Tuesday, February 9, 2016

Yet More Evidence That You Shouldn't Go To The Hospital Too Early

Image from Zwelling 2010 study
Here are two more studies showing that early admission in labor to the hospital is a risk factor for obstetric interventions and for a cesarean.

This is something we've written about before, but given these two latest studies, it's a point worth repeating.

Study #1

In the first study, early admission (at less than 4 cm dilation) increased the utilization of epidurals, artificial augmentation of contractions, and cesareans.

21.8% of first-time moms with early admission had a cesarean, compared with 14.5% of first-time moms with later admission.

In women who had had children before, the cesarean rate was 3.7% in those admitted early, compared with 1.9% in those admitted later.

Most interestingly, the hospital lowered their overall cesarean rate between 2012 and 2014 by admitting fewer women in early labor (10.5% to 7.9%). Take note, fellow hospitals!

Study #2

In the second study, "early" admission was defined as less than 6 cm of dilation. Note the difference in cutoffs between the two studies; this is important.

This change reflects the new recommendation that 6 cm be considered the criteria for "active labor" rather than the old cutoff of 4 cm. Indeed, a recent consensus statement from the American Congress of Obstetricians and Gynecologists and the Society for Fetal-Maternal Medicine suggests that the definition of "active" labor be changed to 6 cm. Lamaze International has highlighted this with their related discussions on "Six is the New Four." Here is one hospital that is considering the new recommendation, which is great.

This study found that women admitted at less than 6 cm had more than THREE times the risk for cesarean (13.2% vs. 3.5%).

When broken down between women who had never given birth before and those with previous births, the increased risk for cesarean with early admission only reached statistical significance in multiparous women (11.0% vs. 2.5%, or more than FOUR times the risk).

In first-time mothers, the cesarean rate was 16.8% in those admitted before 6 cm dilation, vs. 7.1% in those admitted at 6 cm or later. Clearly there was a major trend towards significance (a relative risk of 2.35), but the confidence interval crossed 1.0, which means the findings could have been due to chance. So conclusions are limited there but strongly suggest that with a larger group, statistical significance might well have been reached.

The authors concluded:
Decreasing cervical dilation at admission, particularly <6 cm, is a modifiable risk factor for cesarean, especially in multiparous women. 
In other words, here is a simple way for hospitals to help decrease their cesarean rates.

Summary

The take-home message for mothers is that if you plan to birth in the hospital, don't rush to the hospital too early in labor. 

Consider hiring a doula for labor support both at home and in the hospital. This can help decrease your chances for a cesarean and give you the confidence to not go in too early. This may be especially important for first-time mothers who have never labored before and aren't sure what to expect.

Obviously, if there is something that doesn't feel right or your intuition says needs attention, you should not hesitate to go in and ask for evaluation. And of course, sometimes there are medical considerations that might also call for early evaluation; your care provider will help you determine the situations to be cautious about.

But most of the time, there is no need to be in the hospital right away if labor has started. The sooner you go in, the more likely you are to have interventions like oxytocin augmentation and cesareans. Stay home with good labor support until labor is well-established and moving along. If you go in too early, don't be afraid to go home for a while before you return to stay, as long as both you and baby seem to be doing well.

The take-home message for hospitals is that they can lower their primary cesarean rates just by encouraging women to stay home longer in early labor, and by adopting 6 cm as the new standard for "active" labor and hospital admission for most women.

Given the known health risks of a too-high cesarean rate, this has important implications for public health.


References

Obstet Gynecol. 2016 Feb 4. [Epub ahead of print] Cervical Dilation on Admission in Term Spontaneous Labor and Maternal and Newborn Outcomes. Kauffman E1, Souter VL, Katon JG, Sitcov K. PMID: 26855106
OBJECTIVE: To examine associations between cervical dilation on admission and maternal and newborn outcomes in term spontaneous labor. METHODS: This is a retrospective cohort study of 11,368 singleton, term (37-43 6/7 weeks of gestation) spontaneously laboring women delivering in 14 hospitals in Washington State between 2012 and 2014 using chart abstracted data from the Obstetrics Clinical Outcomes Assessment Program. Women with prior cesarean delivery or ruptured membranes on admission were excluded. Pregnancy history, cervical dilation on admission, and outcomes were analyzed. Associations between early (less than 4 cm cervical dilation) and late (4 cm or greater cervical dilation) admission and outcomes were examined using general linear models with a log-link stratifying by parity. Results were reported as adjusted relative risks (RRs) with 95% confidence intervals (CIs). RESULTS: Early admission compared with late admission was associated with increased epidural use of 84.8% compared with 71.8% in nulliparous women and 66.3% compared with 53.1% in multiparous women (nulliparous RR 1.18, 95% CI 1.13-1.24; multiparous RR 1.25, 95% CI 1.18-1.32); oxytocin augmentation in 58.5% compared with 36.6% in nulliparous women and 45.9% compared with 20.7% in multiparous women (nulliparous RR 1.56, 95% CI 1.50-1.63; multiparous RR 2.14, 95% CI 1.87-2.44); and cesarean delivery of 21.8% compared with 14.5% in nulliparous women and 3.7% compared with 1.9% in multiparous women (nulliparous RR 1.50, 95% CI 1.32-1.70; multiparous women RR 1.95, 95% CI 1.47-2.57). Early admission was associated with increased neonatal intensive care unit admission for newborns of nulliparous women only (RR 1.38, 95% CI 1.01-1.89). Between 2012 and 2014, late admission increased 14.6% for nulliparous patients and 10.1% for multiparous patients, and the cesarean delivery rate decreased from 10.5% to 7.9% (P<.001) for all. CONCLUSION: Early admission (less than 4 cm cervical dilation) is a risk factor for increased medical intervention and cesarean delivery.
Am J Perinatol. 2016 Jan;33(2):188-94. doi: 10.1055/s-0035-1563711. Epub 2015 Sep 7. Optimal Admission Cervical Dilation in Spontaneously Laboring Women. Wood AM1, Frey HA2, Tuuli MG1, Caughey AB3, Odibo AO4, Macones GA1, Cahill AG1. PMID: 26344012
OBJECTIVE: To estimate the impact of admission cervical dilation on the risk of cesarean in spontaneously laboring women at term. STUDY DESIGN: Secondary analysis of a prospective cohort study of women admitted in term labor with a singleton gestation. Women with rupture of membranes before admission, induction of labor, or prelabor cesarean were excluded. The association between cesarean and cervical dilation at admission was estimated, and results were stratified by parity. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated, using cervical dilation ≥ 6 cm as the reference group. Cesarean for arrest was secondarily explored. RESULTS: A total of 2,033 spontaneously laboring women met inclusion criteria. Women admitted at <6 cm dilation had an increased risk of cesarean compared with those admitted at ≥6 cm (13.2 vs. 3.5%; RR 3.73; 95% CI 1.94-7.17). The increased risk was noted in nulliparous (16.8 vs. 7.1%; RR 2.35; 95% CI 0.90-6.13) and multiparous (11.0 vs. 2.5%; RR 4.36; 95% CI 1.80-10.52) women, but was statistically significant only in multiparous women. CONCLUSIONS: Decreasing cervical dilation at admission, particularly <6 cm, is a modifiable risk factor for cesarean, especially in multiparous women. This should be considered in the decision-making process about timing of admission in term labor.

Monday, February 1, 2016

Should You Check Your Home for Radon?

January was Radon Action Month. As we finish up January and head into February, let's take a moment to raise awareness of this problem.

Radon is a colorless, odorless RADIOACTIVE gas that can be found in the soil in many areas. It is a leading cause of lung cancer in this country, second only to smoking.

However, there are no immediate symptoms that will alert you to the presence of radon, and you can't see it, smell it, or taste it. Therefore, you won't know if you have high levels of radon gas unless you test for it.

Have you had your home tested for radon? Here's what you should consider when making this decision.

