Friday's Appt. and Questions to ask the OB

Friday's appointment went well. Tray's heartbeat is still strong and everything looks good. Well, everything except that I'm measuring big. For the second visit in a row, the size of my belly is bigger than it should be. Granted, the OB uses a fabric measuring tape so that measurement is quite crude. If I continue to measure big at next month's appointment, I will have to have another ultrasound. (Side note: With a totally normal pregnancy, the last ultrasound is at 20 weeks! Can you believe that? They don't look at the baby again until s/he is born!)

I know Tray and I just went through a growth spurt so that may explain why I'm measuring big. At our February appointment (19 weeks), I'd only gained a total of 7 pounds, which is under where I should have been. At this appointment (24 weeks), I'd gained a total of 12 pounds (up 5 pounds), which is right around where I should be.

One of the big decisions we recently made was to hire a doula for my labor. A doula is a labor support person for the mother. They offer pain coping techniques including massage, counter-pressure, relaxation exercises, birthing pool, etc. for the duration of the labor. Typically, they also offer support postpartum in the form of home visits and 24 hour phone support for up to 2 months after birth. We met with the doula we eventually hired a couple of weeks ago and Matt and I both really like her. She's a mother of three, a distance runner, a writer, a brand new yogi (like us!), and the former director of the Seattle Midwifery School (which means she's also a midwife, although, she will only act in the capacity of a doula for us). It was very helpful to hear her perspective after assisting at over 300 births!

The hope is that we will labor at home for as long as possible with her assistance. She will bring all of her doula toys (birth ball, birthing pool, rebozo, hot/cold packs, scented oils, etc.) to help us try to meet this goal. (This is, of course, assuming a totally healthy pregnancy and no potential issues.) Ideally, we will birth at home until 6-8 cm of dilation. The hospital is a short 10 minute drive from here, so we will be in a good position to get there sooner if necessary. The ultimate goal is a natural birth, without intervention or drugs but in the hospital with our OB (sounds like an oxymoron in this day and age). This is just a goal and we are well aware of all that lies on the other side of the spectrum. We want to be prepared for all possible outcomes.

At Friday's appointment, we got to have a conversation with our OB about our doula. We were also able to ask our OB several questions our doula brought up during out meeting. First off, our OB is very friendly to the idea of a doula and has worked with doulas in the past (she even gave us a sheet of recommended doulas last time we asked). She's also aware that if we were living in a European or an Asian country, there's a 90% chance we'd be giving birth with a midwife, as OBs are only used for high-risk pregnancies in the vast majority of the world. All and all, our OB is about the best doctor we could ask for right now. The only problem is that she works in a hospital and hospitals follow strict protocols. Let me explain.

Like all of medicine, protocols are developed out of research. Medical research is most often based on the bell curve. Medicine looks at the distribution of a given scenario and a protocol is instituted for the mean (the average) of that distribution (the very top of the curve). So, for example, with a woman in labor, the protocol might be to put her on pitocin (a synthetic version of oxytocin which is what your brain is producing to get your body to start contractions) after ____ hours without natural contractions. The protocol is applied to all women at a certain number of hours (whatever the protocol is), with very little variation. The problem is that variation exists in the real world (as the bell curve proves). On a bell curve, the mean is just the very top of the curve. 50% of people fall on one side of that inflection point and 50% of people fall on the other side of that inflection point (i.e. some women will experience natural contractions much sooner than the average and some women will experience natural contractions much later than the average). But everyone gets treated the same because that's how medicine is able to minimize risk and how hospitals are able to keep up with the demand. Our OB, despite her desire to give us the birth experience she knows we want, will ultimately have to follow the protocol at our hospital, more or less.

In the scenario of a woman without natural contractions, say 8 hours after her water breaks, the hospital will put that woman on pitocin to minimize risk for infection and speed up the labor process. A midwife would let that woman continue to labor at home unless there was some reason for alarm. Pitocin exists for a reason, absolutely, but too often it is applied to nearly every woman who walks though the doors of the labor and delivery ward, before seeing what her body is naturally capable of. However, the real problem with all of the interventions that occur at a hospital during the labor process is that one intervention leads to another, which leads to another, and to another. It can be a very slippery slope. Historically, the ultimate goal of obstetrics was a healthy baby, and protocols were developed in response to that goal. From my perspective, the real goal, however, should be a healthy baby and a healthy mother.

There was an article in the NY Times earlier this week about the c-section rate in the United States. The World Health Organization recommends that the average c-section rate in any country should be no higher than 15%. The c-section rate in the US is now at 32%. One in every 3 women gets a c-section!! Some states are as high as nearly 40%! It used to be that a c-section was only performed as a life saving measure. Now, if I wanted to, I could elect to have a c-section (elective c-sections are probably only a very small percentage of the 32%). I totally see the benefits of a c-section and I can understand why they are performed. But, again, I don't want to be forced to have a c-section because of protocol alone.

The hospital where we will deliver had a c-section rate of 34% in 2008. The flaw in that statistic is that our hospital has one of the best neonatal departments in the state. They see more high risk pregnancies than other hospitals which drive up their total. We asked our OB what her c-section rate is. The last time they measured, as a group (there are 8 female OBs total), they were around 13-15%. We asked our OB how often she delivers her own patients. She's on call one night a week, which means that if I deliver in the middle of the night, I have a 1 in 7 chance that my OB will be the one who delivers our baby (good thing her partners share a similar philosophy!). For daytime deliveries, she's on call 5 days a week (meaning she runs from the office to the hospital (next door) to deliver her patients throughout the day). Overall, she says there's a 60% chance she will deliver our baby. I asked our OB about birthing positions. When a woman gives birth on her back (how most hospitals require a woman to give birth), her pelvis is 33% smaller than if she was squatting or bending over (the baby passes through the pelvis). Our OB says she has delivered babies in all kinds of positions but, typically, once a woman has an epidural, she's required to lay flat so most women give birth lying down. If I'm able to make it through labor to the pushing phase without an epidural, I hope to get into whatever position feels best at that time. Obviously, that position is TBD, but it's nice to know that I may be able to do something other than lay in bed.

The more research we do (books, documentaries, etc.), the more we are glad that we're getting the big picture. We will give birth with an OB in a hospital and that is reassuring in many ways. But we will also have our doula with us and she will know what type of birth we want and she will advocate for us, which becomes especially important when you end up with labor nurses you've never met before and an OB you've never seen because yours is off duty. Also, studies have shown that doulas decrease the likelihood that you will end up with an epidural, a c-section, etc.  Ultimately, we don't know what the labor experience holds for us and, more than anything else, we're trying to prepare for that unknown equipped with as much knowledge as possible.