Tokolytic Thoughts at Term

The boy to be is now term - and my only hope is that he stays put until the elective c-section date and time. Since my last OB appointment I've adopted a much more slothful lifestyle - the letter of the final weeks is "R" for rest and relaxation. There will be no more heavy duty gardening (it can wait). Late nights are not going to happen, the dog can do without any long walks, the girl does not need to be carried anywhere, and if it takes me a little longer to get from point a to point b then so be it. While I've learned that sex does not induce labour (that is an old wives' tale) - there will be no nookie. Same goes for spicy foods and pineapples. Further - as soon as its logistically feasible to go to Vancouver, I likely will. That looks like it'll be this upcoming Wednesday.

The logistics would be better if this were my first pregnancy, but it's not and that being the case there's limits to when I can go there, and there will be some trade-offs to doing so. Our lives are in Victoria, and so are all the resources that may be called upon in the event of an "unplanned" labour. It being a second pregnancy, and given the relatively short duration of my first labour - time is unlikely to be a luxury that I will have should the unplanned happen. The time off work that can be taken by my husband is limited...and so as much as I'd like to not be here, now, it really isn't an option until Wednesday.

So until then I'll be thinking tokolytic thoughts and hoping that the labour day long weekend is not taken literally by either the womb dweller or my body.

Sporadic Blogging Likely

I've been somewhat absent from blogging lately - I've tried to compose posts but, there have been more than a few times when doing so in recent days has proven too overwhelming. I've been checking in on the comments - and must thank those who have taken the time to make them - particularly the words of support and encouragement.

The new edition is looming on the horizon, and I find the reality of that when I try to blog to often be a bit much - so I've been trying to do things that allow me to think about that on my own terms. I'm finding that I am preferring to avoid social situations, as invariably someone comments on my burgeoning belly and the imminence of the arrival (please baby boy - just stay put until the csection date and time, please). I'm finding naming hard, actually baby preparations in general are proving somewhat challenging this time. It's not that I'm not looking forward to having a son, but rather the deep desire to be on the otherside of his arrival. The deep desire to know that everything is okay and that this time is not last time. Part of me thinks if I'm just not ready for his arrival, maybe it just won't happen until I am ready for it - logically I know babies don't work that way. Logically, I know that I can be as ready as possible and things can still go sideways - for reasons completely beyond my control. Logically I know that things going well are a result of the actions of other people and I must trust that this time it will be different.

I am very thankful that I have a supportive and watchful OB who has scheduled a date and time that is as soon as is feasible - I appreciate that he seems to appreciate my desire to avoid a vaginally birth and my desire to avoid giving birth at Victoria General Hospital.

I am also thankful for my husband who also is supportive and seems willing to do what is neccessary to put my mind at ease - if the OB thinks labour might be imminent, he seems willing to go to Vancouver to help me avoid Victoria General Hospital...he also seems to be fairly cautious about what I do in the interim.

Further, I am thankful for my therapist - who has her work cut out for her in terms of helping me remain rational - and coaching me as to the what ifs...I'd prefer just not to think about them but, I know that if the what ifs materialize that having not thought of them could be harmful.

So I'm doing what I can to minimize the risk of going into labour prematurely by trying not to let the anxiety get the better of me, reminding myself that my OB is watching me, not overdoing things, reminding myself that this time is not last time.

And what if?

Then I'll do what is neccessary and what I can- I will go to Vic General (even though that is the last place I want to be - because, the alternative is even more scary - at least at Vic General, there is a chance at getting a csection or an epidural), I will let them know that I was planning on giving birth by csection in Vancouver - the name and number of my OB and psychologist. I will let them know that I'd like to avoid a vaginal delivery. I will let them know that I'd like an epidural as soon as possible. I will let them know that I do not want the lights low or to be told that "my body was made to do this", that I do not want the same people who provided care to me last time to provide care to me this time - if at all possible. That I want the best pain relief available to be used. Then I'll try to keep it together as best I can for the sake of my son. But if I have no choice - I will do what must be done, as I did last time - however, I will not waste a year trusting that what happened was with good reason and beyond the control of the hospital or doctors - I will investigate the reasons, and if good reasons for a lack of access to adequate care that respect what I would have liked to have happen with my body are not found - I will again hold the hospital and my care providers to account. And if there are good reasons, well then the circumstance is entirely different and I will just have to deal with that as best I can - I will be thankful for a healthy son, I will relish mothering him, and I will know that my care providers did as best they could and that sometimes bad things happen despite having done everything to ensure that they wouldn't ...

But I am truly hoping the what if doesn't happen...because if it does, I know it will be among the most painful experiences I will have in my life - and that no amount of wishing myself elsewheres will change that, that no breathing exercises hold a candle to an epidural and that my vagina won't be the same again...and the idea that the what if could happen again without good reason - unnecessarily - well that would demonstrate a deep seated misogyny that should be fought with every shred of my being.

It is reasonable to expect that what happened last time, won't happen this time (although I find myself having to often remind myself that I should not expect what happened last time to happen this time) - but if it does (again and without good reason) - I will do what is neccessary.

Freedom to make informed personal decisions...

In my pre-motherhood days, I believed that feminism was a bit of a historical artifact, that its time and usefulness had come and gone.  Women accounted for large portions of university attendees, labour force participation rates among women had climbed, women even occupy positions of power and prestige.  I believed that as a woman, I was free to choose in much the same way as a man (and perhaps in someways, even more free than most men) what I did with myself.  I never really saw being a woman as being a barrier or precluding myself from having fundamental rights and freedoms.  If being a woman meant I could choose to pursue advanced education, choose to pursue a professional career, choose to marry or remain single, choose to be a mother or remain childless - how could it not mean choosing what to do with my body should I decide to be a mother?  How can decisions so fundamentally personal as to *how* a child is born or *how* a child is fed be subject to outsiders determining what is in my and my child's best interests?  Surely as a woman and as a mother, would I not be in the best position to make this determination for myself and my child?

