To staceyjw: Reply-Turned-Post

staceyjw left a comment on a post I previously had a link to in my list of "favorite posts" in my sidebar, which prior to receiving this comment, I hadn't updated in a very long time.  I have now updated the list, and chose to no longer include that post, because I feel it no longer reflects the direction of this blog, and I have more recent posts that are "more favorite" for me currently.

The post, published October 23, 2010, was called Elective Cesareans as Commentary on a Failed Birth Model.  In it, I explored one woman's writing about her view of the choice of cesarean vs. vaginal birth, and how her assumptions about vaginal birth, which, in my opinion, were largely informed by our culture's negative image of childbirth and common obstetric practices that are often seen as dehumanizing, appeared to color her view.  I contrasted that with the view of birth held by the natural childbirth community, suggesting that perhaps if our system could make vaginal birth a better experience for the majority of women, perhaps less women would request cesareans.

This is the comment:

You don't have to think VB is dehumanizing or rape like to prefer the risks and recovery from a surgery to the risks and recovery from a VB. Sure, VB can go well, but when it doesn't, it can be very damaging (NCB or not, it happens). Personally, I would trade a belly scar and ab pain for vaginal pain and possible damage anyway. This doesn't mean we see "modern" VB as horrible, or anything else, just that when looking at all the ways to birth, we prefer one to the other.

This is because many Moms, including myself, see the actual arrival of our child as the life changing event- the act of becoming a parent, welcoming a new member of the family and enlarging our hearts with another human to love. How the baby gets out/into the family is irrelevant. I dont have to push a baby out my vagina to be a Mom! Focusing on a biological act to make a woman/Mom is also the very antithesis of feminism.

By focusing on VB as a "rite of passage", instead of the actual arrival of the baby (or child, in adoption) you cause a lot of hurt to Moms who didn't VB. This is not necessary, as women have enough to deal with without creating a distinction between Vb and CS, adoption, surrogacy as a way to parent.

Here is my response:

In this post, I was responding to the view of vaginal birth expressed in the Pregnancy Zone article.  I was disturbed by the way the author described vaginal birth, and it did sound very negative and verging on sexual assault to me. I do think that particular writer's negative view of vaginal birth was largely formed by the negative image of vaginal birth in our culture and common medical practices that disrespect women. Obviously, each woman is different, and each woman's reasons for her birth choices are going to be different as well, so your reasons for your choices will be different from hers.

You are right that vaginal birth does sometimes cause serious vaginal damage.  I don't deny that.  With good care, though, it is relatively rare, just like serious complications from c-sections (that some of us NCB people are so afraid of) are also rare.

I understand what you are saying about the arrival of the child being the significant, life-changing event.  I also believe that welcoming a child into your family is always special and sacred, no matter how it happens.  I have problems with saying that the baby getting there is all that matters, because that is hurtful to all the women who are traumatized by the way they are treated while giving birth.  Mistreating a women is never okay, even if you hand her a healthy baby at the end of it.  I do believe that the process by which a woman brings her baby into her family matters a great deal.  I do not, however, believe that there is only one correct way to go about it.  If you read my post Why Natural Childbirth is Not Important, you will see that I feel that  going through the literal biological process of natural birth or vaginal birth is not as important as being an informed participant in the process of a birth (which can also extend into other methods of acquiring a child).  I was referring mostly to medically necessary cesareans in that post, but it also applies to elective cesearans.  Only you know your body, your priorities, and your circumstances, and only you can make the best decision for you. 

The way you have interpreted my use of the term "rite of passage," will lead me to use a lot more care in how I use that term in the future.  There are some who believe women who do not experience natural childbirth will not be as good of mothers for not having gone through that experience.  I may also have believed this in the past, but I was wrong.  Just because one woman feels a certain experience was important or necessary to her development as a mother does not mean all women have to have that same experience to become a mother.  We are all different and all of our "rites of passage" into motherhood will be unique.  I believe that God gives us each individual experiences that best help us learn and grow in our own individual ways.  I feel that whatever you go through to get your child is your rite of passage into motherhood.  For some women, the rite of passage will be adoption or surrogacy--which are often very long and difficult journeys.  For one woman the rite of passage is joyfully pushing her baby out with an epidural, for another it is choosing a cesarean as her preferred method of birth, and for another it may be having an unmedicated birth.

