The Greater Good

The other day a dear chiropractor friend of mine slipped me a film entitled “The Greater Good” and told me to watch it. I went home, fully intending to be bored into oblivion by a tyrannical or severely biased anti-vaccination documentary. I was pleasantly and completely wrong! 

“The Greater Good” is a well-balanced documentary that follows three families through situations involving 'adverse reactions' from vaccinations. It is interspersed with interviews from numerous medical professionals including vaccine developers, pharmaceutical reps, psychologists, behavioral therapists, and pediatricians.

Although the families stories definitely called to the intrinsically emotional mother in me, the information supplied called to my deeper intellect.

My daughter, Briaunna, also reviewed the movie. This is what she had to say: 

The movie was about vaccinations and how they can affect you, good and bad. My initial reaction was anger and pain for the people who were harmed by the vaccines. Helpless children who get vaccinated with, basically, poison. I liked how people are learning more about vaccines… even though many of them have to learn the hard way in order to teach others. I also like how people are learning the true risks of vaccines. 

Did you know that vaccination does not account for the impressive declines in mortality seen in the first half of the century? It was other medical advancements, including learning to just wash your hands (microbiology).

Lately, people have been giving vaccinations to newborns, which really upsets me because I am a baby freak. Also, parents are required to give 69 doses of 16 different vaccines to children. They also put aluminum and mercury in all of the vaccines. Any form of mercury in the body is toxic and can cause damage. 

Did you know that, after 2010, 85 deaths have been reported, all after taking the Gardasil shot?

The only other thought I have is that the government has gotten too much power over us. They say that if you haven’t given your children all of the required shots, you have to go to court and get your shots…. “Or else”. They think that you will endanger your child’s life if you don’t get them vaccinated, which, of course, is all in the way that you look at it. I see more risk to their lives from taking a vaccination, but that’s just me.. and my right to not get vaccines for me or my babies.

The movie covers the historicity of vaccinations, and give us a rare look into the hearts of those who developed them.

At the same time, we hear from the lawyers who defend those families who have been harmed by vaccinations. 

When asked if they believed the business of vaccinations is involved in conspiracy, one astutely replies, "A conspiracy? Yes! But a conspiracy to do good." So much so, that the risks of vaccinations are minimized through government involvement and media bias in order to promote the 'good' that vaccinations provide to the majority.

"The Greater Good" takes a critical look at the government's involvement in implementing and mandating state-wide vaccinations, as well as how individual states are trumping parental and individual rights.

"If the state can force you to put your life on the line, or your child's life on the line, for any medical intervention, then the state has too much power"

Additionally, the movie takes on the very real, very publicly acknowledged fact that many members of our government council also hold shares in the very pharmaceutical companies that create the vaccines which the state promotes. It is as true as it gets: conflict of interest is: when my politicians have a vested financial interest in vaccination pharmaceutical companies. Or, as the movie states:

"the fox watching the chicken coop"

We are given the stats on individual state's exemptions and the bias in media exposure. We are shown the process to bring a vaccine to the public and how 'fast tracking' a vaccination intended for children was foolish. We are given real risks associated with vaccinations, and given a more in-depth look at the studies used to 'prove' the safety and efficacy of vaccination. 

I was, at times, outraged, and other times saddened... I felt I learned so much, even after having done, what I thought, was thorough research on vaccinations... but there were things that still had me dumbstruck and amazed. Just one example: the placebo used in many of these 'safety and efficacy" studies is aluminum, mercury, or a combination of the two!

Some great quotes from the movie that I hope will pique your interest:

"We know that mercury (thimersal) causes neuro-toxicity, there's no controversy about that. Does it cause autism? It contributes to the damage that leads to autism." - John Green III, MD

"There are studies comparing the hair of autistic and non-autistic children. There is much more mercury in the hair of non-autistic children, showing us, at least in part, that there is some genetic precursor that makes some children more succeptible to autism."

 Would I recommend this movie? A resounding yes! Would my daughter? Well, let's just say she is already inviting her tweenage friends over for a 'movie night' at our place - her idea. I recommend this movie to every family who have children, or who will have children, of vaccination age. 

"The Greater Good" does a wonderful job of promoting this one moral: it is not about having you vaccinate or not vaccinate. It is about ensuring that families know the risks, that the studies regarding vaccinations are fair and accurate, and ensuring that vaccines are made to be and required to be as safe as possible.

To visit them on the web

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Would You Rather...

DISCLAIMER: there are graphic pictures in this post.

This is the post that makes women squirm, clamp their knees together, and raise their blood pressure in angst. We are going to talk about tears and episiotomies. I know, I know - it makes my stomach flip and my PC clench.

I think the most 'catch 22' question of pregnancy is the infamous, 'would you rather tear or have an episiotomy?'. Now, any woman in her right mind would say NEITHER! And wisely so.

Don't worry, we are going to talk about how to minimize the risk of tearing altogether. But, in the spirit of informed decision making, we will be talking about what both tears and episiotomies are, the risks and benefits of each, and how to minimize the risk of either occurring. 

TEARS
Let's start with tears. Tears occur for a number of reasons. Some of these include:

• The position mom is pushing in
• If baby has a nuchal hand or arm
• The speed at which crowning occurs
• How aggressive or hands-on the care provider is
• If instrumental delivery is being employed
• How relaxed and elastic mom's perineum is
• How toned and sinewy mom's pubococcygeous muscle is 
• Mom's Ethnicity 

Tearing is a natural separation of the tissue at the outlet of the vaginal opening, usually through the perineal tissue toward the anus. Some times, it occurs anteriorly, or toward the urethra/clitoris. Most tears that occur spontaneously occur at crowning and are less than 1st degree and up to 2nd degree lacerations. Although 3rd and 4th degree tears do occur naturally, it does not occur very often.

