About that school registration form in California…

Since this story came out the other day, about an elementary school in California asking parents to indicate on an application form whether a child was born vaginally or by c-section, I’ve had a blog post brewing.  But I’m spurred to actually write it now because of discussion currently ensuing on The Unnecesarean’s Facebook wall.  Evidently, a lot of people believe that it’s both acceptable and wise for a school to ask this question on a registration form. 

To be frank, I first read about this story on The Onion, and was sure that it was a joke.  It struck me as particularly funny-weird because I was asked the very same question on the application form for Annika’s first daycare, and I thought it was kind of hilarious that The Onion would do a spoof of something I thought couldn’t possibly have actually happened to other real-live people. 

At the time when I was asked, I recall doing the head-scratch and wondering why on earth the daycare needed to know this information.  When I asked, the daycare provider told me that it was so she could assist my child with healing from her birth.  Cue vomit.  

It’s no big secret that I hated my c-section and that I wish that my daughter’s time on earth could have started differently.  But the truth of the matter is that my sadness is more to do with me than with her; I’m big enough to admit that any concerns I’ve had about her experience of those first hours of life are more projections of my own experience of trauma than genuine worries about her.  All evidence suggests that she’s fine and has been from the start.  The c-section really sucked for me:  and that matters enough on its own without trumping up some story that my daughter is forever damaged by the way she came into this world.  

This is not to say that the circumstances of a birth are never relevant.  It’s certainly possible for a child’s birth to have an impact on cognitive function, and that is something of which schools need to be aware.  A friend who is a school psychologist explained this to me when I started ranting about the ridiculousness of asking the question.  People who are trained in assessing such things need to ask questions about birth to ensure that they don’t miss any clues that could help them assist a child in need of educational intervention. 

But there are at least two major differences between what my friend described and what I’m talking about now.  The first is that a specialized psychological or educational assessment, performed for a child with an identified need, is very different from a general school application form, which is circulated among a wide variety of people.  The second is that the question rests on an irrelevant dichotomy rooted squarely in the ideology of the person asking.

If the goal of asking about the circumstances of birth is to understand whether or not a child needs particular kinds of support, the question needs to avoid the red-herring, limited c-section vs. vaginal birth dichotomy, and instead be open-ended:  how was your child’s birth?  A vaginal birth can be chock-full of potentially traumatic complications and/or interventions.  Moreover, while I certainly advocate allowing the physiological process of birth to proceed unhindered (some people call this natural birth), I also acknowledge that unhindered processes can sometimes be really hard on everyone involved. 

The point is:  vaginal or natural birth does not necessarily equal peaceful birth, and c-section does not automatically equal trauma.  A question that assumes that one type of birth is inherently more traumatic than another type of birth with no qualifications or consideration of individual circumstances is asinine, and the response to it is irrelevant.

**Edited to acknowledge the school’s appropriate response to the controversy.

Grace under pressure: the challenge of a long pregnancy

A friend of mine is currently awaiting the birth of her fourth baby.  She’s a week past her due date, and going through the special kind of hell that is prodromal labour.  She’s frustrated, tired and in pain, and yet she is doing something that impresses the hell out of me:  nothing.

My friend’s approach to birth is that it will happen when it happens.  This is not rooted in idealism or the la-la land of the ‘trust your body’ mantra.  She has had her fair share of physical and emotional challenges in life, including in pregnancy and birth, and I think her willingness to go with the physiological process is a reflection of what she has learned from her own past experiences and observations of doing anything other than just going with it.

There is no shortage of evidence supporting the value of patience at the end of pregnancy. The first of Lamaze’s healthy birth practices is to let labour begin on its own.  I’m not going to get into a discussion of the medical arguments for and against induction before 42 weeks (the point at which a pregnancy is considered post-term).  Obviously there are times when an induction is medically indicated.  Those are not the times I’m talking about here, nor am I suggesting that induction is universally bad.  Like any intervention, it has its appropriate time and place.

I’m talking about the normal pregnancies that go past 40 weeks with no evident complications, and how difficult dominant cultural norms make it for women during this time to maintain faith in the physiology of labour and birth, and connection with their bodies.

