Taking traumatic births seriously

I went to see a new doctor this past week.  I’ve been trying for five years, without much luck, to find a doctor who is a good fit for our family.  But we live in an underserved area, and unfortunately there just aren’t a lot of good choices–the doctors who are recommended most highly have full practices and won’t even take names for a waiting list.  So I had  high hopes when I went  into the new clinic on Tuesday, and I went in with a positive attitude:  this will be The One.

Unfortunately, I think I was wrong.  It was all going okay until she asked me if I had any concerns I wanted to address right away.  I said yes, there is one.  I decided a few months ago that it’s time for me to see some kind of counseling professional to go through the details of my second child’s birth, and process what it all has meant in the nearly four years since.  Although Annika’s birth was extremely traumatic, I made only one attempt to discuss it with a professional.  When she was a few weeks old, I went to see the nurse at the health unit who was responsible for counseling women with postpartum depression.  I don’t know if I was suffering from PPD per se, but I was definitely suffering emotionally, and she was free, so it seemed like a logical choice.  She was nice enough, but after I explained the situation (planned homebirth turned emergency c-section after 5 days of prodromal labour and all kinds of crazy things happening, etc.), she told me that I had to stop “wallowing” in self-pity, accept that I had a healthy baby and move on with my life.  Given the fact that I still hadn’t gotten up the nerve to remove the bandage covering my incision, and I still needed help getting in and out of bed because of the pain, I thought her remarks were insensitive and, at the very least, awfully premature.  Needless to say, I didn’t try to talk to anyone about it again for a long time.

But on Tuesday, I decided the time had come.  I’m working with pregnant and postpartum women now, and want to ensure that I don’t project my own issues on to them.  It’s a professional responsibility as well as a personal necessity.  It’s not easy to ask for help, especially with mental health issues, but I sucked it up, put on my big-girl panties, and decided to give it a go.  To be fair, I was nervous and probably didn’t explain very well, but I was assuming that a trained family doctor wouldn’t require a whole lot of detailed explanation, that she would have either seen this before or at least have some sense of how to handle it.  The conversation went as follows.

Me: “Um, well, I’m wondering if you can recommend a counselor or a therapist who I can talk to about my daughter’s birth?”

Doctor:  “Why, did something happen?”

Me:  “Well, it was really hard–I had planned a homebirth, but we ended up with an emergency c-section, and I was pretty depressed for a long time afterward.”

Doctor:  “Is your daughter okay?”

Me:  “Yes.  But–”

Doctor (interrupting):  “Well, then, why do you need to talk to someone?”

Me:  “Um, well, I want to figure it out…figure out why I’m still bothered by it.”

Doctor:  “But your daughter is fine.”

Me:  “Yes.”

Doctor (laughing):  “Maybe it’s like some kind of [laughter increasing] post-traumatic stress disorder?”

Me (feeling ridiculous):  “Well, I don’t know if I’d go that far…I don’t know what to call it, but it’s hard.”

Doctor (still laughing):  “I don’t know anyone who really does, uh, that, but I can ask around.”

Cue me feeling like a complete idiot, totally dismissed, and wishing I’d never brought it up.

Luckily, sufficient time has passed and I’ve been around the block enough times with doctors and therapists that I could handle this–I wasn’t destroyed by it, although it was humiliating.  And I could put it in context:  her reaction wasn’t about me, it was a reflection of a large, systemic problem–ongoing stigma and ignorance about mental health issues–and a smaller problem that is a subcategory of the first:  a tendency to dismiss women’s mental health concerns, particularly around pregnancy and birth.

So instead of being destroyed I got angry.  Not in the doctor’s office, of course; there, I was a good girl, laughing with her as though she were right, as though I was silly to have brought it up at all.  I played my part in the cultural script perfectly, even though it went against everything I believe in; it wasn’t like I decided consciously to play the part, it was the only choice I could make–the possibility of pressing my concerns, of insisting she take me seriously, evaporated the second she started laughing. 

