Tuesday, October 14, 2014

On My C-Section Birth Experience

     My son’s birth was not at all how I’d pictured it.  Early in my pregnancy, I had decided I wanted a natural childbirth experience, a home birth with a midwife.  I saw a midwifery group for all my prenatal visits, didn’t have all the now-usual ultrasounds and testing and interventions, and was on track to deliver my baby in the comfort and privacy of my own home.  Well, that didn’t happen.  I had some preterm contractions at 30, 35, and 37 weeks, but primarily the problem was that Xander never turned.  For those of you who may not know, babies are usually supposed to turn head down by 35 weeks or so, and certainly before birth in the vast majority of cases.  Xander was stuck head-up, with his feet up by his head, which is known as frank breech position.  Although there are some practitioners who will perform a vaginal breech delivery, my midwives are not among them, so at 36 weeks I was transferred to the care of an OB-GYN, and began planning to have a Caesarean section.  Meanwhile, I did nearly everything in my power to encourage the baby to turn, to no avail.  I am very grateful for my doctor, and was especially glad that he was as evidence-based in his practice and supportive of me as he was.  I wanted the baby to come in his own timing, so I wanted to schedule my C-section later rather than earlier, and we decided to schedule it for right when I turned 39 weeks.

     At 38 weeks and 2 days, or about two weeks before my original due date, I went into labor.  I had had the regular contractions before, but this time I knew if we waited a little, I would have cervical changes and it would be considered real labor.  I tracked my contractions for several hours on Sunday night, and then went to bed for a couple of hours.  By 3 am, they had gone from slightly uncomfortable to “oh wow these are legit contractions now!”  So, by 5 am we were at the hospital, ready to have our baby!  I was monitored, and given terbutaline (again) to stop my contractions to allow time for the OR team to arrive and set up.  Because the contractions were stronger (and more painful) than the other times I’d had it, it didn’t work 100%.  I wryly commented to my husband Andrew while we were in the labor evaluation room how very far this scenario was from what I’d originally wanted.  I had envisioned laboring at home, in a peaceful and calm environment, with a midwife who checked on my status occasionally but mostly watched from a small distance.  Instead, I lay in a hospital bed, with monitors, an IV, and a catheter, at one point receiving oxygen by mask, waiting to be rolled into a surgical birth.  I knew it was necessary for my baby’s safety, but that didn’t mean I was thrilled to do it that way.

     In the OR, I received my spinal block and laid down.  I hadn’t realized how much sensation you retain with a spinal.  I could feel the scrubbing of the prep solution on my belly, and later the internal pressure as the surgical team delivered the baby, but no pain; it was very strange.  I was dizzy the whole time from the anesthesia, and unfortunately, I became nauseated right after Xander was born.  I had really wanted to start skin-to-skin time in the OR, to avoid even the delay until we got to the recovery room, and my doctor was very supportive of this idea.  When my son was born, they brought him over to me, and we started to do skin-to-skin, but I could only do it for a minute or two before my nausea became overwhelming.  At that point, my anesthesiologist gave me Benadryl (he had already given me the anti-nausea med Zofran), which pretty much knocked me out.
That was one of the main things I wish had been different about that day, because I felt like I missed out on the first bonding time.  I know that my husband and my son and I spent an hour in the recovery room, and I know we did skin-to-skin then and that my son probably benefited from it, but I felt like we were only there five minutes, because of how little I was aware of it at the time and what I remember of that time now.  I felt like I missed out on that first period of alertness that my son had after he was born.  I even asked my husband later if he had been alert, because I didn’t remember it at all.

     After that hour, I was rolled to my room on the floor, where both sets of new grandparents were waiting.  Throughout the course of the day, everyone in our immediate families and a couple of friends visited.  I’m grateful it worked out for everyone to be there; I know it meant a lot to them to meet Xander the first day.  Most of the day was a bit of a blur to me.  I continued to deal with dizziness and nausea, so I tried not to spend too much time with my eyes open or move my head too quickly, but I still got sick four times that day.  Looking back at photos from that day, I can’t get over how pale I looked.  By the evening, I was finally able to keep some liquids down, and keep my eyes open longer without excessive nausea.  After visiting hours ended, we had the first time alone as the three of us during which I was truly aware.  I think it was around that time that I felt like it began to sink in that our son had arrived.  All day long I had felt emotionally numb, and it had mostly seemed like I was holding someone else’s baby.  I think the nature of a C-section, as well as the drugs I’d received, facilitated this mental disconnect.  When I had time and mental energy to reflect on it, it struck me as so odd how I had walked into a room pregnant, and from behind a curtain came a baby, who was ours.     

