Birth (and life) after Cesarean

I love to listen to birth stories. Many of the stories that I hear are a testimony to the pregnant woman's great ability to "animal out" on her attendant. My favorite is the story of a young woman who had her first daughter by cesarean section She became pregnant again the same month and it turned out she was carrying twins. Her doctor was very alarmed and booked her for a cesarean at 38 weeks, She went into labor at 36 weeks and delivered two lovely girls, vaginally.

Of course, women who are trying for vaginal birth after cesarean don't always have such fine stories to tell. Two remarks have stayed with me over the years, and these were both delivered by obstetricians to a laboring woman. The first was: “Childbirth is like war, and I am on the front line.” The second: “This is Monday morning in a busy hospital. There are road accidents, emergencies …” This was said to a woman who wanted to labor a little more before the decision was made to go to surgery, implying that the birth of a child had to be scheduled in somehow between a messy car accident and some other horrific case. Why did this man want to become an obstetrician? How did he feel about his "patients"? How had he been born? What was it about birth that suggested to him images of war?
What is it about childbirth that makes these people think in terms of war, car accidents, death? Is it just fear? And if it is, what exactly are they afraid of? And , more importantly, where does the midwife fit into this mosaic of fear, or does she fit in it all?

Doctors and midwives who are afraid of childbirth are partly afraid because of their training. Allopathic medicine teaches about pathology rather than the whole healthy being, and pregnancy is often seen as a pathologic condition. But there is another more profound reason for this fear, and it has to do with the fact that Western medical training teaches health workers to rely only upon their own knowledge. How does this lead to fear?
Let me explain. During childbirth there is something present that is outside of us as individuals, out­ side our knowledge, even outside our experience or our skill. That "something" has to do with faith. It is only with a leap of faith that you can appreciate or even accept that a new human being comes out of a woman's vagina. Without that leap of faith, what happens? Two things: more obviously, you have to interfere, pull it out, cut it out another way. But another thing happens as well. Strangely, your faith (most of us have faith in something) gets turned inwards. As an obstetrician, you have faith only in your own skill. And that is what is frightening-- that an event which cries out for the presence of God gets reduced to the simply human.

I'm sure that there are obstetricians who works differently, but I think that it is easier for a mid­wife to accept that there is something else, something larger than herself, working through a birthing woman. It is quite noticeable how many mid­wives are religious, how many live in sight of that something which many people call God. But what happens to the sympathetic midwife working within the medical system? What happens to her sensitivity to that Other which touches us when we give birth?
I have met many diverse people over the years of working with birth.I have encountered some women who probably disliked their work, who were overtired, overworked, who had little faith in any­thing. I have also encountered mid­wives who have accepted modern medicine's vision of birth. And I have met many brave and gentle souls doctors, nurses, midwives, and doulas, who are working within the medical sys­tem and trying to maintain their faith at the same time.

What do we see in a hospi­tal? We see, first of all, an exagger­ated reliance upon technology. We know that the use of technology has a snowballing effect, creating the need for more and more complicated interventions. Secondly, we see a rigid hierar­chical structure in which usually one person is calling the shots. Finally, we see the "spiritual" infrastructure upon which this hierarchy is based, to be inward looking and grounded only in human knowledge.
What happens in the hospi­tal when things start to "go wrong," when things don't follow the pre­scribed path? When I went into the hospital in labor with my first child, the nurse, who was actually a mid­wife trained in Scotland, touched by belly and said cheerfully, "This baby will be born by noon." As time went on, she touched me less and less. By the next morning at the start of her shift, she didn't even greet me. As they let me eat and drink less and less, my cervix grew smaller, I was touched less and I began to feel more and more isolated. I was touched only when necessary. The baby's heart­ beat was checked less often. I began to feel abandoned.

