Sleep: Part I

This is not a post with advice on getting your kid to sleep better or more. This is not a post telling you that you're doing something right or something wrong. This is not a post by someone claiming to be some kind of sleep expert.

Indeed, I'm here to tell you that after two kids and 4-1/2 years, I have come to believe that kids sleep how they sleep, and what works well for one kid will make your life hell if you try it with another. I do think you can influence to an extent your child's sleeping habits. You can provide a healthy sleep environment and encourage healthy sleep habits. You can even "sleep train," to a point. But, in the end, it's the child and his developmental stage that's in charge.

See, I have two boys. They were "sleep-raised" very differently. By "sleep-raised" (a phrase I've just coined here), I mean the attitude and environment we provided for sleep. They have quite different "sleep backgrounds," if you will, our two sons do, and yet, now, with one 4-1/2 years old and one 2-1/2 years old, their sleep habits and sleep patterns are almost identical.

Let's start with my older son.

Boy #1 was (as you know by now) exclusively formula-fed from about 3 weeks of age. He never shared our bed as an infant. He started out sleeping in a Pack'n'Play bassinet in our bedroom, then was moved to a crib in his own room at one month old. He awoke a few times a night for a bottle until about 4 or 5 months of age, then miraculously stopped eating at night of his own accord. That's not to say he slept through the night from that point on, just that we could get him back to sleep just by popping his pacifier back in his mouth, rather than having to make him a bottle.

Until he was about 10 months old, we didn't really have a bedtime routine. When he seemed ready to go to bed (any time between, say, 9:00 and 11:00 P.M.) we'd get him in his PJs, give him a bottle, and lay on the couch or someplace with him until he fell asleep, then transfer him to his crib. Bedtime was difficult, and I was alone with a cranky child from the time I picked him up from daycare around 5:30 or 6:00 (oh yeah, he was in full-time daycare from 4 months of age, too) until my husband got home, any time between 8:30 and 11:30 at night. And he still wasn't sleeping through the night, and we had to get up often to do the "pacifier dance," which was going into the baby's room in the middle of the night, bleary-eyed, contact/glasses-less, to feel around for the pacifier, pop it back in baby's mouth, and hope he'd go back to sleep. There was also a period of about three months, from 8 to 11 months of age, in which we moved his crib into our bedroom because he seemed to be waking up scared and we felt bad. The pacifier dance was a bit easier under those circumstances, but I don't recall that he slept any better.

I was going a little bit nuts.

I then read an excellent book called The No-Cry Sleep Solution, by Elizabeth Pantley (highly recommended!), in the hopes of improving his (and therefore our) nighttime sleep. Pantley gave one piece of advice that I immediately took to heart. Put him to bed earlier. As counterintuitive as it seemed, setting a 7:30 bedtime instead of letting him decide when to go to sleep definitely improved his mood (and mine!), and it gave me a quiet evening instead of one in which I was dealing with a cranky baby for hours on end. My sanity improved almost overnight (haha!). The other piece of advice that hit home was have a set bedtime routine and stick with it. It doesn't so much matter what the routine is, as long as it's calming and consistent. Ours was eat dinner, take a bath, get in PJs, sing a few songs, have a bottle, then fall asleep lying on Mommy or Daddy. Once asleep, he'd be transferred to his crib, where he usually slept for quite a few hours before the nightly pacifier dance began.

When he was about 15 or 16 months old, he started having what we called "parties" several nights a week for two hours. Exactly two hours. Whatever time he woke up, and whatever we did during that time, he'd be awake for two solid hours, then go back to sleep. This might be from midnight to 2:00am, from 3:00 to 5:00am, or any other unpredictable time. Sure something was wrong, I took him to the doctor, who pronounced him perfectly healthy and this behavior quite normal. "You might have to let him cry it out," the doctor advised.

Now, crying it out is one of those controversial topics in Mommy-land. Some parents swear by it, claiming that three nights of screaming led to a lifetime of blissful through-the-night sleeping. Others say that it causes irreparable emotional damage by causing the baby undue stress and making him feel that Mommy isn't really there for him. Then there's the middle-of-the-road types, who say that you do have to teach your kid to sleep at night, and he's only manipulating you if you respond to his cries, so you need to follow Ferber's method (found in the book Solve Your Child's Sleep Problems, by Richard Ferber, M.D.) of "controlled crying" to help your baby fall asleep on his own, so that when he wakes during the night (as we all do), he can go back to sleep without disturbing you.

I decided, after 16 months of rarely sleeping through the night, to try my own version of "controlled crying." I followed our usual bedtime routine, but instead of letting him fall asleep lying on me after his bottle, I gave him a bottle in his room, then immediately put him in his bed and told him it was time to go to sleep, then left the room. He cried and cried. After 5 minutes, I went back in, laid him down, told him to go to sleep, and left again. Five more minutes of agonized screaming. Went back in. Lather, rinse repeat, for about 30 minutes. Then he fell asleep. He woke about an hour and a half later, I followed the process again, and he went back to sleep. I recall that after about 3 or 4 nights of this (with gradual improvement), he would no longer cry when I left the room, he would go to sleep quickly, and he pretty much slept through the night. The two-hour "parties" stopped, too. So it worked, yes.

Unfortunately, as babies are wont to do, he changed it up on us. At around 18 months, he entered the horrendous time known as the 18-Month Sleep Regression. This is an almost-universal phenomenon in which a child, who has been a perfectly cooperative toddler until now, suddenly starts sleeping terribly, or at least worse than before, for a few weeks (usually 4 to 6 weeks, to be honest) for no apparent reason. Yep.

Basically, at 19 months, we had to do another few nights of "controlled crying" to get him back into a better sleeping habit. After that, he pretty much started sleeping quite well. We'd do the bedtime routine, say goodnight, and leave, and he'd go to sleep and pretty much stay asleep. This was most excellent, as I was pregnant with our second child by then and really needed the sleep. That's not to say that we never saw those 1:00ams or 2:30ams or anything after that. He'd still wander in occasionally in the middle of the night (we had put him in a toddler bed by then, too) and wake us. Sometimes, we'd just pull him into our bed to finish out the night, and sometimes we'd escort him back to his. But it was mostly good sleep for everyone at night.

I should point out that the bedtime routine evolves as the kid grows. He no longer took a bottle by that age, and I believe I started reading a couple of books to him each night in addition to singing songs. As he grew, he started getting to choose what song to sing, what book(s) to read, and so forth. But the bedtime routine, even today, is largely unchanged. It's still dinner, bath, PJs, books, and bed. We now say the bedtime Shema (the night-time prayer) together before going to sleep, for example. But the structure is pretty much the same.

I also wanted to tell you about where this child liked to sleep, as it has bearing on what happened once his brother was born. At some point, I think around 18 or 19 months (once he could get out of bed on his own), after we'd say goodnight and go downstairs, he'd gather up his blankie, pacifier, and sometimes a sippy cup in his arms, slip out of his bed, and lie down next to the gate at the top of the stairs. There, he'd fall asleep and sleep peacefully until we'd come upstairs to go to bed several hours later and put him back in his own bed. We allowed this to go on for about a year, even when it meant me, at 9 months pregnant, having to step over the gate and him in order to get upstairs. Even when I had to start figuring out how to climb over the gate and him (see, we couldn't open the gate because he was usually lying up against it!) while holding a newborn. We let it go on because we felt that it wasn't important enough to change. And, frankly, it wasn't. He was sleeping. That's what mattered.

I think the number one piece of wisdom I came across during that time was "If the solution is worse than the problem, then you don't have a problem." I keep this close to my heart, because it's helped me through a lot of so-called "problems" with both kids, and other things in life, too. So, I'm passing it along.