Many women have described their unmedicated birth experiences as significant self-discovery journeys, that made their baby's arrival into their life special in a way that was right for them.  You may feel it wouldn't have be an awesome experience for you to give birth that way, and not all women who give birth unmedicated feel that way about it, but that shouldn't lessen the experience for the women who do.  A woman may feel giving birth on their own terms, without feeling powerless to authority figures or controlled by an obstetric system (that many feel is patriarchal), was an important part of her life, motherhood (and possibly feminist) journey.  Another may feel that having experienced the intensity of unmedicated birth is something she can draw strength from in the future.  Another woman may feel that giving birth naturally brought her closer to God.  To say that there is never value in the experience of natural birth is to discredit these women's experiences.  Not every woman wants or needs that experience for her personal growth, but those who choose it should be free to attach whatever personal significance to it that they see in it.  Seeing significance in the journey of birth doesn't take away from the joy of welcoming a child into your home, not any more than appreciating personal growth one might achieve through a challenging adoption journey would take away from that joy.  It is not a one-or-the-other choice between appreciating the process and the product.

And for some women, the process has nothing to do with it.  Some women will define their transformation into "motherhood" as being completely unrelated to it.  I understand not caring about how the baby gets there.  I used to say I was sure I wanted all the drugs I could get.  My own paradigm shift was more about the belief that it would be safer to avoid drugs and procedures as long as there weren't complications (I do still believe this, and it would take a lot to change my mind) than it was about wanting some great experience.  However, learning that it is possible to have a joyful, empowering experience birthing naturally, and that it wasn't necessarily the horrific ordeal I always assumed it would be was also part of it.  Attempting to birth without pain medication in my first birth turned out to be harder than I expected, and I chose to have an epidural.  For my second birth, I used hypnosis (Hypnobabies, which I now teach), and it helped me increase my endorphins and think of the sensations I was feeling in a positive light.  It allowed me to remain mobile when I wanted to be, and feel connected to what was happening as my baby emerged, which was important to me.  I was overall, really happy with the experience, and felt I learned a lot from it about my strength and the power of my mind, just like I learned a lot about being flexible and accepting change in my first birth.  Both birth experiences were different, both were significant learning experiences for me, neither was superior to the other, and I don't think either gives me any advantage over any other woman--we all have different needs for our growth.

I admit that I have difficulty wrapping my head around the idea of a woman wanting to choose a cesarean without a medical reason.  I know this is because of things in my background that influence my perception of the choice.  It has to do with my faith--my belief that vaginal birth is God's design, as well as my desire to have the option of having a large family for religious reasons (since having cesareans is likely to limit how many children a woman can have), my lack of experience with major surgery, and yes, my history of exposure to natural childbirth literature.  But I recognize that you may have a different background, beliefs, and life priorities than I do.

I take your point and I apologize, for myself and the rest of the natural birth community (though I guess I don't really have the right to speak for anyone else) for hurt feelings caused by the idea that there is any best way for all women to become mothers.  There may be a best way for me to welcome my child (and that "best way" may not be the same for each child--it hasn't been for me so far), but what is best for me and my baby may not be best for another mother and hers.  I will do my best in the future to avoid talking about vaginal birth or unmedicated birth in ways that are hurtful to those who do not have those experiences.

Do I Really Need to be Induced? Resources for Informed Decisions

Responses to the 2006 Listening to Mothers II survey indicate that about 35% of birthing women in the US are having their labors induced by their caregivers. Considering the risks of induction, it is helpful for pregnant women to know which cases usually truly warrant induction and which ones usually don't. I hope that if you are faced with induction, these resources can be helpful to you in figuring out whether or not induction is necessary in your case, taking into account your individual health situation.

There are people out there who know what they're talking about more than your student doula/prospective childbirth educator. I've decided instead of writing about this myself, to provide a list of links to various resources available for information on this topic. I have tried to offer multiple perspectives by including links to many types of sources, including research information, statements from professional organizations, care provider opinions, and consumer-oriented information. If you find a link that you feel would be helpful to include in this list, feel free to let me know in the comments.