Radon in the Home


Radon gas is created when radioactive elements (like uranium) decay in rocks and soil. The gas moves through the soil and can be pulled into homes by slight pressure differences. It typically enters through cracks in the foundation, around construction joints, through small gaps near pipes and cables, or through sump pumps and drains. Once inside, it can get trapped and build up to high levels that endanger long-term health.

Homes that have basements, cellars, crawl spaces, or lower levels are particularly prone to high levels of radon, but it can be found even in homes without these. Radon can also be a problem in well water.

But unless you actually test for radon, you can't tell how much is ─ or isn't ─ in your house.

Cancer Risk

Radon is an important public health issue because being constantly exposed to high levels of radon over time can lead to lung cancer.

How can radon gas cause lung cancer? One article gives a brief explanation:
Radon gas breaks down and releases small particles that can get trapped in your lung. Those particles can release tiny bursts of energy called alpha particles that can damage lung tissue. Alpha particles cannot pass through the skin. The damage done in your lungs by the alpha particles can lead to lung cancer over time. 
Radon exposure is the second leading cause of lung cancer after smoking. It is thought that about 13% of all lung cancers are caused by radon exposure.

The U.S. government estimates that about 21,000 deaths per year are due to radon exposure, though most of those deaths are in smokers. People who both smoke and are exposed to radon are at particularly high risk for developing lung cancer because smoking and radon are powerfully synergistic. Some sources estimate that smokers exposed to radon have 25x the risk for lung cancer than non-smokers exposed to radon.

As a result, some public health commentators believe that radon-reduction campaigns exaggerate the risks to non-smokers and should target only certain areas of the country where radon levels are particularly high.

Risks Vary by Area



Not all areas are at equal risk for radon exposure. In the U.S. map above, areas in the darkest colors are the most at risk for high radon exposure. Homes in Iowa and parts of Pennsylvania are considered at particularly severe risk for radon contamination.

But again, the only way to know if your home is at risk or not is to test. You can live in an area that is at lower risk overall from radon and still have a house that has high levels of radon.

About 1 in 15 American homes are thought to have high levels of radon. Thus, the Environmental Protection Agency (EPA) recommends that all homes should be monitored for radon.

Radon testing kits are relatively inexpensive and can be found in local home improvement stores. There are short-term kits (that measure exposure over a few days) and long-term kits (that measure exposure over a few months, generally considered the most accurate). Follow the directions on the package, then mail in the results. You will notified of the findings soon after and can take action accordingly.

Mitigation usually involves sealing any foundation cracks or construction joints, and installing a way to vent the radon gas from the most affected areas. Some cases can be fixed for a few hundred dollars by someone comfortable with DIY, but more significant cases need trained professionals so it can be done properly, and this cost usually runs $1000-2000.

Because of the cost of mitigation and the uncertainty of the impact of moderate levels of radon on non-smokers, radon testing remains controversial to some. Critics maintain that radon testing is a waste of time in low-risk areas, and should be saved only for high-risk areas or for houses with smokers.

Also controversial is what level of exposure presents enough risk to make mitigation worthwhile. Clearly, high levels of radon (near 20 pCi/L) present significant risk and should be identified and mitigated. Lower levels are more controversial. The EPA recommends an action level of 4 pCi/L whereas other countries recommend 5 pCi/L or even more. On the other hand, some U.S. states recommend getting radon levels down to less than 2 pCi/L. More data is needed.

Please note, radon is not just an issue for homes. Only about 20% of schools in the U.S. have been tested for radon. Since students and teachers spend long hours in these structures most days of the week, they are another potential source for radon exposure. Has your child's school been tested for radon? How about your office? How extensive should testing for radon exposure be?

Why I Care About Radon

Why do I want to educate people about radon? Frankly, I didn't care about it until recently. I heard about it on a TV show many years ago and figured it was just another over-exaggerated health scare to make money for unscrupulous "repair" companies.

However, I changed my mind a few years ago after doing more research into the matter. Frankly, it really looked legit. Nothing to panic over, mind, but something to definitely be aware of.

So we tested our house for radon a few years ago, not really expecting to find a problem. Turns out the area around the kids' bedrooms had quite high levels of radon, even though we live in an area not at high risk for radon. We put in a radon mitigation system post-haste because the levels were pretty elevated. The levels are down to normal now, but we will re-test every few years just to make sure the system is still working efficiently.

I also care now because I think radon may have contributed to my father's death, along with smoking.

Like many soldiers, my father took up smoking in WWII; he smoked for 20 years afterwards. He quit when I was young, but was around second-hand smoke in his job at times.

He also grew up in an area known now for high radon levels. Of course, there's no way to prove that radon had any impact on him. We don't even know for sure that he was exposed. However, the city he grew up in has some of the highest radon levels in that state, and most of the houses there have basements, so I think he probably had a strong chance of exposure.

Although it's impossible to prove, I think the combination of growing up in a high radon area, 20 years of smoking, and years of second-hand smoke tipped him over into lung cancer, even though he had not smoked in nearly 30 years. Sadly, his lung cancer was inoperable. His cancer eventually spread to his brain, and this very intelligent man who loved to discuss theology was reduced to not even being able to operate his TV remote. He died 3 years after his diagnosis. We had to watch him slowly suffocate to death, and that was really terrible.

Sad as his death was, that doesn't necessarily mean that everyone should consider testing; smoking was clearly the biggest culprit in his death. However, the fact that high radon levels were found in my own home nowadays, even in an area not at high risk for radon, suggests to me that more widespread radon testing seems pretty sensible for most areas.

Final Thoughts

At high enough levels over time, exposure to radon gas clearly increases the risk for lung cancer, which is a very intractable and nasty form of cancer. Therefore, the EPA, Surgeon General, American Lung Association, American Medical Association, and National Safety Council all recommend testing your home for radon.

This testing seems sensible to me, especially if you are in an area known to have moderate or high levels of radon, or if you have smokers or former smokers in your home. It is more debatable in areas at very low risk for radon but personally I would probably err on the side of testing most of the time.

It is also not completely clear at what level of exposure mitigation is truly needed. Certainly high levels need mitigation and I strongly believe in taking action in that situation. It also seems like a sensible precaution to me to treat even at only modestly raised levels but I would like more reliable data on just where that treatment line should be drawn.

Factors in your decision on whether to mitigate may include how high the radon levels are, where in the home these levels occur, how much time people spend in this area, the type of soil around the home, whether there is a history of smoking in any family member, etc. If your test results are borderline, you might want to repeat the test before making a decision, since radon levels can fluctuate over time. More data may give you a better picture of the risk.

It's important to point out that testing doesn't commit you to doing mitigation. The test is very easy, not expensive, and pretty effortless to use. Once you have your results, you can decide what, if anything, to do about it. But you can't do anything if you haven't had your home tested. 

Clearly, smoking and radon exposure are an extremely bad combination, so your best prevention is not to smoke. But even if you have never smoked, radon exposure can be a risk. Most importantly, it is a risk that can be mitigated...but only if you test for it. 

So while I believe in taking a moderate, sensible approach to radon testing (and would like more reliable data on which to make decisions), on the whole I do think radon testing is worth doing.

But as always, the decision to test or not remains your decision.

You can find out more about radon here, here, here, and here. Click here for a link that will help you find the risks in your particular state.

Wednesday, January 20, 2016

Supporting Women's Natural Pushing Instincts

Canadian First Nations Birth Sculpture

Just a brief post this week to link to a spot-on wonderful article from Midwife Thinking on supporting women's natural pushing instincts. It goes very well with my series on birth positions.

I know that birth professionals truly mean well, but directed pushing and inflexible positioning can harm women and babies. It's time for these practices to stop.

That's not to say that coaching or help is never needed during pushing, but too often it is given when it is not needed and is harmful far too often. I know I personally experienced directed pushing or inflexibility towards positioning in several of my births, and I know many other women who have too. It's still all too common in many places. In fact, it's rare NOT to see directed pushing in hospitals, and many doctors finish their residencies have seen only reclining or semi-reclining positions.