Can I offer some advice to birth attendants working with women who are hoping to give birth vaginally after a cesarean section? Remember that the previous cesarean(s) have left scars not so much on the uterus as on the woman's sense that she is capable of giving birth. Accept that having a cesarean can hurt. Please don't de­scribe to her how a ruptured uterus may feel. Watch for danger signs yourself. Keep your concerns to your­self as much as possible. Remember "failure to progress" can be linked to fear and stress.
Keep things easy even when they get hard. Remember that a woman work­ing for a VBAC needs the comfort and security of her own home. Remem­ber that she may need to work on building confidence, on throwing away fear, on finding her "animal" self. Re­member as well, if it turns out to be another cesarean, don't abandon her. Give her the support through the birth and afterwards that you give any birthing woman. If a lady has another cesarean, she may feel very low; it may help her to talk to another mother who has been through the same thing. Avoid the mistake of "You're lucky the baby's okay.That's the important thing." Yes it is, obviously, but ... she may still need to grieve.

I am lucky - I have been blessed to have attended many successful VBACs during my years as a birth attendant. Thank you, again, to all the women who have shown me how fearless and strong birthing women are - not least, the woman who have said "Yes, I am ready for surgery, of course, if my baby's life is in danger."
Here's to a happy marriage of modern medicine and safe midwifery, with lower cesarean section rates and happier and healthy mothers and babies. L'Chaim! To Life!

Birth Portals

 Today I am on the second letter ... and that would be B, and B stands for Birth Portals.

This was posted on Instagram by @catearth76 and it is so true! But, and I am so full of "but..." and "wait a minute..." and "sorry what?..." these days, but what about those women who don't use that portal to birth their babies?

No, I'm not talking about how wonderful gentle cesarean is and how it's so great that we can lie on the surgical table and do skin-to-skin. Neither am I talking about women whose babies might have died if they hadn't been intervened with.

I'm talking about women who are pushed, coerced, bullied, lied to, manipulated, scared, threatened into agreeing to surgical birth for their babies when there really wasn't any good medical reason for it. This is a fact, it's real, and it's happening in a hospital near you. Especially now that Covid restrictions have made it impossible for a woman to bring the support she needs into the hospital or birth center, and it's made medical workers much more jumpy and afraid.

What is the actual spiritual damage that is done to that miraculous portal when a baby is yanked out through a surgical cut nowhere near the portal? How can we repair that damage? How can we repair that damage to babies, to women, and to the world? 

This is a question I've been struggling with for decades. I started working as a doula in 1997, and I truly thought that accompanying women to the hospital and providing doula support was a valid option. And, yes, I did have a pretty decently low c-section rate (around 10 %, compared to 25% at the hospitals I attended births at). But watching these births wore me down. Watching intelligent, adult women being lied to and treated like children (actually, since when was it fine to manipulate and bully little children?) hurt my soul.

I quit attending births for a while, for various reasons. And now I've started again, and I'm very clear that I only will accompany women who want to KNOW that they hold a sacred portal between their legs, and they WILL NOT be bullied into messing with it. This is my own bias speaking, partly because I wasn't strong enough to do that - I let every Tom, Dick and Harry and their female counterparts bully their obstetric, know-it-all, fear-mongering way into my obstetric activities. And the reasons behind that are many and unsolvable and complex. But I believe that the way I work now is the way to open up that sacred power, so that women can come back to the recognition of their own selves and their own bodies.

Women contact me at various places in their pregnancy journeys. Since I have been back in the practice, I have spoken with women who want me to walk with them throughout their pregnancies, and others who have called me during pregnancy, during labour, or after giving birth. 

When I walk with a woman through pregnancy, we meet online every week and speak for an hour. Sometimes we could talk about books, or what seeds they're planting. Other times we talk about how the pregnancy is progressing, or where they've decided to give birth, and whom they want around them when they're birthing. We talk about their fears, dreams, desires. We try to plan the kinds of support they will have after the baby is born, and they try to imagine what life will be like when they're responsible for feeding and providing for their new baby.

Sometimes we talk about stuff that's happening in their lives, either in the present or in the past, and how that will affect their birthing. Serious abuse in the past affects how we live in the present, and it can definitely affect our ability to reach deep within to find the power it takes to open that sacred portal. Fighting and anger in the present can sometimes mean that a woman no longer has a home where she can feel safe to give birth in, so that is another hurdle for her to jump over. Physical challenges and illness can also affect our body's ability to give birth, but these are rare. Often women worry too much about the physical aspects of pregnancy and birth, and they don't consider the emotional and spiritual weight of their pregnancy, birth, and parenting.