What is it going to take to change this?  I was struck while Annika was a baby by how little support there was for me to access.  Once the 6-week postpartum visit came and went with my midwives, I was on my own, and there was really no one there–outside of family and friends–to provide any kind of meaningful or helpful assistance.  And while I put on a brave face and muddled through, I think women can expect more than that–I think women deserve more than that. 

If a woman is traumatized by the nature of her birth experience–for any reason, whether or not you believe her trauma is “justified”–she deserves care, and she deserves to be taken seriously.  She is not “wallowing” or making a big deal out of nothing.  Birth is a major life event, and for some women it is one that may require days, weeks, months or years to process.  Is it wrong to ask for healthcare professionals whose jobs include pre and postnatal care to assist with that?

The doctor I saw on Tuesday should not have laughed at me.  I wish I hadn’t laughed with her, because I don’t believe it’s a laughing matter.  Birth trauma is serious.  It can destroy a person’s quality of life and impair her ability to parent appropriately; it can hurt a whole family.  Women’s feelings matter; women’s experiences matter.  Birth matters.  Stop laughing, stop dismissing, and listen.  Asking for help is really hard–if a woman has the courage to go that far, give her the courtesy of going with her and doing what you can to offer some support.

Healthy Beginnings

I had the pleasure this week of being a guest speaker at a couple of Healthy Beginnings meetings, which are drop-in groups for young children, babies and their caregivers sponsored by the local health unit.  I spoke to one group in Duncan earlier in September, and two groups on Thursday in Shawnigan Lake.  I did a little demo of core work with the women (all moms except for one nanny), and checked a few for diastasis recti (everyone was good to go!).  But aside from encouraging more people to strengthen their pelvic floors, I really wanted to get two points across:  a) let them know that I’m here as a resource for them in the community; and b) emphasize the notion that fitness is holistic, and that postpartum fitness, especially, has little to do with fitting into pre-pregnancy jeans.

Let’s talk about the second point first.  I’ve written about this before here so I won’t repeat those points now.  But I was struck at the drop-ins by how much women focus on changing their size after pregnancy.  Of course I already knew this was the case, but every time I see signs of it, the red light starts to flash in my head: teachable moment!  teachable moment!  There are practical reasons to want to get back to pre-pregnancy size–the most significant of which is probably financial, as buying an entirely new postpartum wardrobe right after buying a new maternity wardrobe is an onerous expense.  But there is nothing wrong with taking time to get there, and moreover, a healthy lifestyle + time is the best formula for healthy and lasting post-pregnancy weight loss.  Anything extreme–extreme exercising, or even not-so-extreme dieting–is dangerous, plain and simple (and most likely ineffective).  

The thing is, we all know this, and beating people over the head with such information doesn’t work.  So instead, I tried to focus on the positive:  rather than telling people what not to do, I suggested what they can do to improve their health and wellbeing after baby, and to strengthen their bodies so that they can move with freedom, and with the knowledge that they are protecting their bodies from injury. Even more importantly, I tried to emphasize that they can do that without having to be away from their babies.  (Although there is nothing wrong with working out solo either–the point is, women have lots of options and they can pick and choose what is right for them at any given time.)  And I’ll tell you–it felt very good to look around the room at women’s faces and feel like they were soaking these messages in.  I know the relief I often feel when someone in a position of some authority/expertise gives me permission to be kind to myself and to follow my instincts about what is right or wrong for me as a parent, and I hope I was able to do that for some of the women there.

