Delivering caring, personalized, quality healthcare to women in an environment that is supportive, education-focused and compassionate.

Labor and Delivery

Outpatient lactation services receiving support from TMC Mega Raffle

Little Kailey Nowak decided to enter the world five weeks ahead of her due date. Her mom, Kelly, experienced difficulties with breastfeeding almost immediately. “She wouldn’t latch on, or if she did, it would only be for a few seconds,” she said. “It was awful. I cried every single day for six weeks as I pumped and fed my baby through a bottle. My plan was to breastfeed, and when I couldn’t, it truly felt like I was failing as a mother. People were

The family lives in Sierra Vista and with few lactation support services available there, Nowak’s pediatrician suggested she seek expert advice from the lactation specialists at TMC, where she had previously rented her hospital-grade breast pump. “I didn’t know what to expect, but the lactation specialists solved my problems and had Kailey successfully breastfeeding just two minutes into my session. It was the most magical moment of being a mom. I finally felt like I was doing a good job for her, and I wish I would have pursued this help sooner.”

The Mega Raffle provides funding for new moms to visit the outpatient breastfeeding clinic even if the service is not covered by their insurance or if they cannot otherwise afford it.

 

 

 

This is the fifth of our six-part series of blogs that show how the TMC Mega Raffle is making a difference for patients and the community.

 

Togetherness for Mom & Baby Health – Why we promote rooming-in

Rooming in brings benefits for Mom & BabyIn a scene in the PBS series “Call the Midwife” , Nurse Jenny Lee (the main character) risks getting into trouble to sneak a newborn baby into an open ward so that a desperate mom can hold her child for the first time. It seems shocking today, but not so long ago, babies were kept in the nursery under observation while mom recovered in an open ward with other moms. Family and visitors would clamor for prime viewing spots outside the nursery window to see baby who lay swaddled and isolated beyond reach and comforting touch.

In recent years, as hospitals moved from open wards to private rooms, the practice of ‘rooming in’ has become common place, allowing moms and babies to stay together. Still, the practice of taking baby to the nursery to ‘give mom a break’ or a good night’s sleep continues. And indeed it would seem to make some sense, but research studies have shown that sleep patterns and breastfeeding are often better established when baby stays with mom and mom with support learns her child’s cues. For this reason we promote 24 hour rooming-in for new moms.

Mom to near 2 year old Felix, Cindy shares her experience rooming-in at TMC for Women,

I was going to the El Rio Birth Center and wanted to have a natural birth experience, but that wasn’t in the cards for me. At 41 weeks, it was time to go to the hospital. I was at TMC for two days before Felix was born via C-section. He was 10.5 lbs and a bit of a celebrity for the short time I was there. There hadn’t been such a big baby born in quite awhile. After the C-section, our midwife gave Felix to me right away…

Placed on Cindy’s chest immediately, Felix stayed with mom except for testing and a short time when Cindy cleaned up following the C-section.

The nurses at TMC were very kind and supportive and respectful of my need to have Felix with me at all times. I was there after the surgery for 3 days…It was amazing to have that little guy close to me, I wouldn’t have traded that experience for anything in the world.

What is the Newborn Nursery for?

Our Newborn Nursery is reserved for only those babies who need intensive observation or are having problems that prevent them from staying in their mother’s room.

Moms are encouraged to always keep their baby with them, and at the hospital their partner or a support person is welcome to stay overnight to help them with the baby, as they bond and get to know one another.

Why rooming-in is important

• Rooming-in promotes successful breastfeeding
• Keeping your baby with you at all times helps both of you sleep better
• The safest place for the baby is with the parent
• Being together strengthens your bond – the more time you spend together, the better you will know each other
• You will learn your baby’s cues, and the baby will be calmer hearing your familiar voice and your heartbeat
• You will feel more confident in your ability to care for the baby when you go home from the hospital

Resources
Keefe, MR.  Comparison of neonatal nighttime sleep-wake patterns in nursery versus rooming-in environments. Nurs Res. 1987 May-Jun;36(3):140-4. [Accessed 6-6-2014]

Kate Middleton has a baby AND a baby bump! More about the Postpartum Body

So it seems to be big news that Kate Middleton was photographed with a visible bump when she and Prince William left the hospital with wee baby George. Some posted comments on both news and gossip blogs pondering how it was possible that she was ALREADY pregnant and showing. Really? That would be quite a miracle. This response unfortunately reflects the unrealistic expectations for new mothers to return to their pre-pregnancy bodies immediately following giving birth.

