{Ottawa Doula} Swimming Upstream: Vaginal Birth after Two Cesareans

I have been immersed in a dilemma lately - not my own personal dilemma, but one of my client's.

This woman would like to attempt a vaginal birth after two cesareans. We hear A LOT of information out there about VBAC (pronounced v-back) after one cesarean, and most doctors and midwives would agree that it is a safer choice than scheduling a repeat cesarean (as long as you meet the "qualifications" - no ongoing medical problem where another c-section would make sense, and a low, transverse incision).

The American Congress of Obstetricians and Gynecologists (who issued the report I linked to above) also agree that a Trial of Labour (TOL) for a woman with two or more cesareans is a viable option. The risks of uterine rupture are higher, but variable. Studies differ in their methods and conclusions, and "risk" is communicated to patients in different ways.

For example, read this statement, as stated by my client's doctors (the numbers are not accurate here - this is just to illustrate how they have portrayed risk):

Your risk of uterine rupture triples after 2 cesarean sections. In all the cases of uterine rupture I've seen, the baby has ended up with cerebral palsy.

Now, read these statements, as a properly conducted study may present them:

Women who attempt TOL after 2 cesarean sections have a 1.9% risk of uterine rupture. Of these, only 0.06% experience a complete rupture (where the baby actually enters the abdominal cavity).  

1 in 6000 women who attempt TOL after multiple cesareans experience uterine rupture. 


The first one sounds a lot worse, doesn't it? If you're trying to scare a woman into scheduling a c-section, the first statement packs a lot more oomph.

OBs who have personally witnessed a uterine rupture are much more likely to inflate the risks, because their perception of risk has changed. It's no longer a magic number (eg. 0.5% of women who attempt a TOL after one cesarean section risk a uterine rupture), and instead the one case they've seen colours the way in which they treat all future patients.

To make matters worse, there are no doctors here in Ottawa (at least none I have come across) who support a woman desiring a TOL after multiple cesareans. My client has been continually hassled about her decision, and with each prenatal appointment she attends, a new resident provides more scary stories. No one seems to talk about the risks associated with another cesarean section, which I find interesting.

When you want to do something that goes against the grain, and no one in your community is willing to support you, what should you do?

1) Remember that as a patient, you have rights. You have the right to refuse interventions and treatments offered. You have the right to informed consent.

2) Become armed with research. Doctors are busy people, and often don't have time to stay abreast of new research. Do your own looking around, and begin compiling all the papers that support your decision (start with the new ACOG guidelines, which support your decision to try for a VBA2C). Bring them with you to every prenatal appt., as you'll often be seeing many different doctors and residents.

3) Yes, the health of you and your baby is important. But so is your experience, and oftentimes, doctors will play the "healthy mommy, healthy baby" card, in order to dissuade you from your desire for a positive birth experience. Seek the help of a professional (social work, counsellor, or doula) who can look at the benefits/risks objectively with you, and help you come to the right decision.

4) Did I say that health was important? You betcha! If you're desiring a VBAC (or VBA2C), you best be sure that you're eating really well (see a nutritionist or naturopath for help), exercising every day (gentle exercise such as walking, swimming or yoga) and reducing stress (do some yoga and you'll check two things off your list!). Many women also seek treatment from alternative health practitioners, such as acupuncturists, homeopaths and chiropractors.

5) Read the positive stories. There are women all over the world who have tried and successfully had a VBA2C (I've even read of a VBA4C!!)

Bottom line: if you're taking the plunge, first make sure you know how to swim. Oh...and a little faith goes a long way. Faith in yourself, your body, and your ability to do something that others think is impossible.

Share your story below of something you have accomplished when others tried to tell you it was impossible.

T'was the Night Before December...

Celebrating Christmas in November truly rocks. You haven't yet gorged on sweets at the countless parties and potlucks you will be attending. You're not tired of consumerism and holiday "spend-spend-spend" mode.

The reindeer are wide-eyed and bushy-tailed, gearing up for the big day.

