Where am I going with all this...?!

I came across this again today, it is one of my favorite quotes - and somehow it always tends to pop up when I need to remember it!

Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us. We ask ourselves, Who am I to be brilliant, gorgeous, talented, fabulous? Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There is nothing enlightened about shrinking so that other people won't feel insecure around you. We are all meant to shine, as children do. We were born to make manifest the glory of God that is within us. It's not just in some of us; it's in everyone. And as we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others. (Marianne Williamson)

Last night I hosted the call on Postpartum health, it was an amazing call, and we had a huge turnout! And not only that but I am already talking to 4 other experts about being featured in the coming months! I started the Conference on MotherBaby Wellness in a flash of inspiration because the opportunity to interview Shoshana on such a relevant topic came into my life and this all just grew around it - but I had no idea where it would go!

Sometimes I just feel like, "who am I? I'm just some shnook with an idea. How can I really make a difference?" But when I read those words, I remember that I just have to run with this, that I have to keep doing what I'm doing and let it grow and go wherever the One who inspired it intends for it to go...

(It doesn't take away the fear, though!)

AMA to Label "Ungrateful Patients"

It seems that the American Medical Association is discussing a resolution at their next meeting that will allow them to include "non-compliant" and "ungrateful" in patients' records.The article is featured on the ICAN website, because of it's implications in maternity care.

It can be read here. Please do me a favor - don't just read the response of ICAN. Scroll down to the bottom and open the actual resolution sheet (it's resolution 710) and at least skim the actual resolution. And while you're at it, take a look at some of the other resolutions on the table for next week's meeting of the AMA.

I do take issue with the Michigan Delegation's proposal to label non-compliant or ungrateful patients. I take issue with it because it opens a Pandora's box on what can be considered "non-compliance." But I happen to have also noticed Resolution 709, presented by the Kansas Delegation, which proposes that the AMA take into careful consideration how new payment methods might impact the patient-physician relationship, and provide action steps for physicians to follow in order to make sure that where their money comes from does not affect the way they care for their patients!

If we are going to talk about the arrogance of physicians who want to have a way to label patients as ungrateful, we must also mention the sensitivity of physicians who recognize that the patient-physician relationship is based on the statute of "First do no harm." and not, "first check how much I can get paid for this."

So, as I learned from studying the Rabbis of old, I will start with the bad and end with the good.

The problem with Resolution 710 is that it doesn't give any guidelines for what is considered "ungrateful" or "non-compliant." It seems clear that the purpose for the resolution is a measure of CYA (cover your a**!) where if a patient refuses care and has a negative result, or if the patient is hostile and therefore is difficult to treat, then having a code in their record about that helps the doctors to defend themselves.

But then we come to what else happens with those codes? For example:

A pregnant woman in her 3rd trimester is told by her doctor that she is measuring "large for dates" - that her baby is very big, and might be too big to be born vaginally. He tells her that it will be safer to induce early, before the baby grows anymore. Or he tells her that a cesarean delivery is very likely. She calls me (yes, it's a shameless plug!) and asks me why her doctor is saying this? She's very scared about birth and now she's even more nervous that she won't be able to get her baby out! And why would her body make a baby she can't birth?

So I reassure her. The measurements are based on ultrasound information, which is notoriously unreliable for measuring. There is absolutely lifesaving information that can be gleaned from the use of ultrasound, but accurate measurements are not one of them. In fact, the margin of error for u/s measurements after the first trimester is +/- 2lbs!! That's a huge margin!! That means if you are being told at 34 weeks that your baby is likely to be 8lbs - you may just as well be looking at a 6lb baby! And conversely, if you are told that your baby is not growing, and is measuring behind dates (another reason for induction) you may be told that you're baby is only 4lbs at 36 wks, when really, if allowed to go to term, you'd be having a bruiser of a 9 pounder!

