ACOG's Committee Opinion: Mothers Need Postpartum Care

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The American College of Obstetricians and Gynecologists (ACOG), the body of OBGYNs that sets the standards for US maternity care, issued a new committee opinion statement earlier this month on "Optimizing Postpartum Care" for mothers. This is what they decided:

"To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs."

Currently, women who work only with an obstetrician during their pregnancy have one single postpartum visit after they are discharged from the hospital - at 6 weeks. It appears that ACOG has finally figured out that mothers need to be cared for after the birth too - that one visit at 6 weeks postpartum isn't enough.  It's simultaneously depressing and infuriating that ACOG has released this statement like it's actually news. 

In the 5 week and approximately 5 day interim after a new mother leaves the hospital and before she is seen again at the doctor's office, an abundance of physical changes occur:

  • Vaginal bleeding slows and eventually ceases
  • The uterus returns to its non-pregnant size
  • Breastmilk production begins
  • Breastfeeding is established 
  • Pregnancy hormones drop rapidly and return to non-pregnant levels
  • The muscles and mucosa of the vagina and pelvic floor heal, including any tears or damage caused by the birth
  • The abdominal muscles, which may have separated during the pregnancy, begin to come back together
  • Sexual intercourse may resume

These physical changes are coupled with enormous psychological and emotional shifts. A new baby means the complete disruption of the family's previous way of life. Sleep is greatly reduced. Daily tasks that were simple become difficult and time-consuming. And a mother's (and father's) sense of identity shifts dramatically and irrevocably. All of these changes come with associated risks, where the normal course of things can get off track. The consequences can be devastating if these deviations from normal are not noticed and handled in a timely way:

  • Late postpartum hemorrhage 
  • Uterine or other infection leading to sepsis, causing grave illness or death
  • Anemia
  • Low milk supply
  • Painful breasts and nipples
  • Cessation of breastfeeding due to lack of support
  • Postpartum depression and psychosis
  • Suicide or infanticide
  • Preeclampsia
  • Pelvic floor dysfunction causing urinary incontinence, fecal incontinence, and pain
  • Incomplete or improper healing of the vaginal tissues, causing pain and dysfunction
  • Painful sexual intercourse
  • Diastasis of the abdominal muscles

How many of you have friends who are mothers, or have yourselves, suffered from one of these complications after giving birth? I know many.

And this list is not exhaustive. Giving birth is a complex process, for both the mother and the baby. Why would anyone who knows anything about childbirth believe that a mother doesn't need support from her care provider in the 6 weeks after giving birth to her baby?

That ACOG is only now coming to the conclusion that mothers need ongoing postpartum care, despite decades (centuries, millennia) of evidence, can only lead us to one conclusion: the US maternity care system is yet another way in which our society undermines and silences women. And even more so for women of color.

If you need more evidence that this is true, allow me to point you to a tweet that sent ripples of disbelief across social media a few weeks ago:

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This proud tweet is from a presentation given at the ACOG 2018 Annual Clinical and Scientific Meeting, and suggests that "using condoms to prevent pregnancy [is] ACOG's best advice for reducing the maternal mortality rate that is on the rise in the USA."

Sarita Bennett, Vice President of the Midwives Alliance of North America, summed it up well: "As the only industrialized country to hold the dubious honor of having the most expensive system of maternity care while its outcomes are worsening, the profession who presides over the vast majority of those births [ACOG] seems to think that a cartoon condom holds the answers. Given that these statistics are three times worse for women of color, the sentiment takes on a racist tone to add to the misogynist attitude that is at the heart of the power dynamic identified as a leading contributor to obstetric violence." 

Postpartum care is one of the (many) areas where the midwifery model of care excels beyond the obstetric model. We see our clients five times postpartum, three of those being in the first week after the birth. At every visit, we evaluate and support the wellbeing of both the baby AND the mother. We look at physical recovery and healing, as well as signs that the mother is or isn't coping well emotionally. We support breastfeeding, help with achieving a good latch, evaluate the mother's milk supply, diet and nutrition, and make sure she is getting adequate rest so that her body can heal. That is midwifery care. That is GOOD care for mothers.

It is hard to express how difficult it is to see ACOG and its member physicians slam licensed midwives and home birth on a regular basis and then come out with some asinine statement like this one. It makes me sad for families in the United States because so many do not know, and do not understand, how political and capitalist our maternity care system is. The knowledge gap between consumer and provider is cavernous. Families are caught in the web, thinking they are receiving the best care, and making the best choices for themselves and their babies, when so much of current practice is deeply influenced by money, politics, powerful trade organizations, smear campaigns, and outdated clinical practice.