And best of all, your family still seems awesome to you; before the typical holiday descent into chaos, with drunk Uncle Charlie singing to the neighborhood cats.






I could get used to this....

{Ottawa Doula} Fancy Free

The weekend was a long but joyful one, after welcoming a beautiful babe in the world after a marathon birth.

Doulas call births "marathons" when they require a full night, PLUS! These are the 24+ doozies that sock you a good one. Today has been my "hangover" day (another term we doulas use), when it feels very much like you drank 2 bottles of wine before hitting the hay.

In other news, the little birdies here at The Tweet are taking a bit of a vacation. An unexpected break between now and my next client has provided a window of opportunity - a chance to head to Toronto for a few days to visit with family and friends. We will then make our way further west to the little town of St. Thomas, ON, where we will celebrate an early Christmas with more family.

I fully expect to be immersed in this one-on-one time with my child and my loved ones, so you may not hear from me for a little while. However, if inspiration hits, a computer is never too far away.

Let it be.

So that I take what I know,

And see what I see

Along this path I want to be,

Full of joy and totally at ease

Breathing now, and fancy free.

Getting Old is a Bitch

I'm observing the poor dog that we're doggy-sitting at the moment. He's 16  years old, and currently has vertigo - that crazy syndrome where you lose your internal sense of gravity. It's like you've walked off that twirly ride at the fair and the world won't stop spinning.

Taking care of the ol' man/dog is forcing me to reflect more on my own ageing. I know, I know, I'm only 31 and in the eyes of many of my friends, "a spring chicken." But 31 is still 31, and time marches on incessantly while I scramble to pick up toys, clean paint off the wall, and stare blurry-eyed at my credit card bill.

What was your favourite age? Mine was 14 - it was a time where I had past the awkward pre-teen years, but still hadn't reached the annoying "I know everything" young adult years. I was still innocent in the ways of the world, had my future stretched out before me, and finally felt like I could just be me.

I am now me, but a whole different me, with a whole lot of expectations. And instead of seeing life stretched out before me, I see a lot of roadblocks and potholes.

We're supposed to get wiser as we age; perhaps gain more insight and calm down a little bit.

But with mortgages, babies, toddlers, jobs, and god knows what else, don't we just become more insane as the years go by? Strip away all these things we have collected and restrictions we have imposed on ourselves, and what are we left with?

A very existential conversation, I know, but an imperative one.

Because, really, I think I'd rather be the calm, wise gal than the cranky bitch who walks through the world as though she just stepped off the twirly ride. Any thoughts from the wise of the world on how to get there?

Honey, Mommy is a Nerd

It's amazing when we hear our children repeat the things we say. Not only is it amazing because these little bundles of joy are learning a language and growing up, but it's also amazing because we see ourselves reflected so clearly in their words.

For instance, I've noticed that I yell at the dog a lot. I know this because A. speaks to the dog in a mean tone of voice, with lots of "Sit!" "Off!" "Get!" in her vocabulary.

I'm trying to reform. Speak to my dog with more respect.

The other thing I've noticed about my language is that....well....I'm a bit of a nerd. Here's just a sample of some of the phrases that A. has picked up from me:

Cool, dude!

Awesome!

Oh my goodness gracious!

Gosh!

Gee Wiz! (ok, I'm kidding about this one...really)

My poor daughter. I have committed her to a life of "gee willy wonkers" turns-of-phrase. Will she ever find friends?

I've decided to commit to speaking in a way that is more "hip." Maybe I'll start swearing and drop some f-bombs around the house.

What funny phrases has your child picked up?

{Ottawa Doula} What to do when you're afraid of birth

After posting about the NHS's plans to offer c-sections for free in the UK, I have noticed an increase in traffic from people googling "scared of birth, should I have a c-section."

This has really touched me, and I wish there was some way I could reach out to these women and give them a hug. So here's my way - a blog post!