So, I try to walk with a woman and her family through this important time in their lives while maintaining an open spirit and an open heart. My open heart reflects with theirs and together we can find a place where that shy but powerful portal will open. Women are being cut open for no reason. Placentas are being pulled out with no reason. Women are not listened to when they say they have a pain, for no reason. Women are being ignored when they say they are scared, for no reason.

Or, wait, is there a reason? Who could want to keep that portal scarred and closed? Who could want to stop that power from being unleashed in the world? Who could want a world where we all remembered that we are all birthed through a sacred, fiery, spiritual, creative, awe-inspiring portal? Who might be afraid of a world that was held together by witch power and magic? 

Oh, so I forgot - this is a gratitude note! So I am grateful for Birth Portals. I'm grateful for witches, for womanhood, for love. I'm grateful for the circle of women who surround me and protect me. I'm grateful for the moon and the stars.

Cesarean Awareness Month

It's funny they would have a month for a surgical operation. I have the same feeling about Black History Month. Like, if it's important, shouldn't we learn about black history every day we learn about history? Like, shouldn't the history books be rewritten? They're certainly biased....

I digress. Let's deconstruct history another way:

Pithiviers, France, is remembered by some French Jews as the place where their relatives or friends of the family were sent after the Nazis occupied France. There was an internment camp there where families were separated and the adults were sent to Auschwitz to be killed.

We also remember Pithiviers as the place where Michel Odent was head of the maternity ward from 1962 to 1985. Here, he fashioned his notions of natural birth, by creating an environment where women could give birth in an undisturbed way. He provided singing sessions during the prenatal period, birthing pools, and skin-to-skin contact after birth.

Years ago, I was part of a group of birth workers who brought Dr Odent to Montreal to speak. I remember being so shocked when he suggested that there was a causal relationship between the murder and violent crimes rates in some cities in the world, and the cesarean rates. Effectively, he was suggesting that if you have your baby by cesarean, then they are more likely to become a violent criminal. I immediately took a dislike to him and his silly ideas, and, more importantly, I asked myself why there was a whole room of healthy, young women absolutely worshipping his words? There he was, a shrunken old white guy, talking about how babies needed to go through the vagina and arrogantly proclaiming that women who have cesareans are going down the path to hell, and dragging their newborns along with them.

Fast forward a few years and I was up on the stage. We were doing a little panel about VBACs. A woman stood up from the audience and said that she was newly pregnant with her second, hoping for a vaginal birth after a brutal c-section with her first. She wanted advice from a midwife on the panel. This is what she got: "If you want to give birth vaginally, you have to put your big girl panties on and fight for what you want."

And I remember teaching a class to a group of doula students, and the woman teaching with me said that, generally, women who have repeat cesareans have a lot of unprocessed resentment to deal with, and if they dealt with it their chances of VBAC increases. 

So, in a nutshell, three birth professionals said: women who birth their babies by c-section are driving up the crime rates because their children are more likely to be criminals (also, in an article he wrote in 2008, Odent suggested that cesarean birth may produce more male homosexuals); that women who want a vaginal birth after a previous c-section should somehow grow up so that they can achieve this; and that women who have c-sections may be dealing with repressed feelings, and that repression or other negative feelings such as resentment could be the reason for the surgeries.

If we look at these criticisms from a feminist perspective, they seem very similar to the rape dilemma - don't wear provocative clothing, don't go out at night alone, don't drink, or you will become a victim.

There's a feeling amongst the "natural" birth movement that a woman can have a "natural" birth if she wants it hard enough. We can read of powerful, transcendent, wild, free births where a woman moves through portals to meet her child. These are lovely, indeed, but not everyone can have or would want to have that experience.

In my opinion, giving birth is a very private act. It is so varied, the ways in which we birth, almost as varied as, for example, the shapes of our noses, or the leafiness of our labia. Some women want to birth alone, or just with their partner present. Others want their children there too. Some want a doula or two, and a midwife. Other women prefer a physician, and they want to be in a hospital. Some want to have a midwife follow them, and they want a water birth in the birthing centre.

