The Empowering Cesarean

Empowerment - making one stronger and more confident, especially in controlling their life and claiming their rights.

Let's get one thing straight from the start - noone can empower another person when it comes to the humanistic experience of empowerment. Empowerment is, by definition, one finding ones own strength. So, I cannot empower you... but, you making a choice that feels good and resonates within you can be empowering to you. It is your power of making that choice that feels good. 

I am a huge advocate of low intervention, no pain medication birth. In healthy and low risk birth, less intervention (medications, tools, equipment, etc..) means less inherent risk. But just because I believe in that truth does not mean that it is going to be true for every birthing journey. Every birthing journey doesn't stay healthy and low risk, not every birthing journey couldn't benefit from weighing the pros and cons of an intervention and erring on the side of the intervention. So, that is where we start.

Women can have very empowering births in whatever way that they birth. My years as a birth worker have taught me that truth. The number one deciding factor that makes or breaks the case for a woman's fulfillment of a birth experience and decreases her chances of seeing it as a trauma is choice. When a woman is provided with choices, and is given the space to be a partner in her healthcare and birth planning, she is able to look forward to her birthing time with joy and not fear, fulfillment and not trauma.

If you find yourself planning for an upcoming cesarean, here are some options that are specific to you:

• Feminist Breeder 
• ICAN’s Family Centered Options 

• Sample Cesarean Plan 
• Medical Paper on Facilitating a ‘Natural Cesarean’ 
• Best Cesarean Care Plan – most information is for a planned cesarean

• Gentle Cesarean 

• Kangaroo Care after Cesarean 

• Family-Centered Cesarean

 In addition, you can talk with your provider about using a clear drape or a drape with a window in it, see if your hospital offers the TAP block for post-operative pain management, and talk with them about having a photographer in the OR with you to document those first moments.

Knowing your options, and finding a provider who will have an open dialog about these options, helps to ensure a happy and healthy mom in all birth experiences. 

Open Letter to Birth Makes Sense

I recently came across a post called Birth Boot Camp vs. Bradley Method over at Cory's blog and it saddened me. I may seem like I'm picking on her, but I'm not. I have written before about how sad I am about the 'us' vs 'them' that is coming about in our birthing communities across the globe. Those who should be supporting each other and finding the best fits for every woman's needs instead find ourselves feeling like (for whatever reason) we need to mark our own territories and discredit other methods, certifications, practices, practitioners, etc... I hope that she does change her original post to be less biased, but I pdfed it for anyone who wanted to see the original post... just email me.

At the time that I read her post, it was the only one that the comments had been disabled. I hope it was an accident, although it is the only post with comments turned off... so I wrote her a note instead. I hope she receives it and, if not, she might find it here through backlinks. *edited to add that she did receive my email.

Here was my response to that original post:

I like how you can't post any comments... lol! I will comment here then. This is a VERY inaccurate post. BBC came from a former AAHCC instructor who wanted more updated materials and options to teach their students, so the story goes. Which is a big part of why BBC goes out of their way to discredit AAHCC. As a former Bradley instructor, I can tell you this with confidence:

• Requirements for my training, and a friend who just completed the course include over a dozen books to read, not just 4 like you said (or any instructor I have met). So, in that way BBC and AAHCC are the same. 

• 'Husband' is the word they use for the partner/sister/mother/other support ONLY because the program was conceived in the 1940's/50's. Any support person can take that same role. The main thing is to have support, regardless of what form it comes in, as long as the support person is emotionally connected to the mama on that level. So, in that way BBC and AAHCC are the same.

• AAHCC encourages mom to go 'to bed' when/if she feels the urge to do so. If you were to watch the videos they present during classes, and if you were to read the materials for classes (the actual workbook), you would know that they teach that not every woman finds this to be the most productive, and is only one tool that they teach. In fact, they teach a total of 18 different tools and relaxation methods for birth, including positive position changes, guided relaxation, imagery, color therapy, breathing and vocalization, etc... Many Bradley moms find upright 'sleep' positions and noise to be better relaxation tools - and they teach both of those during classes. So BBC and AAHCC are the same in that way as well.

