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Greenville Memorial and Family-Centered Cesarean

I guess Greenville Memorial didn’t want me to only blog about Greer. They one-upped Greer’s family-centered cesarean.

History: When I first started doula work, sometimes I was permitted in the operating room at Greenville Memorial with my client. It was still hit or miss. However in recent years, the “rule” is only one support person for cesarean births. Until now.

Much to my surprise, at my last Greenville Memorial birth, JoAnn the trailblazing midwife, told me I was going back. I threw on some (cloth!) scrubs and Louise, a favorite nurse of mine, insisted I go with my client as she was being wheeled back.

That was the one-up.

Whenever I’ve been allowed back, I’ve first waited with dad until mom was prepped. This time, I stayed with mom the entire time. I was able to wipe a few tears while she waited, hold her while she received her spinal anesthesia, and talk with her as the surgery began. After the surgery, when dad left for a little while with their baby, I stayed until she was wheeled into recovery.

True continuous care.

Even better? JoAnn says the policy has now changed to allow two support people into the operating room.

I’m not saying I’m responsible for that. I’m just saying I’m glad I didn’t trip and face plant on mom’s uterus or something. Ruin it for everybody, you know? ūüôā

Now, look at this adorable poppet enjoying skin-to-skin time with daddy in the operating room. Don’t worry, she got lots of immediate skin-to-skin time with mama first. Mom voluntarily permitted dad a turn.

IMG_5646

It looks like family-centered cesarean birth will be standard care now at Greenville Memorial.

Now, let’s keep that cesarean rate on the decline!

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Students becoming educators

Lately my childbirth students have been teaching medical professionals all about birthing positions.

1)¬† A first time mama was her OB’s first natural birth.¬† Seriously, first natural birth EVER witnessed.¬† And¬†my student¬†gave birth standing up!¬† Providing her own counter-pressure while her husband sat on the bed and held her from behind.¬† She gave birth to an 8lb+ baby without any tearing.¬† She said she felt her OB and nurse believed her to¬†be a giant liability disaster waiting to happen!¬†

The next day, her OB had lots of questions about the birth.¬†¬†The OB was surprised the woman did not “blow out her vagina.”¬†¬†OB:¬† I’ve always supported the use of epidurals so I can control pushing and you don’t blow out your vagina.¬† But you didn’t seem to have a problem.¬† Mom:¬† I had instant feedback from¬†my body about how fast/slow to push.¬†¬†

2)¬†¬†This mom¬†was a VBAC who never¬†got to active labor during her induction with her first baby.¬† And she wasn’t¬†“allowed” to get out of bed.¬† This time, she¬†stayed at home and birthed 17¬†minutes after arriving at the hospital.¬† She chose a hands/knees position.¬† There was no doctor on the floor so three nurses assisted.¬† The one catching had never done a hands/knees births.¬† I could pick up on some anxiety about the position but mom did all the work.¬† She made it easy for the nurses.¬† And thankfully, they were supportive of her choice–not that I think she would have willingly changed positions¬†at that point!¬† The nurse passed the baby straight to mama where she¬†snuggled skin-to-skin for over an hour.¬†

3)¬† A resident had only¬†done back births.¬† Her words:¬† “I see that you’re pushing well on your knees.¬† But what I like to¬†do for natural births is break down the bottom of the bed, scootch¬†you down and have you pull your legs back.”¬† I wanted to ask,¬†“Um, how is that different from medicated births?”¬† Mom was tricked¬†onto her back “so we can check you.”¬† But she rolled to her side.¬† And instinctively gave herself her own counter-pressure.¬† This clearly made the resident uncomfortable¬†but the mom ignored the nurse’s attempts to move her hand.¬†¬†I heard the attending whisper to the resident “the manuevers are the same for a side birth as a back birth.”¬†¬†When the resident gave me some instruction I can’t remember now, I replied, “Oh, ok.¬† I¬†haven’t done a back birth in a long time.¬† The last birth I attended the mom was standing up.”¬† Wide-eyed resident shook her head¬†in disapproval.¬† Sigh.¬† I hope that one moves on to a hospital far far away.¬†