All of these possibilities should be respected as valid, informed choices. So why are they not? Because, often, if a woman chooses to be followed by a medically trained midwife or a doctor, she ends up giving up her right to informed choice and she gets put on a conveyor belt where she is no longer the central person in this sacred, primal event, and she gets things done to her. The birth process gets put on a schedule; the body is examined time and time again; this or that intervention is done until finally all the options have been exhausted and she is wheeled into the operating room.

Yes, having a doula present will decrease your chances of c-section by a decent percentage, especially if you are a mid- to high-income woman living in an affluent country (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003766.pub6/full) 

Women choose to go the hospital to have their babies for many different reasons, and none of these reasons are an excuse for an unwanted and unnecessary c-section. What could these reasons be? 

• they want the security of being in a hospital
• they wanted to have a midwife follow them but couldn't find one
• they don't have health insurance and/or can't afford a midwife
• they don't have a home that is suitable for a home birth (think abuse, living with a lot of other people who aren't supportive, and those kinds of things)
• they don't know their options
• they are forced to because no one will attend them at home because they're carrying twins, or have had several c-sections, or they're obese, or are substance abusers
• they are followed by a midwife but get transferred to the hospital because of government regulations (labour too long, pregnancy too long, suspected this or that)
• covid-related issues reduce their choices

Any number of these women could end up being part of the 25-30% of women who give birth in the hospital who end up with a c-section. The WHO suggests that 15% is a reasonable rate. I insist that here in our affluent country, a c-section rate of 5% would adequately save the lives that have to be saved by obstetric surgery.

How can you avoid an unwanted c-section? Ask questions. Hire a doula, or find one for free. Contact me and I will do my very best to connect you to the people you need. Find a midwife. Get a doctor who hears what you're saying. Say no. Don't do anything that seems wrong. 

Let's work together to put the Cesarean section back where it belongs - in the realm of emergency surgery!

The Elusive VBAC

 

I love to listen to birth stories. Many of the stories that I hear are a testimony to the pregnant woman’s great ability to “animal out” on her attendants. One of my favourites is the story of a young woman who had her first daughter by cesarean section. She became pregnant again the same month (yes, I know … but true), and it turned out she was carrying twins. Her doctor was very alarmed and booked her for a cesarean at 38 weeks. She went into labor at 36 weeks and delivered two lovely girls, vaginally.

 

Two remarks have stayed with me over the years, and these were both delivered by obstetricians to a labouring woman: “Childbirth is like war, and I am on the front line” is one. “This is Monday morning in a busy hospital. There are road accidents, emergencies…” is the other. This was said to a woman who wanted to labor a little more before going to surgery, implying that the birth of a child had to be scheduled in somehow between a messy car accident and some other horrific case.

 

Why did the first man want to become an obstetrician? How did he feel about his “patients”? How had he been born? What was it about birth that gave him images of war? The second remark came from a woman. What was it about birth that frightened her so much? How could the birth of a child be imagined in the same breath as a car accident?

 

What is it about childbirth that makes people think in terms of war, accidents, and death? Is it just fear? And if it is, what exactly is everyone afraid of? And, more importantly, where does the midwife fit into this mosaic of fear, or does she fit in at all?

 

The doctors and midwives who are afraid of childbirth are partly afraid because of their training. Allopathic medicine teaches about pathology rather than about the whole healthy being. In obstetrics, pregnancy is often seen as a pathologic condition that can throw the whole system out of sync.

 

If we look deeper, however, we can see that there is another, more complex root of this fear, and it has to do with the fact that Western medical training teaches health workers to rely only upon their own knowledge. How can this lead to fear?

 

Let me explain. During childbirth there is something present that is outside of us as individuals; outside our knowledge; even outside our experience or our skills. That “something” has to do with faith. It is only with a leap of faith that you can appreciate or even accept that a new human being comes out of a woman’s vagina. Without that leap of faith, what happens? Two things: more obviously, you have to interfere: pull it out, or cut it out another way.