The City of New York and Mayor Bloomberg doesn't think this is the case.

The Society of Obstetricians and Gynaecologists of Canada doesn't think this is the case (although many of its members do support a woman's right to choose how her child is delivered unless a medical reason precludes that choice from being reasonable).

Many Natural Childbirth Advocates, including Dr. Klein, would prefer if access to certain choices, including epidural pain relief in labour and maternal request cesareans, were strictly limited.

It is one thing to undertake research and better understand the reasons and outcomes of the choices that are made - and to seek to better inform those who must ultimately make such decisions.  Knowledge is a good thing, and the pursuit and dissemination of it should be encouraged.

It is quite another thing to assume that those who must make such personal decisions (note these are decisions that have very limited impacts to people outside of the family unit) are incapable of making these decisions for themselves and to develop policies and practices that effectively constrain individuals from making a choice that is ultimately in their own, and their child's own, best interest.

It is admirable to want to increase breastfeeding rates and rates of normal birth - particularly among those who would like to do so and who have determined that doing so is in their own best interest.  However, doing so in such a way that infringes on the right of others to choose differently, in pursuit of their own best interests should be deplored.  Women should not be forced to breastfeed, forgo pain relief during labour and delivery or forced to deliver vaginally, if they have determined for themselves that doing so is not in their and their child's own best interest.

If feminism is ultimately about a woman's right to be fully informed of her personal choices and to freely choose among them - then feminism is as relevant today as it was 100 years ago.  Feminists should not stand for such clear infringements and violations of women's personal autonomy - if a woman cannot decide what to do (or not do) with her own body, she at the most basic level has been deprived of a fundamental human right.

I may not make the same reasonable personal choices as another woman, but I fully respect another women's freedom and right to make those different reasonable personal choices.  To do otherwise is insidiously misguided and misogynistic.

I give a whoop - I vaccinate, RIP, Harper Whitehead

This post is largely a repost of an earlier post I made. I am reposting this week because of a Canadian baby, Harper Whitehead - who died earlier this year at the age of one month. She died of whooping cough - she might not have needed to as whooping cough (pertussis) is a vaccine preventable illness. Unfortunately, newborns must rely on others to be protected from this disease, when others fail to vaccinate, newborns might pay the ultimate price. When vaccination levels drop, newborns are put at risk.

My deepest sympathies to the Whitehead family. Out of respect for Harper and her family - do your part and prevent another family from suffering a similar unnecessary loss. If you haven't had a Pertussis booster in the last 10 years - get one, the baby you save might be a baby you know.

Repost posted below.

One of the Most Importnat Parenting decisions we've made has also been one of the Easiest.

I have come to the conclusion that most parenting decisions don't really matter in terms of the "Big Picture" despite how much we may antagonize over them at the time.

Breastfeeding versus formula feeding - doesn't really matter - just ensure that whatever form of feeding you choose is done safely and meets the nutritional needs of the child.

Crying it out versus night-time parenting - again doesn't really matter - as long as your sleep needs and those of your child are being met.

Daycare versus stay-at-home parenting - again doesn't really matter - as long as whoever is watching your child is providing for their needs - emotional, physical, financial and intellectual.

None of these decisions are ones that I or my husband are likely to have any remorse over - we chose what was best for our family at the time and our decision is unlikely to have any adverse impact on anybody else.

However, when deciding whether or not to immunize and whether or not to follow the recommended schedule - the decision was not one that was overly hard. Why? Because the most credible sources of information on this subject are overwhelmingly in favour of childhood immunization according to the vaccination schedule.

Vaccines are some of the safest medical products out there - there are decades of data on the safety and effectiveness of vaccination. Vaccinating my child is safer than driving her daycare. Vaccinating my child is safer than taking her to the park to play.

Vaccines are incredibly effective at preventing disease. The vast majority of immunized children will not catch the diseases for which they have been immunized.

There was no contra-indication to my child being vaccinated. She is not allergic to any of the components in vaccines. She does not have any condition for which vaccination would be ill-advised.

The possible complications and consequences of the diseases prevented by vaccines are potentially serious. Infants who catch whooping cough stand a better than even chance of being hospitalized with it, and one percent of them will die. Chicken pox and the measles cause a week or more of misery for the kid - and having chicken pox as a child means having a risk of shingles later in life. Mumps can result in deafness or sterility. For every disease that there's a vaccine, the risks of the disease far outweigh the risks of the vaccine - without exception, I found that the data was clear - denying my child the benefits of vaccination would be a parental failing in ensuring her health and well-being.

Furthermore, I discovered that this was a decision that actually mattered. It mattered because not everyone can be vaccinated - some people have medical reasons why they cannot be immunized and others find themselves susceptible to vaccine preventable diseases due to a compromised immune system. For some of these people, coming into contact with a vaccine preventable disease can be life-threatening. Think of those too young to be immunized. Think of pregnant women. Think of those battling cancer or HIV. Think of organ transplant recipients. Not everybody is a winner in the health lottery. Think of those for whom, for whatever reason the vaccine just doesn't work. All of these people rely on the vaccination decision of everyone else. This is because, widespread vaccination establishes 'herd-immunity' - simply put a high-level of vaccination prevents the disease from circulating in the community. Further, I learned that for many of these diseases people are contagious long before any symptoms emerge. As a result, a person could unknowingly spread these diseases. I simply wasn't willing to make my child a potential biological weapon of mass destruction. She'd probably fare all-right if she did catch one of the diseases that are prevented by vaccines - but would the newborn be all right? Would the cancer victim be all right? Would the pregnant woman and her unborn child be all right? It simply wasn't a risk I'd take.

