The Birth Activist recently wrote about restrictions of food and fluids for laboring and women, and how Robbie Davis-Floyd has written about this phenomenon as a “rite of passage.”  The Birth Activist highlighted a recent Cochrane Review that found that food/fluid restrictions in labor are unnecessary, something I agree with whole heartedly, having eatten a VERY large breakfast more than 12 hours after contractions had started in my first labor.  She then points out that Robbie Davis-Floyd has long identified the ban on eating/drinking in labor as a “rite of passage.”

Speaking of “rites of passage,” what is with making the dad put on scrubs before he can go with his wife to the OR? She wears the same hospital gown into the OR that she’s been wearing for hours in labor…but he needs to put on scrubs. As a doula, when I’m allowed to go in, I’m given a set of hospital scrubs to put on…even though I’m already wearing my own scrubs. I’ve never argued it because it just doesn’t seem worth the ill will…but really, what is the point?

I understand why the medical staff wear scrubs–in case they get bodily fluids on them while performing surgery, they don’t want to carry potentially infectious materials home with them. But the father? Presumably he has exchanged fluids with the mom. And me, as the doula? Well am I really any more likely to get fluids on me when sitting next to the mom’s head during a cesarean than I am holding her leg during a vaginal birth?

It seems to me that the donning of scrubs by persons not on the medical team is yet another “rite of passage.”  Just as the laboring woman is expected to put on an ill-fitting hospital gown upon hospital admission, stripping her of her own clothing and thus symbollically removing some of her autonomy and individuality; I believe that that donning of scrubs before entering the OR is yet another part of the taking the individuality away from the expectant parents in the modern technological birth.

Janelle writes:

Over the 28 years I’ve been a labor nurse and then a midwife, I’ve seen protocols for pitocin (oxytocin) inductions and augmentation come and go.  High dose protocols were common for a while, then low-dose protocols were in vogue.  Knitted in the Womb recently wrote about her experience with a midwife who clearly did not have her client’s best interests at heart when she mismanaged a pitocin induction:

If you want to read the rest of the story, you’ll have to go over and read it from Janelle.  And please, browse around while you are there, because it is GREAT reading. 

But today’s tip was one of those that I disagree with.  Passionately.  So much so, that I’m pulling out a blog post that I wrote 5 years ago this month, and with a few minor modifications, I’m reposting it.  So without further ado…from the archives…

This past weekend I took a trip to the largest Christian bookstore in my area. While there, I took a look at the books on parenting, to see if there was anything new. My eyes fell upon First Time Mom by Kevin Leman. While I don’t agree with everything that Dr. Leman teaches, I find him to be an enjoyable author, and worth recommending. Curious about what he had to say, I picked up the book and skimmed a few pages.

I was heartened to see him strongly advocating practices such as breastfeeding on demand (though I did wonder why he settled on 6-10 feeds per day when the AAP recommends 8-12?), baby wearing, and making sure the mom sleeps when baby sleeps so she doesn’t wear herself out trying to keep a pristine house.

Then of course came the problematic part. He stated with confident certainty that new parents MUST make time to go on a date without the baby by the time the baby is 10 days old. (Update note:  The Generous Wife reccommends an overnight get-a-way every 2-3 months.)  This is to establish the importance of the marriage, to protect it.  Not only is this date supposed to unite the couple, I got the impression that somehow this is supposed to send the message to the baby that the marriage is important. He was specific that the couple needed to leave the newborn with a sitter and go out.

With this he joins the legion of Christian parenting experts who insist on the necessity of dates without the children—these dates ranging from getting the kids to bed early so you can have a dinner alone to hiring a babysitter on a weekly basis so that you can get out of the house.

Now I agree that it is important to keep your marriage a priority after children enter the picture. I don’t even have a problem with parents going on dates. But I have a problem whenever an “expert” starts saying that this is absolutely necessary to your marriage. Especially when that message is sent in a Christian context.

I see no where in the Bible where “date nights” for parents are even discussed, let alone mandated. Given the importance that the Bible places on maintaining marital integrity, I would think that if dates are essential to that goal they would at least get a “by the way…” somewhere in the scriptures. But they don’t.

One of the problems that I see with dates nights is that folks that so strongly advocate them are pushing a “one size fits all” approach to maintaining a marriage (and while The Generous Wife typically has a “take what works for you” tone to her tips, todays had a different tone…almost a “if you aren’t doing this, you aren’t trying hard enough” tone).  Obviously they have found dates nights helpful to their marriage, so they insist that they are helpful to all marriages.

