Tuesday, May 31, 2011

Teaching childbirth education classes

So, we come to the class that piqued my interest in this midwifery course to begin with...

It seems to be a common, albeit unspoken, belief that it doesn't matter what the CBE teacher's outcomes are (i.e. what the parents' birth experiences are like), they'll keep their job anyway. But as CBEs we should hold the belief that we are not effective if we're not producing good results, meaning normal, spontaneous vaginal births. It's no good to have a post-birth reunion of parents who sit around sharing stories about their epidurals, emergency caesareans and episiotomies. A question we need to ask ourselves is do CBE classes really help parents prepare for birth, or are they are part of the problem?

Words are powerful, and for excited first-time parents (as they usually are) who are open and susceptible to suggestion, CBE teachers are in a position of authority and responsibility. What we say goes into their subconscious. Whether we are overtly teaching hypnobirthing or not, we are "hypnotising" our clients. So what words are we using? Consider the difference between

labour and the birth process
delivery* and birth
contractions and stretching sensations (that's what Gloria calls them; I prefer "expansions".)

* I have had a post about why I don't use the d-word in my head for a long time. It'll come out one day! For the time being, I'll just quote Gloria: When we call it a delivery, people think it's normal to treat [the baby] like a pizza.

This isn't about sugar-coating or Pollyanna thinking. For example, calling them stretching sensations or expansions doesn't mean they don't hurt! But it's about accuracy and clarity in what actually happens during birth.

98% of CBE is women getting together, sharing, talking and informing each other. To that I say, Oh, if only!! Yes, absolutely I believe that should be the goal. After all, what does "midwife" mean again? But I don't think it's possible to achieve that unless you happen to already be in a community of birth-savvy women -- and how many of those are there? I suppose the idea is that CBEs can help create such communities, though.

CBEs should help fathers step up to their role of protector. We live in a culture which says men are inept, hapless spectators who are best left on the sidelines in birth. This needs to change. Men should be warriors protecting their wives' birth spaces.

Good education involves theatre and entertainment. Be memorable! Be engaging! Lecturing people is useless. Get them involved and doing stuff. Have a "bag of tricks."

When renting a venue, choose somewhere neutral and unrelated to any kind of health care service. This is to ensure that the staff running the venue do not have a vested interest in what you might be covering in your classes, or insist on having any input. The beach is nice place to go.

Bring in a couple from one of your previous classes to talk to your clients about their birth experience and to demonstrate breastfeeding, nappy changing, etc. Such couples are usually honoured and eager to show off their baby, and chances are excellent that your clients will remember what they say even more than they'll remember what you said.

Have a class reunion about three months after the birth of the last baby. I really love this idea. I wish I'd had that opportunity with the classes Craig and I attended before Cassia was born. I'm not sure if it would have been a good thing (because it was obvious even then that I was the mad hippy of the group, who was going to have a waterbirth and use cloth nappies and not vaccinate my kid), but I felt a certain cameraderie in that group which I never felt with my mothers' group.

Finally, there was one other aspect of this class that was very confronting for me. I'm going to save it for a separate blog post however, because it's more about my personal Stuff than it is about the course. There. How's that for a teaser? :)

Tuesday, May 24, 2011

Breech and twin presentations

3-4% of babies are in the breech position at birth.

Breech comes in four flavours: footling, complete, incomplete and frank.

Frank breeches are the hardest to turn in utero, but are the safest breech position to birth.

The best breech births are the undiagnosed ones. Neither the woman nor her careproviders have had any time to build up fear during the pregnancy.

Breech presentations, while a variation of normal, can be caused by abnormal conditions. Therefore when a baby is presenting breech, it's useful to ask yourself a few questions, such as:
* Is it early? (It's common for babies to be breech before 34 weeks, and they usually turn themselves before birth anyway.)
* Is there placenta previa? Usually placenta previa will make itself known with bleeding in late pregnancy, however occasionally this doesn't happen. A baby may stay breech if the placenta is blocking its way to turn cephalic (head-down).
* Are there any growths in the uterus blocking the way? E.g. fibroids, cysts, tumors.
* Does the woman have a bicornuate uterus? This is when the uterus is partially divided (heart-shaped), and it may prevent a baby from turning. Having a bicornuate uterus does not necessarily exclude a vaginal birth, but it will depend on the degree.
* Does the baby have a problem such as hydrocephaly (water on the brain causing an enlarged head) or a condition involving generalised laxity, e.g. brittle bone disease, Down Syndrome?

The cord around the neck in a breech birth is "almost a good thing" in that it reduces the chance of cord prolapse during birth (cord coming out of the vagina before the baby), which is the biggest risk for breech presentations.

Mary Cronk, a UK midwife who has done a lot of work on breech births, has said "If the labour progresses well and spontaneously... this baby will be born". This accords well with Michel Odent's view that the first stage of labour in a breech birth will give you a good indication of what to expect in the second stage. Basically, if labour progresses well, the birth will go well. If it doesn't (i.e. it stops and starts, peters out, or is very long), it's better to transfer to a caesarean.