     It never occurred to me before that a C-section birth could be such a different emotional experience than a vaginal birth.  In basically all the videos of birth and live births (both vaginal and C-sections) that I’d seen, there was a moment right after the baby’s arrival when the new mom met her baby for the first time – it was usually with tears of joy, exclamations of “our baby!” and always with an expression of a deep emotional response.  When I was planning a vaginal delivery, I so looked forward to that moment, and the pleasant rush of hormones that accompanies a natural birth.  Once we knew we were having a C-section, I knew I wouldn’t get that natural high from hormones, but I still expected that joyous time of realization that my baby had arrived.  I don’t think I ever had that moment.  Laying on the operating table, hearing my baby cry for the first time, I knew that was my baby crying, and I wanted to see him and hold him, but I was incredibly devoid of emotions at the same time.  It was like I wanted to have all the right emotional responses, but they just wouldn’t come.  I understood that a C-section would be a different physical experience, especially in terms of a longer and differently-challenging recovery, but I didn’t think it would be so vastly different emotionally.

     Thankfully, I had started to bond with Xander while he was inside me, and I was already determined to bond with him more and establish a breastfeeding relationship.  I do wonder how much more effort it might have taken to bond with him, though, had I not previously done so and decided to do so.

     Now, it’s been two and a half weeks since I was sent home from the hospital, and physically, I’m doing quite well.  For the first two weeks of Xander’s life, I felt like I had an unexpected amount of energy and was coping exceptionally well with sleep deprivation.  I don’t know if my body just reached its limit or if it was the other night when Xander’s sleep came in chunks less than two hours each, but that energy is gone.  Still, I’m able to do more than I expected to be able to at this point.  I walked up the stairs to our apartment by myself (without too much difficulty, even) the first day we got home, four days after his birth.  We made it to church on that first Sunday, just six days after the C-section.  I’m able to sit up pretty easily now, though I still use a bit of leverage (the crib next to our bed).  The pain from my incision and the surrounding area has been almost nil for awhile now.  Engorgement (when my milk came in) and the migraines I’ve been dealing with have both been much more problematic.  

     Actually, I knew ahead of time that migraines would be an issue for me postpartum, so I went out on a bit of a limb and encapsulated my placenta.  I had heard that the placenta has varied benefits such as helping with milk supply, moodiness, and other hormone-change related problems, and I’d hoped that taking the capsules would help prevent or lessen the migraines.  That has not seemed to be the case since I’ve had eight migraines in the two weeks since we’ve been home.  I haven’t had any problems with moodiness at all, though, and my milk supply has been great, so it’s possible they are still helpful.  Hopefully, the migraines will ease off over the next couple of weeks.

     In my next post, I plan to reflect on new motherhood.  For now, I’m off to try to catch some more sleep.

On Body Image & Pregnancy

     Today I want to touch on body image, our culture’s perceptions of ideal body shape, and the way these things change with pregnancy.  First, let me lay out some basic concepts about this sometimes sensitive subject.  There are and likely always will be various body types: naturally slender people (like me), and naturally curvier people, and people who will stay the same weight regardless of what they do, and people whose weight fluctuates and must be controlled.  Everyone has their natural body type and typical weight range, which may or may not be easily changed.  There is no such thing as ‘the perfect body’, only the ideal for that particular culture and time, and sometimes only the ideal to a particular person.  All people should be concerned about their health and fitness first and foremost, far above body shape or looks.

     This experience of being pregnant has been interesting in about a million ways, but one of the most fascinating things for me was how my body changed.  I loved taking biweekly “belly pictures” and often couldn’t help but stare at my changing body in the mirror.  It was amazing to me that my uterus and skin could stretch to accommodate a growing baby, that my internal organs moved aside to make room, and that my bust grew to prepare to feed this new life.  Not only was this physical process fascinating to me, but it was also interesting how other people reacted to and commented on my body changes.