Another thing happens as well. Strangely, your faith (most of us have faith in something) gets turned inwards. As an obstetrician, or as a midwife, you begin to have faith only in your own skill. And that is what is frightening – that an event that cries out for the presence of the Divine (or whatever it is that you would name that) gets reduced to the simply human.

 

I know that there are obstetricians who work differently, but I think that it is easier for a midwife to accept that there is something else, something larger than herself, working through a birthing woman. It is quite noticeable how many midwives do live in sight of that something which many of us name God.

 

But what happens to a sympathetic midwife or physician who is working within the medical system? What happens to her sensitivity to that Other that touches us when we give birth?

 

What do we see in a hospital? We see, first of all, an exaggerated reliance upon technology. The use of technology has a snowballing effect, creating the need for more and more complicated interventions. Secondly, the hospital maintains a rigid hierarchical structure in which usually one person is calling the shots. Finally, we see the “spiritual” infrastructure, upon which this hierarchy is based, to be inward-looking and grounded only in human knowledge.

 

What happens in the hospital when things start to “go wrong”, when things don’t follow the prescribed path? When I went into hospital in labor with my first child, the nurse, who was actually a Scottish midwife, touched my belly and said cheerfully: “This baby will be born by noon!” As time went on, she touched me less and less. By the next morning at the start of her shift, she didn’t even greet me. As the nurses let me eat and drink less and less, my cervix closed tighter and tighter. I was touched less and I began to feel more and more isolated. Finally, I was only touched when absolutely necessary. The baby’s heartbeat was checked less often. I began to feel abandoned.

 

Our national cesarean section rate is quite a bit higher than the rate suggested by the WHO, which is 10-15%. In Canada overall, the rate is closer to 25%. I’m not interested in exploring why the rate has shot up so precipitously in the past 30 years, leave that to others who love statistics and platitudes. What I am interested in, is threefold:

To create an environment in which every woman has access to a safe and sacred birth.

To provide access to first-time mothers to be able to experience a vaginal birth BEFORE cesarean.

To facilitate VBAC (vaginal birth after cesarean) for women who are seeking that route: to provide information, support, informed choices and LOVE.

 

Here is some advice to midwives, doulas, and physicians who are working with women who want to give birth vaginally after a cesarean:

Remember that the previous cesarean(s) have left scars not so much on the uterus as on the woman’s sense that she is capable of giving birth. Accept that having a cesarean can hurt.

Please don’t describe to her how a ruptured uterus may feel. Watch for danger signs yourself; keep your concerns to yourself and your co-attendants.

Remember that “failure to progress” means that a woman was probably afraid and stressed. She does not need to be reminded of her failure.

Keep things easy when they get tough. Remember that a woman working for a VBAC will do well in the comfort and security of her own home.

Remember that she may need to work on building confidence, on throwing away fear, on finding her “animal” self.

Tell her you love her. Give her and her partner some time to be alone together during labor.

 

Remember as well, that if she ends up giving birth by cesarean another time, don’t abandon her. Give her the support through the birth and afterwards that you would give to any birthing woman.

 

The Shaming of Mothers

More and more evidence is coming out about the dangers of cesarean section. Every time I scroll through my birthy friends' Facebook posts, I see another mega-study that confirms what we knew all along: c-sections are dangerous. Of course, this surgery can and does save lives. But it cannot be true that over one quarter of our childbearing population can't deliver vaginally. 

I believe that for a well-fed, healthy population such as ours in the industrialized worlds, the necessary c-section rate should hover around 5%. Do the math: this means that at least one in five women are suffering unnecessary surgery. This surgery sets the tone for a woman's mothering - it isn't always a traumatic event, but it definitely is a physical handicap and a hurdle that many mothers would rather not have to face. 

I don't want to write about the reasons for these unnecessary trips to the operating theatre; the reasons are varied and complicated. I DO want to talk about how we are making women feel when we constantly post about the dangers, risks, and unredeemable damage caused by cesarean section.