It seemed like it was going to be too tortuous for us and him to try to force him to change his sleeping habits when they really weren't that big of a deal. I was told it was probably just a phase (a very long phase, apparently!), and that he'd eventually start staying in his own bed of his own accord. He didn't, and eventually it did become impossible to keep stepping over the gate and him as our younger son grew. One night, I decided it was time for him to stay in his bed and fall asleep there, and it really only took a night or two to convince him to do so. Life did get easier without that nightly gate-hurdling, I admit.

Nowadays, at the ripe old age of 4-1/2, most nights we get to sleep uninterrupted from whenever we go to bed until whenever we have to get up, or at least until 6:15 or so, which is pure bliss. There are nights when one or the other or both wake up. Son #1 is at the age of irrational fears and nightmares, so sometimes he'll come in randomly and either climb into our bed to finish out the night, or one of us (usually my husband) will escort him back to his bed and lie down with him for a bit. Now he's old enough to tell him he needs to stay in his bed and go back to sleep, and that he doesn't need to wake up Mommy or Daddy unless something is really wrong. It's really only once every few weeks that he has a bad night, which is totally tolerable!

So, the good news (so far) is that your child won't wake you up 3 times a night forever. More good news is that you will one day get to sleep all the way through the night, on your own terms. I actually do get mornings where I have the pleasure of waking him up!

As for Son #2, well, his sleep saga deserves a post of its own. I think the comparison is very interesting, because, as I said, they now both sleep through the night the vast majority of the time, and their sleeping histories are considerably different.

I think I'll also do a follow-up post with the conclusions I have managed to draw from all of this. There do seem to be a few universal truths, and I think these truths apply not just to babies but to everyone when it comes to sleep. Of course, this third baby will probably throw us for another loop, and everything I think I know will just fly right out the window again! Or maybe not. Maybe we'll find out that there really are some universals! I'll get back to you on that in a couple of years.

And Now For Something Completely Different...

I got to install a car seat today and teach someone how to use it properly! While not as exciting as, say, attending a birth, certainly, I do appreciate the opportunity to exercise another area of my growing expertise, despite no formal training, that of car seat safety. You see, along with VBAC and breastfeeding advocacy, my "... on Babies" interests also extend to car seat safety and using car seats correctly. I've written a few articles on my Facebook and LiveJournal about this very thing, as well as producing an article on proper car seat and booster seat use for my son's preschool, which was distributed by email to most of the parents in the school. But that's about as much car seat safety advocacy as I have had the chance to do.

I guess being specifically asked to help install a car seat and then asked to teach its user how to do it properly herself made me feel that people really do appreciate that I know what I'm doing and willingly come to me for help. They trust me. Which is kind of a neat feeling. Of course, there's always that insecurity that I won't live up to that trust. But once I took my car to a have my car seats checked, and I found out that I knew more than the guy doing the checking. So that was enlightening. And irritating. I guess maybe I do know what I'm talking about most of the time. I like knowing that I've made my friends' kids safer in the car by being available to help them when they have questions about their car seats.

I actually would like to take the car seat technician training at some point, along with wanting to be a fully licensed lactation consultant someday, and maybe a doula or something. I have ambitions, I suppose. I don't know how much of that is actually going to happen, at least not as long as I keep having babies of my own!

I am not the be-all and end-all of car seat knowledge, since I have not taken a certification course. I don't know all the brands and all the newest developments. But I know how to use a car seat correctly, and there are general rules that apply to all kids and all car seats, and I read articles that come out with new information or recommendations or guidelines whenever I see them.

So, here are some basics that I like to make sure everyone knows about using their car seats. These are based on the most recent safety recommendations from the NHTSA (National Highway Transportation Safety Administration), the AAP (American Academy of Pediatrics), and other sources of car seat research and information.

1. The safest car seat is one installed and used properly. The car seat with the highest safety ratings on the books is not safe if it is not installed properly or if the child is not buckled properly in it. Read your manual, know the weight and height limits of your seat, and consult with a certified car seat technician if you're not sure about something.
2. Your child is safest in the back seat of the car, rear-facing. This means they should be looking at the back of your car for as long as possible. From the time they are born until at least age two, children are safest in a rear-facing car seat, as long as they are within the height and weight limits of that seat.
3. For most car seats, your child is too tall for the seat, rear-facing, when the top of their head is within one inch (1", 2.5cm) of the top of the car seat. The weight limit of your seat will vary. Most seats now have this weight limit information printed on the seat itself. I highly recommend you take five minutes to read the information printed on the side of your car seat. Typical infant carrier "bucket"-style car seats are rated for infants 5 to 22 pounds. Newer ones may go as high as 30, 33, or 35 pounds. However, I have found that many babies outgrow these seats by height long before they reach the weight limit. Be sure to pay attention to both weight and height. Convertible car seats, which can be installed either rear- or front-facing, typically have rear-facing limits of 33, 35, or even 40 pounds in the newest seats, meaning you can keep your child rear-facing much longer even after she has outgrown the infant carrier.
4. When rear-facing, the harness straps should be adjusted at or below the child's shoulders. This prevents the child from riding up the back of the car seat in a collision and allows the head, neck, and spine to be properly cradled by the seat. 
5. You may decide to turn your child to face the front of the car (front-facing) sometime around the time he or she turns 2. If your child has not yet reached the weight and/or height limit of the rear-facing car seat by the time he reaches age 2, you may consider keeping him rear-facing longer. However, if you decide to have him face the front, make sure you are using a convertible car seat or a front-facing-only car seat with a 5-point harness. Small children should not be in booster seats that rely on the seat belt to keep them in place. In fact, many states' laws now require a child to be in a five-point harness until at least age four AND 40 pounds. Many, many car seats these days accommodate children up to 65 or 70 pounds in a front-facing 5-point harness. A 5-point harness is safer for everyone, not just children, and if the seat belt of the car does not fit the child properly, it can actually do more harm than good in a collision.
6. In the front-facing position, the harness should be adjusted so that the straps are located at or above the child's shoulders. Note that this is different from the rear-facing guideline!
7. Typically, a child has outgrown a front-facing car seat by height when the child's ears are in line with the top of the seat, or when the child's shoulders are higher than the highest harness-height setting. Check your particular car seat's information, usually printed on the side of the seat itself, for the upper weight limit for your particular seat.
8. Your child is buckled into the car seat properly when:
1. The harness is securely clipped into the crotch buckle AND
2. The chest clip is closed and aligned with the child's armpits AND
3. The straps are tightened so that there you cannot pinch the strap at the child's shoulder and maintain a fold in the strap. That is, the harness does need to be quite tight, but it should not cause the child to be pushed into an unnatural position or to be unduly uncomfortable.
9. A car seat is good only for six years after its manufacture date. After that expiration date, you should dispose of the car seat and replace it. 
10. You should immediately replace a car seat if it has been involved in a traffic accident even if your child was not in it and even if there is no visible damage. Your car insurance should cover the replacement of the car seat.

As for installation, every car sold in the United States after model year 2002 is required to be equipped with LATCH hooks in the back seats, and every car seat on the market is equipped with LATCH connectors. It is equally safe to install a car seat with either LATCH or the vehicle's seat belt (if done properly), but do not use both simultaneously. A car seat is installed snugly when you cannot shift it horizontally more than 1" in either direction while grasping the car seat at the belt path. There should be an illustration of this in your manual.

There's tons more to say, but this isn't meant to be comprehensive. If you had your car seat professionally installed and/or checked, then you just need to be sure you are buckling your child in correctly. If you didn't, you may want to find out where and when you can have your installation checked by a qualified person. Depending on where you live, this (free) service may be available at a local fire station, police station, Highway Patrol station, or hospital.