The temptation to evict a baby who overstays his or her welcome is enormous, and there is huge cultural support for it.  North American culture is obsessed with rationalization, predictability and the clock.  Pregnant women have a host of pressures on them as they stare down their due dates:  care providers’ schedules and the desire to have a particular provider attend their birth; hospital and health care policies dictating where and how they can birth depending on the  number of days past their EDD; impending maternity leaves and a wish to maximize time off with a baby actually in their arms; demands to return to work or school within a set time frame, regardless of the actual date of a baby’s birth; the exigencies of travel for family and partners who want to be part of the birth process, and so on. 

More than that, by 41 weeks?  Pregnancy can really freaking suck. It hurts to be that pregnant. Take all the normal pregnancy “discomforts” and multiply them by a million.  That’s 41 weeks plus.  Fun times.  Add to that every friend and family member treating you like a watched pot (“have you had that baby yet?!”), every personal inadequacy you’ve ever felt bubbling to the surface, and care providers pushing interventions, and it’s hard to resist the urge to do whatever it takes to get labour started, from so-called natural approaches—homeopathic remedies, castor oil, pineapple, eggplant parmesan, hiking up hill, shoveling snow, acupuncture, sex, AROM, membrane sweep, and so forth—to medical induction.  

I worked so hard to get my babies born that I was physically and emotionally exhausted by the time I had them in my arms.  I was lucky that my first birth went well, despite finally electing a medical induction (I had no idea at the time that induction posed any risk). I was less lucky the second time, when I tried every “natural” trick in the book, and, whether or not there was a simple cause-and-effect relationship, ended up with a hypertonic uterus before I’d even hit 6 cm.  In both cases, in the final days, I completely lost touch with my body, baby, and pregnancy, and instead became consumed by thoughts of getting the pregnancy over with.  Both times, by 41 weeks, I was convinced that my body would never go into labour on its own, and as crazy as it sounds, that I would be pregnant forever.  Of course I knew at a rational level that the latter could not possibly be true, but after being pregnant for 10 months your mind can start doing funny things.  And the former was a self-fulfilling prophecy:  in neither case did I give physiological labour enough of a chance.

Whether or not a woman requires an induction is a decision that only she and her health care provider can make.  At the time, in both pregnancies, I was absolutely certain that induction was the right thing for me, and at 41 weeks 3 days, going ahead with a medical induction matches the protocol governing childbirth where I live. Yet even women for whom induction is indicated could benefit from a shift in attitudes and approach that honours and values the final days and weeks of pregnancy, rather than seeing them only as days of increasing statistical risk and unpredictable inconvenience. You would never take a cake out of the oven 10 minutes early just because you know it will burn if you leave it in 10 minutes too long, or because company’s coming and you just need to serve the damned cake already.  Obviously that analogy can only take us so far, but it is food for thought in this context nonetheless.

So I salute my friend who is weathering the end of her long pregnancy with grace, if not patience.  Given everything she’s up against, I think she’s amazing.

Q: Why make such a big deal about birth? A: Feminism

People often ask why I invest so much energy in birth activism, and why I care so much about how women have babies.  After all, babies are born every minute of every day, all over the world.  Why make such a big deal about it?

I started caring about pregnancy and birth when I started linking it to my identification with feminism.  I’d always known about both:  for the duration of my childhood, my mother was a family doctor with a busy obstetrical practice, and she was (is) a feminist.  I don’t recall her linking the two explicitly, at least not to me.  (Although we did have a book about Judy Chicago’s Birth Project on our coffee table, and I understood without any doubt in the 1970s that the fact my mother was a doctor at all was because of this feminism thing that she and her friends sometimes discussed.)  But I knew from the time I could be conscious of anything that supporting pregnant and birthing women was worthwhile and that feminism, defined very simply as empowering women to do whatever we wanted to do, was good.

I got that birth mattered, and that women deserved to be treated with care and respect.  I remember little things like my mother’s answer when I asked why she had short nails without nail polish:  so she wouldn’t scratch her patients when she was delivering their babies.  That made deep sense to me as a child, illustrating in an utterly comprehensible and practical way the things we can all do to make women more comfortable when they are vulnerable and in need.