     I have observed that most women who become pregnant enjoy feeling “able to relax” about their bodies and don’t feel pressure to “suck it in” because it’s understood that pregnancy necessitates a certain amount of weight gain and body shape changes, which are necessary for fetal growth.  I found that nonpregnant people make comments about pregnant (and post-partum) womens’ bodies all the time.  It struck me as odd that, just like people feel comfortable touching a pregnant woman’s belly when they would never do such a thing to any other woman or person, people feel that it is acceptable to make comments about a pregnant woman’s body and the changes happening.  As a disclaimer, I think it’s perfectly acceptable to join a pregnant woman in a conversation about the changes she is experiencing when she initiates it or invites commentary.  Less acceptable, though, are the uninvited comments, especially from people who do not know the pregnant woman well.  At times, these comments are downright inappropriate.

     While I was pregnant, I found myself in many conversations about my body, both with people I knew well and people I barely knew.  I don’t know if it was because I stayed slender and then was “all baby” or what, but these conversations seemed to happen every single time it came up that I was pregnant.  One of the comments I received the most (every day for several months, it seemed) was “you don’t look pregnant” and similarly, “you’re so tiny!”  Although it was always clear that the speaker believed this to be a positive comment or even a complement (and I therefore never took offense), I never understood how this was seen as a positive.  In my mind, if we were having a conversation about my pregnancy, especially before it became obvious to everyone that I was pregnant, then I was clearly excited about it, and it seemed likely I would want or at least not mind if it was noticeable to other people.  As I reached the point where I felt I had a noticeable baby bump and I was still hearing “you don’t look pregnant”, I became confused.  I genuinely did not know how I was supposed to take this comment, because the speaker (if it was someone I knew) could see that I didn’t look like my typical nonpregnant self, so it seemed to me as if what they were really saying was essentially, “you just look a little chubby”.

     What I realized was that any comments about another person’s body have potential to cause damage, EVEN when you think you’re saying something positive.  Once, I was chatting with two granddaughters of a patient (who had been there awhile, so I knew them a bit), and one of them said to her sister, “don’t you want to look like that when you’re 5 months pregnant?!”  She was expressing envy for my body, so clearly she thought it was a positive comment, and yet it didn’t feel that way to me.  In my mind, I really wanted to respond that envy for my slender size while pregnant tells me you don’t have any real understanding of how pregnancy is supposed to work.  You’re not supposed to stay the same size or weight!  That is NOT something to wish for; in fact, it can be a legitimate health concern.  At the time, I was very concerned about my difficulties gaining an appropriate amount of weight for my own health and to make sure the baby grew to an appropriate size.  Telling me how small I was only amplified them, and at the same time made me feel unable to share those concerns. 

     I came to the conclusion that all uninvited comments about another person’s body should be very carefully considered, and most should not be verbalized at all.  Even if someone asks you about their body, consider avoiding saying anything about their physical appearance at all!  If someone is asking if you’ve noticed their weight loss, congratulate them on their hard work or improved health.  Chances are good that any other comments have potential to be taken the wrong way, or act as confirmation to the person’s own insecurities.  If someone points out their pregnancy bump, don’t say how big or small they are, maybe just be excited about this stage in their pregnancy (as in, are you feeling the baby move? How are you feeling?).  “You look great” is just about the only thing I would ever recommend saying to someone about their body.  

     We have to realize that comments about bodies don’t start with our words.  They start as perspectives on body shape, image, self-esteem, and personal worth.  These are shaped by media, culture, family background, personal insecurities, and one’s own understanding of the basis of personal worth.  Those are what we need to examine before we perpetuate a misunderstanding of natural physical processes, or promote an unrealistic ideal. 

Thursday, May 8, 2014

On Obstetric Care and the Traditional Medical Model vs Midwifery and Alternative Medicine

 *Note: I don't even consider midwifery care under certified nurse-midwives with master's degrees and licenses actually very "alternative" as far as alternative medicine goes, but that's how the establishment of medicine as a whole (and insurance companies, particularly) see it, so that's how it must function.