• AAHCC encourages mom to be knowledgeable and gain the intuitive, emotional, physical, and mental information/knowledge/wisdom needed to birth in confidence in our culture, and 'coaches' role (aka husband) is there to remind her. They also talk about the benefits of doulas and other support people synonymously with 'husband'. The main reason they teach it like they do is because 'husband' has an emotional connection and is able to help mom make those choices in birth, unlike any professional in the room.

All of that to say that some of the drawbacks of AAHCC:

• The material (pictures/verbiage) is antiquated and needs to be updated. Thankfully, your instructor will work around that. They all have the same complaint and have become very adept at modernizing the information. 

• The requirements to become an instructor are very stringent, even unfairly so. Although there are ways around it. 

• BBC has better bfing material

• Those running AAHCC have dissuaded many an instructor from recertifying, we'll leave it at that.

Some of the drawbacks of BBC:

• It's a newer method and, whether or not they say they are a method, they are. As much as Hypnobabies, BFW, AAHCC, Hypnobirthing, or any of the other methods are. Method is defined as: a particular form of procedure for accomplishing or approaching something. Because you have a workbook, you are a method :)

• The requirements to become an instructor are very stringent, even unfairly so.

• They are so hell bent on discrediting AAHCC and pick on them more than any other method that it puts a bad taste in my mouth.

I'm saying this all in love as a loving rebuke - Bradley picks on Lamaze, Hypnobabies picks on Bradley and Hypnobirthing, and BBC picks on AAHCC. Your business will thrive much better for not making broad opinions on partial information or biased reviews (that sounded mean, I'm sorry). You will find allies in the birthing and general community where others have failed because of this reason. Trust me, having BTDT and been in this industry for over 13 years I can say that with confidence.

Your post, whether you meant it to or not, comes off very 'my method is better than yours' and, as a capstone in your community, you cannot afford that and neither can your community. We are in the same industry, all of us (MWs, CBEs, Doulas, IBCLCs of ALL trainings and methods) are striving for the best for the women we serve. We deserve and should strive for community and camaraderie, rather than us vs them.
So, there's my dollar, keep the change ;-) And sorry if I come off as harsh.

I have reviewed the materials for both classes and can say that they are both great options as childbirth classes. Putting my doula hat on for a moment, a great way to find out which class might fit your needs would be to listen to unbiased reviews from people who have nothing to profit from your choice (i.e. a doula who doesn't teach a specific method of childbirth class, your midwife, etc..). No one method of preparation is going to be the method for all women.

As supporters of the women in our communities, it is best for birth workers to know that and have good, unbiased, information on hand for every woman. Ladies - we are called to bring accurate and unbiased information to the public - let's make sure that, especially when talking about others IN OUR COMMUNITY that we are showing community to our community. We can do that while also encouraging them to make sound decisions.

Lying In

What a perfectly quaint term that is,  Lying In... But, in actuality, that is what a woman and her family should do immediately after baby is born. There are many health benefits to lying in, including quicker recovery, lower incidence of breastfeeding issues, and less incidence of postpartum blues/depression.

The term, ”lying in” is prevalent in other cultures and refers to the time when new mom doesn’t have to do everything, but simply takes care of herself and baby.