Some outdated practices during pushing even actively harm women and babies, yet are still used at times. A friend of mine experienced damage from these outdated techniques only a year or two ago. This must change!

Read the excellent article from Midwife Thinking on supporting natural pushing instincts here

Monday, January 4, 2016

The Importance of Chores


Every so often I go on a parenting rant. Today is one of those days. I need to rant about the importance of chores.

I think assigning kids chores is a vitally important part of parenting. Yet I know too many parents who don't give their kids chores (or who give only minimal chores). 

This past summer we had two extra kids at our house for a couple of months as a favor for someone whose housing had fallen through between jobs. These are great kids and we care about them, so for the most part we didn't mind having them over, but there was one piece of major friction. They had very little experience doing chores and great resentment at being expected to help. That created some real conflict.

This has been a chronic problem. In the past, when visiting, these kids would open a piece of string cheese and drop the wrapping on the floor rather than take it to the trash. I was floored that they expected others to clean up their mess for them. What parent doesn't teach their child to pick up after themselves?

Well, they quickly learned that when visiting our house, you have to help maintain the space you live in. I didn't expect them to do the same level of cleaning as my kids, but they did have to help pick up toys, clean the room they were in, and do some vacuuming. They did it, but oh my goodness, the whining and moaning that went with that ─ it was ridiculous! But at least they got some exposure to these skills and some experience doing them for a few months.

Sadly, it didn't last once they moved back in with their parents because no one there asks them to help clean, and their parents do only the most minimal cleaning themselves. Obviously, this is a learned behavior. But what is it teaching them for later on in life?

These kids were outraged that my kids have to do chores. In fact, they sowed dissension by constantly telling my kids how horrible they have it because they have to help clean. One of the visitors actually told me I was a bad parent because my kids had "too many chores." Imagine! No, my kids are not domestic slaves, but I do expect them to pitch in and help with the upkeep of the house and yard. Duh. They live here, they help out.

Now, these temporary visitors are not bad kids. They are generally pretty nice and have good hearts, so I took the criticism as an opportunity to open a discussion about the responsibility to help the community you are a part of, but it still appalls me that they think that doing basic chores is excessive.

How in the world are they going to become competent adults who take care of their own household if they never learn the skills to do so? How are they going to be good employees later on if they feel incredibly put upon just cleaning up their own darn mess? How are they going to learn to be considerate of others if they expect others to constantly take care of their needs?

An article in the Wall Street Journal notes:
In a survey of 1,001 U.S. adults released last fall by Braun Research, 82% reported having regular chores growing up, but only 28% said that they require their own children to do them.
That number seems distorted to me, frankly. I doubt that only a quarter of parents today are having kids do chores. But from my observations as a teacher, I am pretty sure that it's true of quite a few families. And I'm shocked at the number of friends of ours who have their kids doing only the most basic of chores.

Now of course, every parent gets to make their own parenting decisions, and no one made me the boss of parenting rules. Every family has to work out their own family balance of various tasks. The way our family divides up the chores doesn't have to be the way someone else's family divides up their chores.

But there is a trend right now away from having kids do many chores, and I believe this is doing a real disservice to those kids.

Chores ─ substantial chores ─ are important in developing a child's character.

Why Do Chores?

Why is it important to have kids help out with chores around the house? Partly it's about developing important life skills that they will need as adults. But I really believe it's more about developing the child's character.

Chores Teach Life Skills

Many kids have no idea how to clean a house, how to cook a decent (non-fast food) meal, or how to do their own laundry. They have no idea how to grow food, take care of a car, weed a garden, or do maintenance tasks around the house ─ because no one has taught them how to do it.

Someday, kids will have to take care of themselves. These skills don't just magically appear at age 18; they have to learn them somewhere along the way. Many schools don't have Home Ec classes anymore, so the only place they will learn these life skills is at home. The best way to learn is by doing. And the best way to learn is to start with a little bit at a time, practicing from a very young age, rather than expecting them to suddenly learn these skills all at once when they move out.

Chores Teach a Work Ethic and Good Habits

Kids need to develop a work ethic. They need to be assigned a task, learn how to complete that task satisfactorily, and then actually complete it. They need to do it over and over again, as part of a routine. They need to learn how to do the rhythm of daily chores, weekly/monthly chores, and periodic deep cleaning chores.

A work ethic for an adult job doesn't just magically spring to life at 18. Developing a work ethic comes from doing chores as a kid, taking care of animals, helping with siblings, completing your homework on time, and helping others out in your community.

Kids who don't do chores and who aren't held to any kind of standards regarding homework and other work never really learn this work ethic. They become incapable adult workers who constantly feel put upon because they have to do things they don't like and things that take real effort to complete. If things go wrong, it's always someone else's fault, and they rarely get things done on time or with satisfactory results.

Chores Teach Strength of Will

Kids need to develop the ability to do things that are hard. Many kids won't try something that is hard, or they give up halfway through because they lack the strength of will to finish things or to make themselves work hard. They want everything easy and handed to them on a plate with very little effort.

Chores, music lessons, sports, crafts, art, exercise, hobbies...all these things help teach strength of will. They help kids learn to apply themselves by doing things that are hard at first, that take perseverance, that take daily discipline.

Chores Teach Accountability and Responsibility

Adults are held accountable for doing their jobs at work, for taking care of themselves and their families, for keeping up the homes they live in, for paying taxes, etc. Accountability doesn't just magically appear. It takes daily application of micro-doses of responsibility and then being held accountable for those small responsibilities.

Children must be held accountable for completing their chores satisfactorily. Otherwise, you negate a large portion of the lesson on work ethics. A job halfway done is not a job well-done. Doing the follow-through is just as important as giving chores in the first place.

Chores Teach Independence and Accomplishment

Kids need to learn how to do tasks without constant supervision and hovering. They need to be shown how to do certain chores, then given the chance to actually do them, even if that means failing at them at first. Learning how to improve is part of the process. When kids learn how to do a chore well, there is a feeling of accomplishment. If an adult steps in and does the chore for them, they don't develop that feeling of competency.

Kids also need to keep practicing chores until they can do them on their own, without being asked. This is one of the hardest parts, but it's still important to strive for it. When they can be trusted to do their chores without being nagged, they develop a feeling of independence. They know that yes, they CAN do hard things, and do it on their own. This will be a huge help as they move into adulthood and are required to do things without reminders or someone holding their hands.

Chores Teach Contributing to the Community 

Children are inherently selfish when they are little. At first, they think about their own needs, not the needs of others, and they want to be taken care of, not do the caretaking. But children live in a larger community, and they need to see the bigger picture. Chores help them see that sometimes you have to do things that are not immediately gratifying in order to make the space a better place to live or to help out others who need the help.

Kids often don't understand the amount of work that goes into taking care of a household. Chores help them begin to see how everyone in a household has to contribute in order to keep up the household and keep it functioning. Chores also teach kids to help others and to contribute to society at large, not solely to their own happiness and gratification.

Barriers to Chores

To me, chores for kids is a no-brainer. But of course, if doing chores was easy, it wouldn't be such a stress in so many households.

There are many barriers that can get in the way of giving kids chores and holding them accountable. They are all real and understandable concerns. However, as parents we have to find a way around these barriers so that kids develop these important life skills and character traits.

"I Don't Want To Burden My Children"

One barrier is the parent who wants to give his kids the "gift" of a chore-free childhood so they can just play and enjoy themselves the whole time.

I'm a major fan of unstructured play for kids, so I hear this argument. Unstructured play is how kids learn best for a long time. Our kids today have far too many activities and need more time just for playing.

But giving kids the gift of lots of play time doesn't have to mean that they can't have chore time too. It doesn't harm a child to do a reasonable amount of chores; on the contrary, it strengthens them.

Of course, children should not be slaves, either. You do have to find a sensible balance, but keeping the child from having enough chores is really not doing them a favor.