Suspected Fetal Macrosomia ("The Baby is Too Big")

• Induction of labor for suspected fetal macrosomia (Cochrane Review)




• ACOG Issues Guidelines on Fetal Macrosomia (American Family Physican)




• Big Baby Bull (by Sheridan of Enjoy Birth)




• "is my baby too big?" (Charis Birth Support)

Post Dates Pregnancy (Being "Overdue")

• A Timely Birth by Gail Hart (Midwifery Today)




• The Lie of the EDD: Why Your Due Date Isn't When You Think by Misha Safranski(Associated Content)




• Induction of labor for improving outcomes for women at or beyond term (Cochrane Review)




• Induction of labor: balancing risks--Midwife Thinking's Blog




• Postdates - from Ronnie Falcao's Midwife Archives

Oligohydramnios (Low Amniotic Fluid)

• Oligohydramnios: Too Little Amniotic Fluid - March of Dimes




• Birth Sense: Low Amniotic Fluid: A Cause for Panic? (original post has become unavailable, but I found the text reposted on another site)




• Gloria Lemay: Low Amniotic Fluid. . . I don't think so




• Amniotic fluid index versus single deepest pocket as a screening test for preventing adverse pregnancy outcome (Cochrane Review)

Prelabor Rupture of Membranes (Your Water Breaks and You're Not in Active Labor)

• Planned early birth versus expectant management (waiting) for prelabor rupture of membranes at term (Cochrane Review)




• Pre-labor rupture of membranes: impatience and risk--Midwife Thinking's Blog




• Prelabor Rupture of Membranes--PROM--from Ronnie Falcao's Midwife Archives

Hypertension, Pre-eclampsia, Eclampsia and HELLP (issues involving high blood pressure)

• High Blood Pressure During Pregnancy - March of Dimes




• Preeclampsia Causes, Symptoms, Diagnosis, and Treatment by eMedicineHealth.com




• Pregnancy-Induced Hypertension - from Ronnie Falco's Midwife Archives

Placental Insufficiency and IUGR (placenta not working properly, baby not growing)

• Placental Insufficiency Medical Information - medicineonline.com




• Intrauterine growth restriction (IUGR) --BabyCenter




• Intrauterine growth restirction -- Familydoctor.org

Why Natural Childirth is Not Important

My goal is not for everyone to have a natural birth. Of course I believe that, in cases where everything is going smoothly, mothers and babies will be safest if medical intervention is avoided. However, there are times when things go wrong, making intervention necessary (though it is important to remember that not everyone's definition of "necessary" is the same). Holding an intervention-free birth up as The Ideal Birth sets a woman up for failure if complications occur, which is something she has no control over.

I recently followed an online discussion among student doulas about the use of the term "cesarean birth." Some women wanted cesareans to be recognized as births and some women felt that a cesarean is never a birth because it removes the mother from physically participating in the birth process--since birthing is a verb, and a women having a cesarean is not acting, but being acted upon, it can't be a birth. This lead me to re-examine my definition of what birthing entails.

What does it mean to give birth?

When we use to birth as a verb, we are usually intentionally distinguishing to birth from the more traditional to deliver. In the sentence, "The woman birthed her baby into the midwife's hands," the woman is the subject, actively performing the verb. However, if we were to say "The midwife delivered the woman's baby," the midwife becomes the subject of the sentence, implying that delivery is something the care provider does and not the woman. Yes, words really do have power. Once could say one of the purposes of birth education and advocacy is to help women be empowered to birth their babies instead of having them delivered.

It is true that part of the power of an unplugged birth is that women's bodies are in control and not the machines. A birth without immobilizing pain medication, in which the mother can use positions that are comfortable to her, is truely birth in which the mother is "active." But is natural childbirth the only birthing?