Well what if they aren’t? In the 6 years since I’ve been a mother I’ve probably gone on about a dozen “dates” with my husband–and probably less than half of those have been without any children. A couple of those—3 I think—have been overnight trips (New Year’s Eve 2000, our 5th anniversary, my birthday before our 4th child was born).  (Update:  11.5 years into my marriage, and “date nights” still don’t figure in highly.  Hubby and I do try to find ways to connect, like me bringing lunch to his work site, but I typically have a baby in tow.  Since I wrote the original blog we have added only 2 over-night trips alone, its now been over 2 years since our last over-night trip.)  I can’t say that any of these dates—even the overnight trips—are particularly memorable to me as bonding events for my marriage. They are pleasant events that provide a chance to relax away from the kids, yes, but bonding? Not particularly. Each overnight trip we have gone into so tired from the rigors of everyday life that we generally spend 10-12 hrs sleeping—again, a relaxing and rejuvenating experience, but hardly a time of marital bonding.

What I do find to be a bonding experience in my marriage is sharing in the joys and struggles of raising a family together. Nothing has made me love my husband more than seeing him gently hold our newborn babies, examining the contrast between their tiny hands and feet and his larger ones. The memories that we hold dear and reminisce on together are of working around our house—with kids underfoot for the most part. Often having the kids underfoot is what helps to lead to the situations that are so memorable and bonding. One time when I asked my grandmother—who raised 5 children and had been married for about 55 years when I posed the question—about the necessity of date nights she assured me that she and my grandfather had rarely gone on dates until after the kids were out of the house, and that her belief was that mature adults would find everyday life more bonding than dates away from the kids.

When it comes to date nights in the newborn period, I find them to be an unnecessary burden at best, a squandering of God’s resources at worst. They stand as a “burden” because typically a breastfeeding mother would want to provide breastmilk for her newborn. At 10 days of age she may have great difficulty pumping enough for a bottle in between the frequent feedings the baby requires. Once she obtains this bottle, she may return from the date to find out that the baby refused the bottle, and is now very upset. Since it is generally recommended that breastfed babies not be introduced a bottle until 4-6 weeks of age the mother might try to time the date so that she can be out between the feedings, returning home to nurse. But since breastfed babies often increase their feeding frequency in the evening in response to mom’s lower milk supply, this may prove difficult to manage.

Since many families today are widely spaced geographically the young parents may have no nearby family to provide free babysitting services, so they may have to pay a babysitter while they go on a date. Given how portable and generally unobtrusive newborn babies can be (my firstborn slept at a bowling alley when she was about 6 weeks old!), I think it is a squandering of the money God has blessed the couple with to hire a babysitter. Ironically, one of my more memorable “date nights” since getting married was a Valentine dinner hosted by our church’s Homebuilders’ Sunday School class–we went with our 1.5 day old son in tow (though our two daughters were home with a sitter). It was held in the same historic inn that our wedding reception was in. I nursed my son in a room that George Washington ate in–maybe I even sat on the same chair?

A deeper problem I have with the advocacy of date nights (or over night get aways) is the underlying message behind them. Invariably the message that is clearly stated (as it was by Dr. Leman) or subtly alluded to is that children are a hindrance to the marriage, and parents must be regularly separated from the children to maintain a healthy marriage. While I do think that it is good for children to “get away” from their parents once in a while (I wish my kids could spend the night with Nana and Poppop more than they can—I know I treasured the opportunity to spend the night with my grandparents when I was a child) just as parents do need a break from the rigors of parenting once in a while, I think setting them up as adversaries to the marriage is unhealthy. The Bible states that children are a blessing.

But far too often I think that in Christian society we don’t really see them that way. We see them as “in the way” far to often. We banish them from Sunday morning worship, small group Bible studies and Sunday school social events. I even heard one mother recently proudly proclaim that her children ate their dinner in the kitchen so that she and her husband could enjoy a nightly meal without being bothered by them.

It is through serving others—including our children—that we will be most blessed. May all parents be richly blessed.

The film style was clearly directly copied from Michael Moore’s style without any attempt to express this filmmaker’s own style. Mr. Buonaugurio has passion, and he is right that many people are left in the dark when it comes to childbirth practices in America.   But he offered very little in the way of HOPE for people.

I’ve had 3 home births myself, but right from the begining I was put off by the flip chart in the background that had boldly written on it “The hospital is our enemy.” The hospital is NOT our enemy. It certainly is excessive for the majority of women in America to birth in hospitals rather than at home or in birthing centers, but the hospital serves a necessary role in keeping birth safe.

I continue to be annoyed at how the natural birth community misrepresents the Cytotec issue. I am not a fan of Cytotec, and believe that it should only be used with full informed consent. But that informed consent is being denied by BOTH sides of the debate. The medical establishment does not make women aware that it has an increased risk of causing uterine rupture, meconium passage, and hyperstimulation of the uterus even in women with no previous cesarean sections. The natural birth community does make women aware that the “contraindication” on prescribing it to pregnant women only applies to prescriptions for the treatment of ulcers because it can bring on labor–which, if you watch VERY closely as snips of the package insert information are highlighted in the movie, you will see. The package insert for Cytotec specifically addresses use for labor induction, and while it does not specifically “approve” its use, it only contraindicates its use in women with a previous cesarean or who are on their 5th or greater pregnancy.