"My Kids Are Too Busy"

On the opposite side of the spectrum are the children who are so overscheduled that they "don't have time" to do chores. These are stressed-out kids who need down time, so parents regularly excuse them from having to do any chores.

In this situation, parents need to re-think their children's schedules. Kids' activities are important character-builders, but too much is just as harmful as too little. Chores and unstructured free play time are vital for mental and emotional health. If your kids are "too busy" for chores, then it's time to find more balance in your home life.

Remember, the rhythm and structure of regular chores actually helps calm stressed-out kids and provides them a release from their busy schedule. It provides a transition time from a frenetic schedule to the down time they need so much.

"I Want Them To Focus on their Studies"

Some parents justify not giving chores because they view the child's main job as studying for college.

It is important for kids to do well in school and build their academic skills, whatever their future career path. But the personal growth skills they build from having chores helps in that process. These skills do not exist in a vacuum; building accountability, responsibility, and learning how to do hard things will only help them in their academics.

Parents can find a way to help kids learn how to schedule their time so they can manage academics, activities, chores, and playtime. Sometimes, flexibility will be needed, of course. During particularly busy times, you may need to negotiate a compromise. But too much focus on academics or activities at the expense of other things is harmful too.

"I Can Do It Faster and Better"

Probably the biggest barrier is that sometimes it's just easier to do the chore yourself! You are better at doing the chore, you are going to do a more thorough job, and you can usually get it done in half the time. Plus then you don't have to listen to them whining about having to do it, which seems to be universal for kids these days.

But again, you are not doing the child any favors by doing it for them. You have to be willing to let them fail at the chore, to slowly learn how to get better at the chore, and to learn how to do it more efficiently. THAT'S how they learn the accountability and responsibility and independence.

It doesn't just happen magically; it's a process. And you have to let go of control enough for them to work through that process on their own, even if that means the chore is done less than perfectly at times. For some parents, that letting go of control is the most difficult thing of all, but it's important that we do.

Parents Who Do Too Much

Another barrier is the parent who feels that he or she has to do it all for the kids. Women are particularly prone to this trap because many of us were taught that housecleaning is the woman's main responsibility and having a spotless house is part of being a "good mother," but men can be martyr parents too.

Parents are not meant to be slaves, doing everything for children. We do our children no favors if we do too much for them. It infantilizes them and keeps them dependent.

When children grow up seeing others taking care of all their needs, they begin to feel entitled to it. They grow up expecting others to take care of them, rather than taking care of themselves. They grow up dependent on others, instead of becoming independent and learning to do for themselves. This can transfer to dependency in their adult life as well.

Give your children the gift of independence and self-sufficiency. Let them learn to take care of themselves and others, not just be taken care of.

Gender-Related Chores

Another barrier to independence is gender-related chores. Even today, many girls are expected to do far more housework than boys are. Even when boys are given cooking or cleaning chores, they may not be held to the same standard of quality as women. Conversely, boys are expected to do far more yardwork than girls and girls aren't expected to know how to fix things or handle tools.

This is harmful in many ways. Boys learn the lesson that women are "supposed" to take care of them. This makes them dependent on women and incompetent to take care of themselves. Girls learn that they "need" boys to take care of the house and yard, and grow up feeling helpless around tools and mechanical/physical work.

Both genders should be doing all types of chores. Our boys need to learn to cook, clean, and care for others, and our girls need to learn to care for the maintenance needs of the house and yard. If it's a life skill that might be needed someday, both genders should learn it.

Sometimes, it makes sense in some households to divide chores along traditional responsibilities for a while. That's up to you. But take the long view; kids should learn all types of chores so they know how to do them all. Teaching them only half the chores handicaps them in the long run; someday they may be forced by circumstances to do the jobs they never learned.

The Messy House Conundrum

Sometimes kids don't follow through on chores and it can leave you with a messy house. And then people coming by judge you for your messy house, or the incomplete chore impedes the smooth running of your house.

The conundrum is, when kids don't do their chore, do you do it for them? Many parents do because it's just easier. But what is this teaching the kids? They are not learning to be accountable for their chore. It's better to leave the chore undone until the child can be held accountable and complete the task.

Of course, there are nuances here. Some chores (like taking care of animals) can't be put off because lives are depending on it. Some chores just have to get done in order for the household to function. And sometimes kids get super busy and you need to help out with chores for a while as a compromise.

There's going to be times when you help out, but it shouldn't be a regular thing. Otherwise, the child is really not being held truly accountable, and that's one of the main underlying reasons for chores.

Final Thoughts

Of course, theory is always easier than putting something into practice. Our family struggles with chores, like every other family. My kids do more chores than most of their peers, but they do far less than a lot of kids who grow up on ranches or farms. Finding that combination of enough-but-not-too-much is tough and takes some experimentation.

Most parents would agree that children need to do some chores. However, trying to figure out how much, what chores, at what age, and how to hold them accountable is a difficult job. Every family will come up with different answers.

When considering chores for your own household, think about the following things:
  • What chores need to be completed around the house
  • Which chores are most meaningful for the smooth running of the household
  • What are the ages and capabilities of your children
  • What life skills do you want your children to learn and by what age
  • What is a realistic chore load for them and for you
Start them young. Young children can do more than you'd think, and they love to help at first. Start by having them help clean up their toys. Give clean-up time a regular routine; all toys picked up as part of getting ready for bedtime, or helping clean the kitchen immediately after dinner. Sing a particular song or make a game of it to make it more motivating. The key is having as regular a structure as possible.

As they get a little older, children can help with other tasks like sorting laundry, setting the table, taking dirty dishes to the sink, wiping down the table, etc. In the later grade-school years, they can start doing harder chores, like vacuuming, sweeping, dishes, recycling, taking out the trash and compost, etc.

By the time they are in middle school, kids can do their own laundry and some house and yard maintenance (raking leaves, mowing the lawn, gardening, weeding, composting, etc.). By high school, they should know how to cook a number of basic dishes and practice that by fixing dinner for the family on a regular basis. They should also help out with maintenance chores like deep cleaning, changing furnace filters, maintaining the family car, winterizing the house, etc.

Most people think that high school is when the chores should really kick in, but honestly, our experience is that high school is when it gets most challenging. Once they get really busy with their studies and activities, it's far too easy to step in and do chores for them. Yet as they grow closer to being on their own, it's more important than ever for them to learn life skills and how to manage their time to complete all their obligations. So instead of chores getting easier with age, you may find that you have to be even more strict about chore expectations. 

However, I'm not a fan of tying allowances to chores. Kids should help around the house and yard because they are part of the family unit that lives there, not because they need to be motivated by money. You shouldn't have to bribe your kids to do chores. On the other hand, it's okay for kids to have the opportunity to earn extra money if they volunteer for special projects or extra-big chores.

Flexibility is key. There's no one-size-fits-all chore list that works for each family. Each chore list has to be adapted to your own particular situation and needs.

The point is to make sure that children have regular chores that they are responsible for, and to hold them accountable for doing those chores. 

All too soon your children will be adults and out on their own. Will you have taught them the majority of what they need to know to live on their own? Will they be responsible community members who help out others? Will they know how to be accountable for their work? Or will they expect others to always take care of them and not know how to care for themselves?

Chores are a VITAL part of parenting. Make sure that you are holding your children responsible for helping out around the house. It's one of the harder parenting tasks, honestly, but it's one of the most important ones. 

Tuesday, December 22, 2015

April's Birth Story (respectful natural hospital birth)

April's Adorable Baby
Because there are many egregious examples of bias in the maternity care of women of size, sometimes it can sound like no women of size receive respectful care during birth, but of course that's not true. There are some WONDERFUL care providers out there who really do give appropriate and respectful care to women of size during pregnancy and birth. Periodically it's important to share those stories too. That sounds like a wonderful and upbeat Christmas week post to me!