As such, I am disturbed when I read about whooping cough emerging in the Fraser Valley and Vancouver and the recent diagnosis of a case in Sooke (note Sooke is a bedroom community of Victoria). I am disturbed to read that measles cases are at a 15 year high. I am disturbed because this suggests that vaccination rates have fallen to levels where herd immunity has been compromised and the diseases are able to circulate in the community.

As such, I'd ask parents to take a look at the evidence - the real evidence on the safety and effectiveness from Health Canada, from the Centres for Disease Control, from Dr. Offit and Dr. Albietz, from medical journals and experts in the field of immunology and public health. I'd ask them to look at the information on the diseases that are prevented by vaccination - not only for themselves but also for those with compromised immune systems - those who are in their community. I'd ask them to be critical and skeptical of the information they read. I'd ask them to ask themselves whether or not the claim made has been substantiated or debunked. I'd also ask them to ask themselves whether or not the person making the claim has a stake in the claim being made - are they trying to sell a nutritional supplement? Are they credible?

I've looked at the evidence - and to me its clear, to me it's clear that if you give a whoop about your child, or your community its important to vaccinate.

More Unimaginable than an Unnecesarian: An Unjustifiable Deprivation of Personal Autonomy

I still have a hard time wrapping my mind around what happened to me the day my daughter was born. I just never imagined such a thing could happen in the 15th largest city in Canada, in a level 3 hospital, in 2010. I never imagined that a woman’s clearly communicated desires around her medical treatment could be so callously disregarded either negligently or intentionally. I didn’t fathom such an experience could materialize – I trusted the system, I trusted my care providers, I believed fully that a woman (or man) who is competent to make medical decisions could expect that those decisions would be respected - and that the system would do what it could to facilitate the needs of the patient. Before my daughter was born, I had confidence that I could trust those who work in the system, I had confidence that I could trust the hospital, I had confidence that I could trust that my care needs would be met – and that if they couldn’t be met (particularly after the treatment plan was agreed upon) that there was a very good reason why that was the case – a legitimate reason that wasn’t arbitrary in nature.

When I went into labour, I blamed my body for betraying me, I blamed myself for what was happening. As the labour and delivery nurse directed that I not scream and told me “my body was made to do this” – I hated myself. I prayed that maybe labour would be long enough that I would still deliver by way of caesarean – I trusted there was good reason why I could not be given the Caesarean, I trusted that there was good reason why I could not get an epidural. I assumed that others with more urgent needs or other unforeseen events had intervened – my doctor told me that paediatric appendectomies meant there was no OR available for a caesarean at the time I went into labour. It was bad, but maybe, just maybe it was one of those “bad things happen to good people because otherwise even worse things might happen to others, situations.”

After the delivery, few seemed to understand the significance of what had happened – and while I’m sure many meant well with their sentiments that not having the caesarean was “for the best”, and that “everything eventually goes back to the way it was” (bullshit), and “that’s what Kegals are for”, and “at least you have a healthy baby”, and, and, and – my grandparents (who I love dearly) even sent me a news article extolling the evils of caesareans (thanks, but not helpful). Unfortunately, these well-meaning sentiments did little to assuage the hurt and anger I felt, but rather only served to make me feel as though I wasn’t entitled to feel the way I did about what had happened. I felt alone and misunderstood – don’t get me wrong, I felt a bit odd and misunderstood before the delivery for wanting a c-section without medical indication but I understood my reasons for doing so and felt confident in my ability to make and defend that choice – but now I felt even more alone and misunderstood.

The passage of time has allowed me to put what happened into context – to question what really happened – not that the answers to date have offered any comfort. Unfortunately, that too, has done little to assuage the anger and hurt that lingers. If anything I am even more cynical today than I was in the immediate aftermath. There are some truly disturbing questions that run through my mind on a fairly regular basis...Was I subjected to a vaginal delivery without an epidural to save the health care system money? Did the hospital put its desire to lower the caesarean rate ahead of my legitimate right to choose a caesarean? Was I a victim in a labour dispute between anaesthesiologists and the health authority? Did someone else’s belief in the superiority of Natural Child Birth put their own values ahead of mine – the woman giving birth? If things had gone sideways during the delivery, would we have been safe? Why did my health care needs rank so low in terms of priority – surely there were other elective surgeries that could have been bumped with less severe consequences than bumping a woman who at 39 weeks pregnant has a significant risk of going into labour at any time? Did I not matter? Did my right to make health care decisions for myself not matter? Would my daughter have fared better during a caesarean delivery – would she have avoided the need for Narcan and resuscitation if access to the agreed upon treatment plan been realized? Has this experience put me in an unsustainable conflict with my professional life – or will it prevent me in succeeding in that regard going forward? Will I suffer pelvic organ prolapse or a greater degree of stress urinary incontinence at some later point in time because of what happened? Will I regain the confidence I once had? Will therapy be enough to overcome the damage done? Will the anger and hurt ever recede? How many other women have had the same experience? Will there be meaningful accountability for what happened? Will my daughter and other women be protected from this kind of violation in the future?