Giant study links C-sections with chronic disorders 

Let's shout it out and make women feel really bad about how they birthed their babies. Let's make them feel even worse about an unexpected c-section than they already do. While we're at it, let's talk about how to have a VBAC: all you need is perseverance, inner peace, and you have to be in tune with your body. Right?

Women are having c-sections they don't want. Women are going to the hospital, sometimes with a doula and sometimes (usually) not, and they find at a certain point in their labor that they are not performing well enough, and they are scooted down to the OR. Most women do not want surgery. Most women want a vaginal birth. Many women want to have a vaginal birth even after a c-section. Just one VBAC support group on Facebook has 8,796 members. 

I am asking all of you to spread the word to not spread the word about how damaging c-sections are. Women who have had an unwanted cesarean birth KNOW that they are damaging. Let's try a little tenderness and spread the word instead about loving the mother, home birth, undisturbed birth, midwifery care, all the good things....

First Do No Harm

Why do I feel I have to justify myself when I say that doctors and hospitals are damaging women and babies? I have a little bird on my shoulder that says "Oh, but you don't want to seem like you are against saving lives".

We have some fantastic tools at our disposal now in the field of medical care. We have antibiotics. We have surgery. We have anaesthetics. We have ultrasound. But these tools are being overused and mismanaged.  Women are being hurt and babies are suffering because of our indiscriminate and irresponsible use of methods and materials that should be reserved for special situations.

What are the effects on mothers who want a vaginal birth and come out of the hospital with a scarred uterus? What are the long term effects on her mothering instincts and choices? What are the long term effects of cesarean section birth on newborns? What are the long term effects of epidural medication on newborns? Artificial oxytocin?

What happens when a mother in full labor suddenly becomes quiet and calm because of the pharmaceuticals coursing through her system? How does the baby feel when that happens? Is there a correlation between epidural medication and later drug use? What happens to the part of the brain that responds to addictive substances and behaviours, when the birth process is augmented with artificial oxytocin and opiates?

What happens to a marriage when a man witnesses his wife being treated like an animal? How does that compare to the bonding that takes place when a man sees his wife in full triumphant labor and birth?

What happens to little girls who are born by cesarean section? Are they more likely to birth that way? Is there a cellular memory of the movement through the birth tunnel? What are the long term effects of cesarean section on sexuality throughout a woman's life? Is she more or less likely to be fully orgasmic later into menopause?

Is there a correlation between asthma in children and induction of labor? Is there a correlation between autism and epidurals? What health problems are we seeing that may be connected to our new way of giving birth?

The average cesarean section rate in Canada is conservatively reckoned to be about 20%; higher in some places and lower in others. One in five children are now born surgically. This is a huge scientific experiment that is not controlled, or monitored, or even admitted.

Over 90% of first time mothers in hospitals in Montreal are taking epidural medication.

In spite of recent studies that show the contrary, the majority of women carrying breech babies are delivering by cesarean section.

Forty one weeks is considered standard for induction, Bishop's Score be damned! And if a woman is over forty, she is likely to be induced at 39 weeks.

We need to get these figures down and we need to start examining the effects of our modern tools, methods and materials on the mothers and babies who place their trust in us.

Breathe Together

I have had some feedback about the title of my book. Several reviewers have given it "five stars", but have had doubts about reading it because they thought it would be an angry, polemical work about the horror of hospitals and the saintliness of doulas.

And it isn't.

I have a holistic world view, which means that I believe that there is a place for most types of activities and interventions, within very strict limitations. A 90% epidural rate for first-time mothers is just plain wrong. 90% of all first time mothers do not want an epidural, although certainly some do. And very few first-time mothers actually need pain medication. If and when they do, an epidural is a very effective tool that can provide exactly what the doctor ordered.

Cesarean sections are also very, very useful tools. Surgery can save a baby's or a mother's life. But one quarter of mothers and babies in North America are not in danger of dying during childbirth, adn so we see that this tool as well is overused.

We have come to believe that the overuse of these tools is necessary. Women are afraid of pain, men are afraid of birth, and children are being born into bright lights, machines, masked humans, and a mother nowhere in sight.