Preparing for birth can be a scary and overwhelming experience. I remember coming home from my first prenatal class, curling up into a ball and having a huge cry. The reality of what I was about to face hit me over the head like a ton of bricks, and I didn't know how to deal with the fear.

I studied for birth like it was a PhD comprehensive exam. When I would hear about other women's wonderful birth stories, I would suddenly become fearful - what if that doesn't happen to me? What if I can't do it? What if it all turns out "bad"?

The thing I've come to realize as a doula is that a woman who is well prepared, and well supported, can have a positive experience regardless of the outcome. Happy birth stories can happen in any hospital, with any care provider, as long as the woman feels like the director of her own experience.

Here are some information and tips for women out there who are scared of birth and considering a c-section instead:

1) What are your specific fears? There are most likely 2 or 3 things that you are dreading - for some women, it's the pain; for others, it's the possibility of a tear; others fear things like vomiting, being naked, or losing control (by making too much noise, fainting, or doing other "crazy" things)

2) Write out a plan of how you will deal with this fear if it does happen. Visualize it happening, and then visualize yourself dealing with the situation. Talk to someone about your fears, and have them work through them with you.

3) Hire a doula. Your husband can not be your "everything" and he will be scared as well. Most likely he has his own set of fears. If you can't afford a doula, ask for a friend or family member who has given birth (and who has a positive birth story to tell) to support you.

4) Make sure you have a good caregiver. You all know my thoughts on midwifery care. There is no one better equipped than a midwife to calm your fears.

5) Take a GOOD prenatal class. The classes offered at the hospital are usually biased and extremely boring. Look around for prenatal educators in your community who offer alternative classes. Here are a few great ones in Ottawa:

Ottawa Childbirth Education Association http://www.ottawacea.com/

Birthing From Within Classes http://primadoulas.ca/?page_id=22

Bradley Method http://www.healthy-beginnings.ca/

It's worth the money - another option is to hire a doula who is a childbirth educator, and ask her for some one-on-one classes in addition to your prenatal appointments.

Any other tips or thoughts out there for women who are afriad of birth?

Intention

I had a chat with a very wise friend today, who reminded me that if I continually say "I can't do it," then clearly, I never WILL do it.

Some of you may find books like "The Secret" to be filled with a bunch of Oprah-like gobbly-gook, but it's interesting to observe that the people who truly believe in the power of intention tend to be happy and successful.

If you look back on your life, you are bound to remember people who had a hand in changing the direction in which you were headed. These could have been the "bad" people (an abhorrent co-worker, a loser boyfriend, or a friend who betrayed you), or the "good" people (an inspiring teacher, a mentor, or a business partner). Regardless of whether they were good or bad in your eyes, you learned a big lesson from them, and then moved on.

Without these serendipitous encounters, we wouldn't be the people we are today.

Which comes back to main point of books like "The Secret." In order to fulfill lifelong dreams, you must have both intention to do so, and the right people around you. You can pray, meditate, and visualize all you want, but if you've got some bum hitching a ride with you along the path of life, you're bound to get distracted and have a horrible crash. (And in case you're getting worried, I'm not alluding to my partner-in-life here - this could be anyone; co-workers, friends, partners/husbands, and even other family members.)

Personally, I think I'm doing a good job of surrounding myself with positive and compassionate people.

Where I'm falling short is in the "intention" department. The think, pray, feel and believe part of where my life is headed. Instead, I'm doing what is safe - financially and emotionally.

Image Source

One goal I have as we finish up the end of 2011 is to create a vision board - simply, a big piece of paper (well, you really need stronger cardboard) where you creatively lay out your life goals. These vision boards can be short or long-term. They can be focused on a particular area of your life (e.g. business) and can be as simple or complicated as you make them. I'm hoping my vision board will help me get over my fears and closer to my dreams.

What are your visions or dreams, and how do you make sure you get there?

19 more days to go!

It's November 7th, which marks the 7th day in a row that I've posted on my blog (ok, fine, you caught me - I didn't post yesterday. Sunday is the day of rest.)