Standard obstetric training for vaginal breech births, and therefore management of such, is nothing short of atrocious. Riddled with interventions, oxytocic drugs, restrictions on the mother's movements, supine position, pulling on the baby's body from the hips, automatic episiotomy and forceps applied to the baby's head once the rest of the body is out, etc. It's probably the best illustration of the difference between a birth and a delivery. It's no wonder most breech babies are an automatic caesarean in the hospital system because frankly, they probably are more safely delivered that way. As with doctors who assure you that they "do" VBAC, be cautious about a doctor who says "I do breech births". Find out exactly how they manage breech before you get excited.

The golden rule for breech babies is hands off. This especially applies once the baby has crowned, but obviously hands off the mother during labour is essential too (as with any birth). The reason why a breech baby must not be touched is because touching it can stimulate the Moro (startle) reflex, putting it in a much more difficult position for birth (arms or hands up around the head).

Be ready to bag and mask a breech baby because they are often shocked by the birth experience and can be a bit flat at birth.

After birth, breech babies tend to keep their legs flexed up very high. Each day their legs will come down a little lower, until they're in a normal position. Be careful with a breech baby's hips -- they can be easily dislocated.

And after all that, there was still the topic of twins to cover! A few interesting points:

* The average length of time between births of twins is 47 days. Yes. 47 DAYS. (My guess is that this includes all stillborn premature twins.) How long is it OK to wait for the birth of the second twin in a spontaneous at-term birth? For as long as the mother and baby are OK. Lisa had the experience of waiting 49 hours for one of her client's babies last year. (That birth story is here and here.)

* It's only fraternal twins that run in families.

* Two of the categories of women more likely to have twins are those over 30 and those who are taller than average. Eeek!

* 40% of twin presentations are cephalic-cephalic. It's the most common presentation. However, cephalic-breech is also quite common.

* Fraternal twins are at less risk of birth complications because they have separate placentas and separate amniotic sacs. Identical twins by contrast are at risk of twin-to-twin transfusion syndrome and cord entanglement.

Monday, May 23, 2011

The placenta

Ever heard of velamentous cord insertion?

The veins in the umbilical cord go through the choriamniotic membranes before reaching the placenta.
This condition occurs in approximately 1.1% of singleton pregnancies, and is more common in twin pregnancies (8.7%). To quote from the website I've linked to, with my emphasis:
The most significant clinical problem arising from a velamentous insertion of the umbilical cord is vasa previa, a dangerous condition in which the velamentous umbilical vessels traverse the fetal membranes in the lower uterine segment below the presenting part. In 6% of singleton pregnancies with a velamentous insertion, vasa previa is a coexisting condition. These unprotected vessels may rupture at any time during pregnancy, causing fetal exsanguination and death. Although spontaneous rupture has been reported before labor and with or without intact membranes, this accident occurs most often during amniotomy.
Amniotomy is also known as artificial rupture of membranes, i.e. when they break your waters for you.

I was completely blown away by this knowledge, so much so that I can hardly remember anything else about the class. There was a woman in the class who'd had a homebirthed babe with velamentous cord insertion, so I'd just like to add that it does not mean you can't have a homebirth. But wow. The things you learn.

OK, I've looked back at my notes. Other stuff:

The placenta is an organ of the baby. In other words, it is a part of the baby, just as much as the heart, lungs, kidneys or liver are parts of the baby. A lot of scaremongering occurs about "placental failure" towards the end of pregnancy, especially past 41 weeks, but to put it in perspective, no-one seems to worry so much that the baby's liver will just suddenly stop functioning. Calcifaction occurs in 10-15% of placentas. That statistic is based on research from 1982 -- long before they started pushing the idea that placentas have a use-by date.

In the vast majority of cases, placentas are normal and unremarkable. The midwife should privately, quietly give it a one-minute inspection sometime after the birth, but not make a big deal over it, and certainly not browbeat the parents about it when they're busy falling in love with their new baby. I was silently so grateful to hear Gloria say that. It still kinda bugs me that a midwife at Cassia's birth insisted I look at the placenta afterwards when I wasn't in the slightest bit interested in it. Now don't get me wrong. I would have appreciated having a good look at it later. But later. Like, hours later. (I realise this is asking the almost impossible of a hospital, in which placentas are radioactive and highly explosive time bombs which must be discarded within two minutes of birth.) These are the not so little things you can take for granted at a homebirth.

Placental abnormalities include infarcts (fatty deposits), accessory lobes, cords not located in the centre, blood clots on the fetal side or within the placenta (clots on the maternal side are normal and aid in the separation from the uterine wall), nodules, missing pieces, tumors. The condition of the placenta will reflect the baby's general health.