So yes, ACOG, we should check on the mother more than once after she and her body undergo a deeply transformative physical and psychological process. Thanks for letting us know.

Read the full ACOG Committee Opinion here.

What's the difference between a midwife and a doula?

This is by far the most common question that I get when someone finds out I’m a midwife. So a midwife and a doula are both very important parts of the birth team, but we have very different roles. And there are places that our roles overlap. A doula is an emotional, a physical, and an information support person. A midwife, which is what I am, has a clinical role. In the state of CA I am licensed by the medical board to provide complete care for healthy mothers and babies. That means that during your pregnancy, during your birth, and during your postpartum period, I would be your main care provider. 

Diabetes in Pregnancy & Why You Should Get Tested

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Diabetes is caused by not having enough of a hormone called insulin. You can think of insulin as a little transporter that takes glucose from the food you eat and carries it to your cells, where it can be converted into energy. If you don't have enough of these transporters, then there is a lot of glucose just hanging out in your blood. That's not good. In Type II Diabetes, the pancreas (which makes insulin) says "Whoa there's a lot of glucose here. I better make more insulin to carry it to where it needs to go." And the pancreas makes more and more insulin until it tires out and just can't do it anymore. At that point you have what's called hyperglycemia - or way too much sugar in your body - and you get sick. 

Gestational Diabetes Mellitus (GDM) acts like Type II Diabetes in the way that your body tries to make up for an overabundance of glucose. But it's a little different because what's causing the glucose to build up is not a lack of insulin; instead it's a pregnancy hormone, produced by the placenta, called human placental lactogen (HPL). HPL increases a pregnant woman's cells' resistance to insulin - so when the little insulin transporters come to dock at the cells with their glucose, they are turned away! HPL and the cells' resistance to glucose is a normal development of pregnancy, and peak production of HPL is around 26-28 weeks of pregnancy. In most women, the pancreas is able to keep up with the need for more insulin transporters to take care of all of the glucose, but not always. That's when you get GDM. When you have GDM, your pancreas can't keep up with all of the glucose free-floating around, and the overabundance of sugar can cause problems for both you and your baby. 

Most of the time, GDM can be controlled with diet and exercise. This is very important! You can still receive midwifery care and even possibly have a home or birth center birth if you control your GDM! On the other hand, uncontrolled GDM, where glucose levels are running free, can cause a number of problems.

If your blood sugars are high in your first trimester, the result can be heart or nervous system problems for your baby. If early blood sugars are normal, but rise in your third trimester, the risk for genetic problems is not increased, but other risks increase for the baby, including the risk for stillbirth.

Uncontrolled GDM also causes babies to grow bigger than they normally would. Insulin is similar to human growth hormone (HGH), which does exactly what it sounds like it does. As the mother's blood sugar rises, it crosses the placenta to the baby, and the baby's blood sugar rises. Baby doesn't have diabetes, but also reacts by creating more insulin. The increased insulin acts as a growth stimulator for the baby, and he or she gets really big. This is a lifelong change for the child, and has been linked to childhood and adult obesity later in life. A really big baby also can mean problems for the delivery - it can cause stalled labor, shoulder dystocia (where baby's head is born but shoulder gets wedged behind the pubic bone), and the need for Cesarean section.

Complications for mom include high blood pressure, preeclampsia, and  the increased risk for developing Type II Diabetes later in life.

So who actually develops GDM? The American Diabetes Association established these guidelines for whether a pregnant woman should get tested for GDM or not. Women that meet all criteria do not need screening:

  • Under 25 years old
  • Weight normal before pregnancy
  • Member of an ethnic group of low prevalence (white American or Western European)
  • No known diabetes in first-degree relatives
  • No history of abnormal glucose tolerance
  • No history of poor obstetric outcome

Most women will not meet every single one of these guidelines. Recommended screening is between 26 and 28 weeks of pregnancy when HPL is at its highest. Currently the medical model of screening is called a Glucose Challenge Test (GCT) or a Glucose Tolerance Test (GTT). You may be asked to fast and then drink a sugary drink, wait an hour (or two), and then your blood is drawn to see how much glucose there is in it. 

Another option that is not widely practiced in the obstetric community, but is more common among midwives, is to do home glucose monitoring with finger sticks over a period of time. We do 5 consecutive days of testing, with 4 tests per day. You stick your finger when you wake up before you eat anything, then again 1 hour after each meal (breakfast, lunch and dinner). This gives us a good idea of how your body is metabolizing the foods you are actually eating. With this test, you avoid the sugary drink, which makes a lot of pregnant women nauseous, and you get a good idea of how your body is processing glucose. But you have to be pretty committed to doing the finger sticks over the week at the right times!