"The lying-in period allowed the baby time to settle in and acclimate to his or her new environment. Babies come into this world ready to bond; their central nervous systems are open and ready for new experiences. With too much activity, babies become over-stimulated and do not have the ability to calm themselves. The social demands of entertaining well-meaning visitors deprive both mother and baby of much needed rest. Babies sense their mothers' fatigue and anxiety. They become increasingly irritable and difficult to console. However, babies of mothers who observe a lying-in period have a lower incidence of colic. The mother's familiar presence, adequate rest, and limited stimuli allow the baby time to integrate into his or her new environment."
- Lynch B. “Postpartum Culture: The Loss of the Lying-in Time,” SpeechGiven at DONA 10th International Conference, New Orleans, July 22-25,2004

Suggestions for postpartum:

• let others take care of you (i.e. family and friends, hire a mother's helper or a postpartum doula, etc..)
• treat yourself to a maid service twice in the first 3 weeks. Ask for it for a shower gift.
• Interview/find a lactation consultant or visit your area La Leche League before the birth
• Interview and find a pediatrician that coincides with your parenting choices
• Make a small 'cheat sheet' with relevant information, emergency contact numbers, and help on it (relatives, friends, LLL leaders, etc..)
• stay in your bed for the first 3 days (except for bathroom breaks)
• stay on your bed for a few days after that
• stay near your bed for a few days after that
• stock your freezer with frozen meals and your fridge with easy snacks (yogurt, dried fruit, veggie sticks)
• make an 'in case of' phone list of friends who have had children and whom you can call and ask questions of whenever you need!
• Give partner a Daddy-do list (taking baby for a walk, bathing baby, baby massage, diaper duty, etc..)
• Throw your perfect parent list out the window!
• Call on friends and family members to bring you meals for the first few days
• Have feeding stations throughout the house (bottled water, breastpads, burp clothes, baggie snacks, books)
• Have changing stations throughout the house (diapers, wipes, changing pads, spare onsies)
• EAT HEALTHY and DRINK LOTS OF WATER - this will help you recover faster and ensure good breastmilk for baby

Don't forget that your main concern during this time is not a clean house, couture clothing, or entertaining guests.. it is about taking care of you and baby, period!

Take time for just you - Call a friend and chit chat, even when you don't feel like talking to anyone. This can sometimes help you or your loved ones to assess if you are healing emotionally or if you are experiencing either baby blues or postpartum depression. Take a warm relaxing herbal bath, go for a walk in the sunshine or lay a blanket out and read a good book that is purely entertainment.

Take time for just family - give your baby a massage, snuggle a sleeping newborn and breathe deeply the scent that is uniquely his/hers. Take pictures of mommy, daddy, and baby (and siblings), breastfeed often and on demand. Take your baby for a walk or take a nap outside in the shade with him/her.

Words of Caution
Some women feel like a million bucks immediately after birth or a few days afterward, but don't overdo it - your body will thank you later. Signs you are overdoing it physically:

• bright red bleeding when it had previously started looking like 'old blood'
• decreased milk supply
• clogged milk ducts and/or mastitis
• insomnia/hard time sleeping
• anxiety or panicky feeling
• increase in 'blue' feeling
• your doula, midwife, friend, or husband telling you to sit down 

Many many women experience a 'let down' feeling after birth. It is very common and can range from simple and mild disappointment or moodiness, to more intense 'blues', to something called postpartum depression. Signs that you might be experiencing the baby blues or postpartum depression vary and either can sneak up on you without warning. The best odds of avoiding postpartum depression and baby blues include:

• considering placental encapsulation or consumption
• talk to other mommies, reach out to the outside world even when you are lying in
• be honest with those around you about your emotions and private thoughts - there is no condemnation
• get rid of your idea of the perfect parent. The perfect parent for your child is YOU, that is why you were given him/her
• breastfeed
• eat and drink well
• don't overdo it

Sometimes, though, no matter what we do or how we prepare, ppd or baby blues simply happen. For those reasons, family and friends should  be on the look out and understanding of new moms and their emotional health.

In Closing
Being a parent is an amazing adventure, this is just the beginning. Savor these first few moments, breaths, days, weeks.. they are gone too quickly and forever wished to be reclaimed. This new life, your newborn, and this new person, you, a parent, are both discovering each other and the world through fresh, newborn eyes. Congratulations!