Here is the story of a "supersized" woman who gave birth recently in South Dakota. Many care providers would have predicted gloomy things based on her size (over 300 lbs.) and age (35). Yet she had a healthy pregnancy and baby, as well as an easy and completely natural birth in the hospital with a very caring OB and supportive nurses.

Remember, while there is a higher risk of some complications in "obese" women (especially as size increases), many high BMI women have completely normal and healthy pregnancies and births, especially when they take good care of themselves and are able to labor spontaneously with excellent support. 

The value of truly supportive care providers cannot be underestimated. So let me stop and speak to the care providers among my readers for a moment.
Providers, the most powerful intervention you can provide to women of size is to treat them with dignity and respect at all times. Some women of size have been so shamed and mistreated that they avoid care providers whenever possible. Regardless of what the scale says, all women deserve gentle and respectful care, but far too often they do not experience it. Respectful care can be a transformative experience for women of size who have had mostly negative contacts with health care before. Help heal that relationship; go out of your way to be as respectful and gentle as possible. 
Today, we women of size send a big shout-out to all the providers who DO provide respectful, excellent care to women of size. Thank you for all that you do.

We thank you for your gentle care and for your advocacy on our behalf. We know it's not always easy to do so in the weight-biased environment of many hospitals, but it is SO important that care like this be available to women of all sizes. Thank you for your efforts on our behalf.

And now as a holiday treat, here is April's birth story, an example of respectful care for a woman of size giving birth in the hospital.

I'm from South Dakota and I got my pregnancy care and gave birth at Sanford Hospital in Sioux Falls.  
On my first visit with my obstetrician, she did make a point of talking with us about the increased risks due to my weight (340-ish at the time) and my age (35). She said that I needed to be cautious about gaining too much weight and that I shouldn't be alarmed if I lost weight but also that I shouldn't TRY to lose weight. She also made a point of saying that even though the risks were increased, they were still quite low - especially since I am healthy with no major medical problems.  
I ended up losing about 20 pounds over the next couple of months and then my weight just stayed the same until my last month when I gained back about 5 pounds. Neither she nor any of the nurses that weighed me every visit ever commented on my weight except once when the nurse asked if I was deliberately trying not to gain weight. I told her now, that I ate when I was hungry and she was good with that, she didn't want me dieting.
I did have several ultrasounds over the course of the pregnancy but that was because she didn't like to sit still and the tech had trouble seeing the bits of her anatomy that they wanted to see. Everything went very well with the pregnancy. 
I went into active labor 2 days before my due date though I had been contracting for a couple days before that - just very far apart. I said I wanted a natural birth and they had a copy of a birth plan (checkboxes) that my obstetrician had given me months before. I also brought a simple birth plan I had typed up myself - one page with simple goals and requests. I also requested a nurse familiar with natural birth if possible.   
My nurse was wonderful. They assign each woman her own nurse so she was by my side the whole time. She was super supportive - kept saying how wonderful I was doing and helped keep my confidence up.  I didn't have an IV - they were okay with a heplock and only intermittent handheld monitoring so I had complete freedom of movement. Also, I had a jacuzzi and a shower.  
I labored from early morning until about 4pm I was 7cm dilated. Contractions came constantly after that and I got the urge to push. They checked me and I was 8cm so they said not to push. I couldn't really not push, though I tried and the midwife tried to help. 10 minutes of that and they checked me again and I was 9 1/2 and could push. FINALLY!  
I was half on my side hanging on to the bars on the side of the bed and the nurses (not the midwife) tried to get me to roll onto my back. I refused and said the doctor had said I could push in any position, even upside down (which she had said). So they let me be. 
The doc came in and it was my obstetrician since she just happened to be on call that day. She confirmed I didn't need to move and my daughter practically flew out she came so fast!  The doc almost didn't make it to the room in time - they were seeing hair! 
I believe because of this [being in a side position], the birth went very quickly and I didn't tear at all. All the nurses were very surprised and I feel that they will be more supportive of alternative positions in the future.The nurses were amazed that she came so easily and that I didn't tear even though it was pretty fast. My little girl was 7 lbs 6 oz and in perfect health. 
So, even though there was a lot of pain (though I don't really remember the worst of it now) I'm glad things went as they did and I hope you all can have as wonderful an experience as I did. 
Key thing is ask lots of questions to find out what your doc/nurse is okay with and don't be afraid to speak up for yourself, though keep it civil - if you are confrontational it will just hurt you in the end. You need to radiate calm, confidence, and that you are sure you know what you want. Also remember that we have the right to give birth in the position we choose. 
I found the book "Natural Hospital Birth" by Cynthia Gabriel very helpful also. I highly recommend anyone wanting natural birth in a hospital setting to read it - it is full of tips on how to stay in control even in the hospital. 
Also, I'd like to mention that I'm donating my extra milk to the Mother's Milk Bank of Iowa and I'd like to encourage anyone who has extra breast milk to donate to their local bank. It is so important for the little sick babies in the NICU to have breast milk.  

Tuesday, December 15, 2015

The Healing Effect of Health At Every Size College Courses

When I went to college I was truly shocked by the amount of eating-disordered behavior I saw there.

In time I discovered I knew several people with true bulimic issues, some with binge-eating, and some with anorexic tendencies. Many others simply had a lot of neuroses around food and major guilt about "being bad."

What shocked me most was that most of these eating-disordered behaviors were in people who were "normal" weight or just a bit "overweight" by societal standards.

I didn't usually see these behaviors in the fat women I knew, and I didn't see these behaviors in myself. Instead, I saw them in the people that others expected to have healthy eating behaviors compared to me.

What?!?!?!!

That really shocked and surprised me. It made me start to rethink many of the things I had been taught in Weight Watchers and elsewhere. For years, I had believed that all fat people had eating problems (or they wouldn't be fat, right?) and that nearly all average-sized people did not have eating problems. I knew a few had anorexia and I'd heard about binge-eating and bulimia, but I expected most eating disorders to be in people with body size extremes.

Yet really, most of the people I met with eating disorders looked "normal." They were basically of average size, and because of that fact, they were able to hide their eating disorders very well indeed. No one would believe that they had an eating disorder just by looking at them, whereas many believed it of me based on my looks...but it wasn't true.

Now, I have to qualify that a little. After years of dieting, I had started to develop some eating-disordered behavior, but it was pretty mild. It certainly hadn't developed even remotely to the level of binge eating, anorexia, or bulimia. I was never an emotional eater, I didn't binge, nor did I have the kind of neurotic fixation on food that I saw in many of my peers. Once I realized how screwed up some people's behaviors around eating were, I realized that I was better off than I thought. I didn't have an actual eating disorder, and I realized that simply being fat certainly didn't guarantee one. And once I eventually left the dieting lifestyle, any leftover neurotic eating behaviors disappeared altogether.

College campuses are rife with eating-disordered behaviors. The good news is that some colleges are recognizing this, organizing support for those who need it, and offering coursework surrounding these issues. This is a huge step in the right direction.

I hope that college courses like the one below can help blunt some of this angst and help heal people's body issues. College is a powerful time to heal body image and eating disorder issues, so I hope more colleges will make courses like this available.

Wouldn't it be great to see something like this in medical schools too? I certainly have read about a lot of eating-disordered behavior (including compulsive exercise behavior) in medical students over the years. A Health At Every Size® course like this in medical school be incredibly valuable in influencing a more compassionate and healing approach towards body size and eating issues in future care providers.

Colleges and medical schools, are you listening?