Dark spots (of congealed blood) in the umbilical cord show that blood has stopped flowing and it's safe to cut the cord. Sometimes women are told that the placenta has to stay above the baby (usually in an effort to deter delayed clamping of the cord) but this is a myth.

Cord clamps or ties need to be far enough away from the baby's navel to allow for shrinkage of the cord as it dries. Allow 5 centimetres (2 inches). A word of warning spoken from experience -- make sure the cord is clamped or tied really, really tight. The cord stump can get pretty stinky otherwise! Clamps are not needed on the placenta side of the cord once the placenta has been birthed, although some people still like to clamp it to prevent any possible spurt of blood when it gets cut.

Usually the cord is about the same length as the baby. Occasionally it is very long or very short.

Saturday, May 14, 2011

Assessment of the newborn

This class was basically a list of the fifteen million things a midwife should check out on the baby within the first 24 hours of birth. I'm not going to write out the list. It's very boring, and I'd be here all night if I tried.

There are many different techniques for assessing newborns. The most commonly used one, especially in hospitals, is the APGAR test, but homebirth midwives will often develop their own "system" for checking everything is as it should be. Gloria's own method is to examine the baby from the crown of the head to the toes, then turn the baby over and repeat the process from the back. It takes about five minutes.

The APGAR test measures five key areas: Heart rate, breathing, muscle tone, skin colour and reflex response. Each newborn is given a 0-2 rating in each area for a total possible score of 10. The test is done at 1 minute and 5 minutes after birth, although very often the scores are only recorded retrospectively as there tends to be too much else going on in those first few minutes after birth. The APGAR test doesn't pertain to homebirths because it was developed specifically for medicated babies in hospital settings.

Some UK midwives are questioning whether newborn exams should even be conducted in the first 24 hours because so many changes are occurring, and many initial "problems" in the baby (such as gurgly breathing, heart murmurs) resolve themselves in that period anyway.

This baby looks relatively OK with his lot in life so far.
The class was heavy on photographs of babies in hospitals being weighed, measured, (over)handled, clamped, and tagged. In every case the babies looked (to me) obviously distressed, and I found it quite hard to believe that once upon a time I would have seen nothing wrong with such photos. These days I am so used to seeing peaceful, relaxed and happy babies in homebirth photos that the contrast was quite shocking. (The photo I've used here was just one I pulled off Google Images, and I chose it because it was less distressing than some of the other hospital shots I could have used.) Gloria made a really interesting comment on one particular photo of a baby with a hat on its head, clamp on its cord and tags on its wrist and ankle -- that all these things they do have the effect of claiming institutional ownership of the baby. I know exactly what she means. In those crucial first few minutes of life, when the need for motherbaby in order to establish a bond is strongest, the baby is taken away and branded by the institution. Quite apart from the obvious distress this causes the baby, it also deprives the mother of what she most needs at that moment, and the psychological and emotional impact this has on her is devastating. By contrast, if she is the first one to hold her baby, talk to her baby, dress her baby, and so on, ownership is conferred to her. This is really, REALLY important.

Tuesday, May 03, 2011

The perineum and preventing tears

Don't let the title of this post fool you; we only got so far as discussing the perineum, management of tears and episiotomies (oh joy, what a fabulous topic), before running out of time to get to the really good bit. There was some discussion after the class was officially over about the merits or otherwise of perineal massage, warm facecloths, and "breathing" or "panting" the baby out in order to prevent tears, but nothing I hadn't heard before. At this point I still reckon you can't really prevent tears, i.e. there's no magic formula or rule that will stop you from tearing during birth, and it comes down to common sense management (go gently) plus a decent measure of good luck. Some women birth ten pound babies and don't tear, others birth seven pounders and tear. Go figure.

Interesting points:

* If the labia minora are showing on a baby girl, that's a sign of prematurity. (This had nothing to do with the class, it was just a side point Gloria mentioned in discussion of women's genital anatomy.)

* First degree tears, and often second degree tears, don't require suturing. Lots of rest and nutritious food will take care of it.

* Third and fourth degree tears extend through to the rectal sphincter (and beyond), and require very skillful suturing to heal properly. A poor stitching job will lead to the woman having fecal incontinence.

* Fourth degree tears are almost always associated with mid-line episiotomies (i.e cutting straight down towards the anus instead of medio-lateral, which is cutting to the side), and this is why they don't do them routinely any more. Refer to the research of Dr Michael Klein.

* An episiotomy is the equivalent of a second degree tear.

* When healing tears, conventional wisdom says to keep the perineal area clean with the use of spray bottles, etc. But blood helps the healing process, so don't get too hung up on cleaning. Pat dry after toileting, showering, etc, but that'll do.

* The chemicals present in commercially available pads can make your vulva sore, even if the tear is mending well. Don't wear them for more than five days straight. Cloth pads are the best!

* According to midwife Anne Frye, episiotomies should really be called clitorotomies because they cut through the nerve network to the clitoris. This obviously has important implications for the woman's sexuality.