I am determined to not let what happened influence my parenting of our daughter (or our son after he arrives) – and in that regard I think I’ve mostly succeeded (all be it there are times when I wonder if I would be less frustrated or less exhausted if what happened, hadn’t or if she’d actually have an assembled baby book by now if what happened, hadn’t). I can’t say that what happened hasn’t influenced my marriage or my performance at work or who I am or my subsequent pregnancy – it has, in ways that are very significant. There have been countless hours spent reflecting on what happened – hours that if it hadn’t happened likely would have been spent doing or thinking about other things. It has likely made me less productive at work – I do what needs to get done, but my concentration isn’t what it once was and I don’t seem to quite go as ‘above and beyond’ as I once did, further, I feel conflicted and cynical about much of what I do and am far more sceptical about the health system and its intentions in general (really not a good combination for a person in my position) – thank goodness another maternity leave is around the corner. I sometimes think my husband gets angry with me for being unable to move past the birth – that I’m not as good of a wife as I would be if what happened hadn’t. What has happened has left me feeling powerless, overwhelmed, isolated, vulnerable and violated – there’s a certain confidence in my own abilities that I have struggled to regain – and I fear there are bits of myself that may have been permanently lost.

Is this kind of impact on individual women’s lives really worth avoiding “unnecesarians”? Can this kind of violation really be justified in Canada, in modern times? I must hope that the answer to both of these questions must be a resounding no.

Should 'low-risking' make mothers nervous?

When it comes to pregnancy and birth, chances are really rather good that nothing truly bad will happen. The vast majority of low-risk mothers and babies are fine...except, there are some who aren't.

In the Netherlands, there has been recent reports that high risk women who are cared for by obstetricians in hospitals have better outcomes in terms of morbidity and mortality than low risk women who are cared for by midwives who plan on giving birth at home. That should give some pause for thought - the women who should expect worse outcomes (high-risk patients) actually have better outcomes than many of their low-risk counterparts.

Yet in many parts of the world, there are calls to limit the choices of low-risk women in terms of the care that they can expect to be able to access. In the UK, the new head of the College of Midwives is calling for midwifery led care to be the default care pathway for low-risk women. Here in British Columbia - there have been aggressive campaigns for normal birth (see The Power to Push and Optimal Birth BC) in addition to increased funding for both midwifery and Homebirth. Here in Victoria, it is pretty much impossible for a low-risk woman to choose to be cared for by an OBGYN. In Ontario - Don Drummond recently called for the delisting of elective cesarean sections for the Ontario Health Insurance Plan.

Much of the push for normal and natural childbirth is motivated by a desire to save healthcare dollars, but what has not been answered is the cost at which these savings will be had. How many mothers who want access to epidural pain relief will have to rely on less effective forms of pain relief? How many mothers will be subjected to unneccessary perineal tears? How many mothers will lose their wanted children? How many mothers will suffer PTSD or PDD? How many children will be permanently disabled, because right up until birth, everything was low risk, until suddenly it wasn't? How many women will have their own autonomy violated?

It is one thing to support choice and provide options - and in the context of well-informed patients this should be actively pursued. It is quite another to download risk onto those who would choose to avoid it, particularly in the name of saving money when it is not the system that bears the true cost of bad outcomes.

Thoughts on Informed Consent

I would like to consider myself an intelligent woman – one who is well educated and possesses a fairly high level of information literacy. I am a critical and strategic thinker. I am not a doctor – but I do have advanced training in statistics and can make my way through most scientific papers in peer reviewed journals – I have made a career out of applying my skills in the field of health. I am not generally afraid to find information out from sources who should be “in the know”. I understand risk and uncertainty – and can say that when it comes to things that really matter, like my health or the health of my child, I am not a huge fan of either risk or uncertainty. Provided I have enough information to make a decision – I am a confident decision maker and do not tend to change my mind on a decision unless some new piece of evidence has emerged that merits a change of heart. Further, I tend to be a bit of an independent who is not easily swayed by peer pressure – I do things because I think it is the right thing to do, and do not generally take to being “bullied” into doing something.

As a result, I have regretted very few of the decisions I have made – as I know at the time I made them, I based them on the best information I had available (that was critically assessed) and my own preferences. That and crying over spilled milk does little going forward – whereas cleaning it up promptly and understanding why the milk spilled can prevent a harder clean up job and future spilled milk.

So what does this have to do with anything?

I have been thinking a lot lately about informed consent and medical decisions and how that pertains to maternity care. I have come to a couple of conclusions about it in that context.

First conclusion I have come to is that I was well informed when I made my original decision about how my daughter should have entered the world – I was certainly informed enough to provide “informed consent”, and arguably much better informed than most when they consent to a vaginal delivery. I did not take the original decision lightly – it was very well considered in the context of the available information and my personal context, and looking back, if I had it all to do again – I would still have chosen to deliver by way of caesarean. I might have chosen a different hospital or different doctors – but the choice about caesarean versus vaginal would remain unchanged. That’s with the benefit of hindsight – of having had the experience of a vaginal delivery that resulted in a healthy child and relatively normal physical consequences of a vaginal delivery. I can confidently say that vaginal delivery is not something I would choose for myself – and in particular I can say that vaginal delivery absent an epidural is not something I would choose for myself. I regret still, that the choice was taken from me particularly, absent any real reason for it to have been and feel strongly that denying women informed choice when it comes to mode of delivery is a grievous deprivation of personal autonomy and a serious gap in providing quality maternity care.

The second conclusion I have come to, is that there needs to be improvement in the information provided to women regarding childbirth. The statistics and reporting that are available needs to be better. There needs to be more research on the subject with only one agenda: “improving the health and well-being of mothers and their babies”. Most childbirth education classes probably need a massive re-write to reflect the modern realities of childbirth and to enable women to make reasonable and well informed decisions with regards to their own health and the health of their children. (That being said I was a childbirth education truant for the most part, and so really haven’t sampled a lot of these “classes” but from what I have heard from others, there is more than a little bias in them – at least in BC.) The performance measures used in this area also need to be reassessed.