I’m so proud of my students and other families who are changing the way birth is “managed” in the hospital.¬† It can be a tricky place to navigate and the balance of power can be overwhelming.¬† I think of my client who had a breech baby.¬† While she knew cesarean was her only option in the hospital, she also insisted on delayed cord clamping and skin-to-skin contact.¬† She made a path that other women can more easily trek.¬†

These amazing families inform and change one birth at a time.

The Right People at the Right Time

I had such an unusual birth yesterday.

The mom hired me on Sunday.  As in, the day before yesterday.  She was beyond her due date, not feeling great about her OB group, and wondering if unmedicated birth was possible with her OBs.  She was actually having steady contractions when she interviewed me!  The next morning I joined her and her husband for their birth. 

She was wonderful!¬† Perfectly uncomplicated labor.¬† She never complained or asked for pain medication.¬† She just did the work of labor.¬† She did ask for endorphins once.¬† ūüôā¬† She and her husband wanted to get to the hospital late to avoid interventions with their OB group.¬† And she had one OB in particular that she hoped was not on call.¬† He was…more on that in a minute.¬† We spent the day at their home.

We arrived in triage at Greenville Memorial and she was already pushing.¬† The triage nurse checked her, told her to stop or the baby would come in triage, grabbed a resident, and ran to the last bed available in L&D.¬† Our nurse, Ashley,¬†was one that I’d worked with before.¬† So we trusted each other.¬† And the best part–her OB was busy with a birth at another hospital, so we got the resident.¬† I told this wonderful man, Dr. Palmer, what was important to the mom–immediate skin-to-skin, delayed cord clamping, no routine third stage pitocin, and vertical birth.¬† He shrugs and says, “That’s fine.”¬† And he remembered and followed her wishes exactly!¬† I don’t think her chosen OB would go for¬†most, if any,¬†of those choices.¬† Yay for Dr. Palmer.¬†

Ashley brought the squat bar in.  And this incredible woman pushed out a gorgeous baby girl. 

It was as if all the people meant to be at her birth were brought together with such purpose and care. 

Oh, and her OB arrived¬†about¬†30 minutes¬†after the birth¬†to apologize for missing it…

Cesarean Practices

I’m going to try to write this post without sounding like I’m on a rant.¬† Deep breath and…

I want to talk about the immediate postpartum of a cesarean birth.¬† First, let me mention, that I’ve only attended cesareans at Greenville Memorial.¬† My experience is limited and what I’ve heard of other local hospitals is just that–hearsay.¬†

What bothers me the most about preparing my clients for cesarean birth is the inconsistency of practices.¬† I honestly don’t know what to tell them to expect anymore.¬† Examples:¬†

1)¬† Sometimes I’m permitted in the operating room.¬† If the doctor says I can attend, then the anesthesiologist must ok it.¬† I receive that answer second-hand from a nurse.¬† Sometimes after I’m already dressed in scrubs, I’m told “the anesthesiologist said ‘no’.”

2)¬† In that case, I’m taken to the mom’s recovery room to await her arrival.¬† Since Greenville Memorial doesn’t permit recovery room “rooming-in,” I stay with mom while dad goes with baby.¬† Recently, however, I was not allowed in recovery at all.¬† Like the anesthesiologist decision, it was at the say-so of one person–the recovery room nurse.¬† In that situation, the mom was left alone in recovery while dad stayed with baby.¬† I learned that if I was her immediate family, the nurse would let me in.¬† I’ve never heard that one before.¬† I wonder if it is written down anywhere?¬†¬†

