New Direction?

I admit a modicum of surprise at the lack of response to my last post. I KNOW it got read. 74 times, in fact. (Thank you StatCounter) I shall have to ponder further the meaning of this vacuum of conversation.

In other news, I am feeling rather directionless. We've been at the inlaws now for 12 days. That is a long time to ask ANYONE to let me live with them, even people as saintly as my inlaws (aka the best inlaws EVER). I'm ready to be in my own place and set my own schedule. Oh, and walk around the house without a bra. Or clothes. You know, if I want. I would never ACTUALLY do that, I'm much to proper. Eh hem.

Without school or any other activity or person taking up my time and energy I'm kind of lost. I think I shall open a preschool. That sounds suffiecently time-consuming.

A Letter To A Bastard

NOTE: Toward the end it does get a tad graphic. 

Dr (Name has been removed to protect the not-so-innocent),
I've waited a long time to write this letter. Two years, in fact. At first, I waited until the rush of postpartum hormones had subsided, to make sure I wouldn't be unduly influenced. Then I waited, hoping time and counseling for post traumatic stress would render this letter unnecessary.

But now, on the eve of my daughter's second birthday, I understand you need to know what I have to say, so you can avoid harming other patients in the future.

Two years ago, word on the street was, you were the best provider for TOLAC on the east side. I visited four other offices before deciding my sources were right. I knew that you and I hadn't clicked on a personal level, but that was OK with me, as long as I got my VBAC.
When I presented to the hospital with epigastric pain the day before Thanksgiving, I expected a gallbladder ultrasound and some IV fluids. What I got was a cesarean. Not a medically indicated cesarean, not a voluntary repeat cesarean. A cesarean consented to under duress. A cesarean based on a lie.
It's taken me two years of heavy research and a bio-ethics class to more fully understand what took place that day.
When you came by the hospital to see me the first time that day, you asked if I were ready for my c-section. I said no. We ran blood work. I spent the entire day in a bed doing nothing. The tests came back normal, but you said my pain was probably due to my liver going into failure.  I couldn't believe normal blood work could indicate liver failure, so I asked for, and was refused (according to you, by three different doctors)  a GI consult, you said that you'd consulted with a perinatologist and he'd recommended a section as safest for both me and the baby.  Even though both mine and the baby's vitals had been within the range of normal for nearly the entire visit. (episodes of pain excepted when I did exhibit elevated BP readings but the baby's tracings were normal the entire stay). I did not, at any point during this visit, see or speak with another provider.

When you came back to talk with me that evening, the pain had mostly subsided. It was at this point that you again recommended a repeat cesarean. I asked if my husband and I could think about it over night, since there didn't appear to be any immediate danger. This is the good part. You told me, "If you leave, it will be AMA. Against medical advice, and your insurance company won't pay for anything we've done here today." That verbatim quote is seared into my memory because it was the pivotal statement you made that sent me down the road of a repeat cesarean instead of the VBAC I desperately wanted. It was also a lie. I have no idea if you really believed your statement to be true or if you knew The Hubs and I could never have afforded all those tests and continuous monitoring without insurance. What I do know, now, is that in addition to being completely false, this statement constitutes legal coercion. I did sign the consent form for the surgery, but not willingly. I signed it, because you made it clear signing was my only option.
I knew a second cesarean greatly reduced my chances of a future vaginal birth. You brought that little nugget of knowledge to crystal clear point in the operating room when I asked you to stitch my uterus on two levels, to increase the chance of VBA2C. You said, "not with me, you won't". But that was something I'd already decided.
And then you proceeded to mock me as I lay naked, numb and very cognitively aware on the operating table. With my guts on my chest and your hands in my abdomen, you derided my request and my choices, making perfectly clear your dislike for me as a person and my desire for vaginal delivery; a birth that science has repeatedly shown is safer for both mother and child.

The question I have is this: Was your Thanksgiving meal really so important that you risked my life, my future birthing opportunities and my child? Two years later, do you even remember that day? Because I do. I am fighting an internal battle to be happy it's my daughter's birthday when all I really want to do is curl up and cry because every time you touched me, every incision, every tug, every stitch-- constitutes battery when performed without consent. Dr. Name has been removed. I did not consent.

I hope in future you will treat all your patients, even the one's you don't like, with the respect and regard they deserve. Keep beneficence and non maleficence first in your mind, not a turkey dinner.

note: that's not me. When splayed on a table, I'm MUCH more attractive.