Here is a little explanation of my use of the word "conspiracy":

The root of “conspiracy” comes from the Latin conspirare, from con- “together with” and -spirare “breathe.” My hope is that just as women instinctively know how to breathe through their contractions, we will realize that we all know how to breathe together. Whether we are in a hospital, a birthing center, or at home, when all of us: physicians, nurses, midwives, obstetricians, doulas, birthing women, partners and, of course, the baby, are working as one in the birthing room, then the birth experience will provide a better start for the new family. When the birthing woman and her child, and not a machine or a chart, or a schedule or an agenda, are the center of our attention, then no matter what the outcome, the new mother will feel better about her experience and will be better able to care for her child. When we simplify our approach to birth, we will see that birth is simple.

Ask the Doula - epidurals

I am always getting letters, phone calls, or face-to-face questions about birth, doulas, and such.

Every week, I am going to  try to answer and explore a different question that is presented to me, and, in doing so, perhaps answer some of your questions, and perhaps learn a thing or two myself.

Please send me your questions as comments, and I will select one question each week to answer.



Question Number One

"I was at a birth the other day, and the doctor said to my client that there was a recent study done that proves that an early epidural [that is, administered before 4cm] does not lead to a rise in c-sections. What is your opinion on this?"

I think more doulas and women will start to hear about this study, and I think it reflects a dangerous trend. The doctor who quotes recent research seems very with-it and up-to-date - she's done her homework. But let's have a little look at the research in questions:

The study is a systematic review of six studies that included over 15,000 women. Please click here to retrieve it. As you can see, it is a nice little study, I suppose, with one serious flaw that jumps out on first reading.
It states that the ..."review showed no increased risk of caesarean delivery or instrumental vaginal delivery for women receiving early epidural analgesia at cervical dilatation of 3 [c]m or less in comparison with late epidural analgesia." Early epidural analgesia was defined as that administered at 3 cm or less. Late epidural analgesia was not defined, so it could have been administered anywhere from 4 cm well into the pushing phase. Well, when was it? Was it at 4.5? Or was it after an hour and a half of pushing?

The danger is that, the media being the creature it is, someone could simply snip this conclusion, as I have done, and weave a generalization from it. An unsuspecting woman reads the two-sentence generalization and thinks "ahhh, well, that's a relief, I don't have to wait to take my epidural."

Let's look at the reality:
What do we see, as doulas? As I suggest in my book, IF a baby is not optimally positioned (and, by the way, this is also something that we have studied and studied, and we still can't ever really tell when and if a baby is well-positioned, except by watching her  weave successfully down the birth tunnel), and IF a woman takes an epidural early in her labor, and IF the baby's descent could have been helped by a resistant pelvic floor, then this mother and baby could end up with a surgical delivery.

So, in fact, when I see a nice easy birth and:
a mother who has always taken an epidural (and this is her sixth baby and hey! who am I to argue?)
or a mother who always maintained she would ask for pain meds
or a mother who needs meds for another, outstanding reason (sexual abuse being one - we'll get to that another week)
then I have a better feeling about outcome when she decides to take an epidural (even if I know she doesn't really need it).

But when I see a labor that is not going well, for whatever reason: for example, if a woman is having the particular kind of pain that may indicate a poor position, or a woman is undergoing an induction (more about induction coming up too) that looks like it may fail, then I worry about an early epidural, and its effects on labor.

So what can we do about it? "No, little missy, you cannot take the drugs. I as your doula know best"?
Of course not. Maybe there is not really much we can do in the moment. Maybe prenatal education is absolutely paramount. We need to sit with our clients and talk with them about what they are reading, what they understand, what they believe. We need to work with them and open up to them about our own experiences as doulas, and let them know that although a natural birth is definitely simple, it is not usually easy, and that even during labor they will probably have to make choices. And that her choices WILL affect the way her birth unfolds. If she wants a natural birth in a hospital, she will have to work for it. Part of that work will be not accepting pain medication too early in labor.
I know it goes against the review.
But I have evidence that early epidural administration DOES interfere with the normal progress of labor. That evidence comes from my own observation. No studies, no funding, no university degrees. Just women birthing.