Reference

J Nutr Educ Behav. 2015 Mar 10. pii: S1499-4046(15)00011-1. doi: 10.1016/j.jneb.2015.01.008. [Epub ahead of print] Health at Every Size College Course Reduces Dieting Behaviors and Improves Intuitive Eating, Body Esteem, and Anti-Fat Attitudes. Humphrey L1, Clifford D2, Morris MN1. PMID: 25769516
OBJECTIVE: To investigate the effects of a Health at Every Size general education course on intuitive eating, body esteem (BES), cognitive behavioral dieting scores, and anti-fat attitudes of college students. METHODS: Quasi-experimental design with 149 students in intervention (45), comparison (66), or control (46) groups. Analysis of variance and post hoc Tukey adjusted tests were used. RESULTS: Mean scores for total general education course on intuitive eating (P < .001), unconditional permission to eat (P < .001), reliance on hunger (P < .001), cognitive behavioral dieting scores (P < .001), BES appearance (P = .006), BES weight (P < .001), and anti-fat attitudes (P < .001) significantly improved from pre to post in the intervention group compared with control and comparison groups. CONCLUSION AND IMPLICATIONS: Students in the Health at Every Size class improved intuitive eating, body esteem, and anti-fat attitudes and reduced dieting behaviors compared with students in the control and comparison groups.

Wednesday, December 9, 2015

2015 studies on d-chiro-inositol


Here are a few recent (though small) studies on d-chiro-inositol (DCI) for Polycystic Ovarian Syndrome (PCOS). They had promising results. This is good news.

However, this little taste of research on DCI only points out the gaps that still exist and sure leaves me wanting more. So here's my Christmas wish list for PCOS research.

  • I would like to see some gold-standard randomized controlled studies with larger study groups. What's with all these little studies? It doesn't mean that much until it's been done with large study groups and replicated several times
  • I'd like to see more research from the USA and other countries; why are the Italians the only ones really pursuing this so closely?
  • I'd like to see more research done on how DCI affects metabolism, not just menstrual regularity, and whether it slows or prevents progression to Type II diabetes. It's really the metabolic implications that could have the most potential impact on people's health
  • I want to know if there is any interaction between metformin and DCI
  • I want to make sure DCI is safe in pregnancy and breastfeeding
  • I'd like to see DCI studied in post-menopausal women too; that is a vastly understudied group for DCI. Does it impact the incidence of diabetes, heart disease, or stroke?
  • I'd like to see DCI studied in close male relatives of women with PCOS. If PCOS women have a secondary messenger insulin signaling defect, wouldn't you think that our male relatives probably have it too? And that DCI might benefit them too?
  • I'd like to see this question about which protocol is best (DCI vs. myo-inositol vs. both) settled with better quality research

Okay, I'm cranky and demanding, but with a PCOS medication that shows this much promise, isn't it about time we had larger, more complete, and more qualitative trials?

Come on, PCOS research community, get on the stick. Stop putting out these tiny little fluff studies and start cranking out some meaningful inositol research that starts answering the most critical questions.


References

Gynecol Endocrinol. 2015 Jan;31(1):52-6. doi: 10.3109/09513590.2014.964201. Epub 2014 Sep 30. The menstrual cycle regularization following D-chiro-inositol treatment in PCOS women: a retrospective study. La Marca A1, Grisendi V, Dondi G, Sighinolfi G, Cianci A. PMID: 25268566
Polycystic ovary syndrome is characterized by irregular cycles, hyperandrogenism, polycystic ovary at ultrasound and insulin resistance. The effectiveness of D-chiro-inositol (DCI) treatment in improving insulin resistance in PCOS patients has been confirmed in several reports. The objective of this study was to retrospectively analyze the effect of DCI on menstrual cycle regularity in PCOS women. This was a retrospective study of patients with irregular cycles who were treated with DCI. Of all PCOS women admitted to our centre, 47 were treated with DCI and had complete medical charts. The percentage of women reporting regular menstrual cycles significantly increased with increasing duration of DCI treatment (24% and 51.6% at a mean of 6 and 15 months of treatment, respectively). Serum AMH levels and indexes of insulin resistance significantly decreased during the treatment. Low AMH levels, high HOMA index, and the presence of oligomenorrhea at the first visit were the independent predictors of obtaining regular menstrual cycle with DCI. In conclusion, the use of DCI is associated to clinical benefits for many women affected by PCOS including the improvement in insulin resistance and menstrual cycle regularity. Responders to the treatment may be identified on the basis of menstrual irregularity and hormonal or metabolic markers.
Minerva Ginecol. 2015 Aug;67(4):321-5. Epub 2015 Feb 11. Myo-inositol vs. D-chiro inositol in PCOS treatment. Formuso C1, Stracquadanio M, Ciotta L. PMID: 25670222
AIM: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women in fertile age. It is an endocrine and metabolic disorder characterized by oligo-anovulation, hyperandrogenism and insulin-resistance. Various therapeutic approaches have been attempted in PCOS, including diet and the use of pharmacological agents such as oral contraceptives (OCs) or anti-androgens. Recently, the introduction of inositol in the treatment plan has proved to be as reasonable as useful in countering the endocrine-metabolic disorders of this syndrome. METHODS: The aim of our study was to compare the clinical, endocrine and metabolic response after 6 months of therapy in 137 PCOS women characterized by oligomenorrhea and/or acne and/or mild hirsutism and insulin-resistance. The patients were treated with myo-inositol or with D-chiro-inositol or with placebo. RESULTS: Our study showed that both myo-inositol (MI-PG) and D-chiro inositol (DCI-PG) treatments are able to significantly improve the regularity of the menstrual cycle, the Acne Score, the endocrine and metabolic parameters and the insulin-resistence in young, overweight, PCOS patients. CONCLUSION: Definitely, we assumed that both treatments with myo-inositol and with D-chiro inositol could be proposed as a potential valid therapeutic approach for the treatment of patients with PCOS. Additionally, further examination and for a longer period of treatment are needed.
Arch Gynecol Obstet. 2015 May;291(5):1181-6. doi: 10.1007/s00404-014-3552-6. Epub 2014 Nov 22. Evaluation of ovarian function and metabolic factors in women affected by polycystic ovary syndrome after treatment with D-Chiro-Inositol. Laganà AS1, Barbaro L, Pizzo A. PMID: 25416201
PURPOSE: To evaluate the effects of D-Chiro-Inositol in women affected by polycystic ovary syndrome (PCOS). METHODS: We enrolled 48 patients, with homogeneous bio-physical characteristics, affected by PCOS and menstrual irregularities. These patients underwent treatment with 1 gr of D-Chiro-Inositol/die plus 400 mcg of Folic Acid/die orally for 6 months. We analyzed pre-treatment and post-treatment BMI, Systolic and Diastolic blood pressure, Ferriman-Gallwey score, Cremoncini score, serum LH, LH/FSH ratio, total and free testosterone, DHEA-S, Δ-4-androstenedione, SHBG, prolactin, glucose/IRI ratio, HOMA index, and resumption of regular menstrual cycles. RESULTS: We evidenced a statistically significant reduction of systolic blood pressure, Ferriman-Gallwey score, LH, LH/FSH ratio, total Testosterone, free Testosterone, ∆-4-Androstenedione, Prolactin, and HOMA Index; in the same patients, we noticed a statistically significant increase of SHBG and Glycemia/IRI ratio. Moreover, we observed statistically significant (62.5%; p < 0.05) post-treatment menstrual cycle regularization. CONCLUSIONS: D-Chiro-Inositol is effective in improving ovarian function and metabolism of patients affected by PCOS.

Tuesday, December 1, 2015

Physical Recovery After CBAC

Artwork by Molly Remer, from Brigid's Grove Etsy Shop
Recently, we have been talking about Cesarean Birth After Cesarean, or CBAC (some people prefer Cesarean Surgery After Cesarean, or CSAC). This is when someone wants and works for a VBAC but doesn't have one. Usually it means that she labored but ended up with a repeat cesarean, but sometimes it can involve an unwanted planned repeat cesarean that was done for medical indications or because of unsupportive providers. It is the unwanted aspect of it that is most important.

As we have discussed, everyone celebrates a VBAC but many CBAC mothers feel alone and unsupported, both in their physical and emotional recovery. This needs to change.