If a woman becomes exhausted and decides she wants an epidural to help her relax and get some rest and goes on to push her baby out, we still call it a birth, even though she needed the help of medical professionals and drugs. Some would say, "Of course it was a birth, it was vaginal." But what if that same mother has her labor slow down and needs pitocin to keep her contractions going and isn't able to push effectively with the epidural and chooses to have the doctor use a vacuum? Is the mother still birthing the baby? Is that really much different from a mother choosing to have the doctor perform a cesarean when the mother feels it is medically necessary?

To birth refers to what a mother does to bring her child from her womb into the outside world. Now, does her body have to do this all by itself in order for her to participate in the process? Not necessarily. I believe birthing can be about more than just he limited definition of pushing your baby out. Being actively involved in your birth can also include deciding that your body needs help from a professional, medications, instruments, or yes, even surgery, to bring your baby into the world. In such cases, the birthing is not in the pushing, the birthing is in the choices. I believe that if it is the woman's choice to have a cesarean--she actively decides that enlisting surgical help is the best way for her baby to come into the world, then she is still giving birth.

Natural childbirth is not important. A woman being involved in the decisions about the medical care of her and her baby--that is what is important. Helping women avoid feeling assaulted because they were not involved in what happened during their births--that is the goal. What I do--this blog, becoming, a doula and childbirth educator--that is what it is all about.

ACOG Issues Less Restrictive VBAC Guidelines

A press release today from the American College of Obstetricians and Gynecologists explained that the organization is tweaking it's previously released guidelines for Vaginal Birth After Cesarean, the release states that the organization now includes women with two prior low transverse incision cesareans (such as Dr. Poppy Daniels, the gynecologist who got a lot of attention for her surprise VBAC story), women carrying twins, and women with an unknown type of uterine scar on their list of appropriate VBAC candidates. The press release also clarifies the organization's prior position that VBAC should only be attempted where emergency surgery is immediately available, explaining that while they feel that this is ideal it is not always possible, and that should not prevent women from being given the choice to have a VBAC.

This guideline change likely comes in response to the conclusions of the VBAC Conference held in March 2010 by the National Institute of Health, whose Final Panel Statement called on ACOG to reevaluate their guidelines. There was also an online petition to ACOG with over 1,200 signatures asking for changes in light of the NIH's findings.

I'm calling this one a Victory for VBAC!

The Role of Doulas and Birth Plans

Rixa posted the following comment she received on a post about the Doula Ban and OB Birth Plan at Kingsdale Gynecologic Associates: A physician speaks about doulas and birth plans. My response is a bit too long to put in a comment, so I'm posting it here.

So I am actually a physician. Doula's may be beneficial in some situations, but you all must remember that the role of a physician is to provide good medical knowledge and advice based on evidence.

Unfortunately, a lot of what physicians recommend is not based in “evidence,” but tradition and/or what looks good in court. There is no evidence that continuous fetal monitoring of low risk labor leads to better outcomes, evidence rules against restricting food and drink, physicians did routine episiotomies for years (and some still do), even though they’re were never proven to be beneficial, evidence suggests that clamping the cord right away may not be best—the list goes on.

Where Doula's may be thought of as positive most have zero training and often times may give inaccurate medical advice which is out of their scope of practice. If people want Doula's there should be a government agency licensing those individuals. As you wouldn't want just any person playing your doctor the same gaves for those helping. If they obstruct what we are trying to do they are not beneficial and can ultimately hurt you. Further, they do not have any medical liability. If you want a Doula they should accept medical liability for the 18 years that OB gyns do.

I am thinking of staring doula training soon, and I have looked at the requirements of various doula training organizations, and most are actually quite extensive. Just because they don’t have medical or nursing education does not mean they are not trained. I personally would not feel comfortable or ethical offering and charging for doula services without training or at least extensive personal research on what I was doing. If you have seen doulas offering medical advice, they are not doing their job. A doula’s role is not to speak for or make decisions for the woman, but to help her find her voice. I know I am a bit vulnerable when I’m in labor, and I think a lot of women are. Too often, this vulnerability translates into the woman’s voice being silenced. Doulas (and birth plans) are there to facilitate communication between the woman and the medical personnel—to encourage her to ask questions and be involved in decisions about her care. To me, doctors and nurses who have a problem with doulas and birth plans really have a problem with women having a voice. If what you are trying to do is not what the woman thinks Is best for her and her baby, then doulas are not hurting the woman by “obstructing” it. I don’t have a problem with the idea of having a system for keeping doulas from acting outside their non-medical role, but if they are really acting in that role, they shouldn’t need to accept medical liability

In regards to birth plans. They are all nonsense. When it comes to the delivery room most if not all mean nothing.