     Fair warning: this post is going to be a longer one.  This week, I went in for our first OB/GYN appointment, at 18 weeks pregnant, because I want to do an ultrasound and get it covered by insurance.  I could get a referral to a radiology group from my midwives group, and pay out of pocket, but I thought I'd try to save us $150.  So here I am, a regular person with decent (not spectacular) insurance, seeing an OB while pregnant, paying a reasonable co-pay... what an experience.  I knew as soon as we walked out of the office that I had to write about this experience, because it was so drastically different from my experiences so far at my midwife. 
[Full disclosure: my doctor's office will remain anonymous because I didn't see the actual OB.  I will, however, tell you that I have been seeing and plan to have a home birth with South Coast Midwifery, which came highly recommended.]

     First of all, the reason I was connected to this OB/GYN’s office is that I called my insurance to get a list of doctors, and was told that I had already received authorization to see this doctor, whose name was long but started with a W.  I figured I’d be happy to save the time and effort getting authorization for another doctor, and just called that office to make an appointment with Dr. W.  When I spoke to the office staff, I made the appointment, and asked if we would do an ultrasound as part of the office visit, and I was told we would.  I was thrilled to have an appointment for Monday in which Andrew and I might be able to see the baby and even find out the gender, even though I had been ready to wait another two weeks to get an appointment to do so.

     When we arrived at the office, I didn’t see Dr. W’s name on the list of doctors there, but it said Women’s Clinic so I figured we were probably in the right place. I went to sign in, and asked if this was Dr. W’s office, just to make sure.  The office staff told me that Dr. W had retired over a year ago.  I found out after about ten minutes that my insurance had authorized me to see any clinician in that group and that I had an appointment there, but obviously not with Dr. W.  I told them I was fine to see a nurse-practitioner that day, since they gave me the option. I was confused why no one told me on the phone that I wouldn’t actually be seeing Dr. W for my appointment, but I let it go.  They called me back after we’d been there about 15-20 minutes, took my vitals, and started asking me basic history questions.  The medical assistant took us back to an office to ask questions about my medical history (strangely we never filled out the typical medical history form). We spent the majority of our time with her, and even though I had mentioned that I’d been seeing a midwife group for prenatal visits, she rattled off all the information about delivery, “Your doctor is Dr. A---, he delivers at these three hospitals, but you don’t get to choose, your insurance decides it.”  She also recited their office policy on bringing children to the office, and then asked if this was our first pregnancy.  Eventually she led us to an exam room, and said the nurse-practitioner would be in soon, so I should go ahead and get in a paper gown, which was actually a paper vest and large square paper for the lower half of my body.  Fun times. 

     When the nurse-practitioner came in, she muttered her name so quickly that I didn’t catch it, faced the computer for a moment, and then jumped right into the physical exam, followed by a pap smear.  That procedure was assisted by a random staff member who walked in and out without saying a word.  The nurse-practitioner checked the baby with fetal Doppler for about 10 seconds, and was done with me in less than 5 minutes, at the end of which time they told us we weren’t going to do an ultrasound today. 

     Here are my problems with this experience.  I was not only frustrated at times by this appointment, but I was appalled at the complete lack of concern for any human experience in it, or even a simple concern for “patient satisfaction”. 

-          We were there for over an hour and a half, and spent a total of less than five minutes with the actual clinician.  Everything was extremely assembly-line-efficient, at the expense of any human or caring touch.  I met the nurse-practitioner for the first time with my clothes already off (I was glad she was at least female). 

-          No one used my name other than to call me to the desk and then back to get started.

-          No one acknowledged Andrew’s presence except when the medical assistant asked me if I was married and then if he was my emergency contact.  The nurse-practitioner made a comment about/to Andrew because he had sat behind me to keep me warm while we waited for her to come in, and then proceeded to passive-aggressively and non-verbally push him out of her space. 

-          I felt lied to, because I had specifically asked and been told that ultrasound was a part of the appointment, only to find out at the end that they weren’t going to do one. 

