was communicating with me what was going on. They knew I was planning to breastfeed. It was written in my birth plan and they either ignored it or lost it during the change in plans to a surgical birth. They gave him formula in the NICU....even though I had pumped milk for him. Oh I was so mad!

Gavin and I had a horrible time with breastfeeding. I didn't realize it at the time, but I now know that we weren't bonding the way a mother normally bonds with her newborn and I was heading for post-partum depression. Friends and well-wishers would say things like "what a beautiful baby....don't you just love being a mom?" and on the outside I'd smile and say "sure, its wonderful" but inside I had no idea what they were talking about. I felt horrible!

Exactly one week from the day Gavin was born, we were having a particularly rough night and Gavin refused to latch on to nurse. I got so upset that I walked into the bedroom, laid Gavin on my bed and angerly hoisted myself up onto the bed....rrrrriiiip!!! What was that? I looked down at my incision and thought, "no, no way, that is not what I think it is." I carefully took my pants off and saw a small trickle of blood coming from my incision. Oh Lord, what did I just do? I called my doctor (a different on call dr. than the one who performed my cesarean) and described what happened. She didn't seem very concerned. "It can be normal to have a small amount of blood." We got off the phone, but about 5 minutes later I called her back. I just didn't believe this was normal. "Well, if it makes you feel better, you can go to the ER and get checked out." It was late at night by the time we arrived at the ER. We waited for my mom to come over to watch the baby and it was nearly 11 pm by the time we arrived at the hospital. I had put a maxi pad horizontally across my incision to catch the blood as we transported to the hospital and when the ER technician took it off, blood burbled from the wound.....at that moment, I thought I might die. I imagined Chad as a single dad struggling to bring up this little boy on his own. I pleaded with God not to take me yet. I didn't want to leave my new little family with no mother. Thankfully, they got the bleeding under control. They gave me morphine and that's the last I remember. When I awoke, I was informed that they would be taking me to a room. I hadn't even processed it in my head that I was being readmitted to the hospital. Chad looked awful! Like he'd been up all night....then I saw a wall clock.....4 am......he HAD been up all night! I told him to go home and get some sleep. I'm sure my mom was worried sick and I was also worried about Gavin not having anything to eat. I knew we had some formula at home....it was the free stuff they give you in that diaper bag "gift" at the hospital. As much as I hated the thought of him having the formula, I couldn't think of any better option at this point until I was well enough to pump some milk for him.

I think I'll stop this part of the story here for now. It really could go on for pages, but you get the picture of how horrible this experience was for me. I stayed in the hospital for 2 days and was released to go home. I had home health nurses coming to my apartment to change my bandages twice a day. Oh, I guess I do need to explain one more thing. See, when they put me out with the morphine, they reopened my incision to clean it all out. They did not reclose it due to a risk of infection. I really didn't completely get this until that first dressing change in the hospital, but my incision was not closed. It was packed with gause and bandaged. It was the worst pain I had ever had.....way worse than the contractions during labor.....and it was a very different pain. Not like a muscle pain like contractions, this was like a stabbing horrific pain. I was told that the incision would heal naturally over time. After 3 months, it still wasn't completely healed. I saw a plastic surgeon and had my third surgery in that short 3 month period. It was called a "scar revision" surgery, but my doctor tried to make me feel better by telling me I was getting a free tummy tuck!

Ok, this post has gotten so long that I need to stop for now. In my next post I'll talk about my next pregnancy, my decision to VBAC and all the obstacles along the way.