Vaginal lacerations, both naturally occurring (tears) and surgically performed (episiotomies) are measured in degrees. The degrees of lacerations are explained below:

• Skid Marks -The most common naturally occurring laceration. These are usually less deep than a split lip and do not require any stitches. They heal within a matter of days after birth.
• First Degree (1st) - The smallest laceration, extending only through the vaginal mucosa. It does not involve the underlying tissues. Many midwives do not recommend even stitching these as they heal easily when naturally occurring.
• Second Degree (2nd) - The most common type of episiotomy. It extends through the vaginal mucosa and into the submucosal tissues.
• Third Degree (3rd) - this involves the vaginal mucosa, submucosal tissues, and some or all of the anal sphincter muscle.
• Fourth Degree (4th) - The most severe laceration. This includes the vaginal mucosa, submucosal tissues, anal sphincter muscle, and the lining of the rectum. This can lead to recto-vaginal fistula and a high rate of incontinence.

EPISIOTOMIES
The episiotomy, on the other hand, is performed for a different set of reasons.

• to prevent tearing
• suspected large baby
• suspected shoulder dystocia
• longer 2nd stage
• precipitous birth
• to prevent later incontinence
• fetal distress
• routine (doctor always does it)

Reports state that the US has anywhere from a 9% to over a 40% episiotomy rate.

Stephanie Soderblom LM CPM: www.azhomebirth.com

Simply put, an episiotomy is when a care provider cuts the vaginal opening down through the nerve-filled perineal tissue toward the anus with a pair of surgical scissors. Yep, scissors. For added benefit, though, I have included the more professional definition:

Episiotomy - an incision created in the vaginal opening and tissue surrounding it in order to enlarge the opening. From the root Episio, meaning vulva and tomy, meaning incision or sectioning.

Episiotomies are an automatic 2nd degree laceration, or more. There are two main types of episiotomies: the midline and the medio-lateral. The most common in the US is midline, while the medio-lateral episiotomy is more common in other parts of the world.

Types

A midline episiotomy is when the care provider incises the vaginal opening straight down toward the anus. This type of episiotomy is reported to have less pain and less incidence of long-term tenderness or pain during intercourse than the medio-lateral episiotomy. There is often less blood loss with a midline episiotomy as well. The biggest disadvantage of this episitiomy over the mediolateral is that this type of incision is very likely to continue tearing beyond the incision, causing a larger laceration.

A medio-lateral episiotomy begins at the vaginal opening and is cut at a 45-degree angle toward either the right or left buttocks. The main advantage of the medio-lateral episiotomy is that is has less chance of tearing beyond the incision. The risks include there is a significant increase in blood loss, increased pain, more difficult repair than a midline episiotomy, and the increased risk of long-term discomfort, especially during intercourse.
How Is an Episiotomy Performed?

How It's Performed
Ideally, an episiotomy would be done when 3-4cm of the baby's head is visible at the vaginal opening, and during a contraction. Although it is rather routine to inject a local anesthetic in the perineum when an episiotomy is anticipated, this injection actually makes the perineum LESS pliant, more likely to tear in the first place, and more likely to tear if beyond the incision if the episiotomy is performed. Instead, waiting until the woman is having a contraction and until the babies head is well applied to the perineum ensures that the woman's perineum will be numb from lack of blood flow to the perineum and minimize/eradicate discomfort during the incision.

The doctor or midwife would then insert two fingers into the vaginal opening to protect the baby's head and the incision, between 2-3cm in length, is made.

RISKS (aka WEIGHING THE OPTIONS)

• Risks of episiotomies over naturally occurring tears include:
• higher risk of muscle damage
• can cause tearing beyond the episiotomy (some reports cite 30% tear beyond the incision)
• can lead to urinary incontinence
• local anesthetics can cause more tearing by swelling tissues
• take longer to heal than a naturally occurring tear
• episiotomies always requires stitching
• women report more pain from episiotomies than from tearing
• episiotomies cause more extensive scar tissue than tearing
• higher rates of infection
• swelling
• higher rates of defects in wound closure
• higher rates of sexual dysfunction
• higher rates of recto-vaginal fistula
• higher rates of fecal incontinence

Women who do tear only tear as far as their body needs to to allow baby to pass by. Episiotomies are an automatic 2nd degree laceration, whether or not her body needs that space. And, many times, a woman will tear beyond the episiotomy that is performed.

I liken it to the phone-book tear test. Try tearing a phone book down the side, it is very difficult. Now, make an incision on that side. Now, try to tear it along that incision... the book is much easier to tear. This concept extends (no pun intended) to episiotomies and tearing beyond them.

 

In addition, tears heal faster, with less pain, and less scar tissue. This is because tissue cells look like little bricks. When a woman's perineum does tear, it tears through the 'cement' holding those bricks (cells) together - there is little to no cellular damage.

On the other hand, episiotomies are an unnatural laceration that tear right through healthy cells and the 'cement' around them, resulting in not only tissue damage, but also cellular damage. This increases infection rates, healing time, discomfort in healing, scar tissue, and long term pain and sexual dysfunction.

A final risk is this: there is absolutely no way for a provider to know beyond a shadow of a doubt that a woman will tear until she does. This means that episiotomies for 'might tear's sake is moot. Most episiotomies are unnecessary.

CONSIDERATIONS (aka WTH)

Let's deconstruct both the natural reasons a woman tears and the medical reasons a provider might cut.  

First, the natural reasons a woman might tear:

The position mom is pushing in - lithotomy/supine and semi-sitting (classic) positions have the highest incidence of tearing. Other positions that require mom to bring her legs back as far as possible toward her ears also have higher incidences of tearing. It is no surprise, then that women who have homebirths and birth center births have less incidences of tearing - they are able to choose whatever position feels best (which is usually not these positions) to push in and follow their bodies cues.

Many midwives who serve the Amish and Mennonite community also report that they have a nearly non-existent tearing rate. These communities often birth on their sides or in a squat with their knees together and their buttocks pressed backward. This makes physiological sense, as it decreases the pressure/tension on the perineal tissues, allowing more stretching to occur.

A woman's best bet is to get in a better position for birthing than lithotomy or supine.