Whichever way you choose to go, knowing your risk factors and getting tested for GDM is important. Most pregnant people will test negative for GDM. But if you are one of those who is having high glucose levels, it's important to know this, so that you can make diet and lifestyle changes that allow you to continue with a healthy pregnancy, and hopefully, a home birth!

CPMC St. Luke's May Be A Slam Dunk If You Want To Have A Natural Hospital Birth

St. Luke's Hospital Labor & Delivery

St. Luke's Hospital Labor & Delivery

Yesterday, I went on a tour of what has been argued for years by homebirth midwives to be the best hospital in San Francisco to have a natural birth. Not having had occasion to transfer there myself, I was curious to learn about their facility and policies. This is what I learned...

One of the nurses guided myself and 3 pregnant couples on our 45 minute tour at 5pm on a Tuesday evening. She started by explaining that in labor, patients should come in through the main entrance, unless it is the weekend or after 8pm, in which case patients should enter through the emergency department off of San Jose Ave. There is a cafeteria on the 2nd floor that is open Monday through Friday from 6:30am to 6:30pm where guests can get hot food and snacks. 

Labor and delivery is on the 3rd floor. There are 3 delivery rooms and 3 triage rooms. The delivery rooms are smaller than the rooms at some of the newer hospitals like UCSF Mission Bay. The triage rooms are very small, and are used for patients who are not yet in active labor. Both the labor and the delivery rooms have attached bathrooms - although none of them have bathtubs, and only the delivery rooms have showers. 

All rooms, according to our guide, have telemetry units, also known as wireless fetal monitoring. This allows for monitoring of the baby without requiring that you be hooked up to a static machine at the bed. The monitor hangs around your neck so you can move about. 

The nurse estimated that St. Luke's does about 80 deliveries a month. On the evening of our visit, all 3 delivery rooms were occupied, and 2 out of 3 of the triage rooms were occupied. For that reason, we were not able to see an actual delivery room, just one of the smaller triage rooms. Our tour guide assured us, however, that it is very rare for them to be so full as to have to deliver patients in the triage rooms or reroute patients to another CPMC campus. 

One of the triage rooms at St. Luke's. 

One of the triage rooms at St. Luke's. 

Next, we went up to level 5 to the postpartum unit. The postpartum rooms are also small and uninspired. There is a hospital bed, a television, a fold out chair for partners, and a small sink area. They also have a connected bathroom with toilet and shower. The typical stay for a vaginal delivery is 2 days, and for a Cesarean section, 4 days. 

Postpartum room

Postpartum room

PROS

  • Midwives are the primary providers at all low-risk deliveries. There is a midwife and a physician in the labor and delivery unit 24 hours a day, 365 days a year. The physician attends deliveries only when it is deemed medically necessary.
  • Intermittent fetal monitoring is an option and wireless monitors are available in all rooms.
  • Group prenatal appointments are available in cohorts of 10 families per group. The program is modeled after the Centering Pregnancy model, but was developed by CPMC. In this model, prenatal appointments and pregnancy/childbirth education are blended into bimonthly group appointments. Afternoon and evening meeting times are available. The groups fill up months in advance, so sign up early.
  • The hospital started allowing VBACs in October of 2017. I do not have any more information on the requirements for a VBAC, policies, or rates of successful VBAC at St. Luke's.
  • Laboring patients are allowed to move freely during labor and to push in positions other than flat on their back in bed. In fact, our guide assured me that babies at St. Luke's do not have to be born in the hospital bed - that babies are born on the birth stool, in a squat, on hands and knees, and in a variety of positions. This is a BIG DEAL. I don't know of any other hospital in the Bay Area that will let you deliver your baby anywhere other than in the hospital bed.
  • Baby rooms in with mom.
  • A lactation consultant and social worker are available on the postpartum floor Monday through Friday.
  • There is no restriction on the number of visitors you can have in labor and delivery or postpartum.

CONS

  • The facility is old and the rooms are small.
  • There are no bathtubs in any of the rooms, and only the delivery rooms have showers. 
Ensuite bathroom for one of the postpartum rooms

Ensuite bathroom for one of the postpartum rooms

Unfortunately, our guide didn't have a very good grasp of the actual hospital policies or practices around things like GBS, VBAC, induction, eating in labor, C-section, or pain management options.