'Please consider,' I tell my imaginary client, 'the risks of an early induction. That your baby really is up to 2 lbs smaller that the measurements and might require NICU care; that pitocin use can create overly-intense contraction which can lead to uturine hyperstimulation, stress in the baby, increased pain requiring the use of narcotics - which have all of their risks; and all in all you could end up with a cesarean to "save your baby" which you would have never needed had you been allowed to go into labor all on your own when you and your baby were ready. Plus remember that giving yourself the freedom to use different positions in labor and pushing will allow you to birth whatever size baby your body can grow!' (Except under 3 very specific circumstances, which are not the case with my particular client)

She weighs the pros and cons and decides that she does not want to be induced based on the ultrasound measurement, and thank you very much, Dr. X, but I will go ahead and wait until I go into labor on my own.

Unless there are very clear guidelines on the resolution to define what is "non-compliant," my client here may very well find that label on her chart (or not, depending on whether she has access to it!) and how will that affect her reception at the Labor and Delivery ward? How will the nurses and residents react to knowing that they have an "ungrateful," possibly "hostile" patient on their hands? And heaven help her if she also shows up with a doula! Now they know they're in for a fight!

If the resolution passes - and even if this resolution just brings to light a sentiment among doctors, then the need for women to be very well informed about their options and the research sky-rockets!
And that is my complaint with the AMA Resolution 710.

Now for the praise:

Kudos to the Kansas Delegation for bringing up a very real and tangible problem in the health-care world! This is something that Henci Goer talks about extensively. It is the problem of health care providers thinking about their bottom line when considering patient care. It is no secret that physicians can bill for every intervention they use. For maternity care this is especially problematic, because unfortunately money can cloud judgement and things that seem "harmless" like constant fetal monitoring, and mandatory IV fluids, and AROM (artificial rupture of membranes - breaking the bag of waters) are easy little things that can add to doc's paycheck - but evidence is very clear that these have very little benefit, and can lead to additional interventions directly from their use.

I do hope that resolution gets passed and that the AMA does take a good look at the importance of the patient-physician relationship and how to preserve the trust between doctor and patient by providing care that is solely beneficial to the patient's needs, regardless of the profit of the physician.

What does this all come down to? It seems to me that with all the pressures and limitations that physicians deal with from insurance companies and legislation, the standard of care has become more complicated than just serving their patients. Unfortunately, the true answer and cure for this is total health care reform, and complete re-education of the meaning of health and wellness for physicians and for us (those who are served by the physicians!). In the meantime, it would be very scary for doctors to have the ability to assign value judgements on their patients - even though there may be situations where they are justified. And at the same time it is extremely important for doctors to put their patients' health above their bottom line - after all, if you are studying to be a doctor for the paycheck, then you were always only going to be serving yourself.

Messages from the Universe

There have been a lot of "things" going on in my life over the past year... Deciding to live our dream and move 6,000 miles away from everything familiar, making that move within 5 months, living in a one bedroom apartment with 2 kids and no oven for almost 5 months while we figured out where to settled down, navigating new bureaucracies and systems - including a health care system that is more foreign to me than anything else, and finally finding a beautiful community and a home - all while being pregnant!

So far, my baby's have been born before that magical "40 week" date, and this time seems to be no different, but the stress has actually been moving my pregnancy along even faster than it's ever been for me. My birthing choices have lead me to homebirth as the best option for me and my family - but safety in homebirthing practices preclude pre-term labor - so if I want to have my baby at home, we have to hang on for at least 3 more weeks! (Bringing us to 37!)

My adventures in bedrest over the past week have actually been enlightening, and I learned something that competely came out of left field, but is so relevant in pregnancy and birth that I had to share it with you.

One of the things I've decided to do to pass the time is to knit a baby blanket, this is my first patterned knitting project - for the knitters out there: until now I've basically been making garter stitch scarves. For you non-knitters, that means I've only been doing one stitch! So for this pattern I had to learn to purl. The pattern goes, knit 4 purl 8... knitting 4 - no problem, but then I got to my first purl and by the end of the row, my string was tangled, the thumb on my left hand was cramping and I was ready to call it a day! Instead of throwing the "blanket" it, I decided to try something else. I went through my yarn stash and found a worsted-weight cotton yarn, and some size 7 needles. I casted on a far amount and just went at it in stockinette stitch (that's where you knit 1 row, and purl the next, it's the one that gives you those neat little "v"s on one side of the fabric!) The first row of purling was just as much of a disaster as the blanket, but after 4 more rows, I was purling like a pro! I made myself a nice little square, bound off and now my baby also has a soft little cotton washcloth!