Nuchal hands or arms - nuchal hands or arms mean that there is a hand or arm up near the neck/head. This means that there is something in addition to the babies head to fill that space, increasing the chance of tearing. Obviously, one cannot anticipate or correct this, but they can minimize the chances of tearing from occurring by allowing a slow and steady crowning and resolution to occur. They can also request perineal support and counterpressure to slow the process further. 

The speed at which crowning/shoulder birth occurs - the more time the perineum has to stretch, the less chance of tearing will occur. Likewise, the more precipitous the birth, the higher the chance of tearing. This risk increases, again, with coached pushing or purple pushing.

As a baby begins to crown, the skin stretches. This stretching can sometimes feel like tingling or burning, which is natures way of having mom slow down the pushing. Instinctually, women will let up on pushing and make some noise, blow air out, or 'horse-lip' for awhile, until the burning goes away.

The slower the stretching is allowed to occur, the less chance that tearing will occur. A woman can simply 'blow' through crowning, or even do 'horse lips' to allow her body to birth the baby's head and shoulders, slowing the process down and allowing for optimal stretching.

Another tip is to request gentle counterpressure or warm compresses on the perineum, to support the perineum during crowning and minimize the chances tearing.


Ways to minimize these risks are to request no coached pushing, employing blowing/horse lips through crowning or simply letting your body do the pushing, and warm compresses or counterpressure on the perineum.

How aggressive or hands-on the care provider is - the more the provider pulls on vaginal tissue during crowning, the more swollen the tissue will become, and less elastic. Also, the more the provider pulls on and manipulates baby's head, the greater the chance of tearing.

Likewise, it is common practice in the US to pull on baby's head after it is out to hasten the birth of the shoulders. This can create unnecessary tension on the perineum, causing iatrogenic tearing.

The best odds for a woman to eradicate this as a reason for her body to tear is to make sure she has a provider that she trusts to not to act aggressively with her perineum or her baby's body.

If instrumental delivery is being employed - if a vacuum extractor or forceps are used, the incidence of tearing does increase but is not guaranteed to occur. Because instrumental delivery means a more precipitous birth will most likely occur, as well as because there is the addition of a foreign object filling the vaginal opening along with the baby's head, the chances of tearing do increase, but again, is not a guarantee.

One way to minimize this possibility is, first and foremost, reduce your chances of needing instrumental assistance by considering an unmedicated birth, an upright position for birthing in, and patience to bring baby down, especially for first time babies, which, on average, take 2 hours of pushing. Another way to minimize the chance of tearing, if, after employing the above, you still require instrumental assistance, request gentle traction, when crowning begins, 'blow' through the contractions or don't push, and allow the shoulders to be born without the assistance of a vacuum or forceps.
 
How relaxed and elastic mom's perineum is - the more relaxed mom is, the more hydrated and well nourished mom is, the stretchier her perineum is.

When a mom can breath easily, without tensing up her pelvic floor, her perineum is able to stretch gently and optimally. Coached pushing should be avoided, and a mom should listen to her body's cues on when and how to push. Studies show that a woman's vocal folds/jaw/throat is directly related to how relaxed her bottom is.

In addition, good hydration and nutrition are vital for tissue health and elasticity. Drinking water during pregnancy and throughout labor and birth will ensure that your tissues are nice and supple and well hydrated. Likewise,

"Good nutrition is vital to your body's work in preparing the perineum for stretching during birth. Hormonal changes during pregnancy cause the tissues of your cervix and perineum to become extremely thick and elastic. Crucial to this process is an adequate intake of protein, vitamin E, and short-chain fatty acids, which consist of two types of 'good' fat, Omega-3 and Omega-6. Short-chain fatty acids are found in nuts and seeds, cold-pressed oils, all types of beans, and fish such as salmon and tuna" "Avoiding an Episiotomy", Nancy Griffin, Mothering Magazine, # 75, summer 1995, (p 60).

Vitamin C is also very beneficial for cellular elasticity and regeneration. It can be found in citrus foods, most readily, but also in dark green vegetables.

Finally, squats and intercourse encourage good circulation and elasticity of the perineal tissues. Squatting is natures way of keeping our bottoms healthy and sex encourages relaxed perineal tissue with good tone.


So, a mom can help ensure that her perineum is well prepped for birth through relaxation/vocalization/breathing, prenatal nutrition, prenatal and labor hydration, and prenatal exercise.

How toned and sinewy mom's pubococcygeous muscle is - how healthy a lifestyle mom lives and how well she has treated her PC muscle (sex, squats and Kegels) has great bearing on her ability to have a more controlled pushing stage, a well flexed baby's head, and less chance of tearing.

Women who have sex throughout pregnancy have well oxygenated, more toned and conditioned PC muscles, as well as have good control of this muscle. A toned and controllable PC muscle means that babies head is more likely to be well flexed, allowing the smallest part of the baby's head to emerge from the vaginal opening first, gently stretching mom's perineum for less chances of tearing.

In addition, squats will ensure that the PC muscle remains a long, sinewy muscle, keeping it elastic and not bulky and rigid. A woman should, during pregnancy, make sure that she is taking care of her PC muscle, making sure it is not only toned, but also stretchy.

Ethnicity - women of Caucasian or Asian ancestry tend to have a higher risk of tearing. Some theorize it is because of cultural or social upbringing. Others, genetics. 


Now, for the medical reasons a provider might give to perform an episiotomy:

Routine (doctor always does it) - This argument is usually given in conjunction with any of the below reasons for performing an episiotomy.

Many practitioners who believe in routine episiotomy state that a first time mom will 'nearly always tear'. I can tell you, from my experience, I have seen only 2 first-time moms naturally tear, and only one required/asked for stitches.

Other practitioners will tell you that it is easier to repair. Truth is, an episiotomy is easier for the one stitching to line up the seams... in other words, it takes less time to sew up... what they don't mention is that, although it is faster and easier for them to stitch up an episiotomy, an episiotomy is NOT easier on your body to repair. Naturally occurring tears heal faster, with less pain, less blood loss, less rates of infection, less emotional trauma, and less incidence of long term complications, such as fecal or sexual incontinence.