On the second topic: although part of my reason for going to the drop-ins was to let women know about Fit 4 Two, I had a bigger purpose in mind, and that was to let them know that there is a place they can go if they have questions about things to do with health and fitness during pregnancy, birth, and postpartum recovery.  I got involved with Fit 4 Two because I wanted to reach out to women as someone who is not a clinician of any sort, but has other kinds of information to share, and is happy to be a source of support.  Sometimes people hesitate to call on professionals when they have questions they feel are minor, or they have questions that professionals may not be equipped to answer (even the best birthy clinicians may know little about exercise physiology, for instance).  I wanted to introduce myself to the women as a fitness professional, but more importantly as their peer:  I know a lot about pre and postnatal fitness, but I’m also someone who has struggled through the pre and postnatal phases  and can lend an empathetic ear if they too are facing challenges.  So I was so glad to have the chance to go into these groups and let the women there know that they can email or call me any time with questions; if they are within my scope of practice, I’ll answer, and if they are outside it, I can help connect them with appropriate resources.  The point is that they aren’t alone, and they don’t have to pay a penny to be supported at this time in their lives, when so many women end up feeling isolated, inadequate, and often (sadly) at war with their own bodies.  Of course I’d love for them to take my classes, but it’s not about that; it’s about creating genuine relationships, and meeting women where they are, whether they are ready for and interested in a group workout or just need some basic information about how to work with their pregnant or postpartum bodies.

Oh, and I got to cuddle a newborn.  That was probably the highlight of the whole thing for me, personally.  There is nothing better than holding someone else’s newborn baby…  😉

Fit 4 Two is back in session in the Cowichan Valley!

Well, Fit 4 Two Mid Vancouver Island is now officially back in business!  Friday and Saturday I taught two trial sessions of Stroller Fitness, one in Shawnigan Lake and the other in Duncan, to introduce the class to a new group of moms.  It was so much fun! 

First of all, the babies–the babies!  Who doesn’t love a cute baby?  It’s awesome to look out at the class and see these adorable little faces.  It’s also a really interesting challenge to learn not to be distracted by their sweetness while teaching the class. 

And the moms…I’m impressed!  There were moms ranging from 2 months to a couple of years postpartum, and all of them rocked it!  Some were more accustomed to exercising than others, but each one gave it her all, and it was exciting to get to introduce people to a new kind of work out.  My hope is that everyone came away with some new knowledge and ideas about ways of moving their bodies, which they can carry on into their lives whether or not they choose to take more classes with me. 

My goal for the next classes I teach is to do more to emphasize building and/or re-building mind-body connections.  This is such an important skill to have for everyone, but all the more so for pregnant and postpartum women–it’s crucial during labour and birth, and while trying to figure out how to move and live in a body that has just had a baby.  Our bodies change so much during pregnancy; they literally feel different to inhabit, and it takes some pretty big adjustments to work with new proportions, appreciate new capabilities, and manage new stresses and strains.  I believe really strongly in mindful, conscious movement, and pregnancy and the postpartum phase–when everything feels different, and every day is a new experience–are exciting opportunities to discover exactly what that means.  

This week I’ll be continuing with Stroller Fitness, and teaching the first classes in the Mom & Baby, and Prenatal Fitness series.  These are both studio-based classes, whereas Stroller Fitness is outdoors and mobile, combining intervals of strength training with power walking and/or cardio drills.  The studio classes this week will also use intervals, including aerobic-style cardio and work with resistance bands, hand weights, and body balls.  I’m hoping to see some of the Stroller Fitness moms at the Mom & Baby class on Tuesday, and looking forward to seeing a new group at Prenatal. 

Getting into the fall session is confirming what I already knew, which is that teaching these classes is absolutely a labour of love for me.  It is really exhilarating to work with these women, to provide an environment where they can make connections with each other, and to know that people are leaving the classes feeling better than when they came in (even if better means a little sore, lol).   I’m looking forward to another great week!

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.

Failure of Progress

I have real issues with the notion of “progress.” I first started thinking critically about the term while studying history during my undergrad degree.  Thinking about history—the process of change over time—you start to realize just how few things in life go steadily upward or get steadily, unproblematically better.  Rather, things happen in contradictory, often unpredictable, and always contingent ways.  We don’t get smarter with the passage of time or more clever, or stop repeating the same mistakes or necessarily do anything better; in the present and the future we are just as flawed as we were in the past, only in an ever-changing context.

