We are not moving today!

God has been gracious today. Allan's evaluation was superb and though his store manager is looking for slight improvements in three fairly minor areas, he is in line for being promoted to a co-manager position soon. That was a no-brainer as Allan has superb management skills and I didn't doubt for a minute that he would not have anything but an excellent eval.

His store manager also asked specifically that he stay in the store because he needs his strong leadership right now. Even though, his district manager did ask if he would transfer to Grande Prairie, which he declined again... mostly because there is no way in heck that we could afford to move there on his wage (even with a raise). It was really a moot point though, given his store managers request, but is a future option for sure.

Ironically his other boss (our builder, who we have been working for part-time) called to ask how the eval went and offered Allan a full-time job until he was able to open a sales position for him this fall. I of course told him when he called to tell me of his eval outcomes.

Wow, the options we have been praying for suddenly all fall in our laps in the same hour. We were asking for a sign as to which path we should travel, following Allan's management career in Wal-Mart or moving to the very lucrative construction/sales career offered by our builder. It seems that the latter is where we may be heading... but at a more leisurely pace which is OK with me.

I have never participated in a Meme before, so here it goes...

Four jobs I've had:
1. Real Estate Agent
2. Art Gallery Framer
3. Photo store manager
4. Doula

Four movies I'd watch over and over again:
1. Mulan ('cause I have kids. I know every word by heart and it is still good)
2. Sweet Home Alabama (I have no clue why, but I do)
3. Anything with Tom Hanks (what a gifted actor)
4. Anything with Angelina Jolie (again with the gifted thing)

Four places I've lived:
1. Camrose, AB
2. Lloydminster, AB
3. Spruce Grove, AB
4. Kingman, AB (well on a farm just outside of Kingman... where I grew up)

Four websites I visit daily:
1. orgyn.com
2. Focus on the Family
3. Keel the Pot blog
4. Christianity Today (an article called The Baby I'll Never Forget)

Four of my favourite foods:
1. Anything chocolate
2. Mashed new red potatoes with butter and dill
3. Fried chicken, especially KFC
4. A crisp apple pear

Four places I'd rather be right now:
1. Somewhere warm
2. Cleo's with an unlimited budget
3. At a spa, with my sisters and mom
4. In the new house we are designing, I can't wait!

Secondary Infertility Post-Cesarean

Well it looks like the experts have finally weighed in on secondary infertility after a cesarean delivery.

Subfertility link to cesarean 'may not be causal'
Source: Fertility and Sterility 2006; 85: 90-5

Investigating whether cesarean delivery is independently associated with later subfertility.

The observation that women who undergo a cesarean are less likely to have further pregnancies than other women probably does not reflect a cause-and-effect relationship, research findings suggest.

While it is biologically plausible that the surgery involved in a cesarean section may affect future conception, women who undergo this mode of delivery also differ in many respects from those who do not, including their history of primary infertility, which could confound the association.

For their study, Gordon Smith (Cambridge University, UK) and co-workers studied the relationship of cesarean delivery with later subfertility, with adjustment for potential confounders. They used retrospective data from a cohort study of more than 100,000 women who had their first baby between 1980 and 1984.

Compared with women who had a spontaneous vertex delivery, those who had a planned cesarean section were significantly more likely to not have a second birth during follow-up, with a relative risk of 1.21. Adjustment for maternal and obstetric characteristics, however, attenuated this association to a relative risk of just 1.07, which was no longer significant.

"These data suggest that the association between cesarean birth and subsequent subfertility is more likely to be caused by confounding than by a causal relationship," the researchers conclude.

Well duh. Though some of us certainly do know that despite normal ovulation pre-cesarean and infrequent or no ovulation post-cesarean (though for me it took two cesareans to truly obliterate my ovulation), there are many many women who choose to not have more children because of the negative emotional impact of the surgery. I could list many women whom I have talked to personally who are terrified of another cesarean. Being post cesarean in today's obstetrical quagmire that ACOG has put birthing women in allows only two options, elective repeat cesarean section or homebirth - with or without midwifery care.

Finally, let us never forget the women who cannot become pregnant without it being life-threatening (for instance, a friend of mine experienced embolic thrombosis as a result of cesarean surgery - she risks her life to even fly).

Giving Birth in a Hospital? Think Hard.

It has long been known by physicians, nurses and mothers alike that obstetrics is practiced a far stretch away from an evidence-based standpoint.