The truth is, of course, that it takes a while for the uterus, that a day or two before held a dozen pounds of baby, placenta, and fluid to shrink to its usual size (that of a fist). It takes up to eight weeks for this process to be complete. So that bump is perfectly normal.

Breastfeeding aides in the return of the uterus to its original size.  Breastfeeding releases oxytocin, which causes uterine contractions, slowing bleeding and helping the organ to shrink. For women who’ve already given birth, these contractions are sometimes painful, like early labor–typically not the case for first births. But there is no way that any woman, breastfeeding or not, will have a flat postpartum belly.

Tucson’s own Jade Beall, whose photographs of mothers’ bodies in all their un-Photoshopped glory have received staggering attention around the globe recently, commented on the Kate’s post-baby photo on The Daily Beast:

This is a historic moment for women around the world. Kate has chosen to confidently show what our bodies can look like after undergoing one of the most life-changing feats a human can experience.”

I, for one, was thrilled to see Kate not only hiding under a tent-like dress, as was done in previous generations, but actually rocking an empire waist, accentuating the perfectly normal body of a brand-new mom. (Of course she also had perfectly coiffed hair, but that’s how it works when you have your own full-time stylist. Hey, I wouldn’t have minded a nice shampoo and blow-out after delivery…)

It’s so wonderful that what must be the most widely seen photo of a new mom this year is both beautiful and educational.Thank you, Kate, for not hiding the normal belly of a new mother. And thank you Jade, for your work in sharing the beauty of bodies in all their glorious forms.

Things the Books Don’t Tell You—Cesarean Birth

First of all, the obvious: Most Cesarean sections are unplanned. This means that even if a woman has all intentions of delivering vaginally, she still may deliver her baby surgically.

How can you prepare for a C-section, even if you don’t plan to have one? Well, at the very least read the C-section chapter in your birth book of choice—I didn’t, and my son was born via an unplanned C-section. I wish I’d known a little more about the procedure ahead of time. Even if you do prepare as well as you can by reading about surgical birth, you may still find the procedure and recovery to have aspects that you didn’t expect.

  • This is major abdominal surgery, and for many women, their first surgery ever. Even though you will likely be awake during the procedure (general anesthesia is used only in emergencies), your body still undergoes a great deal of change, and it may take a while to feel normal.
  • Some people find the sensation of the baby being removed uncomfortable, while others don’t feel much of anything.  Many people feel nauseated and/or dizzy as a result of the drugs that are used in the epidural or spinal block, as well as from the rather intense tugging that typically is involved.
  • The incisions are closed with dissolving sutures internally, and with surgical staples on the outside. You will return to your doctor’s office after a few days to have the staples removed. Some people find this uncomfortable; I did, and hadn’t expected to, so it was a bit alarming.
  • Contrary to what some people believe, mothers can usually begin nursing, if desired, quite soon after the surgery. Once the repairs are complete, if there are no complications, the mom may be back to the labor and delivery room and have a postpartum experience that is similar to that after a vaginal delivery.
  • It may be possible for the father to return to the labor and delivery room with the baby while the mother is still in the operating room.  This is a nice opportunity for dad and baby to bond. When my son was born via C-section at TMC, my husband actually got to carry him in his arms back to our labor and delivery room.  Within an hour I was back in the room as well and immediately began nursing. The very helpful nurse and my doula recommended a football hold for a more comfortable experience.
  • Often women experience generalized swelling after delivery from all the intravenous fluids that are necessary when preparing for a surgical birth.
  • You will be encouraged to get up and move around as soon as you are ready after the surgery. Nurses will help you take your first steps. You will also be given a series of exercises to do while lying in bed to help you recover.
  • While you may feel ready to resume regular exercise not long after you leave the hospital, it’s important to allow your incision to heal. You will be told what you can and cannot do following surgery.
  • Even after a C-section, women will bleed vaginally for quite a while after birth. Lochia is part of the postpartum experience no matter how a baby is delivered, and typically lasts about a month.
  • Lastly, the rather ugly mesh “granny panties” that the hospital provides are very useful, so stock up! Same with the giant pads. I took a few home and it made things much easier.