My OB actually encouraged me to write a birth plan for my son’s birth. I stated clearly in my plan that I wrote it to help the hospital staff know how to support me in the way that would be best for me. I think “plan” is actually not a good word for the purposes of this document—it is not designed to plan the details of your birth, but to let your care providers know what kind of care you want—a tool for communication. Then the providers know that if something comes up that conflicts with what you have written, you want them to discuss it with you. Of course, if you don't discuss the birth plan with your care provider before hand and they are not equipped or are unwilling to follow your wishes, then, yes, it is meaningless.

Women who write birth plans are sometimes accused of being "control freaks," and of trying to control something that is uncontrollable (birth). People claim that these uptight women are incapable of submitting to the power of nature that is necessary in natural birth and thus, they can't relax enough to progress and often end up with cesarean sections. However, most of what is in birth plans is actually about avoiding medical control of birth, because these women want nature to control their births, as long as nature is doing well, of course. So, is the beef with birth plans really about submitting to nature or is it about submitting to you? Maybe if physicians stopped trying to control birth themselves and quit trying to force women to follow their medical birth plans (whether written or not), then birth plans wouldn't be necessary?

Your in pain you said I don't want drugs you change your mind you get drugs. Happens everywhere all the time.

The implication here is that wanting an unmediated birth is a naive notion and most women wise up about it once they experience labor. Anyone with this attitude is someone who is likely very unfamiliar with natural birth and will not know how to support a woman in it. This attitude among physicians is exactly why we need doulas who know about natural childbirth to provide women the emotional and physical support they need.

Look the most important thing is not extra personnel in the delivery room. The important thing is a safe and healthy delivery for both the infant and mother. Any mother or father for that matter that thinks anything else is more important should not have children till they get their priorities straight.

Of course having a healthy mother and baby is important. Some people (including some women and some doctors) believe that having a birth with as little medical intervention as possible is a good way to accomplish that goal. It is not harmful for a woman to make sure a medical procedure is really necessary before agreeing to it. Frankly, the insinuation that people who are not willing to just do whatever the doctors want them to shouldn’t have children is insulting.

The Fear Problem

Fear of the Unknown

It is normal to fear the unknown. For most first time pregnant women, birth is a huge unknown. Not only have we never done it, we may not even have ever seen it done. In North America today, I think it's highly unlikely that the average woman has ever been at a birth before giving birth. She also won't see uncensored images of vaginal birth in any public media. So, unless her school showed birth films in health class (mine didn't) or she takes a childbirth education class, seeks out birth videos on the internet, or watches a birth documentary such as The Business of Being Born, she may not even have seen a baby birthed before she is expected to do it. As I discussed in a prior post, some women seem to think that viewing a birth would disturb them, so they don't seek out any birth videos.

Add this that the fact that virtually every pregnant woman reaches a point in her pregnancy where, looking at her much-changed body, she realizes her baby is going to have to come out, but to her it just seems impossible that it could. It really is an unbelievable thing, even for those who have seen it and done it. That's kind of the miracle of it. Much of the medical system, however, seems to believe that it really is impossible without their help, and they are also afraid of the rare and very scary things they've seen or heard of going wrong, and they pass that fear on to women to add to their fear of never having done it and thinking there is no way her body can do something that seems impossible. Medicalization of birth also increases the "unknown" factor--it is something for educated doctors and nurses to know about, not average women.

Fear of Pain

It is also normal to fear pain, because pain is usually an indication that something is wrong, and we find it unpleasant. Our young pregnant women has heard others talk about how birth was painful for them and that they would never think about doing it without medication (or they did and it was a bad experience), and this just compounds the fear. She has probably seen birth shows on cable TV, which edit birth footage in ways that focus on the dramatic, because they are in the business of making exciting television, not of educating women about what birth is and can be. She probably has also heard a few stories of births where there were complications--maybe a vacuum delivery or an unplanned cesarean. She may fear something going wrong or having something strange done to her. Many women also feel fearful when they are in an unfamiliar place, surrounded by strangers, as is often the case with birth today.