Best odds, talk with your care provider before birth to find out what their policies/beliefs are.

To prevent tearing - as previously discussed, there is no way for a provider to know, beyond a doubt, that a woman is going to tear until she does. And, even so, if a woman is to tear, a tear heals faster, with less pain, statistically with less degree of damage, and with less scar tissue and long term side-effects than an episiotomy does. In addition to all of this, an episiotomy has a high risk of tearing beyond the initial incision.

Truly, the only time that a woman can really benefit from the 'to prevent a tear' argument is when there is good reason to believe mom might tear anteriorly (toward the urethra or clitoris). 

Suspected large baby - If a large baby is the only reason given, it is a sad one. Many providers who perform routine episiotomies state that large babies need more room to maneuver the birth canal. Truth be told, the perineum will not hold back the birth of a large baby, only bone or mom's relaxation might. So, an episiotomy might shorten pushing by a contraction or two, but it is not going to 'rescue a large baby' from not being able to be born.

On the other hand, any care provider who has done perineal massage can tell you, a woman who is tensing against the birthing waves meant to bring baby down can hold her baby in. This is especially true for large babies or 2nd stages that are very intense.

The best a mom can do when she is told her baby may be large is to visualize her body opening gently for babies exit, remember to breath when waves come and only push when her body tells her to. Likewise, a provider skilled in deep perineal massage can be helpful in finding and releasing tense vaginal muscles during baby's descent.

This will allow for baby to have, not only room to navigate the birth canal, releasing tense vaginal muscles, but will also give the perineum time to stretch, the baby to rotate his shoulders under the pubic bone, and tissue to be soft and supple - able to stretch around any baby.

Suspected shoulder dystocia - again, all of the above same applies.

Fetal distress - This is one of only two good reasons to perform an episiotomy (the other is when an anterior tear is likely/occurring). When a baby has been showing true distress during 2nd stage and is showing further distress at crowning, an episiotomy can reduce the length of 2nd stage by a few contractions. In an emergency situation, this can be a lifesaving tool.

When a baby is truly in distress, an episiotomy can buy the provider precious moments by getting a finger hooked on babies shoulder, or mom the ability to push baby out with the next contraction/without a contraction, and without needing to wait for the perineum to stretch.

This occurrence does not happen very often, but, when it does, those few contractions can make a world of difference in baby's health.

Longer 2nd stage - Although, as stated above, episiotomies can shorten 2nd stage by a few contractions, that is all it shortens it by. If a long second stage is the only reason given, an episiotomy is only going to shorten a birth by a few moments, but postpartum recovery will be a lot more intense/extensive.

Rather than use this time to hasten birth by a few moments, this time could be better used to let mom get ready to receive her baby into her arms, encourage mom verbally, give her a drink and provide warm compresses to her bottom, and allow her to listen to her bodies cues.

Precipitous birth - If a woman is birthing very quickly, some providers will want to perform an episiotomy. Again, it is because fast births can (not will) mean a tear might occur. The funny thing is, medical texts say that, after creating the incision, a doctor or midwife should give gentle pressure against the perineum and baby's emerging head to prevent rapid or abrupt delivery, to minimize the chances of tearing beyond the incision... this is laughable as that is one of the ways to minimize the chances of a naturally occurring tear. It makes me think, 'why didn't you do that in the first place?!?!?'.  

As stated in the natural reasons, the best bet is to provide gentle counterpressure to slow a fast birth, guide mom in an easeful crowning and gentle resolution, and help mom to breath her babies head out instead of actively pushing. 

To prevent later incontinence - Studies have shown that episiotomies do more to contribute to later incontinence issues than a naturally occurring tear or an intact perineum because of the substantial risk that the episiotomy will either automatically go through muscle as well as skin, or will tear through the same.


BEST ODDS FOR 'NEITHER'
To ensure your best bet for not tearing or having an episiotomy, consider the information above. Mom's benefit from an intact perineum by eliminating the risks associated with perineal lacerations. In addition, babies benefit from an intact perineum by having their chest pressed over the intact perineum, which breaks up the mucosa in the lungs and encourages baby to expel it from their throat, mouth, and nose, before the first breath. When this occurs, many times a baby does not require suctioning and start their first breaths with a clear airway.

I consider the above information to be best consolidated in the 4 P's:


Prenatal Health - Eating a well rounded diet full of fresh fruits and veggies, especially citrus fruits and dark green and bright colored veggies, good oils and fats/omegas, and water hydration will give your tissue elasticity and healthy suppleness. Remembering to not only be attuned to your PC muscle, but also to perform regular squats will give your bottom elasticity and control for the 2nd stage.

Perineal Massage - I am not a huge proponent of clinical perineal massage during pregnancy. By clinical perineal massage, I mean the type where a woman or her partner hooks their finger into the vaginal opening and pulls/rubs at 8 and 4 o'clock positions until the perineum burns. This is not natural and can be psychologically damaging.

http://beautyandthebump.blogspot.com/

I believe that it sends the wrong message. It tells women that their body's are not capable of stretching well enough unless the woman does something unnatural to encourage it. It also sets a woman up for fear: fear if she didn't remember/know to do it prenatally that she will tear orfear that she will feel the burning that she experienced prenatally if she did perform clinical perineal massage.

What I do encourage is for women to have a healthy and active sex life during pregnancy and for she and her partner to be comfortable and familiar with her perineum and vagina through personal/pleasureable perineal massage.

If a woman is familiar with how stretchy her perineum is, if she is comfortable and knowledgeable of her vaginal muscular bands, if she is familiar with how to touch those tense bands or tendons, feel the tension, and release it or massage it away, she is more apt to do that in labor. If a woman's partner is used to the same, the woman is more apt to respond in same to similar touch/sensations during labor and birth.

Likewise, if she is familiar with what PC contraction is, she is more apt to be able to release that common tension during pushing if she can feel it with her own fingers, or feel her partner's touch and recognize the resistance and relaxation of this muscle.