Birth mattered and it also seemed absolutely mundane, and often annoying.  I was not amused as a child by having trips to the park and the pool interrupted because my mother was on call and some lady was having a baby.  I did like making pictures with all the colourful tape at the nurse’s station in the hospital where I sometimes had to wait for my mother while she worked.  But I didn’t like having to wait. And sometimes I was impatient:  I once told her to “just do a c-section” when a patient seemed to be laboring for an awfully long time, interfering with whatever it was I wanted my mother to do for me.  Yeah.

It was all very matter of fact until after my first baby was born.  I realized then that birth might be common but it’s actually never mundane, and that all the care and respect that I received as a pregnant and laboring woman—that I took for granted from a family doctor who my mother had trained—was not necessarily the norm.  I learned after the fact that I was lucky to have grown up believing the things I believed about women and to have had the kind of birth I had, and that my total, unfailing trust in my doctor and my mother’s medical angle on birth might be worth questioning, even though they believed in the medicine they were practicing and my outcome was good.

My daughter’s birth almost fifteen years ago radically altered the way I understood women’s relationship with medical approaches to childbirth.  The high I felt after giving birth, the incomparable sense of accomplishment and power, was so incongruous set alongside my unquestioning willingness to let my doctor manage my pregnancy and to accept—even anticipate—interventions simply because they were ‘normal.’  I began a long process of reframing and rethinking, asking questions, demanding justifications, searching out evidence of benefits and risks, wondering what ‘normal’ even meant and why anyone automatically believed, in the context of intervening in pregnancy and birth, that it was good.

It didn’t take long for me to recognize that the framework for my analysis was feminism.  Feminist thinking made it possible for me to de-center medicalization without demonizing individual doctors, and to explore other approaches such as midwifery without romanticizing them.  Feminist thinking encouraged me to look at pregnancy and birth first from the perspective of the women who experience it, and consider the ways in which ‘normal’ pregnancy and birth are constructed by particular social, historical, political and economic contexts.  Feminist thinking made it impossible for me to look uncritically at any action that interfered with women realizing or being supported in realizing the unhindered potential of their bodies, and allowing their bodies to take up space, and be noisy, messy and inconvenient.

It probably comes as no surprise that this has all led to some *cough* interesting conversations between me and my mother.  We agree on the fundamentals:  birth is not a medical emergency, interventions should be kept to a minimum, and women deserve respect.  We agree on many critical points, including a shared sense that today’s skyrocketing caesarean rate is a problem and the importance of supporting all women in making truly informed decisions about their own reproductive health.  But then there are other topics, such as the relative safety and advisability of homebirth, where the discussion gets a little more complicated and I have to remind her:  intentionally or not, you raised me to think this way.

Believing in women’s bodies and their capacity to grow, birth and feed babies without undue intervention, and in women’s right to control their own reproductive labour—not only whether they give birth, but how they give birth—is central to my belief in women’s capacity to be agents in their own lives and effective political actors.  I don’t reject medical intervention when a woman needs it.  I do reject the dominant medical model that says intervention is almost always necessary.  And I reject the notion that just because birth is common we shouldn’t care about it or that birth activism makes mountains out of molehills. Minimizing issues that are unique to women is a time-honored tool in the war against us.  And it’s often in the struggle for autonomy in our everyday lives—including what some consider the mundane, uninteresting work of pregnancy, birth and mothering—where we discover what power really means.

After a surgical birth

I spent a lot of time today thinking about how women and babies are treated immediately following caesarean deliveries.  This topic is often in my thoughts because of my own post-op experience.  For reasons I still don’t understand, I was not allowed to touch or hold my perfectly healthy newborn daughter until we were out of the OR and in recovery, about 45 minutes after she was delivered.  In the OR, both of my arms were strapped down, and everyone present just ignored me when I asked repeatedly to touch her.  Being completely stripped of power as an individual, as a woman, and as a parent in the first hour of my daughter’s life is still one of the worst memories I have of that day.  The resulting anger and loss is almost indescribable.