The third conclusion I have come to is that those women who have informed themselves on what their reasonable options are and have made certain decisions regarding those options, need to be respected and supported for the choices that they have made.

Maternal Choice Caesareans: Misunderstanding, Misinformation and Misogyny is Still Alive and Well in Canada

Recently, Jamie Komarnicki of the Calgary Herald wrote a news story about a doctor (Dr. Magnus Murphy) who is publicly advocating for women to be able to have the choice of caesarean. The story got a lot of play across the country and has been picked up by many other news papers, and has resulted in a number of radio interviews. Dr. Magnus Murphy, is a urogynecologist and a former obstetrician. He has seen first-hand the longer run effects that normal birth has on women and has spent a good part of his career surgically correcting those problems. That’s right, the big push to avoid surgery (c-sections) – often results in surgery months or years later for many women. Recently, Dr. Murphy teamed up with journalist and well-known caesarean advocate Pauline Hull and published what is the most comprehensive and compelling book on the subject to date, Choosing Caesarean, and despite its title, neither Dr. Murphy, nor Pauline Hull is about selling caesareans to everyone or out-rightly abandoning the way children have come into the world since the start of humanity. Rather, they see it as a reasonable treatment option that should be considered relative to the default of vaginal delivery – one that will be appropriate for some and inappropriate for others. They see it as a matter of informed consent and choice – and they also see women being denied an opportunity to make a choice that might be of clear benefit to themselves as individuals. They present clear evidence of the often generally unknown facts of these two delivery options.

It’s good that this information is getting out there and that the universal supremacy of normal birth is being questioned – it’s about time women were made more generally aware of the choice they are making, the risks and the benefits of both vaginal and caesarean delivery options. It’s about time the information given to women about birth didn’t just come from the Natural Childbirth Industry.

What’s sad is that the comments sections in response to the stories are invariably filled with misogynistic, misinformed and misguided sentiments about this subject. People seem more than willing to make other peoples’ bodies, their business. I will happily concede that everyone is entitled to an opinion on a subject, however, the opinions expressed on this subject are generally far from well-informed and many demonstrate a tremendous lack of logic or understanding of the issue. Everyone is an armchair OBGYN. Of the 14 comments made on the story when I looked, 9 were negative – ranging from benign misunderstanding to utterly misogynistic. Here is a small selection of some of the less enlightened comments on this particular news story that I’ve read – I’ve copied them verbatim, so any spelling or grammar errors are not my own:

Golden Years:

“I don’t think they should be elective – but whatever, that’s your choice I guess. If you do “elect” to have on though, you can darn well pay for it on your own. Not on my dime!!!”

Steve Q:

“Quack quack.”

Anon147951286:

“Personally, my opinion. .. A vaginal birth is "natural" our bodies were designed to give birth. C sections are not natural, in some circumstances women need the help of a c section due to complications of child birth. I do not think its right to have a doctor pushing his ideas on women telling us childbirth vaginally is not safe- women have given birth forever . I have given birth 2x and I and my children are healthy and fine. Firstly- pregnancy ruins your bladder, and if your bladder is not drained before pushing a child out that can also ruin it. Get the facts people. I'm not against a c section- but it is also a major surgery. If its because complications with a natural birth- fine. If not, why would we do otherwise?”

Anon916080527:

“I personally would not want a section unless it was an emergency. Women that have a normal vaginal deliver are out of the hospital in a day or two. The women with sections are dragging their IV poles around the recovery is much longer.”

Notnecessarily:

“I’m sure there’s a financial benefit...the health benefit...not sure that is a guarantee for either baby or mother.”

Schapdel:

“Women have been having babies for thousands and thousands of years before modern medicine and we’re over 6 billions on the planet. I think the natural way works fine thank you very much!”

Bill200:

“And tell me again about those ballooning health care costs? What the heck- let’s take what’s normally a low-risk, relatively short and natural procedure involving no surgical intervention, and turn it into a major surgical procedure that requires women stay in hospital for multiple days.

Are their complications from natural childbirth? Yes. The advocates for c-sections suggest the complications from emergency c-sections should not be compared to natural childbirths. Equally, the complications of planned c-sections should be compared to natural childbirth, rather than simply talking about the latter.

Anyone who advocates for this is probably either going to make money off it by performing c-sections, or wants her own choices to be viewed as “natural”. C-section doesn’t form the basis for a “natural birth plan”, notwithstanding their book title.”

Dostros:

“Breaking News....Big pharma company promotes taking expensive pills for whatever ails ya’!”

Toyota:

“If you can’t do the time, don’t do the crime. Honestly, women and their partners today need to get a grip on reality. If you want a c-section for reasons other than an emergency, you should look into a surrogate.”

So what should women who are more informed on this subject do?

They should support those who are brave enough to put themselves out there and advocate for fully informed choice about birth options. They should work to dispel some of the myths and misconceptions that are commonly held by also commenting on these stories. They should call out the stupidity, misogyny, and failure in logic for what it is. They should think critically about what is said, and question whether or not it is actually coming from somebody who knows what they are talking about. Lastly, they should talk with their own health care providers, they should review the legitimate evidence on the subject, and they should proudly make whatever decisions best serve their own needs and those of their children – and respect the decisions of others, even though they may be different from the ones they would make for themselves.

Respect is not just given, it is earned. So go out and earn it!

Filed. Let the legal process begin.

As of this morning - I filed my case regarding the denial of my maternal request c-section in July 2010. The legal process begins...may it result in a recognition of a woman's legitimate right to informed consent and to choose between planned vaginal delivery and planned caesarean delivery in Canada - and may it prevent other women from unnecessarily having similar experiences.