Pushing - Women who push in positions that feel 'right', and are not coerced or led into certain positions, tend to have better chances of keeping their perineum intact. Likewise, when a woman can push to her body's cues, and not to the providers count, tend to stretch more readily. Women who are encouraged to be vocal if they need to, breath through those contractions that they feel the need to, and otherwise open their vocal chords for relaxation tend also to stretch more readily.

Choosing to birth in water, or at least a darkened, quiet room, encourages mom to be relaxed, and thus, her vagina and perineum is relaxed.  The warm water of a water birth helps the perineum to stretch as well, and a darkened room allows a woman to feel uninhibited, private, and safe - all of the ingredients mom needs to be relaxed.

As baby begins to crown, when a woman can reach down and touch her babies emerging head, women will often give themselves vulvar or urethral/clitoral support, pant or blow through contractions, and otherwise ease/massage their babies out.

When a woman is not able to or willing to feel her baby's emergence, often times, reminding a mom to breath or vocalize through the crowning stage will help her to stretch more easily.

I have that, women who place their fingers inside their vagina during pushing can bring their babies down more efficiently, slow crowning more readily, avoid any perineal trauma more naturally, and spontaneously catch their babies more easily. I believe that the more 'in tune' a woman is with this intense time and her body's cues, the better the outcomes we have.

Patty Ramos: http://www.doulapattiramos.com/2008/11/birth-up-close.html

Practioner's Help - a care provider who trusts in a woman's ability to birth her baby will be more patient in the absence of distress, allowing mom more time to stretch naturally. This provider will also be more apt to listen to mom's body and her own rhythm for pushing, rather than a count of 10 or purple pushing.

This care provider will also encourage mom to be in whatever position she wants to be in, and will provide/promote a safe haven for a woman to open up to the power of birthing without coercion or demands. Likewise, a practitioner can help by encouraging a relaxed vagina and perineum by providing perineal massage, warm compresses, lubrication at crowning, and perineal/anterior support during crowning and birth, if the woman would like him/her to.

CONCLUSIONS
As you can probably tell, I am very much against routine episiotomy and highly encourage women to make an educated decision regarding this procedure before the option presents itself. I always encourage the mom's I work with to talk with their care providers before birth to find out what their provider's stance is and to talk about any inconsistencies with them ahead of time.

Treating women like mothers during their labors and births, giving their bodies the benefit of the doubt when they take a few moments longer, in the absence of fetal or maternal distress, can allow a woman to claim her birth and baby as a positively transforming act, rather than a traumatic experience.

As a woman who has had both an episiotomy (1st birth) and skid marks (last birth, and having been told that my scar tissue was so extensive that I 'would definitely' tear with any subsequent births (which I never did), I am an avid supporter and believer in all of the practices herein to minimize the possibility of a naturally occuring tear occurring. Would I rather tear or have an episiotomy? Neither. But, if push comes to shove (or, more accurately, if push comes to the risk of tearing), I would rather tear.

Remember, if you have done all that you can to ensure that you will have an intact perineum and you still tear, remember to trust that your body did only what it needed to to birth your baby. 

Take a moment to read this woman's beautiful birth story of a large baby with not even a skid mark. She talks about how she believes she was able to ease Laslo's birth and even shares a birth montage. Enjoy. 

RESOURCES/FURTHER READING

• Evidence Report/Technology Assessment No. 112, The Use of Episiotomy in Obstetrical Care: A Systematic Review (AHRQ Publication No. 05-E009-2).
• Lemay, Gloria "Midwife's Guide to an Intact Perineum," Midwifery
  Today Issue 59
• Obstetric Myths Versus Research Realities, Chapter 14: Episiotomy
  
• Murray W. Enkin MD, FRCS(C), D.J. Hunter MD, FRCOG, FRCS(C), Laura Snell RN, SCM (1984)
• EPISIOTOMY: EFFECTS OF A RESEARCH PROTOCOL ON CLINICAL PRACTICE
• Birth 11 (3), 145–146. doi:10.1111/j.1523-536X.1984.tb00768.x
• Hartmann K, Viswanathan M, Palmieri R, Gertlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review.JAMA 2005;293:2141-8.
• Saying No to Episiotomy : Getting through Labor and Delivery in One Piece By Elizabeth Bruce, Mothering Magazine, Issue 104, January/February 2001
• University of North Carolina, Center for Women's Health Research. Routine episiotomy does not provide benefits: the importance of asking questions about common things.
• The Second Stage of Labor
  
• Viswanathan M, Hartmann K, Palmieri R., Lux L, Swinson T, Lohr KN, Gartlehner G, Thorp J. The use of episiotomy in obstetrical care: a systematic review; summary. Agency for Healthcare Research and Quality (Evidence Report/Technology Assessment: Number 112.)
• Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 1997, Issue 2. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081
  
• Roberts CL, Tracy S, Peat B. Rates for obstetric intervention among private and public patients in Australia: a population based descriptive study. BMJ. 2000;321:137–141.
• Senate Community Affairs Reference Committee. Rocking the cradle: a report of childbirth procedures. Canberra: Commonwealth of Australia; 1999. www.aph.gov.au/senate_ca.
• Roberts JM. Recent advances: Obstetrics. BMJ. 2000;321:33–35.
• Albers, L. L.; Sedler, K. D.; Bedrick, E. J.; et al., D; Peralta, P (2005). "Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial". Journal of Midwifery & Women's Health 50 (5): 365–372. doi:10.1016/j.jmwh.2005.05.012. PMID 16154062
• 10% Primipara Sutured Tear rate in the absence of episiotomy. Birth 2008;35(2):167.
• Woolley RJ. Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part I. Obstet Gynecol Survey 1995; 50:806-820
• Woolley RJ. Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part II. Obstet Gynecol Survey 1995; 50:821-835
  

The First Cut is The....