I'm participating in NaBloPoMo (National Blog Posting Month), through BlogHer. I'm not posting my blog posts on BlogHer - even though I have an account that rarely gets used - but I'm attempting to boost creative writing by forcing myself to write. Even when I'm bored, and having nothing interesting to say.

Today is one of those days - normally, I just wouldn't post, because I don't really have any exciting news, links or burning questions to put out into the world.

But writing is an art, and alas, I must practice. Since I have basically dropped all other art forms from my life at the moment, writing is my only outlet, and it's a really important one.

I wrote last week on the topic of self care, and I'll continue along those lines today. I'm still participating in A Peek Inside the Fishbowl's 100Club, and although I can't say I've been doing my jumping jacks every day, I've certainly kept up my walking.

My focus this week is on eating habits. After last week's Halloween candy binge, I began feeling really worn down and sluggish. Not to mention my face is a mess (a post later this week on adult acne - blech!!) So, I'm attempting to change some habits, and although I would like to say "forever," I've decided to be realistic and take it one week at a time.

My three problem areas are:

1) Alcohol: yes, I know there are benefits to having one drink each day. But there are also drawbacks, especially when trying to control blood sugar levels, which I have a devil of a time doing.

2) Sugar: My overall diet is fairly decent, but I do have a sugar problem. I realize that I can't cut sugar out of my life completely (trust me, I've tried), so I'm hoping to cut back...A LOT. This means that I'll be attempting to bake a low-sugar cookie this week, sweetened with maple syrup or honey. Stay tuned for that recipe on Friday!

3) Caffeine: as most of you probably do, I indulge regularly in this crack stuff. It's increased substantially in the past year or so, and I'm now at 2 mugs of black tea and 1 coffee each day. Cutting back is key, as I'm not willing to give up my one mug of morning tea.

Have you been making any lifestyle changes lately! Send me your tips and affirmations!

{Ottawa Doula} Scared of birth? No worries, have a c-section - for free!

Thanks Laura Hughes (@Lo_Hughes), for sending me this article and inspiring another blog post! :)

I read an interesting piece in The Globe and Mail today, in their online "Hot Button" topics.

Supposedly the country's National Health Service is going to cover the cost of women undergoing c-sections for no "identifiable reason." In other words, elective cesareans.

I'm sure the whole natural birth community will be up in arms over this one. Who knows, it may even increase the cesarean section rate in the UK, which is definitely not good news.

But I wonder whether this is the right response - firing off an angry blog post about women who are "too posh to push" is setting yourself up for a lot of criticism. You may not worry too much about that, but I know I do.

I care about women. All women. And I care about their freedom of choice.

No, personally, I would not have an elective cesarean. And I would hope other women wouldn't make that choice as well - I don't think it's the right one.
But a c-section is an option that is out there, and doctors are all too willing to offer one.

The point of this article, though, was to point out that the NHS will now be covering c-sections. That's a different story, than say, an opinion piece on women being "too posh to push." All of a sudden, the option is open to women who, previously, may not have been able to afford it.

So the question becomes: progress or problem? Is offering cesareans for women who are, for example, deathly afraid of labour/birth OK? What about for women who have been sexually abused? And women who believe the myth that you will never be the same "down there" after a vaginal birth?

The choice is out there, whether we like it or not. And although I strongly feel that the answer to my question above is "problem," I also don't feel comfortable blaming the women themselves for making the wrong choice. I don't know what their situation is in life, and I don't know what issues they face.

Instead of offering cesareans for free, I think the NHS would do better putting their eggs in another basket. Why not begin providing non-baised and supportive prenatal education to all women, for free? Maybe those who harbour extreme fears of birth would be at least better prepared to face the challenges. And what about doula support, for free?

So no, I don't believe this issue is one of "too posh to push." I believe this issue is one of dollars and sense. More dollars, and a load of nonsense.