Please feel free to ask me questions about this one. As I mentioned, there's a lot more I could say, but I was hoping to keep this brief...ish.

Doctor's Appointment and Uterine Rupture Information

My health insurance is with Kaiser Permanente. This means I don't get a lot of say in who provides my medical care. So while I might be able to tell those of you out there with other insurance plans to research your care providers and choose one whose philosophy and practice fits with your desires and goals, I personally have little opportunity to exercise this luxury. I am given the choice to see the same provider for each appointment, and I am asked if I have a preference of provider, but they are all within the one medical office nearest me, and they all operate under Kaiser Permanente's standards and policies, of course.

My prenatal care is provided largely by a Certified Nurse Midwife* (CNM), but because I am a VBAC candidate, I also see an MD once in a while. I really like the CNM I've been seeing. I feel she is very much pro-VBAC and in tune with my desires. I also feel that she understands and respects that I do have a lot of knowledge and doesn't talk down to me. She also appreciates my sense of humor (this is very important to me - that I feel I've connected on a personal level to my care provider). She also seems to be perfectly willing to spend as much time with me as I feel I need, doesn't seem rushed, and answers my questions thoroughly. All-in-all, I'm very happy to see her repeatedly for my care.

*A Certified Nurse Midwife is a registered nurse who has taken advanced training in obstetrical and gynecological care. She is qualified to oversee pre- and postnatal care and provide primary care during labor and delivery, as well as provide general GYN care.

When it came time to see an MD so I could be informed of the risks and benefits of VBAC and sign a consent form, I was asked if I had a preference for which MD to see within the facility. I actually did, but I couldn't remember his name. Oops. I had seen one doctor near the end of my previous pregnancy who was very pro-VBAC and whose personality I liked. I wanted to see him again, but I couldn't remember his name. Curse my lack of memory for detail! Hehe. Anyway, I said to the receptionist that I had seen a doctor before that I'd liked. She looked at my chart and saw a doctor I had seen early in this pregnancy, told me his name, and asked if I'd like to see him. I didn't think he was the one I meant, but I rememberd also liking him well enough, so I agreed to see that doctor. (Now I've jogged my own memory and remember the other doctor's name, so if I need to see an MD later on, I'll request him.)

I don't mean to disparage this doctor, by the way. He is very good at what he does and has been in practice for a long time. But my visit with him was strange. He did the usual prenatal things, listening to the heartbeat with the Doppler, measuring fundal height, asking if I had any questions. He also went over my ultrasound results, which were all reassuringly normal. (I'm having another boy, by the way! I think I forgot to mention that...)

Anyway, then he went into the VBAC portion of the appointment. He asked the reason for my previous cesarean and noted that I had already had one successful VBAC. He said that in about 1 in 200 vaginal birth after cesarean attempts, the uterus may rupture during labor. "This can cause the baby and the mother to die!" He hastened to add, "Of course, you could walk out into the street and be hit by a car, too!" Right. "Oh, but you've had a vaginal birth already. That improves your chances of having another." Ah, thanks. He also added that a c-section has higher risk for the mother, but a vaginal birth has higher risk for the baby. This didn't sound right to me, but I didn't press him. I was in that weird place where I felt like I knew more about it than he did, which is not a feeling you want from your doctor.

The vibe I got from him was "noncommittal," if that makes any sense. It was like, he didn't really care one way or another if I had a c-section or a vaginal birth. On the one hand, that's nice. I get to choose. On the other hand, if I was on the fence, putting the words "baby and mother can die" in the same sentence as "labor" would make me lean heavily toward c-section. Which leads me to believe that he favors the repeat c-section. It's hard to tell. I do know that Kaiser in general does seem to support and encourage VBAC**, so he may be torn between his own medical opinion and the policies of his employer.

**Of course they do. The interesting thing about Kaiser is that they are insurance company and medical care provider in one, so they would like to take the cheapest route whenever possible. A successful vaginal birth, especially one without interventions, costs considerably less than a c-section. So, once VBAC was determined to be both safe and inexpensive, it made sense for Kaiser to jump in with both feet. I'm not unhappy about this. Just realistic.

Anyway, what the doctor said bugged me enough that I went and did some research of my own on uterine rupture. His statistic was essentially correct. In about 0.5 to 0.9% of trials of labor after cesarean (VBAC attempts), the uterus does rupture at the site of the previous scar. I won't lie. This can be very dangerous and often at least results in fetal death, if not maternal death as well due to severe internal bleeding. However, if you are in a facility where the rupture can be detected and you can be taken to an OR immediately, there is a good chance that an emergency c-section will save both you and your baby. According to an excellent article I found, there is approximately a 10 to 37-minute window in which emergency intervention must take place.

The trouble with uterine rupture is that the early signs and symptoms are quite vague, usually first indicated by an abrupt deceleration of the fetal heart rate. A later sign is a feeling the mother has of intense pain and then a feeling of ripping or something "giving way" within her. At that point, she must be immediately rushed to the OR.

The statistics quoted in the study were very interesting. First of all, it is extremely rare, but possible, for a uterine rupture to occur even if there is no prior uterine scarring from previous c-section(s) or other uterine surgery. The primary risk factor for this is five or more previous pregnancies. Again, I stress, this is extremely rare.

There are other factors that can lead to uterine rupture, the primary one being poor health or lack of prenatal care and labor support. Uterine rupture is much more common in underdeveloped countries.

The most interesting bit of information was that the risk of uterine rupture is much lower if you have had a previous vaginal birth, either before or after the cesarean section. A successful vaginal birth prior to the c-section increases your chances of a successful VBAC considerably, and considerably lowers your risk of uterine rupture. A previous successful VBAC also considerably lowers your risk of uterine rupture, from approximately 0.5% (that's 1 in 200) to 0.45%. I know that doesn't look like a big difference, but it's interesting. The authors of the article referenced here surmise that, "a successful prior VBAC attempt assures that (1) the maternal pelvis is tested and that the bony pelvis is adequate to permit passage of the fetus and (2) the integrity of the uterine scar has been tested previously under the stress/strain conditions during labor and delivery that were adequate to result in vaginal delivery without prior uterine rupture."

A successful vaginal birth prior to the c-section reduces risk of uterine rupture during subsequent VBAC attempt to just 0.2%!

However, induction of labor after a previous c-section increases the risk of uterine rupture rather noticeably, to anywhere from 1.4% to 4.0%, depending on the study referenced. If I had known this prior to my Pitocin-induced VBAC, I might not have done it. Since it worked out for me, it apparently was the right choice, though. I suspect there is a difference in this case for women who have previously undergone labor (even if it ended in c-section) than for those who have not. That is just my opinion, based on what I've read. There also might be such a range depending on the length of the labor and the amount of medication needed to start and sustain labor.

The risk of rupture is also increased with each additional prior cesarean section, which is why after more than two previous cesareans, most care providers will recommend a scheduled repeat c-section over a VBAC attempt.

Also note that, in general, the risks to mother and baby associated with a repeat cesarean section during a trial of labor (an emergency c-section) are higher than the risks associated with a scheduled repeat c-section.

You all know by now that I am obviously very pro-VBAC, but it is important to know your risks. I want to point out that for almost anyone who has one previous c-section, whether you have had a prior vaginal birth or not, your risk of uterine rupture during a trial of labor are about 0.5%. For comparison, the risk of developing a post-operative infection after a c-section is approximately 3 to 5%!

So, despite my doctor's frightening statements about uterine rupture and getting hit by a car, I am fully confident that a repeat VBAC is the right choice in my case. I believe that my nearly-complete labor followed by a subsequent successful vaginal delivery have proven my body's ability to start and sustain labor and that my pelvis is plenty wide enough for a baby to come through.