But that's not the point. The point is that when I first tried that pattern, my hands felt completely awkward, I was in pain, and felt completely discouraged. My truth at that moment was, "I cannot purl. My hands won't do it, I'm not coordinated enough, and there's just no point, because this is one of those (few!) things that I'm just not good at." Two hours later, I was a master purler and the woman who "couldn't do it" didn't exist anymore. My confidence skyrocketted, my pain was gone, and now I've done 12 more rows of the blanket! It looks great!

What does this have to do with birth? Many of us start off our pregnancies, or journey into pregnancy with some fear. Fear around conceiving, miscarraige, morning sickness, pre-natal complications, diagnostic tests and screenings, labor pain, birth, becoming a parent... They may stem from your own previous experiences, second hand stories from you mom or grandmother or friends, books, media - or even straight from your care provider! You may be thinking, "I can't do this! My body just isn't made for it, not every woman can give birth, that's why there are drugs and cesareans," and the internal chatter can go on and on...

But here's the real TRUTH! Pregnancy, labor and birth are just as much a muscular interaction as knitting is, or learning to swim or an exercize or dance routine, or training for a marathon or riding a bicycle. The "pain" associated with childbirth is a muscular pain, not an injury pain like dental work or a broken leg. And just like you wouldn't run a marathon without training - just like you wouldn't take a narcotic towards the end of your aerobics workout to stop the burn - you can train your uterus, you can move with the burn of contractions and work to relieve the intensity. And as you experience these changes in your body, you feel powerful, capable, fearless! (And by the way, feeling a little invincible doesn't hurt when raising kids either!)

The cesarean rate in the US is over 30%. That statistic states that 1 out of every 3 women in NJ is incapable of birthing her baby... how's that for confidence?! If you're not ready to throw the knitted blanket in - if you know you don't want to be in that 30%, but don't know how - I'm here to tell you that you can! And fighting those statistics is as simple as getting the support and information you need to purl that next row! That's what being your Virtual Doula is all about.

Visit me at www.wholebodybirth.com for more information and to find the balanced, evidence-based answers to all concerns, from pre-conception to postpartum!

In service and with love,
~Ayelet

An Answer to Postpartum Depression

I read this article today about a study done in Canada to see if allowing new moms to get more sleep in the hospital would have a positive impact on staaving off PPD.

I wanted to share my thoughts:

It does make absolute sense that getting as much sleep as possible in the post-partum period would stave off ppd. However, I have to disagree on the method. It seems like just another medical "band-aid" to me as opposed to actually looking at the core of the problem and curing that.

In times gone by, a birthing mother's community supported her completely through her birth. There weren't such things as "hired" doulas b/c your mother, aunt, neighbor, sister... was with you and supported you as a doula does now. After the birth, the women of the community would care for the new mother with everything from housework to cooking to laundry to caring for older siblings for at least 6 weeks. Mom and baby did nothing but lie in bed, nurse and sleep.

The reason new mommas don't get enough sleep after birth is because they aren't supported in the same way as we once were.

In my opinion, it is a sad commentary to say that the only way we can re-create that support is by increasing our stay in the hospital - where the nurses are caring for several babies at a time, many are left to cry in their cribs - esp if mom has opted to exclusively breast-feed, and mom is just further from her natural environment, rather than supported in it.

I'm not saying it's an easy fix, and I'm not arguing that we need more sleep! I am saying that the true answer is not having your baby cared for by others - it's educating women and families on the importance of postpartum support. And creating support systems within communities and families to aid new mothers in transitioning to life with a newborn (even if the new baby is not the first).

After Odeliya's birth, my midwife came for the first pp visit the next day. She sat Yoram down and explained to him that I am considered "postpartum" for the next 6 weeks and whatever he has to do to make sure that my job is sleeping and caring for baby - he needs to do it. The risks are not just PPD, also hemmorage, uterine prolapse, and prolonged healing that can occur if mom is expected to go back to her "normal" routine within those first 6 weeks.

If you are at risk for PPD and want to know how to make sure that you have the support you need to be cared for after your birth, email me to set up an intake appointment to assess your needs and set up a plan so that you are looking forward to having your baby - instead of dreading it!

Love,
Ayelet