Wow... I opened my inbox this morning and found a plethora of information on the results of the National Institutes of Health (NIH) Consensus Development Conference on Vaginal Birth After Cesarean: New Insights

The conclusions (per their draft statement) are shown below, although you can follow the above link and read the complete study, as well as additional information:

Given the available evidence, TOL is a reasonable option for many pregnant women with a prior low transverse uterine incision. The data reviewed in this report show that both TOL and ERCD for a pregnant woman with a prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about TOL versus ERCD. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.

One of our major goals is to support pregnant women with a prior transverse uterine incision to make informed decisions about TOL versus ERCD. We urge clinicians and other maternity care providers to use the responses to the six questions, especially questions 3 and 4, to incorporate an evidence-based approach into the decisionmaking process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When both TOL and ERCD are medically equivalent options, a shared decisionmaking process should be adopted and, whenever possible, the woman’s preference should be honored.

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.

We are concerned that medico-legal considerations add to, as well as exacerbate, these barriers. Policymakers, providers, and other stakeholders must collaborate in the development and implementation of appropriate strategies to mitigate the chilling effect of the medico-legal environment on access to care.

High-quality research is needed in many areas. We have identified areas that need attention in response to question 6. Research in these areas should be prioritized and appropriately funded, especially to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of TOL and ERCD.

The LA Times reports on these findings as well in Panel urges more choice in birth after C-section.

A National Institutes of Health panel says vaginal birth after caesarean is reasonably safe and should be more widely available. Many hospitals ban the practice as a matter of policy or liability. Vaginal birth after caesarean, or VBAC, is reasonably safe and should be more widely available, a National Institutes of Health advisory panel concluded Wednesday.

Such deliveries once accounted for 25% of U.S. births among women with a previous caesarean delivery, but have now fallen to less than 9%. Many women would like to attempt a vaginal delivery, however, and the panel's consensus statement is expected to increase their access to the option.

Daniel DeNoon reports in NIH Panel: End Bans on Vaginal Birth After C-Section:

But women who might want to give labor a try very often don't get a chance. That's because of so-called "VBAC bans" -- hospital policies that forbid a vaginal birth after a cesarean (VBAC) unless fully equipped and staffed surgical and anesthesia services are readily available. These policies align with current guidelines set by gynecology and anesthesia professional societies.

Not all hospitals are able to comply with this standard, so many women who have had a C-section have no choice in the matter. In fact, 30% of hospitals stopped offering women this choice after the professional-society guidelines went into effect.

Denise Grady of the New York Times wrote on this subject in her article Panel Urges New Look At Cesarean Guidelines:

A panel of medical experts on Wednesday recommended steps to reverse a trend that has dismayed many pregnant women: the increasing difficulty of finding doctors and hospitals that will let a woman try to give birth normally if she has had a Caesarean section in the past.

The new recommendations came at a conference held in Bethesda, Md., by the National Institutes of Health to examine why the rate of vaginal birth after Caesarean, or VBAC (pronounced VEE-back), has plummeted, to less than 10 percent from 28.3 percent in 1996. The repeat operations are feeding the nation’s overall Caesarean rate of 31.8 percent, which has been rising steadily for the last 11 years.

Lauran Neergaard, AP Medical Writer, covers that Women Need A Chance to Avoid Repeat C-Sections

Too many pregnant women who want to avoid a repeat cesarean delivery are being denied the chance, concludes a government panel that urged doctors to rethink litigation-spurred policies that have swung the pendulum back toward the days of "once a C-section, always a C-section."

Fifteen years ago, nearly 3 in 10 women who had a first C-section were able to deliver their next baby vaginally, a trend called VBAC for "vaginal birth after cesarean."

Now that rate has dropped to 1 in 10, in part because a third of hospitals and half of physicians ban women from attempting VBAC, a panel of specialists convened by the National Institutes of Health said Wednesday.

But VBAC remains a safe alternative for the right candidates, and when those women try labor, between 60 percent and 80 percent of the time they do give birth vaginally, the NIH panel concluded. It urged that doctors offer mothers-to-be an unbiased look at the pros and cons, so they can decide for themselves.

Lolita Carico writes, at Mama Gloss, in her article Why Are C-Sections on the Rise,

Cesarean sections are the #1 most performed surgeries in the United States, with 1 in 3 pregnant women giving birth via c-section. That figure is up significantly since 1996, when the rate was 1 in 5.... The debate rages on, but a new report being released today by the NIH (National Institute of Health), has determined that VBAC’s are just as safe as normal births. The findings could lead to a decline in c-sections.

MSNBC shares on Women Need the Chance To Avoid Second Cesarean:

Visit msnbc.com for breaking news, world news, and news about the economy

I have high hopes that this exposure will change (over time) the unethical ban of VBACs in hospitals across this nation (and two in my own area) and create an uproar by consumers over insurance companies dropping women seeking VBAC or even women who have had prior cesareans and find themselves pregnant again - and force change.

As the results of this conference snowball across the birth community news, blogs, Facebooks, and Tweets, I anticipate and joyfully expect more women to seek out alternatives, vocally so, and hospitals/practices to be urged to make changes to accommodate these options.

Additional Blogs of Note:

The Feminist Breeder (along with more coverage of the conference) concludes in Once a Cesarean, Rarely a Choice :

Time will only tell if the more positive points made by NIH consensus will have an impact on access in this country. From a birth activist’s point of view, the statements made by many of the conference speakers were a huge leap in the right direction. However, our cesarean and VBAC rates will not be reversed overnight, and in the interim, scores of women are left without a choice but to either fight the system for their VBAC, or submit to a surgical birth. To these women and their families, this is really no choice at all.

Science & Sensibility writes, in Do Women Really Need To Know The Uterine Rupture Rate To Make Informed Choices About VBAC:

The NIH press release about the VBAC Consensus Meeting includes only a single instance of the phrase “uterine rupture.” Having spent 2 1/2 days watching the streaming webcast of the event, my strong sense is that this was by design. During the expert testimony, we heard over and over again that uterine rupture is the most feared outcome of a VBAC. We heard in gripping detail what happens when a uterine scar ruptures in labor, and even saw photographs of the devastation. We heard about deaths and hysterectomies and hypoxic injury to newborns that occurred with uterine ruptures. But after all of that, we heard a rather consistent message that uterine rupture itself is not the issue.