Feel the Love

Blackberries are my favorite fruit. I made four jars of blackberry jam this morning. I made a blackberry pie the other night. They are in season around my birthday, so they are a yearly treat for me. They taste of the end of summer, the sugary heat of June and July is stored in their black bubbly taste. They have a rich taste that lends itself well to jam. So I'm jamming.

Jamming and reading my emails. And I read a beautiful account of a birth attended by one of "our" volunteers doulas. She assisted a mother who labored for many hours, and finally the decision was made to go to surgery. The baby was born, and the mother is recovering well from surgery and is mothering, as we do, to the best of her ability. Her doula was fully present for mother and baby from the beginning of labor, in the labor room, in the operating room, and at home.

If I look at the details of the story, I could probably find places where decisions were made that were not optimum, that may have led to further interventions, where this woman could have avoided surgery. But that's what I love about "my" volunteers and apprentice doulas. They are not working from information, experience, or an agenda. They are the best doulas I know, because they are working from a sense of companionship. They are loving the birthing woman.

I know several artists and musicians. A familiar refrain in the world of creativity is "Ah, if I could draw/see/play as a child does! If I could regain that way of looking at the world, where everything is new and interesting." In the birth world, as well, that sense of innocence, of wonder at birth, is something that we all strive to keep. I remember when I was looking forward to going to my first birth - I would have done anything just to be at that woman's side and accompany her through labor and birth. Not to say that I am not as dedicated to birthing women as I used to be. But I know them better - I've seen more - I don't have that freshness of vision that a "new" doula or a child has.

As doulas, we need to remember to forget ourselves and our knowledge when we are accompanying a woman in labor. Just as I greet the first wild blackberries with joy and appreciation, we should greet every birthing woman with respect and with a sense of her "newness" in the world.Forget about how much or what you know, and remember that it is her journey and you are a guest. Be happy.

Old Scars

The cesarean section epidemic has been growing in intensity and numbers since the 1970's, in most of the western world, and increasingly in China, India, and South America.

It is a given in most conservative medical circles that the scarred uterus is more fragile during subsequent pregnancies and may rupture during labor. While I do not believe a healthy, though scarred, uterus will rupture without provocation, I have witnessed severe psychological and emotional scars from unnecessary surgery. The World Health Organization suggested in 1985 that a 15% cesarean rate would be optimal. I believe that in countries where mothers and babies and generally healthy (this may exclude the U.S. because of high obesity rates), an optimum emergency c-section rate would be under 5%.

All sorts of shocks and aftershocks have been linked to cesarean sections. Failure to bond, failure to thrive, autism, asthma, breastfeeding problems, PTSD, ADHD, you name it, unnecessary surgery has been implicated.

But what about the effects on a woman as a woman? What about the women who have been having this surgery over the past thirty years? The young ones may mistakenly believe that it is easier on the body for the baby to be extracted surgically; that the low transverse scar just above the pubic bone will heal and remain an almost-invisible thin white line; that urinary and fecal incontinence will be miraculously avoided; that their vaginal muscles will be tight and virginal forever. The middle-aged ones, the menopausal ones, the ladies who have had possibly multiple cesareans, based on the old "once a cesarean, always a cesarean" dictate of the 70's and 80's; these women represent the tip of the cesarean iceberg and their numbers are growing as this rate increases.

Much has been said, especially by men, about the effects of menopause on a woman's emotional state. The old stale jokes abound. But the fact is, that many women start to feel anxious and disoriented about their new status as non-reproductive beings.

I didn't. I have five sons and I am very happy about my contribution to the ongoing human race but I was content to let menstruation go. I do feel ambivalence about growing older - after all, who wants to die? As we age, we do march slowly but surely towards the next big chapter.

So, with the loss of our reproductive capabilities, as we get used to our bodies and ourselves during this phase of life, it is difficult to have to watch the little white bikini line grow into a larger, lumpier line where no matter how many times we march off to the gym, the pleasant softness of middle age insists on bulging unpleasantly underneath and over the top, as if a tight elastic were stretched just above the pubic bone. And it hurts - it still hurts - even after twenty, thirty and forty years.