Additional Resources:
Help Guide for PPD and Baby Blues
Assessment Scale for PPD and Baby Blues - personal form to fill out

All About Medications

There are many options when it comes to the use of pain medications for labor and birth. Some of these options may not be available at your particular place of birth, so, if you plan on using medication during labor and birth, it is a good idea to consult with the anesthesiologist at your birth place. This will also enable you to talk to the about your concerns and to ask any questions that you  might have about the procedures involved.

As with any/every intervention, the use of pain medication during labor and birth inadvertently always carries risk. Weighing the benefits with the risks will allow for families to make the best choice for their birthing needs and desires.Best odds, interventions should be reserved for emergencies; interventions should never be routine.

When accepting an intervention, such as pain medication, always ask yourself:

• What are the risks?
• What are the benefits?
•  Do I accept the possible risks in order to receive the benefits?

Some doulas, like myself, use an epidural agreement with mothers. This epidural agreement is useful in all situations involving the choice of medications. Herein, we will be talking about the benefits and risks of medications that might be available to you, so that you can make an educated decision regarding them during your birthing time.

Medicated Pain Management - Analgesics:

Pudendal Block: An injection of narcotic medication (usually  bupivacaine) is given through the vaginal wall and into the pudendal nerve in the pelvis, numbing the perineum. This is not a readily available option and most doctors don't offer this anymore. The few women I have worked with who have had this (in past births) said that the administration was quite painful and one said the numbing was 'confusing'.

• Pros: given shortly before delivery so less medication reaches baby, quick acting and short term (2-4 hours), alleviates pain associated with the second stage of labor 
• Cons: does not relieve the discomfort of contractions, short window of time that it can be administered, may cause residual to permanent nerve damage, increases swelling of perineum, decreases elasticity of perineum (which increases risk of tearing), can puncture fetus, can puncture uterus or arteries of mother.

Paracervical block: An injection of narcotic medication into the tissues around the cervix. A form of
local anesthesia. This is not a readily available option and most doctors don't offer this anymore. The few women I have worked with who have had this (in past births) said that the administration was very painful.

• Pros: decreases contraction and dilation discomfort, short term (1 to 2 hours)
• Cons: can puncture uterus causing infection, can puncture placenta causing hemorrhage, can puncture baby, can cause swelling in cervix, can cause damage to cervical tissue.

Stadol: an analgesic (works on whole nervous system instead of one area) which is administered via IV. It is an opiate derivative (narcotic) with an additive to combate the dysphoriate reaction to narcotics.

• Pros: near instant relief, takes the ‘edge off’ of hard labors, moderate (2-4 hours) spanning. Oftentimes sleepiness occurs, contractions feel shorter in duration.
• Cons: loopy or high feeling, hallucinations, nausea, depressed respiration in mother and baby, decreased cardiac output, decreased oxygen in blood in mother and baby, fetal heart rate deceleration, and/or epidura hematoma (bleeding on the brain) can occur. Roughly 20% of women have a sensitivity or allergy to the narcotic Stadol. Does not remove pain, simply makes one not care about the process or the pain, or too sleepy to resist the contractions.

Demerol: a narcotic analgesic which is administered via IV sometime in the early-late phase of first
stage. This medication is very closely related to Stadol.

• Pros: near instant relief, makes one relaxed enough to not care about pains of labor, moderate (2-4 hours) spanning. Oftentimes sleepiness occurs, contractions feel shorter in duration.
• Cons: loopy or high feeling, nausea, irreconcilable fatigue, depressed respiration in mother and baby, decreased cardiac output, decreased oxygen in blood in mother and baby, fetal heart rate deceleration, and/or epidura hematoma (bleeding on the brain) can occur. Does not remove pain, simply makes one not care about the process or the pain, or too sleepy to resist the contractions.

Nubain: another narcotic analgesic, administered via IV throughout the first stage of labor.