Aduki Bean Stew

I may have posted this recipe once before on this blog, but I think it warrants a re-post. This is my "birthing stew" - the recipe I was throwing together during early labour with darling daughter. I actually couldn't finish it because the contractions were getting so strong, but I ate quite a bit of it in the postpartum period.

The Aduki (also spelled Azuki or Adzuki) bean is not a well-known legume - it is most popular in East Asia, and is often boiled down and sweetened into a red bean paste. I could see the Aduki bean becoming as popular as quinoa, for its high levels of B vitamins, iron, zinc and magnesium. All in all, an excellent health food. Also, in the postpartum period, the fibre and iron is excellent for the breastfeeding mom! You can find the beans at the Bulk Barn.

This recipe is from Jillian McKeith's You Are What You Eat cookbook, with some modifications. Try it over quinoa, rice or millet:

1/2 cup aduki beans, presoaked for 12 hours
1tbsp olive oil
1 tsp garlic, minced
1 onion or leek, chopped
2 carrots, chopped
half butternut squash, peeled and cut into small chunks
half teaspoon ground cumin
half teaspoon turmeric powder
3-4 cups veggie stock
handful of kale, ripped into bite-sized pieces
chopped fresh parsley (optional)

Drain the beans and rinse well. Put into a large saucepan of water and bring to a boil. Boil for 15min, and then drain and rinse.

Heat the olive oil up on low heat, and add garlic and onion/leek. Cook until softened. Add carrots, butternut squash, aduki beans and spices. Cook for 2 min. Poor in stock, bring to a boil, and then simmer for 10min. Add kale and simmer for another 5min. Serve with fresh parsley.

Escape

Sometimes I wish I could escape.

To a place where no disembodied voices speak to me - no radio, no TV, and no computer.

This place would be quiet, except for the wind and the tinkling of the leaves.

This place would be warm; wood-stove warm.

In this place, I would need to sit - through it all. Sit through the fear, the silence, the sadness and the joyfulness. When I wasn't sitting, I would be walking, concentrating on the strength of my body.

This place would have simple foods, grown and picked by me. Tea in clay mugs would litter the tables and counters.

Books well-worn and dog-eared would be stacked by the bed, and a simple quilt would be my warmth in the evenings.

This place would be my escape.

Where do you want to escape to?

{Ottawa Doula} Midwifery: Fact and Myth

It's not shocking to me at all how often I come across regular folks who have no clue what a midwife does.

I was there, too.

Before becoming pregnant with my first child, I gave no thought to my care provider. I pictured myself visiting my family doctor and being referred to an obstetrician. It was the fortuitous meeting I had one day with a local midwife that changed the course of my life forever (I guess you could say my pregnancy changed the course of my life forever, but I'm going for dramatic effect here!)

I interviewed this student midwife for a short one-month placement at Hopewell (Ottawa's only eating disorder support centre - as a side note, all midwives are expected to do one community-based placement; women with eating disorders get pregnant too, hence this midwife was particularly interested in this issue) She opened my eyes to the possibility of having a midwife care for me during my pregnancy.

So I would like to share with you some of the things I've learned about midwives, which will dispel some of the myths floating around out there. These tidbits are designed to surreptitiously indoctrinate gently urge you to seek out more information about midwifery care.