Right now I hope to be granted the strength and courage to survive the process - and hope that doing this puts "IT" to rest.

Processing an "Unexpected Birth Experience"

I sometimes wonder if I should have contacted a therapist sooner after the birth of my daughter. While the ultimate outcome of her birth was, as expected: a healthy baby, the way by which that came about was entirely unexpected and in the process I feared that the outcome might not be good. For a long while, I thought that maybe if I just buried what happened and focussed on being a good mom, focussed on enjoying being a mom, focussed on all that was good - it would not matter - this seemed to be a feasible way to cope. What happened just wouldn't matter, it would fade into the past and life would go on. Perhaps, I thought that my complaint was without merit or substance - after all I was subjected to nothing more than what women have endured for millenia, nothing more than what millions of women do every year (natural childbirth) - what right did I have to expect anything different? Maybe I was not entitled to feel bad or upset - maybe I was one of those "cry babies" who bemoans a "bad birth experience", and that I needed to just pull on my big girl panties and grow up - I have a healthy baby, and isn't that what really matters? I even had well meaning friends and relatives tell me that not getting the elective c-section was, "for the best" and a "blessing in disguise". Perhaps, I was just failing to see the silver lining in this situation - and in particular, what right did I have to put my need for what is commonly viewed as a "medically unneccesary" c-section ahead of others with "legitimate medical needs". Perhaps, I thought that by seeking the help of others, I would be admitting to being weak, or worse, thought of as a "bad mom". At the time, I thought the advice, "give it time" was good advice.

So that is what I did.

I focussed on motherhood and gave it time and tried to bury it...except like a zombie, it would not stay dead. I could not help but think about it, often when I was alone, in the shower or asleep. "IT" lurked just beneath the surface and was still very much so, a "live" issue. A restless ghost in my past, making its presence known at times both predictable and unpredictable. More than a year passed before I realized that it wasn't going to fade - that the mark on my life was more akin to a tattoo than a bruise. Contemplating a subsequent pregnancy breathed new life into "IT" - particularly after the stillbirth at Victoria General Hospital in August 2011. I couldn't ignore "IT" any longer.

It was then that I started to blog again. It was then that I wrote to the "Patient Care Quality Office". It was after I received that response that I contacted a psychologist. Perhaps if I had contacted a therapist sooner, I'd be closer to letting "IT" rest in peace now. Perhaps I would have realized how neccessary it was to face the zombie head on, identify it for what it really was and constructively find ways to put "IT" to rest. Perhaps, this pregnancy would be more at ease. But then again, maybe I was just doing what mothers with bad birth experiences but are left with healthy babies are "expected to do" - cope with it as best they can, on their own. Maybe it's that expectation that needs to change.

The Gifts of Adversity

I grew up in adverse circumstances - my parents were not well off, they divorced when I was young. For most of my childhood we were poor. My father struggled, went back to school and earned a diploma - I was 9 at the time of his graduation. My mother struggled, went back to school and earned a degree - I was 15 at the time of her graduation. There were new partners, remarriage and redivorce. We moved. Money was tight even when things were better in my late childhood. There was no money for post-secondary, although it was clearly expressed how important training beyond high school was. I put myself through university and graduate school. Despite such adversity, what mattered was always there - we were loved and supported in the ways that mattered most - and my childhood homes were free of abuse and neglect. We had what mattered.

There were gifts of growing up in such adversity - insights into who I am and the world around me, that I might not otherwise have. And while, I want my children to gain many of the same life lessons and insights, I do not want them to know the same struggles - I want life for them to be a bit better yet again. I know I am in a better position than my parents were, and for that I am very thankful, however, I still hope that my children will find themselves in an even better position and will be thankful for the privileges they have and would hope that they'd hope for better for their own children.

There will and have been gifts from my current struggles, I know this, and I am thankful for them. However, I do not want to squander the opportunities that my experience might yield - for doing so is to let the anger and hurt overwhelm, to do so is to let others suffer when they do not need to. I do not want my daughter to know the same struggles, nor to have the same experience. I want better for her - I know better is possible.

Planned Vaginal vs. Planned Cesarean: Research Spotlight

One of the things that comes up again and again when discussing modes of birth, is the idea that planned vaginal delivery is better for both mother and child than planned caesarean delivery. I remember when I was preparing for the birth of my daughter and looking into the research to help me decide what I should plan to do, that there was scant little that looked at planned mode of delivery and outcomes. Much of what existed at the time was retrospective in nature and lumped in emergent cesareans with elective cesareans. Logically, I knew that the risks varied depending on the type of cesarean it was (pre-labour, post-labour but non-emergent, and emergent caesarean) and I also new that most emergent cesareans were the result of planned vaginal births.

In the nearly two years since her birth, that seems to have improved a bit. The research that is out there is much better than it was then - and includes a very comprehensive book Choosing Caesarean by Pauline McDonagh Hull and Dr. Magnus Murphy. As well as a variety of other pieces of research that have been published since July 2010.

One of those pieces of research is the work of Geller, J.; Wu, J.; Janellie, M; Nguyen, T.; and Visco A. (2010) “Maternal outcomes associated with planned vaginal versus planned primary caesarean delivery” American Journal of Perinatology, Vol. 27(9): pp. 675-83. This paper came out after my daughter was born, but its results are interesting because of the prospective approach that was use. The paper examines the outcomes of 3868 planned vaginal deliveries and 180 planned caesarean deliveries. The paper found that planned caesarean had less chorioamnionitis at 2.2 percent versus 17.2 percent (a bacterial infection of the fetal membranes), less postpartum hemorrhage at 1.1 percent versus 6.0 percent (massive blood loss), less prolonged rupture of the membranes (2.2 percent versus 17.5 percent) but a longer hospital stay (3.2 days versus 2.6 days). There was no difference in transfusion rates. It was noted that laboured caesarean delivery had increased risks to the mother compared with either vaginal delivery and pre-labor caesarean delivery.