In some cases, C-sections are planned. If a baby is in a breech position, vaginal delivery is rarely attempted. If a woman has previously had a C-section she may or may not have the option to attempt a vaginal delivery. If her previous surgery involved a vertical (classic) incision, the risk of uterine rupture increases and a vaginal delivery is contraindicated. If the incision was of the lower, transverse variety (around the bikini line), some obstetricians will allow her to attempt to deliver vaginally.  It is also dangerous for a baby to be delivered vaginally if the mother has active genital herpes. Women carrying multiple fetuses often have planned C-sections, as do women with placenta previa.

Surgery has inherent risks and there are good reasons that many wish to avoid a C-section if possible.  But if the baby needs to come out immediately, for either the baby’s health or the mother’s, surgery is may be necessary. While a C-Section can be disappointing for many women, keep in mind that C-sections can save lives—both of mothers and babies.

Know that just because you had a c-section with one child, that doesn’t necessarily mean that all your children will be born via C-Section. We encourage you to talk to your obstetrician about the possibility of a Vaginal Birth after Cesarean and attend one of our VBAC Classes. Tucson Medical Center hosts VBAC classes every other month. For information on registration, call 324-2075.

Birth Plan – A Real Life Example

Birth plans are, by their very nature, a personal thing and while we gave a guide of a generalized birth plan previously, we thought it might be helpful to share some real birth plans prepared by others. Our thanks to the parents who gave permission to use their birth plans as an example.

In this example the mother had a health history that resulted in a high-risk pregnancy. She had some resulting constraints on her birthing options which she notes in her birth plan.

BIRTH PLAN/PREFERENCES

  • Mother’s Name:
  • Partner’s Name:
  • Mother’s Specialists: Drs. X, Y and Z

We realize that “planning” a birth is ultimately a futile exercise. We do have some preferences when it is possible and/or advisable to consider them.
General preferences/information

  • I have a history of X (medical details including current specialist information, and medications)
  • I am not currently on an anti-seizure medication and Dr. X is my neurologist.
  • I/we would like to be told what is happening in as much detail as possible. To be included in major decisions unless an emergency situation precluded it, and being given time to discuss the options.
  • We may request that one additional person be allowed in to support us, x, x, x, x, x or x.

Pain management

  • I understand that I will be given an epidural before the second stage (for medical reasons) limiting my movement. Prior to that I would like to be able to move around as much as possible.
  • Please let me know if other medication is called for and explain my options.

While all the specific health information would be in the mother’s file, having this information handy and ready to discuss with a nurse, doctor or midwife that you haven’t seen before is useful.

Labor

  • After the epidural, I would like to be told when to push and when not to push.
  • We have no preferences as to when the cord should be clamped/cut.
  • We would like to donate the cord blood if possible.
  • If possible, we would like my husband to cut the cord.
  • I would like to avoid an episiotomy and would appreciate measures taken (warm compresses, massage and positioning etc) to do this.
  • In case of Cesarean: I would like the process explained to me as it is carried out. My husband would like to be with me, at my head.

Have you thought about donating the cord blood? Some people like a step by step account of what is going on, others do not. Where do you fall? Most of us plan to have a vaginal birth, but there are still instances where a Cesarean Section is medically necessary. Don’t skip that section in the pregnancy books because you don’t plan on having a C-Section. Being informed about all possibilities is powerful.

After Delivery

  • We would like to have immediate skin-to-skin contact with and breastfeed the baby after birth, unless emergency prevents it.
  • If possible, we would like the baby to remain in the room with us after the delivery; if this is not possible, the father will go with the baby.

Postpartum care

  •  I would like a private room, if available, and for my husband to stay with me.
  • Unless required for health reasons, I do not wish to be separated from my baby.
  • I would like a visit from one of the hospital’s Lactation Consultants or a trained breastfeeding specialist to help with breastfeeding.
  • We appreciate support about breastfeeding, baby care, postpartum mama care

Private rooms, breastfeeding support, keeping baby and mama together (rooming in) immediately after and following birth are all part of our common practices at Tucson Medical Center.

NEWBORN CARE PLAN/PREFERENCES
Baby’s name:
Mother’s name:
Father’s name
Feeding preferences: Breast milk
General preferences/information

  • I plan to breastfeed my baby and would like to begin nursing very shortly after birth.
  • Unless medically necessary, I do not wish to have any bottles given to my baby (including glucose water or plain water).