Two things today made me think about this even more than usual.  First, I made the mistake of watching A Baby Story on TV at the gym this morning while working out on the elliptical machine.  (My theory is that watching shows that inevitably piss me off will raise my heart rate a little more, increasing the value of my workout.  Totally bunk science, I know, but it’s my way of justifying really bad TV choices.  Anyway.)  In the show, a woman who had hoped for a vaginal birth gets a c-section.  The hospital staff dismiss her sadness and fear prior to the surgery; afterward, they ignore her as she calls for her newborn baby, who she can hear but not see crying somewhere beyond the curtain separating her head and chest from the rest of her body.  Her baby is brought close to her face for a minute or two—already clean, dry and swaddled—but then whisked away, leaving the woman lying there with a stunned and wounded look on her face that resonated just a little more than I would have liked. 

It wasn’t easy to get the images from this morning’s A Baby Story out of my mind, and then later in the day, by coincidence, I happened upon this post at Cesarean Parent’s Blog.  The author describes a situation that should be the norm post-op in cases where a baby and mother have no health issues requiring immediate attention.  Just like after a vaginal birth, women who have had caesarean surgeries should have the opportunity to have skin-to-skin contact with their newborn babies.  Not all women will want this, and in some cases it won’t be appropriate.  Obviously women and their health care providers need to make smart decisions responding to the specific context and requirements of each birth.  But barring the need for immediate medical procedures, offering a woman the chance to hold her baby—and keeping the baby close to her/his mother— is the humane thing to do.

I write about this here because the reality of a 30-40% caesarean rate means that more women than would otherwise expect or require a c-section need to be ready for the possibility that they will have one.  For those for whom the birth process is important or who want to see and feel their babies fresh from the womb—before they have been sanitized, weighed, measured, poked and prodded by a succession of strange hands—it might be worth spending some time thinking about how an ideal post-op period would look and feel and what the hospital staff, attendants and others might be able to do to support their wishes.  None of this guarantees a positive experience, and achieving an ideal is far from the point.  The point is not to stay ‘in control’ (no such thing in birth), but simply to remain subject instead of becoming object.  For some women, preserving those post-birth skin-to-skin moments amid the challenges of a surgical procedure (especially one with such a troubling political context) can make all the difference in terms of their overall feelings about their births, their babies, and themselves.  If doing so poses no medical risk to mother or baby, and, indeed, has myriad proven benefits, why not?

ICAN of the Cowichan Valley

Forgive me, readers, for it has been many months since my last post.  I took a little professional detour (can you detour from an already diversified path? hmmm…).  It was interesting, and among other things, gave me an opportunity to reevaluate my values and priorities. 

And now that I’m back from my sojourn, I’ve re-prioritized my work around birth advocacy.  To that end, I’ve (finally!) gotten around to doing something I’ve been talking about for years:  I just started a new chapter of ICAN, the International Cesarean Awreness Network, here in the Cowichan Valley.  ICAN of the Cowichan Valley, like other ICAN groups, will offer resources and information about cesarean sections, and provide support to women who are recovering from a c-section or trying to avoid an unecessary surgery. 

After I had Annika, I attended one ICAN meeting down in Victoria.  But for a variety of reasons, including distance (it was a 2-hour drive, round-trip), I never managed to get to another one.  I’ve always regretted that, and wished I’d had a practical option beyond suffering in isolation with the aftermath of her birth.  I did have a wonderful circle of online friends who helped me through those years, but there is a lot to be said for face-to-face, local connections, especially in the postpartum phase.  And there is also a lot to be said for a specialized group like an ICAN support group.  It’s often hard for women to talk about their experiences with surgical birth, as many people still trot out the ‘but you have a healthy baby!’ dismissals, and unecessary c-sections have become normalized in our society.  ICAN groups can offer a safe place for women to connect with others who are likely to empathize, and willing to listen without judgment to their stories.

I’m still in the process of getting the group up and running–it was only officially registered yesterday, and I have yet to plan any actual events or meetings!  My hope is to find a central space where we can gather, perhaps beginning in late May or early June, and go from there.  So, local folks, please help to spread the word and encourage people to contact me at icancowichan@gmail.com.  Local and far-flung, like our Facebook page. Thanks to all of you for helping me let people know about this important new resource.