If you have questions, I'll try to field them, but I'm no expert. I just used Google like the rest of you. :)

Vaginal Birth After Cesarean (VBAC)

Having discussed cesarean sections in some detail, we come to a topic very close to my heart. C-sections have become common enough (30% of all births in the United States), that it is not at all shocking to meet a mother who has had at least one c-section. Indeed, c-section is so high in the consciousness of many of us who have given birth, especially those of us who have had c-sections, that it is sometimes hard to believe there are women who have not gone through it. A couple of months ago, I was telling a friend of mine about attending another friend's birth and how exciting it had been. She asked, "Oh, did she get her VBAC?!" In fact, both of her births had been vaginal, but because this friend I was speaking with had had a c-section, and I had had a c-section, and several other of our friends had had c-sections, she had forgotten that this particular woman had not!

Because most of the women I know who have had c-sections had not planned or wanted to give birth in that fashion, VBAC is also very high in our consciousness. For my friends with one child (so far), whose long labors or other circumstances led to unplanned, emergency, or unwanted-but-scheduled c-sections, my "achievement" of a successful VBAC is something I'm very happy to talk to them about and that I am often asked about. This post, then, is not so much about numbers and stats, although I will put some for everyone's own edification. This post is about why I wanted a vaginal birth and how that can still happen even if you've had a c-section (or two!) in the past.

I hope this is post is informational, emotional, and meaningful, and I hope that if you are on the fence about whether to consider or attempt a VBAC, this post helps you decide.

Let's start with some basics. In almost all cases (except for those in which c-section is necessary to save the life of mother and/or baby), vaginal birth is safer than c-section for both mother and baby. I listed some of the risks of cesarean section in the previous post. Certainly, there are risks associated with vaginal birth, as well, but these are typically less severe or less common than any of the complications or risks associated with cesarean birth.

Additionally, the recovery from a vaginal birth is generally considerably shorter, easier, and less painful than recovery from a c-section. Most women are up and about after just a few days following a vaginal birth. The typical hospital stay is 24 to 48 hours following a vaginal birth, compared to 72 to 96 hours following a c-section. Yes, there may be pain from vaginal or perineal tears or episiotomy upon sitting or using the bathroom. The abdominal area may be tender. There may be painful uterine cramping (as there would be following a c-section anyway). But because you have not experienced major surgery from which your body is attempting to recover, you will likely be surprised at the ease with which you are able to recover from the vaginal birth as compared with the c-section.

In July 2010, the American Congress of Obstetricians and Gynecologists (ACOG) issued a practice bulletin stating a desire for less restrictive guidelines for VBAC. VBAC is considered safer than cesarean delivery in most cases for women with one or two previous cesarean births. ACOG recommends allowing women a Trial of Labor after Cesarean (TOLAC) in most cases, if desired.

The most common risk cited in argument against VBAC is the possibility of uterine rupture, in which the uterine wall opens up during labor. This can be, but is not always, a catastrophic emergency, sometimes resulting in emergency hysterectomy. However, uterine rupture does not always lead to hysterectomy or even future infertility, although it does require emergency intervention in the OR. Most importantly, the chance of uterine rupture is less than 1% of all VBACs! Most major risks associated with repeat cesarean are statistically higher than the risk of uterine rupture during a trial of labor.

I mentioned in my previous post that I am most concerned with the non-medical risks of cesarean section delivery. These are mostly the emotional consequences of not experiencing the desired birth scenario. Many women feel that their bodies have failed them, or that they have missed out on something very special. These feelings can lead to postpartum depression and/or delayed bonding with the new baby. In addition, depending on the environment in which the c-section is performed, there is often a delayed initiation of breastfeeding. Plus, the pain and long recovery time associated with c-section can interfere with breastfeeding as well, sometimes leading to formula supplementation and/or breastfeeding cessation. This, in turn, can lead to further emotional consequences for the mother and continue the disruption of the bonding process between mother and baby.

I know this because I went through it, and I have spoken with many other women who have experienced these same feelings. (That's not to say every woman who has a c-section feels this way, or that every woman who has had a c-section has any difficulties with breastfeeding, or that any woman that does not breastfeed or stops breastfeeding experiences these feelings of betrayal, failure, guilt, or anger.)

I think it's pretty obvious, then, why a woman who has experienced an unwanted c-section would want to attempt a VBAC should she decide to have another baby. Having a VBAC can be incredibly healing. It's a way of saying, "Yes, my body can do this."

Approximately 60 to 80% of attempted VBACs result in a vaginal birth. This means your "odds" of success are quite good.

You are a good candidate for VBAC if:

• You have had one or two previous cesarean deliveries using a low transverse (bikini) incision. If you are not sure what kind of incision you had, you should ask your doctor. The vast majority of c-sections performed these days utilize a low transverse incision.
• You have a healthy pregnancy.
• You do not have any conditions that would render vaginal birth unsafe, such as placenta previa, placental abruption, prolapsed cord, breech baby.

In other words, you are a good candidate for VBAC if you would be a good candidate for vaginal birth anyway. The only real difference is that it is more risky to attempt a VBAC if induction is necessary due to an emergency situation such as preeclampsia. These risks would have to be discussed with your care provider.

You may hear that delivering a second (or third) child is easier than the first. This is generally true if you have labored in the past or experienced a previous vaginal delivery. If your c-section was scheduled before you went into labor, and you have never experienced labor and cervical dilation, then you should expect your trial of labor to be like a "first birth". If you have been through labor, and especially if you dilated fully or at least past 6cm, your trial of labor will likely be faster and easier than your first labor.

For example, in my case, I had labored for more than 24 hours, reached full dilation, and had pushed for two hours before the c-section was performed. Thus, my second labor, my VBAC, went very quickly and smoothly, as I had been through an almost complete labor process in the past. If I had not had that previous labor, it is entirely possible that the induction attempt would have failed and I would have had a second c-section. I say this only to make it clear that every case is different, and you will have to discuss with your care provider any concerns you have about your particular experience. (I don't say doctor, because you may decide to deliver with a midwife, or at home or at a birth center, rather than in a hospital setting.)

The ways to increase your chances of a successful VBAC are essentially the same as those that would be more likely to ensure a successful and healthy vaginal birth in any case. First, choose a care provider who is VBAC-friendly, natural-birth friendly, and will listen to your desires. You can usually find such a person by talking with friends who have had VBACs, attending an ICAN meeting, and doing your own research. Then, during labor, avoid medical interventions as much as possible. Go for as "natural" a birth as you can. Stay mobile. Change positions. Don't be tied to the "flat-on-your-back-with-your-legs-in-the-air" birthing position. You can give birth squatting, on hands and knees, sitting on the toilet (yes, I know someone who did this...twice), reclining, or any way that feels comfortable.

As a final thought, since this has been on my mind recently, what with my upcoming second VBAC attempt (I'm due in September), if your trial of labor does result in a repeat cesarean section, it may be very hard to process. I can't speak to those feelings, and I won't pretend to try. But I know a few women who have not been able to deliver vaginally despite one or more VBAC attempts, and I know it can be devastating. I think it can be helpful to make the operating room environment as comfortable as possible, to insist on holding your newborn absolutely as soon as possible after delivery, to initiate breastfeeding within that ever-so-important first hour, and to know that you selected a care provider with your best interests, and the best interests of your baby, at heart.

Finally, ICAN - the International Cesarean Awareness Network - is an excellent informational and supportive group for women who have experienced (or wish to avoid) a c-section, who are interested in VBAC, or who need help healing emotionally and physically after an unwanted cesarean. I urge you to find a local chapter if you are considering VBAC. The support of women who know exactly what you've been through is invaluable.