• You cannot have an OB (or family doc.) and a midwife; you can  have one or the other. There are exceptions - some women advocate for "shared care." These are generally women who are higher-risk but would like a compassionate, caring midwife to support them in their medical decisions.
• Midwives are highly trained professionals. They have not stumbled out of the forest wearing birkenstocks, and they don't arrive at your birth with a dirty towel and piece of shoestring
• Their training program is 4 years long, most of which is hands-on clincial experience
• Midwives care for low-risk pregnant women - they will not take on women who clearly need the expertise of an obstetrician.
• Midwives DO deliver primarily in hospitals. Yes, they do homebirths as well, but only if you're a good candidate, and only if you actually want to!
• Midwives will call in an OB consult if something abnormal comes up during your pregnancy/birth. Often this is just a quick face-to-face with an OB, whereby they give some advice and then you are back in the care of your midwife. Sometimes, transfers of care happen, but most midwives will stay with you and support you throughout.
• Midwives are trained to view birth as normal, until proven otherwise (OBs are trained to view birth as abnormal, until proven otherwise)
• Midwives discharge you from hospital earlier - which means less time stuck in semi-private rooms with other crying babies (and maybe even crying mommies).
• Midwives visit you at home in the postpartum period. AT HOME....like, on your couch!! I can't stress enough how amazing this is.
• A midwifery appt is usually 30min long, and allows for lots of discussion time. It's casual, and you get to meet with both your primary midwife (many times) and your secondary midwife (several times). An OB appt is 15min long, and if you go to the Ottawa Hospital, you will most likely never see your OB. You'll see a different resident each time.
• A midwife catches your baby. An OB "delivers" your baby (like a pizza), and they will arrive in the room when the head is crowning.
• Midwives have signicantly better outcomes than OBs - lower rates of intervention (e.g. episiotomy) and lower c-section rates
• Midwives practice informed decision making and informed consent. That means, every single little thing that happens during your pregnancy/birth is discussed beforehand, and you always have the right to refuse. Hospitals claim they practice these things too, but it's variable.

There are probably many more points I could add, but I hope this dispels some of the myths you have been hearing about midwives here in Ontario. As you may have read from my last post, there is a big push for more midwifery care here in Ontario. A birth attended by a midwife costs less than one attended by a family doctor, and significantly less than one attended by an OB.

We are now headed in a direction where soon, most low-risk pregnancies will be followed by midwives. It may not happen next year, but certainly in the next ten years. It just makes sense.

If you've had the care of a midwife, please share your story below! What was your experience like?

We Care!

The Boston Globe Magazine published a piece today, written by an obstetrician in the US.

C-section rates are highly variable, as the article points out. Some hospitals with different policies and procedures, and better support for OBs, have lower rates. Other hospitals skyrocket past the national average.

Here in Canada, our average rate is around 25%. Ottawa's cesarean section rate is higher - over 30%

There are some key points I'd like to highlight from the article:

• According to this doctor/author, many obstetricians just "don't care" about cesarean section rates
• There are multiple factors that influence rates. Here are just a few:
• hospital policy (does the hospital administration care about their rates?);
• surgical assistants on-staff;
• rates of women with previous cesareans (most women who have one will go on to have more cesareans);
• whether the hospital caters to high-risk pregnant women;
• liability; and
• individual OB preferences (for example, is the OB skeptical of traditional medical practices, or do they tend to make the call more quickly?)

So if a cesarean section rate comes down to individual hospitals, how is a national (or international) strategy ever to be successful? As the author writes,

"In 2000, the federal government set a goal of reducing the caesarean rate among first-time moms to 15 percent (from 18 percent in 1998) by 2010. Instead, officials watched it shoot up."


My question is this - how can we work to make hospital policy and "culture" more transparent? If there are hospitals in our city who have higher c-section rates, wouldn't it make sense for consumers to know why? Perhaps then we could do something about it. Just because we live in a country with universal health care, doesn't mean we can't demand better quality service.

I'll tell you this: many OBs may not care about their cesarean rates, but we pregnant women DO. Unless there is some extreme fear of labour/birth, the majority of women want to avoid a cesarean section. And yet, here we are, getting wheeled into the operating room despite our wishes.

Did you know that midwives have a 30% lower c-section rate than a family doctor who delivers babies? Who knows how much lower that rate is when comparing OBs and midwives - probably a huge difference. Doesn't it make sense to transfer the care of ALL low-risk pregnant women to midwives? Let's leave the surgical stuff and emergencies up to the experts.

It's time for change. Please take a look at the Association of Ontario Midwives "Benefits of Midwifery to the Health Care System." Speak out, and contact your local MPP.