I note that the sample size of planned caesarean delivery in this study is quite small - this would mean that the confidence intervals would be larger than ideal (ie. there could be a lot of variability between this group of women and another group of women – larger sample sizes lead to smaller confidence intervals and greater certainty about the values that are reported). However, at first blush, this research seems to fly in the face of the generally accepted wisdom that planned caesarean is somewhat riskier for the mother than planned vaginal delivery. Previous research has indicated that its somewhat more risky for the mother, but less risky for the baby. I also note that the increased hospital stay for planned caesarean delivery is not substantial at about a half a day of increased length of stay compared with planned vaginal delivery.

I will also note that this study does not look at longer run risks and benefits of caesarean delivery or vaginal delivery - and those should also be carefully considered among mothers who are planning their mode of delivery.

BC, Southern Vancouver Island still lagging in epidural access - are women continuing to be denied access to pain relief in Labour?

The Canadian Institute for Health Information (CIHI) released new data for 2010/2011 on childbirth in Canada on June 21, 2012.  This data shows that British Columbia continues to lag in the provision of epidurals to women in labour and delivery.  While more than half of women (56.2 percent) experiencing a vaginal delivery in Canada received an epidural for their delivery, fewer than one in three (32.5 percent) British Columbians received an epidural for their delivery.  This was just slightly more than the 30.3 percent who received an epidural in 2009-2010.  Among all provinces in Canada, British Columbia had the lowest epidural rate among vaginal deliveries in 2010/2011.  In Quebec, about 70 percent of women having vaginal deliveries received an epidural – the highest rate of epidural use in Canada.

Within British Columbia the rate of epidural use, by place of residence, varied significantly.  Those who reside in Vancouver were by far the most likely to have received an epidural for their vaginal delivery with 49.7 percent having one 2010/2011, up from 48.9 percent in 2009/2010.  The lowest rate of epidural use in British Columbia was among those who reside in the Northwest at 17.4 percent followed by those residing in Fraser East at 17.9 percent.  Among residents of South Vancouver Island – those most likely to be served by Victoria General Hospital – the use of epidurals for vaginal deliveries was 34.8 percent in 2010/2011 compared to 34.1 percent in 2009/2010.  At the current rate of growth (2 percent per year) in epidural use for vaginal deliveries among residents of Southern Vancouver Island it will be 2036 before rates of use will match the 2010/2011 Canadian average.  Women giving birth on Southern Vancouver Island and many other parts of British Columbia are a generation or more behind in terms of access to epidural use for vaginal deliveries than other residents of Canada.

Of course it should be noted that the data available is not sufficient to conclusively say that there is and continues to be an access problem to adequate pain relief for many women giving birth in British Columbia – nor is it sufficient to say that there is an access problem to epidurals specifically.  The data that would be needed to draw conclusions about the adequacy of access to maternity care simply does not exist at this time.  There is no way to know how long those who received epidurals waited (often in agony) from request until placement.  There is no way to know how many women wanted access to an epidural and simply could not get one at all or the reasons why they could not get one.  There is no way to know how many women found alternate methods of pain relief adequate.  There is no way to know whether or not those labouring off hours (during evenings and weekends) experienced less access to these services than those who had the good fortune of going into labour during regular operational hours.  In short, in terms of truly measuring the quality of maternity care services, the statistics fall short.

 

However, given the huge disparities, both between British Columbia and the rest of Canada – and within British Columbia, and my own experience and the conversations I have had with other moms – I believe that there is an access problem to quality care, at least as far as residents of Southern Vancouver Island are concerned that needs to be addressed.  How long must many British Columbian mothers suffer?  At current rates of improvement my daughter will be 25 before the use of epidurals in Vaginal deliveries on Southern Vancouver Island match the 2010/2011 Canadian average – a whole generation will have been born potentially without reasonable access to what is currently considered the ‘gold standard’ in pain relief for labour and delivery.

 

For more information, please go to CIHI’s website (www.cihi.ca), click on “Quick Stats,” select “Interactive Data” under “Type” and “Hospital Care” under “Topic,” then select from the “DAD/HMDB Childbirth Indicators by Place of Residence” or “DAD/HMDB Newborns Born in Hospital” statistics.

 

Why minimizing childbirth pain and improving birth experience matters

One of the things that made my experience particularly traumatic, to me, was the degree of pain that I had experienced.  I had some pharmaceutical pain management techniques offered to me, specifically, Fentanyl and Nitrous oxide gas – but I still recall being in more pain than I had ever been in my life up to that point and in more pain than I ever care to be again in my life.  I had given some thought to the management of pain that I could expect after a caesarean delivery and how to mitigate and cope with that pain – in fact I had some fairly realistic idea of what I could expect having had an open gall bladder surgery 13 years prior to my first pregnancy.  Needless to say, though such strategies are useless for coping with the circumstance that I was facing.  I had not given any thought as to how I would manage the pain of labour and delivery, because, I had not planned on ever having to manage the pain of labour and vaginal delivery.