C-Sections

It's hard to start a discussion about VBAC (vaginal birth after cesarean) until we've established what a cesarean section is and what it's for. So this post will be about c-sections specifically, and the next post will be about VBAC. This is a series of posts that are more "clinical" in nature than personal, but it's all from my own perspective, having been through both scenarios.

I'm not here to tell you that you shouldn't have a cesarean section, or that if you had one by choice, you did something wrong, or that if you had one that wasn't by choice, that you were in some way wronged. I'm not here to tell you that there is never a need for a c-section, or that all c-sections are bad, or that I wish c-sections never had to happen.

Indeed, thank G-d we have the medical knowledge to perform a c-section when necessary, because a necessary c-section is a routine, reasonably safe alternative to vaginal birth that can save the lives of both mother and child.

I do, however, believe that c-section is an overused procedure. A c-section is a sometimes-necessary abdominal surgery which requires the doctor to cut through layers of skin, fat, and muscle, rearrange internal organs, cut through the huge muscle that is the uterus, pull the baby out, and then close it all back up. It isn't a simple procedure like the removal of an ingrown toenail or unwanted mole. Major abdominal surgery carries risks to both mother and baby. The most common risk to the mother is post-surgical infection. Other risks for the mother include severe blood loss, reaction to anesthesia, and blood clots. Risks to the baby include lung or breathing problems and birth injury (such as being cut by the scalpel). Risks to the baby of a planned (scheduled) cesarean, as opposed to one that occurs during labor, also include premature delivery, which can carry many complications of its own. It should be noted that a planned cesarean does appear carry fewer risks to the mother than an emergency c-section.

There are also long-term risks of c-section, or multiple c-sections. These include increased risk of future placenta previa (where the placenta is blocking the cervix), future placenta accreta (where the placenta is too deeply attached in the uterine wall), uterine rupture, and risk of future emergency hysterectomy during birth. These risks increase exponentially with each additional c-section.

What Is A Cesarean Section?


A cesarean section is a surgery used to deliver a baby. Rather than a typical birth, during which the baby is pushed through the cervix and vaginal canal in order to leave the mother's body, in a cesarean section, a surgeon cuts through the mother's abdominal wall and into the uterus and removes the baby through this incision, then repairs the incision with sutures.

Here is an excellent photo essay with explanations showing a typical cesarean delivery. (Slightly graphic, although photos are small. If blood or depictions of surgeries disturb you, I don't recommend clicking.)

Basically, the surgeon cuts through the abdomen with a scalpel, makes an incision in the uterine wall, retracts (pulls back) the sides of the incision, suctions out the amniotic fluid, disengages the baby from the pelvis (if necessary), and delivers the baby head-first through the incision. When the head is out, the fluids are suctioned from the baby's mouth and nose to clear the lungs and airway, then the rest of the body is pulled free of the incision, the umbilical cord is cut, the baby is (usually) shown to the mother, then taken to the warmer to be cleaned and examined. The placenta is removed and examined to ensure it is intact. Then the uterus is sutured and the abdominal incision is closed up. The entire procedure typically takes about 45 to 60 minutes, with the first 5 to 10 minutes being delivery of the baby.

Depending on the practices of your particular doctor and hospital, it may be possible to hold your newborn on your chest during the second phase of the surgery, and even breastfeed him or her if desired. This would have to be discussed with the doctor prior to surgery.

When Is A C-Section Necessary?


**This is not a comprehensive list, just a sampling of instances when cesarean section is indicated.**

There are instances when a c-section is medically necessary. In such cases, it is determined that a vaginal delivery carries too much risk to mother and/or baby, and a c-section is a safer way to deliver the baby.

• Placenta previa. This is when the placenta is blocking the cervix. Attempting to deliver vaginally under such a circumstance would cause severe maternal blood loss, often leading to maternal death.
• Prolapsed cord. This is when the umbilical cord precedes the baby through the birth canal.
• Fetal or maternal danger which requires immediate delivery of the baby when induction of labor fails or would be too dangerous. An example of this would be preeclampsia or eclampsia, which is a dangerous rise in maternal blood pressure that can cause seizures or stroke. Eclampsia is often fatal to the mother. If maternal blood pressure fails to come into a safe range within a reasonable amount of time, delivery of the baby immediately is indicated, as delivery of the baby is the only "cure" for preeclampsia/eclampsia. Medical induction may be attempted, but if it fails, cesarean delivery is necessary to protect both mother and baby.
• True fetal distress during labor.
• Abrupted placenta. This is when the placenta detatches from the uterine wall before delivery of the fetus.

Thus, there are times when a cesarean section is absolutely needed, clearly saves the life of mother and/or baby, and we can be grateful that such a relatively safe method of delivery exists when vaginal birth is not possible or indicated.

Why So Many C-Sections?

However, the rate of cesarean section in the United States now exceeds 30% of all births. It's hard to fathom that almost one-third of all pregnancies and births result in a life-or-death situation such as one listed above. If that were the case, we would be seeing mothers and babies in mortal danger during childbirth far more often than we do. Indeed, the maternal and neonatal mortality rates in this country are reasonably low. What are some reasons for cesarean section that may not be medically necessary? (In some of the following examples, the end result of c-section may actually have been necessary. However, they are not emergency situations, and usually there are or would have been ways to avoid c-section in these cases.)

• Maternal preference. Some women just don't want to go through labor, so they request to schedule a c-section. This enables them (and their doctors) to know exactly when and how the baby will be born.
• Previous c-section. Many doctors and hospitals do not allow VBAC, so a woman giving birth through a particular care provider may not be offered the option of VBAC. In such a case, she will be advised to schedule a c-section. Alternatively, a woman may feel that the risks of VBAC are not ones she is willing to face and so elects a c-section. Or, perhaps the difficult or traumatic labor which resulted in the previous c-section makes her unwilling to attempt labor again, and planned c-section seems to be a more palatable option for her. Finally, depending on the reason for her previous c-section, she and her doctor may feel that any future labor would also result in c-section, so rather than take the risk of needing an emergency c-section, or of going through labor only to result in a second c-section anyway, she elects a planned c-section. In addition, if a woman has had three or more previous cesarean births, VBAC is considered too risky. Also, VBAC is not considered safe if the previous c-section incision is not the "low transverse" or "bikini" incision.
• Breech presentation. Breech presentation is when the baby is not head down at the end of the pregnancy or when the mother goes into labor. The preferred way to deliver a baby vaginally is head-first. Some babies do not turn around near the end of the pregnancy and present feet-first or buttocks-first at or near the onset of labor. Most OB/GYNs in the United States prefer not to attempt a vaginal delivery of a breech baby, and so they will recommend a scheduled c-section in order to ensure safe delivery of the baby. There are variations of breech presentation that would make vaginal delivery impossible or very dangerous to mother and/or baby, in which case, of course, a c-section is indicated.
• Prolonged labor. Some women may labor for many hours or days. Sometimes this is because labor is not progressing as it should, the cervix is not dilating properly, or despite hours of pushing, the baby does not come down into and through the cervix even after full dilation. These cases are usually labeled "failure to progress," and the doctor or midwife may suggest a c-section to deliver the baby and relieve the mother. It is difficult to know from case-to-case whether a c-section was necessary, because it depends on the reason that labor is not progressing. However, often the mother, doctor, midwife, or other birth attendant can make changes that may help move labor along. I won't get into a long list here, but "failure to progress" is a vague term, and in order to determine whether c-section was medically necessary, one needs to know the reason for the stalled or prolonged labor.
• Twins. It is possible to deliver twins vaginally, although most OB/GYNs and hospitals prefer to deliver twins via c-section. There are additional risks during vaginal delivery of twins that simply do not exist in the delivery of a single baby, so these risks need to be discussed with your doctor.
• Large baby. Sometimes it is estimated that a baby is simply very large and the mother will have a very difficult time delivering him or her vaginally. This is not to say that a vaginal birth is definitely impossible with a large baby (plenty of women have delivered 10+-pound babies vaginally). However, if it looks like your baby is headed into the 10-pound or more range, your doctor may bring up the possibility or probability of scheduling a c-section.