I’m not going to write more here about the source of our collective faith in the notion of progress—that’s another essay for another time.  But I am going to say something about what our faith in progress does to our bodies in the context of both fitness and birth, two situations where the word “progress” gets used all the time, uncritically, and with damaging results.

In both fitness and birth, “progress” is an effort to impose objective values on the most subjective thing of all, individual bodies.  It maligns our bodily integrity by suggesting that we should gauge the work our bodies do from an outside perspective:  somehow, we won’t know that our bodies are working well unless we take the extra step of measuring, stacking ourselves up against an external set of values that most of us really don’t understand.  In fitness circles you’ll often hear things like, “Track your progress!  Get measureable results!” as if fitness should be measured in inches or six packs, and as if there are some magical measurements that guarantee we’ve done something right. 

In birth, tracking “progress” during labour—the rate of dilation and effacement, combined with a baby’s descent through the pelvis—holds a woman’s body to the rules of statistical averages at a time that we know is quite unpredictable.  And that makes me angry because it doesn’t really make a lot of sense.  We persist in making assumptions about labour progress, insisting that “normal” dilation is 1.2 cm per hour and holding women to that standard even though we know that birthing bodies frequently don’t follow those rules

Well, taken by the thousands, parsed into all sorts of ideal numerical values, added together and divided appropriately, they do.  But yours doesn’t.  Neither does mine.  Statistics are numerical abstractions reflecting large-scale trends; but they aren’t illustrations of any one human being.  You and me:  we are individuals who are likely to follow a typical curve, but who may not, and may still be perfectly fine.  In fact, interfering with a body during birth to try and compel it to get in line with numerical averages can cause problems where none would otherwise have existed.  How many times does a perfectly healthy woman with a perfectly healthy baby end up in the OR because of “failure to progress,” when that “failure” was in fact no failure at all, but rather a body that simply needed longer than the charts said it should to give birth, and as a result longer than people—birth attendants, family members, the woman herself—were willing to wait?  

The critique I offer here is not new.  Emily Martin, a cultural anthropologist, wrote years ago about the damage done to women by superimposing the schedule of industrial capitalism on to our bodies.  Anything irregular—anything challenging the pace of the mechanical clock and the expectations of the schedule-setters—has been termed a failure or a problem, when it could have been recognized positively, as an adaptive response to a particular set of physiological cues.  This has set women up to be at war with ourselves because while we may wish to follow the schedule—who doesn’t want to have her baby on that magical due date, her period on the very day it’s expected, her labour to end after a predicted number of hours?—these are things that, without herculean effort, we simply can’t control.  Instead of accepting that unpredictability, we fight against it in what is, overall, a losing battle.  Because no matter how much we try, our bodies are not machines.  Our bodies don’t respect the clock (or the measuring tape or the scale) and they probably never will.

We can’t make our bodies meet the metrics of progress without doing things that put us at risk.  Inducing or augmenting labour without medical necessity, for example—something I admit I’ve done myself—is risky behaviour that multiple studies have shown invites complication.  Following exercise plans that focus solely on measureable “results”—again, something I have definitely done in the past—is risky, too.  It interferes with our internal sense of our own fitness and health, and instead makes our visual cues, mediated by cultural ideals of beauty and strength, paramount, often leading to injury, illness or frustration.

The good news is that there is a way out.  It is possible to improve your fitness level, challenge yourself physically, and to move through a major life event such as birth without the judgment that “progress” implies.  Your body need not always be in competition with itself.  Imagine what it might feel like to let your body be as it is on its own schedule (or lack thereof), aware of and embracing a kind of movement through time that is completely different from the time on the clock, and existing in shapes and forms that have no relationship to the number on the label of your pants.  Imagine what fitness might mean if it was mainly about how you felt, instead of how you looked.  Imagine what labour might mean if there were no “right” due date or number of hours or centimetres.   

How would acknowledging the failures of progress change your fitness goals?  How would it change the way you treat your body not only in signal moments like labour and birth, but in everyday life?

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