Courtroom Mama ruminates, over at The Unnecesarean, NIH VBAC Consensus Development Conference: Gift Horse or Trojan Horse?

There are a lot of wonderful things to say about the recent NIH VBAC Consensus Development Conference. Hopefully it will expand access to VBAC by urging ACOG to reconsider the “immediately available” standard, and end the practice of banning VBAC rather than working to lessen the risks through physiological management of labor and other techniques. I’m happy to see that they are finally acknowledging that there is no way to reduce infant mortality to zero, and that the risks inherent in VBAC are no different from the risks of catastrophic outcome in any other delivery, making singling out of VBAC nonsensical. I applaud the panel for that.

But, as a law geek and a birth geek, I have to look a gift horse in the ass here.

When the draft statement first came out, I was a little bit troubled by the part that is now the end of page 14 and top of page 15.

Along these same lines, the 1999 ACOG guideline urged, “After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat caesarean delivery should be made by the woman and her physician.” Presentations at the conference suggested that this important recommended practice is not uniformly followed, but there are no strong data documenting the extent of this problem.

In my opinion, this portion of the recommendation didn’t strongly address some of the concerns raised in the prior two days about what happens to women who aren’t ideal VBAC candidates and who nevertheless don’t want to have surgery. Surely I wasn’t the only one worried…

Stand and Deliver posted a great review on her blog, along with much more linkie love on the whole event.

Doula-la talks about what Shrimp and the NIH Panel have in common.

Karen The Pittsburgh Doula covers a small blip and privies us to her 'shell shockedness' of the whole communication-sphere of the US going abuzz with the news.

Academic OB/Gyn writes about a possible solution through Micro Tort-Reform. Very good read.

VBAC in the News is covered by Your Best Birth.

Momotics talks about what wasn't covered at the conference.

And, to close, Refuse to Be A Womb Pod writes I know what you did last summer

I did something last summer.
Actually, I did it for the second time.
Most professionals think what I did is dangerous.
I was told I shouldn’t do it. Many institutions have banned it.
I meet women very often who have never even heard of what it is I did.
Sometimes women say they wish they could do what I did
but they aren’t allowed.
Or brave enough.
Or wide enough or thick enough.
Or, it’s just not convenient
enough.
Sometimes the very law itself doesn’t allow women to do what I did....

Go to her blog to read the rest.

All About Inductions: Do Due Dates Mean Your Baby is Due?

I'm sure you know, from my past posts, the answer to that question: Most likely, no.

I abhor the term 'due date'; this term means a day of collectibility. Once you reach that estimated day of collectibility, suddenly you are considered "late". Late carries the burden (no pun intended) of being defunct, dysfunctional, or errant. "Overdue" infers something that is spoiled, going bad, or rotting (i.e. milk). Did I mention that I abhor that term?

Unfortunately, the Estimated Due Date (EDD) commonly used by health professionals is not nearly as accurate, and thus the majority of inductions are not nearly as pressing, as they claim.

Pregnancy is assumed to last 10 lunar months or 40 weeks (280 days). People often use this formula to calculate the EDD: The first day of your last menstrual period, minus 3 months, plus 7 days.

An example of using this formula:

First day of my last period was December 13th.

December 13th minus 3 months = September 13th

September 13th plus 7 days = an EDD of September 20th

This is a relatively easy formula. The problem is, it is only somewhat accurate - and then only when a woman has a regular cycle of 28 days, a luteal phase of 14 days, and did not take any oral contraceptives... uh oh, I just saw 95% of hands in the room go down.

How did we come up with this majority-inaccurate formula? Dr. Franz Naegele came up with it, which puts all women on a bell-curve for convenience and estimations' sake. It is a good guide to help estimate age, but should not be considered rule.

Carol Wood Nichols, previous Assistant Professor at Yale University School of Nursing, Maternal-Newborn Nursing/ Nurse-Midwifery Program, and Director of the Yale Nurse-Midwifery Practice, developed a calculation that takes variations in cycle length as well as previous childbearing into account.

Nichols' calculator, as cited in Anne Frye's "Holistic Midwifery Vol 1" states:

For first time moms who have true 28 day cycles: LMP (last menstrual period) plus 12 months - 2 months,14 days = EDD

Example: For December 13th, the EDD is then September 30th

For women who have different cycles or who have already had other children (multiparas), add or subtract the number of days her cycle varies from 28 days... for a full list of formulas using this rule, see below:

1. 1st-time mothers with 28-day cycles: LMP + 12 months - 2 months, 14 days = EDD
2. Multiparas with 28-day cycles: LMP + 12 months - 2 months, 18 days = EDD
3. For cycles longer than 28 days: EDD + (actual length of cycle - 28 days) = EDD
4. For cycles shorter than 28 days: EDD - (28 days - actual length of cycle) = EDD

Let's use me as an example... I don't have a normal 28 day cycle, I cycle regularly around 31 days. Using the same example as previous, I was a grandmultipara by the time I was pregnant with my son.

Hint: the EDD given by my caregiver of September 20th was grossly inaccurate. My EDD was somewhat more accurate based on the 1st-time mothers with 28-day cycles formula from Nichols, resulting in an EDD of Sept 30th...

Let's go a step further though; following Nichols' rule for cycles longer than 28 days (line 3.):

Dec. 13th plus 12 months - 2 months,14 days = Sept 30th.
Sept 30th + (31-28) = Oct. 3rd.

My son was born on October 6th.

In addition to all of this fun calculating (BTW, did I fail to mention that I had to take calculus 3 times before I passed?), there was a study performed by Mittendorf, which results showed that the average length of pregnancy is longer than usually calculated, especially for European first-time mothers. And those of us in the childbirth field can attest to the fact that most of the first-time mothers we work with deliver after their EDD as calculated by Naegele's gestational wheel. First pregnancies are often longer than subsequent pregnancies.