As part of our CBAC emphasis this past month, I shared my CBAC story a few weeks ago, as well as the CBAC support website I created to discuss the many feelings that a CBAC can involve and some ideas for working through them. I also wrote a 3-part series for the Science and Sensibility blog that discusses how birth professionals can better support people who have had a CBAC:
  • Part One - CBAC: A Unique Grief
  • Part Two - CBAC: The Forgotten Mothers
  • Part Three - CBAC: Supporting Women When VBAC Doesn't Happen
For the International Cesarean Awareness Network (ICAN), I wrote a brochure on CBAC so birth professionals have something to give the CBAC mother immediately afterwards to help support her emotional journey. And I will be recording several webinars for ICAN about CBAC as well.

For my last posts in this series here on this blog, I'd like to focus on physical healing after a CBAC, what you might be feeling after a CBAC, and some things you might do to help in  your emotional healing as well. As always, take what works for you and leave the rest behind.

Physical Recovery

Having a CBAC is hard. Usually it involves recovering from both the rigors of labor and major surgery, and of course recovery can be harder after multiple cesareans. In addition, CBAC mothers have a higher incidence of complications like infections and bleeding, and about 2% experience significant morbidity.

It is hard to process emotions when your body is struggling to heal. Many women find it is helpful to focus first on physical recovery after a CBAC. Here are some ideas to help promote physical recovery.
  • Rest as much as you can. The most potent tool for physical healing is rest. If you are doing too much, your body must divert energy from its recovery. It can be hard to get enough rest with a new baby, but with the support of others, you can prioritize as much rest as circumstances allow
  • Ask for help. Don't be afraid to enlist help from friends, family, your partner, or a post-partum doula. Others should be doing the cooking, cleaning, shopping, and caring for other children; your priority is to feed the baby and sleep as much as possible at first 
  • Take pain meds when needed - Don't neglect pain medication post-partum; you've had surgery. Take them a little bit early, before the pain gets ahead of you. Taper them off over time, but don't be afraid to take them for as long as you need them
  • Set up your home to make recovery easier. Have all the supplies you need right at hand, including a water bottle, the phone, extra diapers and burp cloths, healthy snacks, a footstool, and extra pillows to make positioning more comfortable. Include some entertainment for yourself (a book, the TV remote, music) for those moments when baby just won't let you get up
  • Eat healthy. Your body needs help to repair tissue and replace lost fluids. Get plenty of iron-rich and vitamin C foods and stay well-hydrated to replenish your blood supply. Adequate protein plus vitamins A and E are important in helping to rebuild tissue. Let others feed you, but keep around plenty of easy snack foods like string cheese, nuts, fresh and dried fruit, and pre-sliced vegetables to make grabbing a bite easier while caring for the baby
  • Don't go back to your regular schedule too quickly - Many women go back to a normal schedule too soon after a baby is born, and their body lets them know it's too soon with increased bleeding and pain. Respect what your body is telling you. Take it easy for as long as you can once you get home from the hospital
None of these hints is a magic pill that will wipe away all pain and difficulty. You still will have a surgical recovery, with all the pain and fatigue that entails. Although CBACs are usually harder than primary cesareans, not all are hard. Some have an easy recovery. Others have more difficult recoveries, and a few have very complicated recoveries. Let's talk more about these. 

Dealing with Complications

Although major injuries are quite unusual after CBAC, they do sometimes occur. Women who have experienced major physical trauma (like severe bleeding, significant infection, severe scar tissue, surgical injury to nearby organs, uterine rupture, or hysterectomy) will need significant support as they recover.

If you have experienced complications, it is important to take recovery slowly, since set-backs can easily occur. Get as much rest as possible and seek out complementary therapies like acupuncture, chiropractic, Maya Abdominal Massage, physical therapy, or nutritional counseling to help support your recovery.

Bleeding 

One study found that about 35% of CBAC women experienced significant bleeding, while other studies have found much lower rates. Differing thresholds for defining hemorrhage explains many of these differences, but blood loss is a real risk to be aware of.

If you experienced significant bleeding during your labor or cesarean, have your provider check you for anemia. Being anemic can make healing more difficult, impair milk supply, and prolong fatigue, yet many providers are not proactive about monitoring for this. Taking extra iron, eating iron-rich foods, and taking supplements like Floradix can help your iron levels recover. Women with hypothyroidism may have more trouble with anemia and should probably be extra proactive about this and have additional tests.

If you experienced a major hemorrhage, you should be watched for Sheehan's Syndrome. This is when part of the pituitary gland dies due to a relative lack of blood supply to the area if a hemorrhage happens during childbirth. This can impact milk supply negatively and eventually lead to secondary thyroid dysfunction and many other distressing symptoms. Sheehan's Syndrome often doesn't present fully until years later, sometimes not fully triggered until a successive health crisis (surgery, infection) causes an adrenal crisis. If you experienced a major hemorrhage during your birth, be aware of the symptoms of Sheehan's Syndrome and be ready to advocate for testing if needed.

Infection 

Women who have a cesarean after a VBAC trial of labor have increased rates of infectious morbidity. One study found that 25% of CBAC women experienced chorioamnionitis afterwards, although other studies have found lower rates.

If you experienced a major infection after your CBAC, this can involve a long hard healing process. If you are still in the hospital (or are readmitted later), ask about IV antibiotics instead of oral ones, and ask for a consult with a wound or infection specialist.

Some women have had better healing on an infected cesarean wound using a wound vacuum (Negative Pressure Wound Therapy, NPWT), while others have found it painful and not very useful. Basically it sucks out fluids and infection and draws more blood to the area to improve healing. Bandages are changed about 3x/week, which some women find quite painful; be sure to take your pain meds at least an hour ahead of time. Some people report that using alcohol between the skin and the bandage ahead of time can help remove adhesive tape more easily, and infusing saline first into the sponge inside the wound can ease its removal considerably.

Medical-grade honey is another option (FDA-approved) that has shown some promise in limited studies. It is rarely utilized for cesarean wound issues in first-world countries, but can be another option to consider if you do not want the wound vacuum or find it too painful. You might have to strongly advocate for it since it is used more often in non-obstetric wounds and most OBs won't be familiar with it.

If you are heavy, ask about using weight-based dosing for your antibiotics. Not all antibiotics need weight-based dosing but many do, yet the research shows that the majority of doctors tend to under-dose patients of size, especially those with a very high BMI. Research also shows that "obese" people benefit significantly from longer courses of antibiotics, IV antibiotics instead of just oral ones, and more frequent dosing regimens, so ask your care provider to consider these options too.

Scar Tissue and Nerve Damage

Some women develop significant internal scar tissue (adhesions); the more cesareans you have, the more at risk for adhesions you are. One study found that 46% of women with three or more cesareans had developed "dense" adhesions. These types of adhesions can lead to significant pelvic pain, difficult menstruation, and even bowel obstructions.

Severe cases of adhesions may require additional surgery to break them up. Although this has the risk of creating more adhesions, some women find significant relief with it. Other women are able to address pelvic pain from adhesions through physical therapy, massage, yoga, acupuncture, and Maya Abdominal Massage techniques, which can help loosen and break up the scar tissue.

Some women experience long-term numbness after their cesarean from nerve damage. Although this has little medical significance, it can have significant emotional significance to the woman involved, who may mourn loss of sensation in the area. Sometimes an "itching" feeling can be felt from the inside, even though scratching on the outside does not help. The loss of sensation in the area around the scar is often cited by cesarean mothers as one of the more distressing results of their cesareans. Again, the techniques above may help loosen scar tissue and restore some degree of nerve function.

Injuries to Nearby Organs

Because the uterus is located in the abdomen, one of the risks of surgical birth is injury to nearby organs like the bladder and bowels. This is not a big risk, but if it happens to you it is a big deal.

One study found an incidence of 0.86% of bladder injuries in women who had a CBAC after a trial of labor. Although this risk is low, it does increase in the face of prior cesareans, especially if dense adhesions are present. It is also increased in the face of induction and augmentation.