TMC is recognized by the International Board Certified Lactation Consultants for our breastfeeding program. The preferences listed above would be considered the norm at TMC’s Mother/Baby Unit.

Complications or unforeseen problems

  • If there are serious health problems with the baby, we would like to feed and care for her as much as possible, along with the specialized care from the doctors and nurses.
  • If the baby does not survive, we have preferences we will discuss with you at that point. Please do not proceed without consulting us.

No one wants to think about these things, but what if?

Creating a birth plan helps you explore parts of childbirth you haven’t thought about and articulate your preferences. Check out our earlier blog post, What is a Birth Plan, and theTMC website page about birth plans too.

This was originally published on June 12, 2011 on TMC for Children.

Going For It – VBAC

The author and her husband as she goes for the VBAC

The second in a two-part personal story about the decision to deliver vaginally following a Cesarean Section.

Still and all, I wanted to try to deliver vaginally. It seemed like an experience I might regret not having. (What? You don’t want to know what it’s like to have a person come out of your vagina? C’mon!) Also, with a one-and-a-half year old son in the house, having major surgery seemed unappealing. The idea of being unable to pick up my little boy whenever I wanted made me unbearably sad. It’s one thing to recover from surgery when that’s your main job (well, that and taking care of a newborn!), but another when you have a toddler in the picture as well.

At every prenatal visit the doctor would ask me about scheduling a C-section, and I’d remind him or her that I wanted to try a VBAC. I guess because VBAC rates are still low, the assumption was that I’d schedule a C-section. This may have changed in the last few years, but I remember being slightly discouraged by the presumption of my birth plan. I’ve talked to other friends who’ve planned VBACs (all turned out successfully, I might add) who felt similarly confused or discouraged by the assumption that they would schedule a C-section. One friend emailed me a couple months ago, right before her due date, that the fact that her OB kept asking if she wanted to schedule a C-section made her think that they thought her chances of success were low, so maybe she should just schedule it after all. I felt the same way—did they know something I didn’t?

My guess is that practitioners want to help pregnant moms keep their eyes on the prize—a healthy baby—and they want us to keep our expectations reasonable. I’m sure there are women who, after being particularly disappointed by an unplanned C-section, feel very invested in having a successful VBAC, and I can see how it’s important to help them keep perspective.

As for me, my pessimism was helpful—I figured I had a 50/50 chance of a vaginal delivery, even though the statistics were much higher. I wanted to keep my expectations low. Still, I read all I could on VBACs, and visited a chiropractor and acupuncturist to see if there were ways I could increase the likelihood that my baby’s head would be in a good position.

I admit that every few days I’d question my decision, wonder if I wasn’t just setting myself up for disappointment. Why even try? Why not just schedule the surgery and forget about it? That way my mom could buy her plane ticket and we’d know what the baby’s birthday would be and I could stop wondering how things would turn out.

Also, the idea of a long labor following by surgery, like with my son, was highly unappealing to me—who would want that, really?

In the end, my desire to have a trial of labor, as the docs call it, won out, and I’m happy to say that it turned out beautifully.

The same OB who delivered my son delivered our daughter, and as crazy as it might sound, the labor was actually quite fun. (Did I mention again how amazing my epidurals were at TMC?) The recovery was pretty easy, in the sense that I could get up and walk to the bathroom afterward, and not having staples was pretty awesome.

I was kind of surprised by the aftermath of a vaginal delivery in ye olde lady bits, but that’s to be expected, and all seems to be back in working order. (Pelvic floor therapists are FABULOUS—don’t hesitate to ask your OB/GYN for a referral!)

In the end, we all know what matters is delivering a healthy baby. Having a VBAC won’t magically make everything better in your life. As the saying goes, no one gets a medal—the baby is the prize. Still, I was really elated to be able to experience a vaginal delivery, to hold my baby daughter on my chest with her cord still attached, to nurse immediately, and to avoid surgery. Mostly I was happy to be able to pick up my beautiful toddler son when he came to meet his newborn sister for the first time.

My entire VBAC story can be found here, in embarrassingly abundant detail.

To V (BAC) or Not to V…..

The author with her son as she approaches 40 weeks and faces the decision of whether to VBAC or not to VBAC.

That is the question.

Right?