3)¬† If baby is healthy, he is taken to the nursery where inane people smile at the babies lying alone in isolettes behind the glass.¬† I have so much trouble with this scene.¬† The babies are alone.¬† These newborns are not skin-to-skin with a parent, are lying on their back under bright lights, and are surrounded by unfamiliar open space and smells.¬†Why are people smiling at this? ¬†But I digress.¬† The inconsistency is how quickly and easily the dad¬†is able to bust his newborn out of the nursery.¬† Sometimes, it is no big deal.¬† Dad walks over to the nursery door and requests his baby.¬† Sometimes, he is told that the baby must be observed for an hour.¬† Sometimes 2 hours.¬† Sometimes he is told the baby must have a bath first.¬† I’ve actually¬†started suggesting¬†my clients flirt or fib to get their baby.¬† I watched one dad do both!¬† Tip:¬† go to the Mom/Baby info desk, ask for the room number of your wife, then go tell the nursery that you have been assigned a room and need to take your baby to his room.¬†

What logic suggests it is best practice to keep baby alone in an isolette immediately after birth?¬† When every medical journal is promoting immediate skin-to-skin and early initiation of breastfeeding, why this practice?¬† Babies do best in arms.¬† Why do newborn nurseries still exist?¬† Now I’m sure Greenville Memorial has a logistical reason for this practice but I doubt it is based on logic.

What my issue boils down to is this:¬† how your baby is handled after a cesarean birth is often determined by one person’s whim or mood.¬†

Another example:¬† one of my clients wanted the baby to be placed skin-to-skin on her chest following her cesarean.¬† She and her doctor discussed how that would work.¬† Everyone agreed.¬† Doctor exited.¬† OR nurse entered.¬† She said “absolutely not.¬† the OR is too cold for skin-to-skin.”¬† And so ensued a tense¬†discussion that ended with a sour OR nurse¬†influencing much of what subsequently occurred in the OR and in recovery.¬†

In some hospitals (even St. Francis),¬†families remain in recovery together.¬† In some hospitals, babies are¬†routinely placed¬†skin-to-skin on mom immediately and in a few hospitals, permitted to nurse in the operating room.¬† I’ve heard of one Australian¬†doctor who encourages the mother to “birth” her own baby during cesareans.¬† He delivers the head and then guides the mom to pull the baby to her chest, cord still uncut.¬† I’m not sure how the whole¬†sterile field issue¬†is handled in that situation.¬† The point is that there are ways to make a cesarean birth feel more like, well, birth.

Step 4 of the Mother-Baby Friendly¬†Hospital Initiative¬†is to initiate breastfeeding within one hour of birth.¬† And while I’ve had one client who nursed her baby immediately after leaving the OR (before baby was removed to the nursery), this is not the norm.¬†¬†On average, for the cesareans I’ve attended, the delay has been more like 2-4 hours.¬† ¬†¬†¬†

And in case you’re wondering why breastfeeding within the first hour of birth is so important, here are a few reasons:

1)¬† Mom’s body regulates the baby’s body temperature.¬†

2)  Baby is less stressed, calmer, and has steadier breathing and heart rates.

3)¬† Baby is exposed to bacteria from the mother which are mostly harmless, or against which the mother’s milk contains protective factors.¬† Mom’s bacteria colonizes the baby’s gut and skin.¬† These compete with more harmful bacteria from health providers and the environment, and so prevent them from causing infection.

4)¬† Baby receives colostrum which, among many other protective factors, stimulates the baby to have bowel movements so that meconium is cleared quick.¬† This helps get rid of the substances in the baby’s body that produce jaundice and may help reduce it.

5)¬† Touching, mouthing, and sucking at the breast stimulates oxytocin to release in the mom.¬† Oxytocin causes the uterus to contract which may reduce maternal bleeding.¬† It stimulates other hormones which cause a mom to feel calm, relaxed, and “in love” with her baby.¬† And finally, it stimulates the flow of milk from the breast.

6)  Mom experiences joy.  The process of bonding is strengthened.

If you had a cesarean birth or attend cesareans, what has been your experience?  What are the practices like at other hospitals?