Please read about my healing birth here.

Kiddo Update

Sorry for the several weeks worth of gap in posting. We moved and I've been building a train table for the kids' Christmas. Just so you know, it's cheaper to get a train table off Craigslist than build one from scratch, but if you want a very nice, very new train table, build it. I'll do a post soonishnest on the whole shebang.

Here's what the kids are up to, more for my records than anything.

ZSA ZSA

• Is talking a LOT. Every sentence starts with, "I want".
• Likes to spin in circles until she falls down, then get up and do it again. Sometimes she says. "I fyeeing!" while wearing a cape and running in circles. 
• Says lots of things she doesn't mean, like "go away". Every time I take her up on the offer, she cries. So we've starting working on what go away ACTUALLY means. Next on the list is "hurts".
• Calls dogs (and random other things) "scaweey MONstoos" (scary monsters)

The Boy

• Is loving spending time with Grandpa. They feed the cows and take rides in the truck, during which The Boy falls asleep. (Thank you, Grandpa). My kids are so lucky to have such awesome grandparents.
• His most common sentence is, "Mom, I want you to play a game with me". At least it starts with "Mom" instead of, "I want".
• LOVES school and was sad when Thursday rolled around and we didn't have preschool. Very sad. I need to start one up here in  January. 

My Birthday

This year my birthday has really snuck up on me.
I think that means I'm getting old.
I had come to terms with the 6 gray hairs in my part, even.
Then...
I found a gray hair in my EYEBROW (which I promptly plucked, because, hello gray eyebrow hairs and chasing toddlers don't go together)
This new discovery made me re-count the gray hairs in my part.

TWELVE.

GASP!  

When did this happen? I'm willing to bet half are child-caused and the other half are school related. 

Ms. Clairol and I need to have a serious discussion.
I'm fine with being mature but I am NOT OK with gray eyebrows.
Back to my birthday, or lack thereof.
This year the presents are kinda boring.
The Hubs got me prescription sunglasses. I'd say I need these because I'm old, but I've worn glasses since 3rd grade. I REALLY need these because my current sunglasses are SO last decade...and three prescriptions old. I get headaches switching back and forth. Eves Saint Laurent frames, normally $250, but I got them for $18, because I'm awesome like that. And they were discontinued. :)
We were going to try cross country skiing this week, but alas! Time, money and motivation were all in seriously short supply over the weekend. Instead, I'm going to take a math final for my birthday.
Hooray.

The Bed-A Satire

I don't know WHAT The Hubs gets up to at night, but every morning our bedding is in complete shambles. Before I was married, I woke up in a bed that was already made. One flip of the covers to get out, and reverse it to make the bed.
Now, it takes a planning meeting and SpecOps forces to put our bed back together again, because All The Kings Men and All the Kings Horses just weren't cutting it anymore.
I've quit trying. Making the bed simply can not occupy half my morning.
I had a new strategy that consisted of :

1. Agreeing with The Hubs that the last person out of bed had to be the one to make it
2. Getting up earlier than The Hubs.

Apparently, he thought of the same strategy, because suddenly I'm waking up to an empty bed at 4:45am.
I can't compete with that.

Resistance is futile. I'm giving in to the dark side and leaving the bed unmade. Don't tell my mother.

Reducing Unnecessareans

OK, this paper could have been better, but I just didn't have any TIME. So I totally turned in my rough draft. Don't judge me. I have a 98% in this class.

In the United States today, an unborn child has almost a one-in-three chance of coming into the world via surgical birth. The 32%² rate is over twice the upper limit recommended by the World Health Organization. It’s one of the highest rates in the developed world. What’s more, this increase in cesareans hasn’t markedly improved fetal outcomes and has drastically increased the risk of maternal mortality. It is time to address the issue of “unnecessareans”.

            In 2003, The United States fetal mortality rate was over 7% with a cesarean rate at 21.1%. In contrast, during the same time period, The Netherlands had an infant mortality rate of 5% and a cesarean rate of 12.7%. They also had better maternal outcomes.¹ The most current statistics for cesarean in the United States put it at 32%.²

An article in the October 2010 issue of “OB.GYN News” by David Priver, MD goes over some of the reasons the cesarean rate in the United States is so high. They include professional liability, the demise of operative obstetrics, impatience, lack of an analytic approach to VBAC (vaginal birth after cesarean), and no one teaching the skills to do vaginal breech births to today’s obstetricians. (Luckily, midwives are still teaching new midwives this skill set and Canada has recently asked its midwives to teach new OBGYNs these skills.)