Well, for some women it’s not a question—not all hospitals allow women with previous C-sections to attempt a vaginal delivery. Still, the most recent recommendation from the American College of Obstetricians and Gynecologists (ACOG) is that VBAC attempts should be an option for women desiring them, when medically appropriate.

Hospitals that allow women to skip an elective C-section if possible generally require the constant hospital presence of an OB and anesthesiologist during VBAC labors because of the slightly higher risk of uterine rupture. The hospital has to be at the ready if anything goes wrong. For this reason, some smaller hospitals that don’t have enough staff to have someone on site for the entire duration of labor do not allow VBACs.  Often doctors will not want to induce patients who’ve had previous C-sections, as the stronger contractions may increase risk of rupture.

But larger, well-staffed hospitals like TMC still allow women to attempt a vaginal delivery. Will the rates of vaginal deliveries after C-sections go up as hospitals provide not only this option, but also support in the form of VBAC prep classes?

The discussion about whether to attempt a trial of labor is one to have early, and perhaps often, with an OB who is experienced with VBACs. Even armed with all the information and a “go-ahead” from one’s doctor, some women do not want to take the chance of going through labor only to end up with a surgical birth.

Amy, a Hebrew school director from Georgia, decided to schedule a repeat C-section for several reasons.  “I felt pretty aware when I chose my OB that while he was theoretically okay with VBACs, that he wasn’t exactly going to bend over backwards, she explains. “

“So in a sense, I feel like I chose not to try that hard, if that makes sense. For me, it had a lot to do with my first experience with labor, which was really pretty bad, and desperately not wanting to replicate that experience. I felt like as long as I was doing a VBAC, there was a chance of the same pattern – 2 weeks overdue, induction, long labor, then a C section. I think my top priority in my second birth experience (other than everyone coming out healthy) was not letting it be like my first.”

Shailagh, a psychologist practicing in Oregon, was similarly averse to having a repeat of her first birth experience, and felt that her chances for a successful VBAC were low.  “I felt like I could try the uphill path of going for the VBAC, but I had been semi-convinced that what happened with my daughter would happen again: labor did not occur naturally and I was induced because we were past the due date and the amniotic fluid was looking a bit low, then she did not progress when I was induced. She was sort of stuck sideways and did not descend, and I was there for 3 days with the Pitocin [synthetic oxytocin], not eating, and finally had to do the C-section.”

She wasn’t sure that she was willing to have a trial of labor if she felt the outcome wasn’t going to be any different.  “I could not face another grueling time capped with a disappointment, so I went for the scheduled c section. The fact that my local hospital (and my OB/GYN) would not be able to do the VBAC made it an easier decision. Had I had a local, supportive caregiver who could give me info and facts that would have led me to believe that I could do labor and vaginal delivery for the second one, I might have done it. It felt like I was sort of on my own with researching and figuring it out.”

As for me? My son was born at TMC in 2006, and I went through the pregnancy certain I would have a vaginal delivery. I even confess to skipping the C-section chapters in the childbirth books. After all, my son was measuring on the smaller end, I had no risk factors, the placenta was ideally located, and I have a roomy pelvis. Why on earth would I have a C-section?

Well, we all know that Things Happen. I was fortunate to already have a (very awesome) epidural in place when it was decided that the only way our boy was going to come out was surgically. I had dilated fully, but because of the position of his head, my cervix swelled, making the opening smaller. (Talk about disheartening—being checked by the L&D nurse and told that you are at 7cm, when you were just at 9cm!!) His heart tracings didn’t respond well to Pitocin-induced contractions, and without the Pitocin the contractions weren’t strong enough to compensate for the swelling. So out he came, not in the manner we expected, but healthy and beautiful with APGAR scores of 9 and 9.

I recovered quite quickly and easily from the C-section, much to my surprise. But when I became pregnant about a year and a half later, I immediately started thinking about my delivery options. My OB practice, formerly Associates in Women’s Health, now Genesis OB/GYN, had a lot of helpful information on VBACs, and they have assisted at many VBACs at TMC.

A repeat C-section seemed like an obvious choice—I already had a (very barely visible, thank you Dr. V!) scar, and this way I would be well rested when the baby was born, and there wouldn’t be any wondering, no potential disappointment. Also, why on earth would I want all that trauma to my vagina when there was a nice neat way to get the baby out? Having a C-section scar AND what I feared would be “a broken vagina” sounded like a raw deal.

…to be continued