I was able to glean some information about St. Luke's C-section rate from online. According to the California Hospital Assessment and Reporting Taskforce, CPMC St. Luke's had a NTSV C-section rate of 21.7% in 2014. For reference, the statewide rate for that year was 26%. The NTSV C-section rate includes only first-time moth­ers giv­ing birth around their due date, hav­ing a single baby that’s po­si­tioned head down.

Without knowing much more about key procedures or policies, all of the obvious cons are related to the facility. And guess what - there's good news here. CPMC is currently in the process of building a new campus for St. Luke's. The new campus will be right next door to the current one, and is on track to open towards the end of August 2018. That's in 8 months, folks! So many of you reading this will benefit from the new facility, which is certain to be leaps and bounds better than this one. I'm told there will be bathtubs :-)

If you are healthy and are having a healthy pregnancy, then having your baby at home or in a freestanding birth center is the best option if you want to avoid a C-section or other restrictive or invasive procedures. That being said, if you are absolutely set on a hospital delivery, you should seriously consider St. Luke's for your care if you are desiring a natural birth. Having a midwife as primary provider and being able to deliver in the position of choice makes St. Luke's much closer to a mother-baby friendly model of care than most other hospitals in the Bay Area. I wouldn't be surprised if many of their other protocols are similarly progressive. 

In my opinion, once St. Luke's is in the new facility, it'll be a slam dunk for Best Hospital in the Bay Area for a Natural Delivery.

Addendum: Shortly after I published this post, the lead midwife at St. Luke's reached out to me by email to clarify some aspects of the facility that my tour guide hadn't been completely accurate about. Those updates have already been made in the body of this post. She also emphasized that along with the move to the new facility, St. Luke's was working to implement changes to make the midwifery-centered approach even stronger. This is really fantastic to hear. While a nice facility can certainly make your experience more pleasant, there is nothing more important than the values of the team that is providing your care. 

All About Birth Centers

 
Many birth centers offer the option of delivering your baby in the water, also called water birth. Very few, if any, hospitals allow water birth.

Many birth centers offer the option of delivering your baby in the water, also called water birth. Very few, if any, hospitals allow water birth.

 

What is a freestanding birth center?
A birth center is a freestanding building, not connected to a hospital, where women go to receive maternity care (prenatal and postpartum) and give birth. Birth centers cater to women desiring a natural birth, without medications or medical interventions. Birth centers only care for healthy mothers and babies. High-risk pregnancies are not appropriate for birth center care.

The American Association of Birth Centers has more info.

What is the difference between a hospital and a freestanding birth center?

A freestanding birth center is a home-like environment. Many birth centers have luxurious queen beds, dimmable lighting, and a warm and cozy interior. At a birth center, you are free to move around, to eat and drink in labor, and to birth in whatever position feels right to you. Medical equipment is often hidden in cupboards, easily accessible, but out of sight, so it doesn't detract from the environment. Intermittent monitoring of the baby's heart rate is done with a handheld doppler, as opposed to a continuous fetal monitor. Interruptions and medical interventions are kept to a minimum so as not to disturb the laboring person and the natural process of birth.

But not only do birth centers offer a different kind of environment, they offer a completely different kind of care than hospitals.

Monty Python’s The Meaning of Life illustrates the problem birth centers solve in a typically comical and dramatic fashion…

 
 

Birth centers, in contrast, provide care according to what’s called the “Midwifery Model of Care.” In the Midwifery Model, care is delivered by midwives, not doctors. Here’s what a family can expect at a birth center:

  • Personal attention
  • Time with their care provider
  • In-depth education around pregnancy, birth, nutrition, tests, options, etc.
  • Individualized care tailored to their specific needs
  • A care provider who will stay with them throughout their labor and birth
  • They will know who will be at their birth
  • The freedom to move, eat, make noise, and do as they choose in labor
  • A peaceful, private environment in which to give birth
  • Overall, high-touch, low-tech care

Here’s more about the Midwifery Model of Care.

98.8% of women using a freestanding birth center would recommend it to a friend and/or return to the birth center for a subsequent birth.

If birth centers are so great, why aren’t more women choosing them?

Good question — because there aren’t enough of them.

 
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But why would women desire a birth without medication and/or interventions?

Pregnancy and birth happen by a complex chain of events triggered by hormonal and other physiological changes. Every time we introduce something, like a medication or another type of intervention, we run the risk of upsetting this very fragile biological process. When the process of labor is interrupted, it causes problems which necessitate other interventions to stay on track and keep everyone safe. This phenomenon is called the “Cascade of Interventions.” It can be thought of like a snowball — one intervention leads to another, and then another, and another. The ultimate intervention, where the baby is removed by surgery to the abdomen, is called a Cesarean Section. In the US, 1 in 3 women is having a C-section. This is SO HIGH! And it has grown considerably over the last several years.