The ethical dilemma facing healthcare providers is, how do we provide the best outcome for mothers and infants, while also providing care that is above reproach and therefore, immune to litigation. One part of healthcare that has changed in recent decades is the belief that the fetus is a patient, too. Prior to sonograms, we didn’t care as much if the fetus lived or died, it was much more important that the mother live to birth another day, hence the advent of the crochet hook abortion for fetus’ too large to fit through a malformed pelvis, or for term fetal demise. Abdominal surgery just wasn’t a viable option if you wanted the mother to live.  This changing view occurred simultaneously with a skyrocketing litigious movement, making physicians less likely to practice evidence-based medicine, and more likely to perform what was deemed “best practice” by lawyers, regardless of the personal convictions of the physician, or what research showed to be the best course of action in a certain situation (i.e. breech vaginal delivery over primary c-section for a woman who hasn’t even gone into labor yet).

Medical schools began to train new obstetricians not in the management of normal birth, but in the pathology of abnormal birth. New OB’s looked for, and found, pathology everywhere they looked because that’s what they were trained to see.  This new way of teaching coincided with the introduction of fetal heart-rate monitors; a device strapped to the laboring woman that supposedly gives a realistic readout of fetal distress. Health care workers began to treat “the machine that goes ‘ping’”, not the patient. Studies have shown, and even the American College of Gynecology and Obstetrics agrees, that the use of continuous fetal monitoring doesn’t improve the outcome for most infants, and has quite a marked effect on decreasing outcomes for the mothers, namely in the form of cesareans and their vast and varied complications.⁵

We start to see now that doctors have forgotten their oath to do no harm to the mother, in their haste to prevent perceived harm to the fetus. One can only surmise the foremost thoughts in the mind of the physician are the lawsuits he’s evading by following “best practice”.  The real question is, in whose best interest are decisions being made?

When we approach this dilemma from the viewpoint of an absolutist metaethical theory we can ask ourselves, what known truths are being subverted by the physicians in their push for unnecessary surgical births?  There are several answers: the innate autonomy of the woman to make informed choices about her body and her birth, the duty of the physician toward primum non nocere, and the duty of the physician to ensure informed consent. All of these innate rights are being violated in the push for surgery to “cure” what might be “wrong”, not with the primary patient, but with the fetus.

We can look to other countries for ideas to drastically lower our surgical birth rate while maintaining or improving patient outcomes for both mother and child.

The first thing health care providers could do is to spend more time with patients educating them prior to conception, and throughout pregnancy. This would not only allow time to educate, but also foster trust between the mother and the person she has chosen to see her safely through birth. Currently, mothers receive no prenatal counseling and physicians spend on average four minutes per visit with each mother. This means the average healthy mother spends 22 minutes with her provider between conception and the start of month eight. By the time birth is eminent, a mother will have spent less than an hour total with her doctor. Contrast that to the midwifery model of care that has the patient spending, on average, one hour per visit and that hour is frequently in the mother’s home. In addition, many midwives adopt a model of group prenatal care that allows for additional time spent with a group of women in similar gestation, fostering a community of trust and support between both the provider and other pregnant women. This model has been shown to drastically reduce the fear and pain associated with childbirth.  Obviously most doctors are not in a position to offer this level of care, and most people couldn’t afford for a physician to provide it. An alternative would be to let doctors provide the care for truly high risk patients, and shift to midwifery for healthy women.

Another factor in the high cesarean rate in the United States is an epidemic called “failure to wait”. In our need for instant gratification, we forget that babies are not parcels delivered by UPS. They do not have an “arrive by” date, nor do they expire if not delivered within a prescribed time limit of 39 weeks, 6 days. The latest research surmises labor begins when the baby’s lungs send out a signal saying “we’re ready!” and not a moment before. For prima gravid patients, this is 41 weeks, 3 days! Cervical ripening agents and pitocin not excepted, a baby simply won’t be born before it is ready. Pitocin isn’t even an FDA approved medication for labor induction without medical cause, yet women request it, and doctors prescribe it and health care providers abuse the dosing schedule, increasing the rate too quickly or using a starting dose exceeding the package insert, all to make the baby come before the ball game/vacation/holiday/dinner. There is even a movement called “pit to distress” which basically says we’ll ramp up the pit until the baby can’t handle the intensity and frequency of contractions, at which point we’ll tell the mother her baby is going to die unless we do a cesarean. This isn’t even a lie because at that rate, the baby WOULD die—squeezed to death by the womb.