Disclaimer

I really want to stress that neither the first list, of universally indicated reasons for c-section, or the second list, c-sections that may not have been necessary, is comprehensive. Depending on your situation, you should discuss with your doctor or midwife your birth preferences and particular conditions before determining whether you should have a c-section. Obviously, during labor, especially during an emergency in labor, there isn't time for much discussion, so it is important to be fully informed of the risks and benefits of c-section in various cases before delivering your baby or going into labor.

Non-Medical Risks Of C-Section

C-section, especially unplanned or unwanted c-section, can result in feelings of failure on the part of the mother, i.e., Why couldn't I deliver naturally? Why did my body fail me? Why couldn't I make a perfect pregnancy? This can lead to postpartum depression and delayed bonding with the baby. C-section, depending on the environment or circumstances in which it was performed, can also delay initiation of breast-feeding, which carries its own set of risks for mother and baby.

In this blog, I am more concerned with the non-medical risks of c-section, although I do think it's important to know that, even though c-section is a routine medical procedure that is relatively safe, it is still major surgery that carries risks to both mother and baby that do not exist (or exist at a much lower rate) during a traditional vaginal birth.

Elective C-Section 

I want to expand on elective c-sections for a moment before signing off for tonight. Many women choose to schedule a c-section near their due dates despite having no medical reason to consider c-section. Perhaps they simply do not want to experience labor, or they want control over when their baby will be born. For many women who choose this route, they are very satisfied with the outcome, do not harbor negative feelings toward their chosen method of birth, and both mother and baby recover well and quickly.

My only concern in such cases is that c-section is, as described above, major abdominal surgery that does carry risk. If we look at c-section as elective surgery, we can discuss it in similar terms to something like gastric bypass. In most cases, or nearly all cases, gastric bypass is a "last resort" attempt to control obesity and its associated health problems. Typically, a person is not a candidate for gastric bypass unless all other weight control options have been eliminated and the person's health is in danger from obesity-related complications such as hypertension, diabetes, arthritis, etc. Gastric bypass carries risks that need to be weighed against the benefits of performing the surgery, and against the risks of not performing the surgery. Certainly, gastric bypass has helped many individuals lose weight and improve their quality of life and is a viable option when risks and benefits have been appropriately discussed.

I feel that c-section should be considered in the same way. It is a life-saving surgery that has helped many women and babies survive relatively unscathed a birth scenario that without c-section may have ended in tragedy. However, like any other surgery, c-section involves risks that must be weighed against (a) the benefits of having a c-section, and (b) the risks of attempting a vaginal birth. If both mother and doctor approach the topic of c-section in this way, a more productive discussion of birth options will result.

Me, The Doula?

A friend of mine, RM, gave birth back in March to a beautiful baby boy, her second. She asked me to attend the birth as her birth coach/doula, despite my rather significant lack of actual experience or training in such a role. I'm not sure having given birth twice really qualifies me as a "doula," per se. But I was honored and touched that she trusted me to be there and help her through it, and now, having done it, I am so glad I agreed!

I admit to having been quite hesitant at first. Would I know what to do? Would I be comfortable seeing, er, "those parts" of my friend? Would she be comfortable with me there? Would I be unfortunately affected by any blood or fluids? And, what was I supposed to do?

We had watched "The Business of Being Born" together, in addition to other reading we had done, and we were both very well aware of how easily the natural birth process can be derailed by accepting or being offered interventions at all, or too soon, or unnecessarily. We were both very conscious of what was called in the documentary "the cascade of interventions." This is the vicious cycle of intervention-leading-to-intervention that usually begins innocuously enough with, "Would you like pain relief?" or "Would you like the epidural now?" For many women, they get the epidural, they're happy, the baby comes out at some point later, and everything is fine. But for a significant percentage of women, it's not quite so smooth a road. For many, the epidural can cause a sharp drop in blood pressure in the mother, which can lead to fetal distress. Alternatively, the epidural can slow labor, which can cause the labor process to be labeled "failure to progress," which can prompt the doctor to order Pitocin to "move things along." I've discussed the dangers of Pitocin briefly before, but, as a reminder, the use of Pitocin can sometimes lead to otherwise unncessary c-sections due to fetal distress, usually signified by a sudden sharp drop in the fetal heart rate, not to mention other stress on the mother and baby because of the strong contractions produced by the Pitocin.

Back to the birth I was actually attending, though. Once there, over the next few hours, I relaxed and fell into my role. RM's husband and mother-in-law were there with her at first, and I felt like kind of a third wheel. Fourth? Anyway. The nurse came in to let RM know that she could have pain relief whenever she liked. She was dilated somewhere between 3 and 4cm. She wasn't sure it was quite time for the epidural yet, and she also wasn't sure about other pain relief options, such as Stadol. She didn't want to risk slowing or stalling labor, and she also didn't want to risk a sleepy or lethargic baby if he came too soon after administration of drugs. She also wasn't convinced that the narcotics would help her at all. She was definitely uncomfortable, though.

The nurse mentioned that the anesthesiologist was about to go attend a c-section, and he wouldn't be available for about an hour if she declined the epidural just then. She finally decided, after some discussion with me and her mother-in-law (who is a nurse), to accept a dose of Stadol, which should make her more comfortable for the hour during which the anesthesiologist would be unavailable, after which time she could think about the epidural again.

The Stadol worked perfectly, and she was quite content (and a little high) for about an hour. Her contractions continued at a steady pace, and her mother-in-law and I chatted while her husband dozed. Finally, my friend started to come out of the drug-haze, and the nurse came back to check on her. She had been comfortable, and the contractions were manageable, so she decided to continue to hold off on the epidural, but she also declined another dose of narcotics.

Over the next several hours, labor seemed to come almost to a halt. The contractions weren't getting stronger or closer together. She wasn't really dilating at all. It was somewhere around 11:00 P.M. Her husband was sleeping. Her mother-in-law had gone back to RM's house to be with her older son (and relieve the nanny), and it was just the two of us to talk over her decisions. I'm pretty sure that's how she wanted it.

The nurse came in to offer to remove the fetal monitors for a while so that we could take a walk to help move things along. She said she could keep the monitors off for 40 minutes, then have them on for 20, then off again, if she wanted. This is called "intermittent monitoring," and in my research and reading, I had learned that typically you have to demand intermittent monitoring, since they prefer to keep you on the monitors at all times so they can keep an "eye" on the baby. I was very impressed that the nurse actually offered intermittent monitoring! I strongly felt RM should get up and walk around, for her own sake as well as for the sake of helping labor along. We walked the halls and talked, mostly about birth and breastfeeding, for about 40 minutes. During that time, she had to stop several times for contractions, but when we got back to her room, she said she felt really good. She was put back on the monitors, where we saw that her contractions were still fairly far apart and not very powerful. This was unsettling. After almost four hours of labor, it seemed like something should be happening, especially since this wasn't her first baby.

She rested for a bit, then decided to try walking again. This time, she didn't experience a strong contraction for the entire 40 minutes, and when we returned to her room, she was tired and worried. So was I. I guess I can selfishly mention about here that I was already noticeably pregnant, and it was late, and I was also quite tired, although I can't say I was as tired as she, since I, thankfully, was not in labor!