So, all of this to say that the EDD given by your care provider is simply to give you an idea of your baby's birth date. Don't use 40 weeks as an expiration date, but simply as a guesstimate.

When asked when your baby is due, consider telling people more vague answers to keep from prying questions (are you still pregnant?) and bothersome phone calls (have you had the baby yet?). A vague answer could very well consist of "I'm due early October".

Remember that pregnancy, on average, lasts 38 to 42 weeks, this means you have a due month, not a due day.

How do you broach this subject with your doctor? It truly helps to have a chart of your MP to prove cycle length, and gives you better bargaining chips for setting EDDs in your chart. Remember, though, you don't need to consent to an induction if your knowledge of your body conflicts with their policies.

I know that it is becoming fairly common for doctors to 'always' induce between 39 and 41 weeks. But, there is no medical justification for an induction simply for 'expiring' your EDD as determined by the Naegele Wheel. As this post just explained, it is perfectly normal and natural to go over this date. Induction for 'expiration' alone is not justified. For your and your care provider's peace of mind, though, you can start a kick chart around your EDD.

To begin a kick chart, choose a time of the day (1 hour in duration) when your baby is usually very active. For consistencies sake, try to do your kick counting at this same time every day. Relax (lie or sit down) so that you can pay attention to your baby and are not distracted by TV, work, or the computer (or you may miss the smaller movements - which you have become accustomed to over the last 32 weeks or more).

You can drink a glass of cold water to perk baby up even more right at this time if you would like. During that 1 hour count baby’s movements (this includes kicks, punches, turns, rolls, hiccups, etc..). You should be able to count around 10 or more in one hour. On the chart I linked above, when you reach 10, put an X in the window that marks the duration of time you had to wait to reach that count.

If you feel less movement than normal at that time of day and cold water does not wake him up, try for another hour after eating a small snack to give baby and you a boost in blood sugar. If baby is still less active than usual, consider consulting your caregiver.

In closing, remember, it is your choice to consent to an induction or not. An induction may sometimes be necessary, but the majority of inductions are not. Millions of healthy babies have been born after their EDD and, depending on your true estimated due date, without a medical reason for it, an induction can cause more complications and necessitate more interventions if mom's body and baby are not ready.

ACOG, Misinformation, and the VBAC debate

Amber Craig didn't like what was going on in the world of medicine regarding policy and standards of practice. In response to the American College of Obstetricians and Gynecologists' stand on VBAC, Ms. Craig wrote a well-thought letter to the president of the ACOG, citing sources and medical studies pertinent to the conversation at hand. In it, she suggested that they reverse their restrictive policies on VBAC - which, as a result, encouraged many hospitals and practices to "ban" women from seeking VBACs.

Well, she received a response. The ACOG wrote back, in a letter full of misinformation. So, Craig wrote back again, gently correcting them with cited resources, from their own medical publications.

The ball is in their court... Where it will go from here, who knows... But, if you are a VBACtivist, if you are a childbirth educator, doula, obstetrician, midwife, or woman, I recommend taking a look at these letters. Here you are (start at the bottom and work your way up).

Hi, My Name Is Nicole and I am a Conspiracy Theorist

I have been called a conspiracy theorist for touting that women's options are actually disappearing the more liberal we get with our birth practices.

With recent articles like Choosy Mom's Choose Cesareans, and responses from myself and others, it sounds like we are just hot under the collar and making up dark images of a 'right to choose'.

But are we?

Emotionally and physically, women are hurt, and their options are forever limited or made to be seemingly insurmountable uphill battles. Cesareans are becoming so prevalent and rates are increasing because of 'choice', policies, and iatrogenic complications, that we made an awareness month about it to promote more public education regarding this major abdominal surgery.

ICAN has a great resource on hospitals and VBAC bans... check it out for yourself BEFORE you go into labor or choose a cesarean... you will have a better idea of if you will be 'allowed' a VBAC next time around. That is one battle that many of us were already aware of...

But the battle just got bigger.

Now, after a cesarean, women with abdominal scars could very possibly find themselves without insurance. Some insurance companies are beginning to refuse women coverage if they have had a previous cesarean or give them higher insurance costs.... Unless they are sterilized or infertile!

“Obstetricians are rendering large numbers of women uninsurable by overusing this surgery,” said Pamela Udy, president of the International Cesarean Awareness Network, a group whose mission is to prevent unnecessary Cesareans.

Not only are women feeling pressure to have Cesareans that they do not want and may not need, but they may also be denied coverage for the surgery.

“You have women just caught in the middle of this huge triangle of hospitals, insurance companies and doctors pointing the finger at each other,” Ms. Udy said.

ugh! This is not how I, or any other professional in my field, wanted to be vindicated. I would rather be considered a conspiracy theorist than to see our healthcare and the lives of children and moms be affected in such a profound and inhumanitarian way.

• A Doula Too blogs about the horrible realization that our public is coming to: our cesarean rates are out of control, hurting our healthcare options, and hurting our babies.
  
• Karen The PA Doula is outraged and incensed - wanting to find a way to fix this mess.
  
• Navelgazing Midwife positively lights on the fact that this might make VBAC more possible and sought after and make cesarean a 'less achievable' OPTION for women when not medically necessary - will women start making more informed and mother-friendly, newborn-friendly healthcare choices?
• Pushed Birth reminds us that, with cesarean rates on the rise, it is a horribly unfair and hard place for families to be: coerced into unwanted cesareans either by default or by iatrogenic complications, and then refused basic care and health coverage - limiting their choices for care even more.
  
• Crunchy Domestic Goddess gives a great post on how others are responding to this article and have foreshadowed this day previous to it.
  

What next peeps? What do we have to do and be put through to get the information in between those plates of bones resting on top of your spine? Those of you in white lab coats - is it worth it to be home in time for dinner?Oi. I am going to the pool to cool off.