 

There is some evidence that suggests that the circumstance I was in, being unprepared and completely lacking control over it, likely made it much more painful than it might have been otherwise (see:  Tinti, C. Schmidt S., & Businaro N, (2011) “Pain and emotions reported after childbirth and recalled 6 months later: the role of controllability,” Journal of Psychosomatic Obstetrics and Gynaecology, Vol. 32 (2), pp. 98-103).  This suggests that adequately preparing women for what they are likely to experience and providing them with some degree of control over it might mitigate their experience of childbirth pain.

 

I also have little reason to believe that the memory of the pain I experienced is likely to fade over time.  I know that now, nearly 2 years after the event, I still remember it as being extremely painful and distressing.  One longitudinal study has found that the memory of labour pain among those with negative birth experiences tends to remain negative over time – with little change even 5 years after birth (see: Waldenström, U., & Schytt, E., (2009) “A longitudinal study of women’s memory of labour pain – from 2 months to 5 years after the birth,”BJOG: An International Journal of Obstetrics and Gynaecology, Vol. 116 Issue 4, pp. 577 to 583).  This suggests that efforts to mitigate the experience of pain among childbearing women and efforts to mitigate the risk of negative birth experiences are worth it as pain in birth is not something that women generally forget about, particularly when their experience has been negative.

 

Further, there is some evidence that severe, unrelieved pain may contribute to the development of Post-traumatic Stress Disorder (PTSD) as a result of childbirth (see: Reynolds, J.L. (1997) “Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth,” Canadian Medical Association Journal, Vol. 156 (6), pp. 831-835 and Denis, A., Parant, O. & Callahan S. (2011) “Post-traumatic stress disorder related to birth: a prospective longitudinal study in a French Population,” Journal of Reproductive and Infant Psychology, Vol. 29, No. 2, pp. 125-135) .  There is also some evidence that unexpected events may also contribute to PTSD after childbirth (see: Leeds, L. & Hargreaves, I. (2008) “The psychological consequences of childbirth,” Journal of Reproductive and Infant Psychology, Vol. 26, No. 2, p.p.108-122).  While I am working with a psychologist, I have not been officially diagnosed with post-natal PTSD, however, if it looks like a duck, walks like a duck and sounds like a duck – it is in all likelihood a duck or at the very least a duck-variant and no amount of “putting up a good external show” is going to fix it.  This evidence also suggests that the provision of quality maternity care services might prevent serious psychological morbidity.

Given this evidence – it appears that:

*minimizing unexpected events during childbirth,

*improving childbirth education to accurately portray the realities of childbirth,

* improving the information given to women about their realistic options for pain relief in labour,

* improving access to a broader range of pain relief options in hospitals that serve women during labour and delivery,

* improving facilities that serve childbearing women during labour and delivery – particularly with a view to improving access to pain management techniques, and improving the physical environment of these facilities;

*and, improving the ability of women to exercise personal autonomy during labour and delivery by respecting an informed decision making process whenever practical -

Would likely result in a much higher quality of care and would likely mitigate the risk of adverse psychological and physical outcomes for mothers and their babies.  What is particularly shocking is that none of these suggestions have anything to do with decreasing the rate of caesareans or increasing the numbers of women who attempt to VBAC – both of which seem to be the only measures of quality maternity care that the BC government seems to care about at this time.

You have a healthy baby, why sue?

One of the reasons I have decided to litigate is that the idea that the principles of informed consent and patient autonomy could be wilfully frustrated in favour of achieving other specific goals (reducing c-sections and increasing the rate of VBACs) and saving health care dollars, is really disturbing.  When such things are done in the context of pregnant women and their foetuses, people who are vulnerable and very dependent on the healthcare system - it is even more disturbing to me at a foundational level.  It sends a message that people, pregnant women, can be violated and abused if it results in achieving other objectives - even those that are just held by an individual care provider or hospital.   It makes me cynical.  On really bad days, it is down-right depressing.

I believe it is a reprehensible breach of the fiduciary duties that are owed by the state, hospitals and healthcare providers, to their patients and that such actions result in significant emotional and physical harm.  I believe it is an abuse of power and amounts to nothing less than battery and assault – state sanctioned torture, if it is not addressed and corrected.  I feel as though a stand needs to be taken – and there needs to be a strong disincentive to frustrating a person’s right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice .

    

I believe the system, and those who work in it have an obligation to facilitate informed consent and to respect patient autonomy – to remember that healthcare should be a service that is done for people and not to them.  Further, I do not believe in modern day Canada, that there is any legitimate reason why a woman should be restricted in making medically legitimate and reasonable choice regarding the management of her pregnancy and the delivery of her child.  Caesarean birth has a long history and is a proven method of delivering a child, its risks and benefits are known, it is a medically legitimate option.  Epidurals also have a long history and are a proven method of managing the pain of childbirth, and similarly its risks and benefits are known, similarly it is a medically legitimate option.  Vaginal childbirth and other methods of pain relief are also options for the delivery of a child and the management of labour pain and also come with their own risks and benefits and are also medically legitimate options.  I believe a woman is entitled to know what her options are, to be provided accurate information on the risks and benefits of those options, to have access to professional advice and that her decisions regarding those options should be respected and facilitated.  I further believe that these services need to be reasonably available, and that access to them should not be arbitrarily withheld where they are available. I believe excellent care providers and hospitals understand that this is a critical element in providing quality care to the mothers and babies they serve - and that hospitals and care providers who do not understand this, need to and that they need to understand it now.

 

I believe what happend to me needs to be held to account and prevented from happening to other women and their families. Maternity care is not an exception and cannot be an exception.

 

That’s not to say that the sustainability of the healthcare system isn’t a concern and that endeavours should not be made to save health care dollars, it is and efforts most definitely should be made to save health care dollars – however, that should never come at the cost of misleading patients to make choices that are not in their own best interests and it absolutely should never come at the cost of quality care.