Effects of Fear on Birth

We know that fear causes the body to release chemicals that can stop the birth process. This makes sense from an evolutionary perspective--a tribal woman wouldn't want to give birth if a tiger was chasing her, but as is explained in the book Birthing From Within (not a hypno-friendly book, by the way), the body doesn't know how to distinguish between real and imaginary tigers, it only knows fear. Fear also increases our perception of pain and prevents us from enjoying birth.

So, what is our average (and now thoroughly terrified) first-time pregnant woman to do?

Most likely, she'll figure that she has a highly-skilled doctor and well-equipped hospital that will keep her and her baby safe because they're the experts, and she'll decide she will get an epidural, so she won't need to worry about pain. It is likely that her preparation won't go much beyond this. She will still have other fears to deal with, though. For example, what if she's afraid of needles?

Fear of Needles

Fear of needles is pretty common. I see nothing unreasonable about having a fear about a sharp object penetrating one's skin to introduce foreign substances into one's body. I realize that needles do a lot of good in medicine, but the idea of them is just disturbing to me. It is sometimes fear of needles that leads women to seek out natural childbirth.

My Answer?

The best answer to the fear problem is childbirth education. And by childbirth education I don't mean most hospital-sponsored classes where the woman learns a little (but usually not enough) about what is going on in her body, what routine medical procedures to expect (without letting her know she has the right to refuse all of them), and that epidurals are usually safe and not anything to worry about. I mean childbirth education that is free to tell you what the hospital doesn't want you to know.

Most natural childbirth classes address fear in two ways. They tell women that they can give birth without medication, just like women did before medication existed, and teach them pain coping techniques which helps increase their confidence and overcome their fears about pain. Some of these techniques rely on freedom of movement, so these classes usually encourage women to consider declining unnecessary routine medical procedures that interfere with movement (such as IV fluids and continuous monitoring). They also address fear of the unknown by teaching about the natural process of birth, as well as explaining how medical interventions might affect the process and giving information about the risks and benefits of these procedures and encouraging women to choose for themselves whether to accept them or not. Feeling like they are involved in decisions about birth helps women feel less afraid.

Fear of Medical Interventions

However, the downside to teaching about medical interventions (both in classes and other places such as books/films/internet groups) is that sometimes this education has the unfortunate side effect of creating fear of medical interventions. So, fear of pain, birth, and the unknown, are replaced by fear of hospitals, pitocin, and iatrogenic complications. Remember, fear interferes with birth, no matter what the source or intention. Going into birthing with any kind of fear is not healthy. And there is always a possibility that a woman will need medical intervention in her birth, and if that happens, we don't want her to be afraid of it. I recognize that fear of pitocin had negative effects in my own first birth.

I want women to be able to make birth decisions without fear. The presence of fear makes it difficult to use the other things we need to make decisions--our logic and our intuition. Sometimes natural childbirth sources are guilty of some of the same fallacies as the medical side of things. Those who believe in liberal use of medical technology in birth will focus on a few rare complications as reason why a woman shouldn't choose a homebirth, a VBAC, minimal monitoring, no IV or heplock, etc, while ignoring the majority of births that go right. Natural birth advocates sometimes focus on the rare scary complications of epidurals and cesareans, without mentioning that the majority of women who choose an epidural or need a cesarean have no major problems. It is important for women to understand the risks of interventions, while at the same time understanding that there are times when the benefits of these interventions clearly outweigh the risks.

Overcoming Fear

I feel that the best type of childbirth education would present information in a way that doesn't scare women, but provides them with unbiased information that allows them to make informed, and not fearful, choices. Good childbirth education also has ways of helping women overcome their fears. Hypnobabies includes a fear-clearing exercise that works very well for this. Some other ideas can be found in this post by Felice at The Gift of Giving Life.