-          There was NO education whatsoever.  The only questions they asked about the pregnancy mentioned morning sickness and bleeding, but there was no discussion of what’s normal and what isn’t with regards to symptoms like ligament pain, or when to expect to feel movement.  There was no discussion at all about nutrition during pregnancy, except to ask if I was taking a prenatal vitamin (which isn’t all you need, in case that’s not obvious).

-          There was absolutely no recognition of the emotional side to pregnancy, except a half-hearted “congratulations” from the medical assistant.  There was no acknowledgement of an emotional response to hearing the baby’s heartbeat, for what could have been the first time for all they knew.

-          Some office staff had literally no idea what I meant when I told them I am seeing a midwife group for my prenatal care and didn’t need to see the doctor again.

     See, my midwife group doesn’t have to do much to be leaps and bounds above my experience at the OB/GYN.  They don’t need to be nicely decorated, or have very comfortable rooms, or make sure that you meet all the midwives at your various prenatal appointments so that you know whoever it is that ends up delivering your baby.  They just need to be human, and treat you like a person.  All the rest of those things are just icing on the cake, because by simply acknowledging that pregnancy is an emotional and personally meaningful experience, by using your name and customizing care to you as a person, they have already succeeded where we in the traditional medical model are apparently failing. Andrew and I said to each other several times while in the appointment, and more so afterwards, “This is why we’re going to a midwife!”, but I can’t help but think about all the people who don’t have that option.

     Firstly, there are all the millions of women who don’t even know that they have choices about where and how they deliver their babies, or who don’t know they should be utterly unsatisfied with mediocre care and no prenatal education, with no personal caring.  Additionally, there are plenty of families for whom choosing something other than what is covered by insurance is simply not an option financially.  Of course, I know that not all OB/GYN offices provide the kind of experience I had; perhaps it was because the Women’s Clinic group I saw primarily serves cheaper insurances and low-income women.  Does that make it any more acceptable?  Of course not!  In fact, it’s more maddening to me, because of all the women who need good prenatal care, with education about what to expect, and what kind of nutrition they need, it’s low-income women!  The fact that certain populations (i.e. upper middle class and upper class) can afford to educate themselves with birthing classes and receive better prenatal care by going to their first choice of OB/GYN or choosing to see a midwife does not solve the problems of the traditional medical model of obstetric care.  Sadly, all it does is widen the gap of health care from one end of the spectrum of income to the other.

     How do we fix this?  How do we move away from the assembly-line model of care for pregnancy and birth, in OB/GYN offices and hospitals? How do we improve our absolutely terrible rates of maternal death and complication, preterm birth, and our sky-high rates of C-sections? How do we reduce the costs of healthcare as a whole and of pregnancy-related hospitalizations specifically?  Obviously, there are no easy, one-quick-fix answers to any of these issues.  That certainly doesn’t mean that there are no answers.  I think we start by encouraging women from every walk of life to educate themselves, through free classes offered by hospitals, information available at public libraries, and reputable websites.  Insurance companies would do well to cover midwifery care under licensed midwives for low-risk pregnancies, which are in fact most pregnancies.  The majority of births should be pushed out of the typical hospital setting and back into the home, or the birthing center, and birthing centers attached to hospitals.  Women and their partners in the birth process should be thoroughly educated about the real risks and complications of epidurals, C-sections, and every other intervention that is used in delivery, and never manipulated by any clinician.  Doctors should be trained with at least 75% normal deliveries, and see at least a handful of births with no medical interventions at all, including those in non-traditional positions.  All health care staff who work with laboring women need to evaluate their expectations for the length of time labor and deliver should last, and make sure that they’re realistic, and not merely ‘by the book’.  These changes would make for a good start in the right direction.

     Although I have personally chosen to have my prenatal care and delivery with a midwife, I strongly identify with the traditional medical care system, and I know we can do better.  We have a duty to our patients to do better with our care, because we should care and remember they are people first.  We have an obligation as a country to do better with the cost of health care, because our debts and spending are out of control.  We have a responsibility as an example to the world to do better, because we are a first-world country with third-world rates and stats. 

Want to educate yourself? Here's a great place to start: http://chriskresser.com/naturalchildbirth