The World Health Organization believes we should aim for a maximum of 10–15% of women receiving C-sections. The US is currently at about 32.4%. Most women don’t want a C-section and one of the best ways to avoid getting one is to have your baby at home or at a birth center. Out-of-hospital births end up with a transfer to the hospital and a C-section rate of only 5.2%.

More Than Half Of C-Sections Performed In U.S. Aren’t ‘Medically Necessary’
Pregnant American women give birth via caesarean section at more than double the rate the World Health Organization…www.huffingtonpost.com

What’s so bad about C-Sections?

“Like any other major surgery, c-sections can have complications, like damage to other organs, internal bleeding, blood clots or infection. Recovery after a c-section is typically longer than that of a vaginal birth. Moms who have c-sections may experience as much as six weeks of post-operation pain and bleeding, versus bleeding and vaginal discharge for two to four weeks after a vaginal birth. Finally, women who have a c-section for their first baby will face risks for subsequent pregnancies, like a higher chance of the placenta implanting or growing abnormally, or uterine rupture along the site of the scar.” Huffington Post

There is also substantial lifelong risk to the baby, as found by a recent study published in the British Medical Journal and reported by CBS News (among others).

What about pain?

Birth centers specialize in unmedicated birth. They educate women and their families prenatally about what to expect in labor and how to cope with the intensity of birth. Most women do just fine. I have heard women say that labor was not nearly as painful as expected, and that having a spider bite incised was far more painful!

That is not everyone’s experience, however. So birth centers do offer tools like massage, hydrotherapy (water is very relaxing in labor), TENS units (electro-stimulation), and other natural measures to help women cope.

That being said, there are some pain medications that pose minimal risk and can be used safely in a birth center. Those medications are nitrous oxide (laughing gas) and some types of narcotics.

How much does birth center care cost?

Not only do birth centers provide more personalized, attentive care with fewer interventions, but they are also far less expensive than hospitals. The New York Times did a great job of summing up the incredible costs of having a baby in their 2013 article, American Way of Birth, Costliest in the World. Here’s an excerpt:

“When she became pregnant, Ms. Martin called her local hospital inquiring about the price of maternity care; the finance office at first said it did not know, and then gave her a range of $4,000 to $45,000. “It was unreal,” Ms. Martin said. “I was like, How could you not know this? You’re a hospital.”

[…] Add up the bills, and the total is startling. “We’ve created incentives that encourage more expensive care, rather than care that is good for the mother,” said Maureen Corry, the executive director of Childbirth Connection.”

American Way of Birth, Costliest in the World
LACONIA, N.H. — Seven months pregnant, at a time when most expectant couples are stockpiling diapers and choosing car…www.nytimes.com

By comparison, cost of care in a birth center is usually a flat fee and varies by cost of living in that part of the country. Ranges are from about $4000 in Austin, TX to $9000 in the San Francisco Bay Area.

Does health insurance cover birth center care?

YES! Most PPO plans cover some portion of birth center and midwifery care. The amount varies considerably by plan, but many plans cover between 1/3 to the full amount of the fees.

Are birth centers licensed?

In California, licensing of birth centers is optional, and there are a number of reasons a birth center might choose to forego licensure. All midwives, however, are licensed. Licensed midwives are licensed by the Medical Board of California. Many other states also have legislation for licensing midwives and birth centers.

Is birth center care safe?

Yes, it is. Midwives that work in birth centers are fully licensed and have followed a course of study that prepares them to safely care for families in a birth center setting. Birth centers stock a variety of tools to handle potential emergencies, including medications to stop bleeding, resuscitation equipment for both the baby and the mother, and oxygen. All staff are trained in Neonatal Resuscitation, CPR and Advanced Life Support in Obstetrics. Statistics for nearly 17,000 out-of-hospital births and their outcomes can be found here.

Do birth centers carry malpractice insurance?

Yes, birth centers and the midwives who work in them are required to carry malpractice insurance.

Where can I learn more about the maternity care industry in the US?

Ricki Lake did a fantastic documentary called The Business of Being Born that gives an enlightening look at the issues surrounding maternity care in the US. Here’s the trailer…

The full version of the documentary is available for free on YouTube.

So in summary…

Birth centers…

  • are safe
  • are consumer friendly
  • have extremely high customer satisfaction
  • provide more personalized care
  • offer a peaceful, luxurious environment
  • and are cheaper than the competitor (hospitals).