I was most especially annoyed by the failure of the moviemaker to more fully address the NICU stay of his daughter. He invited us into this deeply personal area of his life, and then for reasons unknown, did not provide a full explaination of what happened in the NICU. It was clear to me from looking at the baby in the hospital that the original transfer had merit–her respiration was clearly not normal. But the days of “observation” after she was released from the NICU…what was going on there? I suspect it was an unnecessary treatment that may be part of the reason the movie provides no real hope for the viewer. Mr. Buonaugurio learned first hand how difficult it can be to stand up to the medical establishment and say “this treatment is not needed. I’m not accepting it.”

In the end, I did not like this film.  I think it has value if it is used as a discussion starter (such as I did this evening in using it for an EmPoWeReD Birth moview showing)…but I don’t think it has value if viewed as a stand-alone product.

And yet, because a primary cesarean, is, by definition, the first cesarean a woman has, it may be, perhaps, her most important.  Because it is the one that forever labels her as high risk in future pregnancies.  As Joy Szabo and many women like her have found, having a vaginal birth after the cesarean, even having multiple vaginal births in ones history, does not erase the scarlet letter that a woman “earns” when she has that primary cesarean.

So before going any further, I want to clearly define what the “primary cesarean rate” is.  A “primary cesarean” is the first cesarean a woman ever has.  Where the misdefinition often comes in is saying that the primary cesarean rate applies to the cesarean rate in first time moms.  But this is not the case.  One woman I know had a planned cesarean for her first birth, while another had 3 vaginal births, followed by an emergency cesarean for her 4th child.  By definition, both of these cesareans are “primary” cesareans.

But since a woman who has already had a vaginal birth is much less likely to have a cesarean birth for her subsequent births, most primary cesareans do occur in the first pregnancy (case in point, with the pair above, the first mother was automatically scheduled for a cesarean for her second birth, even though the first cesarean was for breech that did not recurr in the second pregnancy.  When she desired a VBAC for her 3rd birth, she needed to drive nearly an hour to her prenatal visits, and 2 hours to the hospital where she had her birth.  The second woman was just assumed to be able to birth vaginally for all of her births following her first, and was suprised to need a cesarean for her 4th).

I have long contended that the risk a first time mother has of birthing via cesarean lies somewhere around 1.5 times the primary cesarean rate, but I did not have any hard data to back it up, just my “logical suspicions,” and data from the Listening to Mothers I Survey.  Correspondingly, in 2005 the primary cesarean rate in PA was 21.9%, while the data that is now available through the CDC Wonder Database shows the cesarean rate for first time mothers in PA in that year was 29.9% –this is 1.37 times the primary cesarean rate.*

Given this, the choice of which hospital to birth in** has significant impact on a first time mother’s odds of having a cesarean.  While the cesarean rates of hospitals with LDRs in PA ranged from 23.2 to 53.6%, the expected cesarean rate for first time mothers ranges from about 16% to 61% — or even higher.  So watching the “primary” cesarean rate, not just the total cesarean rate, of a hospital, is of vital importance to the first time mother who hopes to avoid unnecessary surgery.

The following table presents all of the cesarean rates for the 113 hospitals with LDR’s in PA.

*The CDC Wonder data set starts tracking birth method–vaginal vs. cesarean–in 1999.  In 1999 through 2002, the cesarean rate for first time moms was over 1.5 times the primary rate, trending slightly downward from 1.52 in 1999 to 1.5 in 2002.  Then it abruptly dropped to 1.33 in 2003, then rose 0.02 each year.  If that trend continued, the cesarean rate for first time mothers in 2008 was about 1.41 times the primary cesarean rate.  To calculate the range of cesarean rates first time mothers could expect, I calculated the primary rate times 1.37–the ratio from 2005, the last year that I am able to calculate it–for the low value, and times 1.5 for the high value.  Due to variability between hospitals, there is always the possibility that either of these values could be higher or lower.

**While hospial choice is important due to the environment that is present in any given hospital, women should remember that the cesarean statistics do not tell the whole story.  They should be sure to ask questions about how likely they are to get the type of care that they want in the hospital.  They also should be aware that even a hospital with a low cesarean rate may have a care provider with a very high cesarean rate, and visa versa, so they should ask specific questions of their care provider about cesarean rate and practice style.  I wrote more about choosing a care provider at this post:  Finding the Right Maternity Care Provider.

I also wonder about Allegheny General Hospital in Pittsburgh (9.5% VBAC) and Holy Redeemer Hospital in Montgomery County (7.2%), both of which seem large enough to staff adequate anesthesia services.  Many hospitals that have VBAC bans will cite not being able to staff 24 hr anesthesia as the reason, and all 5 of the hospitals with “official” bans handle less than 700 births per year.  Of those with “defacto” bans, 73.6% handle less than 1000 births per year; while across the state, 54.9% of hospitals that routinely handle birth serve less than 1000 births per year, so the size of the hospital does seem to be an issue.  However, with 26.4% of hospitals with “defacto bans” in place serving well over 1000 births per year, some up to nearly 3000 births, obviously other factors are coming into play than merely concerns about lack of adequate staffing.