A third idea for reducing the cesarean rate in the United States would be to not only discuss, but educate and encourage women with previous cesareans to birth vaginally. Set up support groups and classes to make sure mothers make informed decisions about their options. You would be hard-pressed to find a surgeon who discussed all the risks of repeat cesareans with mothers. Just a few are adhesions, baby having to spend time in NICU because the cesarean was performed prior to spontaneous labor so baby has difficulty breathing, and placenta acreta (a disorder where the placenta grows into the scar tissue from the previous incisions and won’t let go when the surgeon determines it’s time; this frequently leads to hemorrhaging and subsequent hysterectomy).

In healthcare today, women need to demand better care from their providers. If our physicians won’t do the job of educating, we must find our education elsewhere. ICAN, the International Cesarean Awareness Network has many good resources and chapter leaders can be found in most parts of the country. Healthcare workers must act as guardians of labor and laboring women, ensuring the proper management of normal labor. Meaningful tort reform MUST pass, to give doctors the freedom to do what is best for patients, not the malpractice insurance agency, and every person must realize birth is a delicate dance between the baby and the mother. Health care providers are there simply to make sure the two of them do what they were designed to do, and nothing more.  

The risk of complications up to and including major abdominal surgery to birthing mothers can be reduced if our society takes a step back and remembers to treat birth as a physiological process to be watched and guided, rather than a pathological condition in need of treatment or management; birth by design, rather than birth as cure. Teaching the nation’s birth attendants the normal processes of labor in its many variations, rather than a set form of numbers that MUST be adhered to, “or else” will go far in reducing unnecessareans.

1.      http://www.nationmaster.com/graph/hea_bir_by_cae_sec-health-births-by-caesarean-section

2.      Ob.Gyn News August 2010, p.1

3.      http://www.theunnecesarean.com/storage/cesarean-rate-by-year-US.jpg

4.      http://infochimps.com/datasets/infant-neonatal-and-maternal-mortality-rates-by-race-1970-to-200

http://www.ourbodiesourblog.org/blog/2009/07/acog-issues-new-practice-bulletin-on-continuous-electronic-fetal-monitoring

The Saga of a Song

Every night, Zsa Zsa and I have a routine.

I get the toothbrush, she yells "TEEF!!!" and we brush.

We say a prayer with the family.

I read her a story.

Then we shut her doors, say good night to the baby in the mirror and flip off the light after which Zsa Zsa says, "rock-a-bye".

We sit in the rocker and she snuggles into my chest and dictates the songs. 

Always the same songs.

Always in the same order. 

1. "Sunbeam!" I get two bars in and she stops me.
2. "Jesus!" This can get confusing because she either means "Sunbeam" again, or "I Am A Child of God"
3. "Heavenly Fadder!" This one is "I Am A Child of God"

This is all well and fine until we get to nursery on Sunday, because in nursery, we sing these songs. She does OK until we get to "I Am a Child of God" at which point my already tired daughter throws a MAJOR hissy fit. We're talking, screaming, falling to the floor, heal banging included, until the song is over.

Every.  Week. 

Travel Plans and Life Plans

We have tentative plans for our move back to Arizona. Finals are the week of the 12th. My last final is the 16th. This is also (crazily) the day we've planned to toss all our worldly possessions into the car, top with children, and drive to St. George.
The next day we will repeat the above scenario, minus the final, and sub the destination with Gilbert, AZ.
I'm hoping to spend a few hours with family in St. George on Friday. Especially my grandpa.
The Boy is a champion traveler, but Zsa Zsa....well not so much. Two straight days in the car with her will require heavy medication (I don't care who gets it, me or her) or a long rest for the kids Friday before we get back in the car.
 I have SO many plans for when we get back home!
High on the list are:
potty training (Zsa Zsa, not me. I've got that one down, thankfully)
ditching the ever-present binkie (again, Zsa Zsa)
starting a preschool in my front room, because teaching in Idaho has been SO much fun!
taking another math class, so I can get done with math and never have to take it again
build a toy kitchen for my kiddos out of re-purposed materials
build a set of beds from www.ana-white.com


or maybe this