The nurse came in to check on her and said that the doctor planned to come in around 6:00 in the morning to break her water if that hadn't happened by that time. It sounded far off, 6:00 did, and it seemed like surely she should already have had the baby by then, if things continued as expected. Except. Except labor wasn't...labor. In fact, she was barely feeling anything, except tired.

The nurse at some point said that RM did have options. She could just go home if she wanted, and wait, and see if labor eventually picked up on its own. She wasn't obligated to stay there. She didn't have to accept any interventions. I was actually kind of amazed by this, too, since most hospitals just want you in and out, baby in arms, within a reasonable amount of time. And it wasn't like she wouldn't eventually have this baby! RM felt very strongly, however, that she couldn't go home still pregnant, and that she couldn't be pregnant another day. She was already past her due date, and she was very uncomfortable, and she intended to have this baby that day. I completely understood!

I went to lie down for a few minutes while she rested, then wandered back over because I was bored and couldn't sleep. We talked and watched the discouraging monitors. She didn't feel like walking anymore. Suddenly, I noticed that the baby's heart rate, which had been between the 120s and 140s, suddenly dipped into the 60s. At first, I thought it just meant the monitor had shifted and lost the heartbeat, but then three nurses charged in, and I realized it was a real emergency. It appeared the baby was putting pressure on his umbilical cord and causing himself distress. I got out of the way while they gave RM oxygen through a mask and had her shift positions, finally ending up on her hands and knees on the bed, to try to take the pressure off the cord. His heart rate stabilized pretty quickly, the crisis was averted, and they helped her back into a more comfortable position. They asked her to keep the oxygen going for a while to make sure the baby was getting enough.

The nurse went to report to the doctor, then came back to say that the doctor was aware of the "spontaneous deceleration." She said that if it happened again and they couldn't get him stabilized, it might mean she would need an emergency c-section. The nurse suggested that it might be a good idea to have the epidural, just in case, because that way they wouldn't have to knock her out completely if a c-section became necessary. The anesthesiologist was just outside, not busy with anyone else, and he could come in right away. It would also give RM the opportunity to sleep, or at least rest, more comfortably.

RM was rightly worried about the use of an epidural when labor was already moving so slowly, but she was impressed with the nurse's making a strong suggestion, when before she had only said what was available. This time, RM decided to take the epidural, just in case. It was also only a few hours until 6:00, and she felt that if the doctor were going to have to break her water and possibly administer Pitocin to get the contractions moving again, she may as well already have the epidural. I was leery, mostly because I was concerned that if there was another emergency, she wouldn't be as mobile, so how could she get up on her hands and knees or whatever if that became necessary? But she opted for it, and I didn't think it was really a terrible idea, and I had a pretty good sense of how much I didn't know by this point, so I got out of the way while the anesthesiologist did his excellent work, and RM was able to relax.

As the nurse had feared, there was a second spontaneous deceleration, but the epidural wasn't so strong that she couldn't feel her legs, and they were again able to get RM up on her hands and knees, the baby recovered, and no further interventions were necessary.

6:00 came and went, and the nurse came back to say that the doctor was on the L&D floor, but another of his patients was ready to deliver, so he was going to attend that birth first, then come back to break RM's water and see if anything else was needed. He came back a little after 7:00. Her water broke, and the fluid was clear (i.e., no meconium, meaning the baby had not had a bowel movement in utero, which can be dangerous), but contractions did not pick up. He strongly suggested that she have a small dose of Pitocin. His words were, "I'm trying to save you a cesarean here." Now, with most doctors, that would not have impressed me. Indeed, it would have almost seemed counterintuitive to me. However, RM had researched this doctor, and he had been in practice for 40 years and had the lowest c-section rate in the county. In other words, he knows what he's doing. I felt strongly she should do it. Because she had given birth vaginally before, her body was prepared for a second vaginal delivery. Plus, labor was not moving along really, and once her water was broken, it was important that the baby be delivered relatively soon. It was worth trying the Pitocin, because if it worked, she'd have her baby soon, and she would avoid the c-section, which is the one thing she knew she absolutely did not want. She finally agreed to a small dose of Pitocin, just to help the contractions along.

Help them along it did! Just 10 minutes or so after the Pitocin was administered, she had dilated another centimeter, after hours and hours at 4cm. Not long after that, she started yelling, which she hadn't done before. She said the epidural wasn't strong enough, and OH MY GOD she wanted to push, and she was going to poop that baby out now! I realized she was in transition already, and it was a very different experience to be on the receiving end of that yelling, instead of the one doing the yelling! It's an amazing change to watch, from "whoa, contraction," to "HOLY CRAP!!!" I called the nurse in to give her a bolus of the epidural anesthetic, to try to help with the pain, at which point the nurse realized as well that RM was in transition. She begged her to wait until the doctor arrived before she started pushing. He was delivering another baby just then and would be there any time.

This is when everything got very exciting. The doctor arrived, RM's husband got into the mix, and I got to just step back and watch and offer an encouraging word when one came to mind. I also brought a damp paper towel for her husband to put on her forehead. Although I've forgotten a lot of the details of those last few hours of my first labor, I specifically remember my mom bringing me a cool towel for my forehead, and how good that felt. They broke down the bed to become a delivery table, and the doctor took up his post. He felt for the baby and said he was still pretty far up there, and it still might be a while, and he seemed to be a larger baby. In other words, she might be pushing for a while.

I could see RM's response on her face. "Oh no it won't be a while!" she thought, very emphatically, and when she was told to go ahead and push when she wanted to, she pushed. She PUSHED. She PUSHED. And, I'm not exaggerating at all, 10 minutes later, there was a head! TEN MINUTES. Now that's what I call pushing. A perfect body followed the head, and I couldn't believe how exciting it was to witness that. Everyone calls it a miracle, and there is absolutely no better word for it. You go from screaming straining woman to squalling baby just like that. There's just suddenly a baby there. It's the most incredible and exciting thing I've witnessed. I can't even describe it. I had an oxytocin rush! I was bursting with adrenaline! And I wasn't even doing anything, just standing there!

The baby was 7lbs., 2oz., a little smaller than her first (and not at all a "bigger" baby!). He was perfect and came out raring to go. RM became fixated on two things: Deliver the placenta, and give me the hell my baby so I can nurse him. Once she successfully delivered the placenta and that was done with, she watched impatiently from the bed as they did all the initial measurements and such over on the warming table. I stood by watching. I felt like I was on guard, standing beside him in his mother's place, making sure he was safe. The nurse offered RM food, water, whatever she wanted. "I just want to hold him," was her only response. "I just want my baby. I want to hold him." I was antsy, too, ready for her to have him back so she could get in that oh-so-important initial breastfeeding. I had also been drafted as her unofficial and unlicenced "lactation consultant," although I can hardly claim that title. I have no training, except for lots of reading and having nursed one baby.

After about 20 minutes, he was brought to her, clean and swaddled. The labor nurse promptly unswaddled him and together we helped her place him against her chest, skin-to-skin, so she could nurse him. I had forgotten how hard it is to hold a newborn to your breast. You need three or four hands. But she got him there, and he went to town. It was so beautiful.

I left about an hour later, still totally high on adrenaline, oxytocin, and a sleepless night, after getting a chance to hold him and getting a sneak peak at his name (which wouldn't be used publicly until his bris (ritual circumcision) the following weekend).