Sometimes these injuries occur for other reasons. One CSAC mother I know shares her story of recovery after a severe surgical injury by a doctor who was angry with her for laboring "so long":
My bladder was severely damaged through a surgical error during my CSAC. The surgical error was made in an O.R. environment of carelessness and anger that I had fought against CSAC and labored for so long (~60 hours).
Things that helped me recover were: Time, innate stubbornness, acupuncture to help my bladder relearn how to contract after surgical reconstruction, EMDR therapy for PTSD, and antidepressants. My recovery was long and so hard and 7 years later I can finally see the progress I've made.
Uterine Rupture

Uterine rupture is rare but it does happen occasionally. When it happens, it can be absolutely devastating, emotionally and physically. Although usually the rupture is able to be dealt with in a way that preserves both the uterus and the baby, in worst case scenarios the uterus, the baby, or both may be lost. The mother can be left with tremendous physical and emotional trauma.

Obviously, the mother will need to watch for many of the complications listed above. Sheehan's syndrome in particular should be monitored for. Once the initial healing is over, the mother may feel better physically with some of the complementary therapies listed above.

There are groups that specialize in support for women who have had a uterine rupture. You can find more information about these groups here and here. Please also look into the resource groups listed below that help women deal with birth trauma.

Hysterectomy

Women who have a CBAC are at increased risk for hysterectomy, although the absolute risk for this is also low. In one study, about 1% of CBAC women had a hysterectomy during labor.

Of course, if you are among that 1%, it feels like a very personal risk. To lose your uterus and all future childbearing potential is a tremendous grief. Even though the hysterectomy may have been necessary, it still can be traumatic to recover from physically. Hormonal changes due to the hysterectomy may intensify both the physical and emotional recovery. Find a sympathetic care provider to help ease you through these changes. A naturopath or a doctor with a more "alternative" mindset may be your best bet. Acupuncture may also help ease these changes.

Unfortunately, there are not a lot of resources available specifically for women who experience hysterectomy after a trial of labor. There are groups that offer support after hysterectomies in general; these groups can be found here and here. If you search on these sites for "hysterectomy during childbirth" you will find other women who have had similar experiences. Here is a link to an article on coping with unexpected hysterectomies.

Women who lose their uterus during childbirth may develop symptoms of Post-Traumatic Stress Disorder (PTSD). There are a number of organizations out there who can help women dealing with PTSD after childbirth, including Solace for Mothers and others listed below.

Conclusion

The good news is that research shows that the rate of significant complications after a CBAC is quite low. Medically speaking, most CBAC mothers will experience a pretty unremarkable recovery.

However, recovering from a cesarean is always a challenge, especially when you already have older children to take care of. Many mothers try to do too much too soon and end up delaying their recovery and exhausting themselves. It's important to remember that you've had major surgery and to let others take care of you as much as possible.

If you experienced a complication after a CBAC, that can make your recovery, both physical and emotional, harder. Even more difficult are the rare but very serious complications like injuries to adjacent organs, uterine rupture, or hysterectomy. If this has happened to you, please be sure to get extra support for your physical healing and personal support for your emotional healing.

Although most women benefit from focusing first on their immediate physical recovery, sometimes the emotions of a CBAC are so overwhelming that they need to be addressed right away in conjunction with the physical healing.

If you feel overwhelmed emotionally, find a way to debrief the birth as soon as you can. This can be with your providers (if they are supportive), with a doula, with a birth-friendly therapist, or with your partner. The important thing is to find someone who is truly supportive and emotionally safe to speak to, not someone who will downplay your emotions or tell you to "just get over it."

Finding a support group of like-minded women who have been through a similar experience is also vital in dealing with birth trauma. See the resources below for links to birth trauma resources and support groups.

More on emotional recovery in the next post in the CBAC series.


Resources

Emotional Support for CBAC Mothers:
Emotional Support After a Difficult Birth:
References 

*Note: The medical community uses the term "failed" in the following abstracts. Do not let their terminology bring you down. We are NOT failures and we did not fail. 

Scifres CM, Rohn A, Odibo A, Stamilio D, Macones GA. Predicting significant maternal morbidity in women attempting vaginal birth after cesarean section. Am J Perinatol 2011 Mar;28(3):181-6. PMID: 20842616
...We set out to identify factors that are predictive of major morbidity in women who attempt VBAC. A nested case-control study was performed within a large retrospective cohort study of women with a history of at least one cesarean. Women who attempted VBAC were identified and those who experienced at least one complication of a composite adverse outcome consisting of uterine rupture, bladder injury, and bowel injury (cases) were compared with those who did not experience one of these adverse outcomes (controls)...Of 25,005 women with a history of previous cesarean, 13,706 (54.9%) attempted VBAC. The composite outcome occurred in 300 (2.1%) women attempting VBAC. Using logistic regression analysis, prior abdominal surgery (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.2 to 2.1), augmented labor (OR 1.78, 95% CI 1.29 to 2.46), and induction of labor (OR 2.03, 95% CI 1.48 to 2.76) were associated with an increased risk of the composite outcome. Prior vaginal delivery (OR 0.39, 95% CI 0.29 to 0.54) was associated with decreased risk for the composite outcome...Women attempting VBAC with a history of abdominal surgery or those who undergo augmentation or induction of labor are at an increased risk for major maternal morbidity, and women with a prior vaginal delivery have a decreased risk of major morbidity. The multivariable model developed cannot accurately predict major maternal morbidity.
Obstet Gynecol. 2006 Jul;108(1):21-6. Maternal complications associated with multiple cesarean deliveries. Nisenblat V1, Barak S, Griness OB, Degani S, Ohel G, Gonen R. PMID: 16816051
...The records of women who underwent two or more planned cesarean deliveries between 2000 and 2005 were reviewed. We compared maternal complications occurring in 277 women after three or more cesarean deliveries (multiple-cesarean group) with those occurring in 491 women after second cesarean delivery (second-cesarean group). RESULTS: Excessive blood loss (7.9% versus 3.3%; P < .005), difficult delivery of the neonate (5.1% versus 0.2%; P < .001), and dense adhesions (46.1% versus 25.6%; P < .001) were significantly more common in the multiple-cesarean group. Placenta accreta (1.4%) and hysterectomy (1.1%) were more common, but not significantly so, in the multiple-cesarean group. The proportion of women having any major complication was higher in the multiple-cesarean group, 8.7% versus 4.3% (P = .013), and increased with the delivery index number: 4.3%, 7.5%, and 12.5% for second, third, and fourth or more cesarean delivery, respectively (P for trend = .004). CONCLUSION: Multiple cesarean deliveries are associated with more difficult surgery and increased blood loss compared with a second planned cesarean delivery. The risk of major complications increases with cesarean delivery number.
Am J Obstet Gynecol. 2007 Jun;196(6):583.e1-5; discussion 583.e5. Perinatal outcomes after successful and failed trials of labor after cesarean delivery. El-Sayed YY1, Watkins MM, Fix M, Druzin ML, Pullen KM, Caughey AB. PMID: 17547905
...Matched maternal and neonatal data from 1993-1999 in women with singleton term pregnancies with prior cesarean undergoing trial of labor were reviewed. Women with uterine rupture were excluded. Maternal and neonatal outcomes were analyzed for successful and failed trials. Predictors of success and failure were examined. RESULTS: 1284 women and their neonates were available for analysis. 1094 (85.2%) had a vaginal birth and 190 (14.8%) underwent repeat cesarean. Failed trials of labor were associated with higher incidence of choriamnionitis (25.8% vs. 5.5%, P<.001), postpartum hemorrhage (35.8% vs. 15.8%, P<.001), hysterectomy (1% vs. 0%, P=.022), neonatal jaundice (17.4% vs.10.2%, P=.004) and composite major neonatal morbidities (6.3% vs. 2.8%, P=.014). CONCLUSION: Failed trial of labor in women at term with prior cesarean is associated with increased maternal and neonatal morbidities.