An epidural is not the only way to protect your pelvic floor

There has been a lot of discussion this week about press coverage given to a new study suggesting that epidurals may prevent trauma to the pelvic floor during delivery. Basically, the idea is that an epidural relaxes the muscles such that they don’t tear. I don’t know whether or not that is true. I haven’t read the study itself, only representations of the story in various places. I know that Amy Romano at Science and Sensibility is sceptical, and I think she is a pretty trustworthy source of information. It has been interesting to follow the discussion between her and the study’s authors in the comments section of her blog. (And ire-provoking to see the known ideologue Dr. Amy Tuteur’s $.02 popped in there, too—but I digress…) Whether or not the study’s conclusions have merit, the coverage of the study, particularly in the Globe and Mail, has been quite atrocious.

I’ve said it before and I’ll say it again: I don’t think there’s anything inherently wrong with epidurals. They have an appropriate time and place, and the only person who can really say for certain whether or not an epidural is indicated is the woman with the baby descending through her pelvis. I’ll trust her to be the judge of how she wants to manage those sensations. So, this is not an anti-epidural rant. Hell, I was practically desperate for one with my first baby—got to the hospital in transition and begged for one. I was too far gone, at 8 cm, to qualify—and in retrospect I’m glad that was the case, as it was a very cool experience to give birth without drugs—but at the time, if someone had tried to suggest that I was wrong to ask, I’m sure I would have wrung his or her neck with my own bare hands. That said, there are definitely risks involved with an epidural, just as there are risks with any invasive medical procedure. Risks v. benefits. That’s the name of the game.

So, there may be benefits to epidurals that we didn’t know about before. That’s awesome. It’s always good to learn new ways of preventing women from lasting harm to their bodies. Women want good options when it comes to health care. But a) this study isn’t saying epidurals prevent tears—it’s saying epidurals may play a role in preventing some kinds of pelvic floor damage; and b) the uncritical coverage of this study has not explained that there are also many other steps women can take to safeguard the health of their pelvic floors. The point is: there is nowhere near enough data to say that epidurals are necessarily the best approach, and they certainly aren’t the only one, either.

What else can women do? There are the often-cited birthing strategies that include not giving birth on one’s back, but instead choosing a position that is more in synch with physiological processes occurring and can benefit from gravity; avoiding fundal pressure; and pushing spontaneously, rather than following directions for pushing. But there are other things women can do as well, before they get to the moment when they are actually in labour—a moment when they may or may not want/be able to think about those strategies.

Women who perform simple pelvic floor exercises during pregnancy and after delivery can greatly reduce their chance of pelvic floor trauma and the speed of postpartum healing. The stronger the pelvic floor, the more flexible; the more flexible, the more likely those muscles will get up and out of the way and not tear while a baby passes through. A strong pelvic floor can also prevent/reduce the significance of other common pregnancy- and birth-related concerns, such as hemorrhoids, prolapse, and urinary incontinence. And as a bonus, contracting the pelvic floor automatically gets the transverse abdominus to co-contract, helping to tone the abdominal muscles. These are seriously awesome exercises that can be done anywhere, at any time of day, with no special equipment.

 So, what do you do? Basically, you want to do a modified Kegel, which can then be performed in various series, at various speeds, and in various patterns. If you’ve never done a Kegel before, the idea is to draw the muscles of the pelvic floor (PF) up and into the body, as if you’re stopping yourself from going pee. Draw them in, breathe, hold for a few counts, breathe, relax. Once you get the hang of that, you can move on to combine PF work with other core strengthening exercises such as curls (unless you have diastasis recti), superwoman, and cat-cow. You can do them sitting on a chair or an exercise ball, standing, lying on your side, on your hands and knees, in child’s pose—there are many positions that work, all of which have a slightly different benefit.

The bottom line (pardon the pun) is: strengthen your pelvic floor. Pregnant or not, this is a good thing to do. But if you’re pregnant or contemplating giving birth at some point, strengthening your pelvic floor is a noninvasive, key step in minimizing the risk of tearing and other significant trauma to the perineal region.