It was really enlightening for me to be at a birth but not giving birth. I was able to see some of the goings-on and listen more carefully to the "hospital speak," and I had the time and wherewithal to really consider every decision. Though none of the decisions would have affected me directly, RM is a very good friend, and I wanted her to have that satisfying and fulfilling birth experience that she deserved, that every woman deserves. Her first birth, though accomplished vaginally, had been quite traumatic for her, and I know she was nervous about her second being just as bad. I was so happy to see her so content once she had her son to her breast, and I knew things had worked out much better for her this time.

I was full of emotion for weeks after the experience. Just thinking about it could make me cry. I wrote her a note to thank her for the privilege of witnessing something so special, and she wrote back a very lovely note thanking me for being there. I knew I had helped somehow, even just by being moral support, butI also had felt quite helpless at times, because there was so much I didn't know, and there are so many things I wouldn't have known to do. I still don't. That's why a "real" doula has training, and attends lots of births. Because there's a lot to know, even if you're not the one actually supervising or devliering or doing anything medical.

Still, it's an experience I would repeat in a heartbeat, assuming I was physically in a position to do so. Right now, I think my own delivery has to be next on my agenda, and then it would be difficult to attend a birth when I had a newborn of my own. But one day, if another friend is having a baby and wants some support as she labors, and I'm available, I would be thrilled to participate again.

There's a specific Psalm that it is traditional to have beside a laboring woman's bed, to recite during labor, and to place in the newborn's bed. I'd like to transcribe a translation here, sort of as a concluding thought.

Psalm 121:
I lift my eyes to the mountains -- from where will my help come?
My help will come from the Lord, Maker of heaven and earth.
He will not let your foot falter; your guardian does not slumber.
Indeed, the Guardian of Israel neither slumbers nor sleeps.
The Lord is your guardian; the Lord is your protective shade at your right hand.
The sun will not harm you by day, nor the moon by night.
The Lord will guard you from all evil; He will guard your soul.
The Lord will guard your going and your coming from now and for all time.


(From the translation at http://www.chabad.org/library/article_cdo/aid/732833/jewish/Psalm-121.htm)

When We Know Better, We Do Better

I just learned this quote from Maya Angelou today, and thinking about it, among other things going on around me, prompts this post. It's also an apt title.

It's hard, sometimes, not to feel guilty about past choices we've made. To give an example totally removed from pregnancy, childbirth, or breastfeeding, I do transcriptions for a periodontist, among other people. He'll often mention in his letters that 20 years ago, or when his patient was younger, they had a particular dental therapy performed that we would never do today, as now we know it causes problems decades down the line; problems that my client, of course, tries to fix for the patient. To bring the point closer to this blog, doctors used to recommend that women smoke during pregnancy in order to reduce the size of their babies for easier delivery. We used to routinely give antibiotics for every ailment. We used to fire-proof using asbestos. Now we know better. Now we no longer do those things. "When we know better, we do better."

It's hard not to feel guilty for making choices in the past that we now know may have negatively affected our health or the health of our children, even if we didn't know better. This is especially true in childbirth and breastfeeding. Many, many babies in the 20th century never received a drop of breastmilk, because doctors and mothers were convinced that formula, because it was "scientific," surely had to be better than paltry breastmilk. Breastfeeding was for poor women who couldn't afford better, as was giving birth at home instead of at a hospital. Should our grandmothers feel guilty if they did not breastfeed our mothers? Should our mothers feel guilty if they did not breastfeed us?

Maybe "guilty" isn't the right word. Maybe a little guilt is all right, since guilt about a past error can be impetus not to repeat that error. But it should not be a stigma. I didn't "know better" when my first son was born. I followed the advice of the people I trusted - nurses and doctors. Maybe "we" as a society "knew better," but I didn't, so I didn't do the best thing I could. I did feel guilty about it for a long time. How could I have deprived my son and myself of something so precious?

But now I know better, so I do better. I did better, and will do more in the future.

My grandmother was 20 years old when my mother was born, back in 1953. My mother was born seven weeks premature. At that time, premature babies were routinely placed in pure-oxygen environments, as it was believed to help them breathe. It was found that this environment was not, in fact, healthy at all, and caused blindness and other problems for many preemies of the time. Thankfully, my mother was not given this particular treatment. When we know better, we do better. My grandmother wanted to breastfeed her daughter. She had no idea how, had no support from hospital staff, but she felt that it would be best for her baby. The doctors at the time said that surely what a preemie needed was specially developed formula, that breastfeeding her 4lbs-something baby could only be detrimental, and how could she be so crazy as to want to do that. So, bowing to the pressure of the wisdom of the 1950s, my grandmother acquiesced and gave her first daughter formula. My mother is a healthy grandmother herself, now. We don't know if she suffered ill effects from her precarious early days on this Earth. But we do know now that those doctors were wrong. A study released just two days ago by Johns Hopkins reconfirmed that the absolute best food for a premature infant is, shockingly, breastmilk, at least in the goal of preventing potentially fatal necrotizing enterocolitis (NEC).

When my mother's younger sister was born full term, 18 months later, my grandmother again wanted to breastfeed. Though my aunt was full term, she was quite small, barely 5 pounds, and, again, the hospital would not "let" my grandmother breastfeed her own daughter because of her size. She needed to put on weight, you see, and formula was the best thing for that!

Finally, 4.5 years after that, my mother's younger brother was born. I don't know if my grandmother even bothered to ask if she could breastfeed, or tried to breastfeed, after not being allowed to with her first two babies. My uncle, unfortunately, unlike his sisters, is not as healthy as they are. He has Crohn's disease. My grandfather told me that when my uncle was a baby, they tried formula after formula, but all of them caused him distress. My grandfather was a pharmacist, and "the Enfamil guy" promised to hook my grandparents up with the best of the best formula to be had in 1959. Still, this didn't work for my uncle, and he ended up being fed pure cow's milk before he was a year old, as that seemed to be the food he tolerated best. He is suffering from quite a few health problems now, most as a result of the Crohn's disease. I can't help but wonder, if he had been born in 2009 and "allowed" to breastfeed, would he suffer from such severe intestinal problems 40 years down the road? It will be interesting to one day see a study on whether breastfeeding in infancy reduces the risk of developing Crohn's or colitis in adulthood. (This is all speculation, of course!)

Should my grandmother feel guilty about not breastfeeding her daughters and son? Should she in some way feel that she "caused" her children's health problems, especially her son's? For that matter, should she feel guilty for smoking through all of her pregnancies (probably causing her babies to be premature and low-birth-weight, as we now know)? I'm not sure, frankly. I don't see what good it would do to feel guilty. She may have regrets. She may wonder, as I do, how things would have been different. But we can only move forward. We can only say, "Well, now we know that breastmilk is the best food for preemies. Now we know that breastmilk helps prevent intestinal diseases in babies. Now we know smoking during pregnancy can be harmful to the baby." We know better, so we do better.

And when we know better, we can educate the next generation. We can support them in making the best decision with the best information they have at hand. My grandmother fully supported her daughters in their desire to breastfeed their respective children. And she and my mother and aunt fully supported me in my desire to breastfeed my children. And I can send that information on forward to my future daughters or daughters-in-law (G-d willing!).

A friend of mine, in discussing our birth experiences, said that she does regret that she never got the home birth, all natural, water birth experience as she had planned. Instead, she ended up with four c-sections, although not by her initial choice. But, one day, when her daughters or daughters-in-law come to her and say that they want to have natural home waterbirths, of course she will be supportive of that, and will be by their sides if they want her there, and will weep with joy when her grandchildren are born the way their mother's want them to, the way, probably, nature intended.  We can regret. We can feel guilt. But we can use that regret and guilt to make the future better than our past.

Of course there's no sense in wallowing in what may have been. We can't change it. We simply can't. But we can start right now with doing better.