• Pros: Near instant effectiveness, moderately spanning, similar reactions as marijuana. Oftentimes sleepiness occurs, contractions feel shorter in duration.
• Cons: abdominal cramps, nausea and vomiting, rhinorrhea, lacrimation, restlessness, anxiety, elevated temperature, respiratory depression in the neonate, and death. Does not remove pain, simply relaxes mom so that she forgets or does not concern herself with the process of labor. Roughly 20% of women have a sensitivity or allergy to the narcotic Nubain.

More information on the medications listed above:
http://www.drugs.com/cdi/nubain.html
http://www.drugs.com/cdi/stadol-solution.html

Medicated Pain Management - Anesthesia:

Spinal (saddle block, intrathecal) Block: an injection of opiates between the vertebrae of the low-mid back, through the epidura, and just beyond the dura – before the spinal cord. This injection is directly into the spinal fluid.

• Pros: near instantaneous relief, less medication than epidural, less chance of infection as there is no running line, should completely numb the uterine area. Should still be able to feel the tightening of the contractions. Feelings of pressure but no pain with contractions.
• Cons: can be ineffective (either completely or in ‘windows’), re-administration means another needle. Can cause fever, maternal drop in bp, fetal respiratory depression, arresting of labor, inability to push, urinary incontinence, decreased cardiac output of either mother or neonate, increase risk of jaundice, fetal bradycardia (decreasing heart rate with or without contractions), improper engagement (head or presenting part not moving through the pelvis correctly), breastfeeding problems, fetal death, maternal death, or cardiac arrest. Long term consequences can include chronic lower back pain, spinal headache, ruptured discs, or permanent nerve damage.

Epidural: a cocktail of various opiates and narcotic anesthetics placed into a catheter (thin tubing). The catheter is fed between the vertebrae of the low-mid back and into the epidura space before the
dura/spinal cord; hence the term ‘epidural’.

• Pros: can be given in varying doses, works quickly (within 5-10 minutes), easy to re-administer if it runs out, easy to increase the dose if necessary for a c-section, should completely numb from the uterus to the toes. Ideally, will retain mobility of legs and feet. Feelings of pressure but no pain with contractions.
• Cons: can be ineffective (either completely or in ‘windows’), cause fever, maternal drop in bp, fetal respiratory depression, breastfeeding problems, increase risk of jaundice, fetal bradycardia (decreasing heart rate with or without contractions), improper engagement (head or presenting part not moving through the pelvis correctly), arresting of labor, inability to push, urinary incontinence, fetal death, maternal death, or cardiac arrest. Long term consequences can include chronic lower back pain and ruptured disc.

Walking Epidural (Combined Spinal Epidural, CSE): a combination of the epidural and the spinal. An initial injection into the spinal fluid, then a catheter line running continuous low-dose narcotics and opiates to the epidural space of the spinal column.

• Pros: quick acting, again can be given in varying doses. easy to re-administer if it runs out, easy to increase the dose if necessary for a c-section, should completely numb in the uterine area while still allowing movement of the legs.
• Cons: all of both the epidural and the spinal. In addition, though it is called a walking epidural, a mother does not have full use of her legs and will still be, most likely, confined to bed or sitting in a chair.

More information on the medications used in the spinally administered medications,  bupivacaine and
Fentanyl:
http://www.drugs.com/cdi/fentanyl.html
http://www.drugs.com/mtm/bupivacaine.html

Nitrous Oxide:  this option is becoming more readily available in the United States. Nitrous Oxide is an odorless and tasteless gas that is inhaled during contractions. It is self administered through a hand-held face mask and takes effect within a minute.

• Pros: Alters pain perception, can  be used intermittently or continuously and can be stopped at any time. Short term relief. Has very little effect on baby as nitrous oxide dissipates from the neonates blood stream upon first breaths. Can be administered in any birth setting.
• Cons: Doesn't eliminate pain, dizziness, drowsiness, nausea, and restlessness can occur. Can cause problems with mild maternal hypoxemia.  

In closing, consider printing out and going through the PMPS here. This worksheet can  help you to establish just what types of pain management you are comfortable with and just want support your birth team might be able to provide for you during your birthing time.