Starting way back in North America when midwives attended most births in the home while physicians pined away in their offices, trying to think up new ways to attract customers, er, patients, physicians thought they had a clue about birth. Or rather, how they could improve birth. It isn't obstetrics that improved birth, to be honest it would be hard stretched to say that the office of obstetrics has caused a great deal of problems. General knowledge of anatomy and physiology, the advancements of hygene, and understanding of infection are what have really increased safety. Let's look at what obstetrics has done...

• As much as 100% episiotomy rates at certain times during the last century, and even when it was proven to cause harm or at least not improved outcomes in almost every situation, the rates are shockingly high, as much as 50% or more in some practices.
• EFM (electric fetal monitoring) has not only became common in all hospital L&Ds, it is still used today as standard of care despite it's causing highly interventive outcomes (like cesarean section). Even more frustrating, continuous EFM is known to cause complications in labouring mothers because of lack of maternal mobility which is a key aspect in a well-progressing labour.
• Anyone who knows me knows I am appauled by the skyrocketing caesarean rate. Over 8% places unnecessary risks to the mother specifically and the baby inadvertently (prematurity and cuts from the scalpel to name only two). Just ask the WHO counsel who recommended a rate of no higher than 10-15%. They know the numbers should be lower but US supporters knew they could not sell such a low number to obstetricians "back home" so they settled on the higher average. Incomprehensible that physicians would knowingly risk patients lives to protect their own liability insurance and their personal time (heaven forbid they lower their patient load and reduce their income!). Equally incomprehensible is the number of hospitals and insurance companies who have contributed to this outrage.
• Breech babies born by cesarean instead of vaginally based on one flawed study... knowingly so the minute it was published. Last week a new study refutes the Hannah breech trials and stands behind the safety of vaginal breech birth, yet we have scores of delivering physicians who don't know the basics of leopold maneuvers (relying instead on ultrasound results) nevermind how to catch a frank or footling breech.
  
• Speaking of ultrasound, how can so many things be tested on our unborn without adequate testing like this all-too-common screening tool? No long-term and precious few short-term studies have ever been done on the effacity of ultrasound screening.
• Which then brings me to the sheer number of drugs that are "safe" for mothers until proven otherwise. I will not even start counting the number of drugs resulting in birth defects, stillbirth and more that have been used on pregnant women without adequate testing. Just recently we have the new "stop smoking patch" that has been found to cause birth defects and metronidazole causing the very preterm risks it was preported to fix.
• Oh, and let us not forget the biggest one, the safety of birth in hospitals. The huge homebirth study published last year in the not only shows the safety of homebirth, it shows the huge risks of hospital birth by contrast. Heck, just last week a young healthy mother gave birth and lost all four of her limbs because of the bacteria she recieved from the hospital she chose to give birth in. Terrifying to me.
  

Infant Bonding

In my research for the new online Postpartum Doula workshop I will be teaching, I have been reading a lot about infant bonding. At Birth Psychology I was reading this and was struck by one woman's response:

I had herpes, and they whisked the baby away to intensive care for observation and wouldn't even let me touch him for three whole days. I grieved. I felt that he had died. Finally on the third day I went to the nursery and demanded him. But I felt very little when I got him. I know it's nonsensical, but my emotional feeling was that he had died, and this was someone else. I wanted desperately to love him, and I knew that nursing would be the fastest way to make up for the bonding I had missed, so I made myself nurse him and I hated it for a long time. When I would sit down to nurse him I would feel so impatient I could scream. It took months for me to feel that I was really his mother, and he was really my baby. Finally it did happen, but it was awful for a long time.

Wow. Deja Vu. Here is my story with its parallels:

I had an emergency cesarean section under general anesthesia and while going under I prayed that God would be kind and save my baby as I believed I would not survive. I did survive yet the experience left me detached as a result of the emotional trauma I had experienced. Four hours after I went under the knife, a screaming infant was placed in my arms in my postpartum room. I searched the face of this strange little thing, almost frantically looking for something, anything, that would identify him as my own. It was only when I saw the stork bite on his forehead, the same mark of both my sister and my beloved Grandfather, that I relaxed and a warm flood of love flowed over me. Bonding came quickly as I fell in love with this tiny baby, yet it was a fine thread that could have been easily broken with a far different bonding outcome had I not been able to identify with him.

Theological Breakthrough

Eric, my eldest, has been struggling with confirmation classes for three reasons. First being that he is older than his classmates (which include his brother), second because he is a kinisthetic learner and third, well he is a firstborn/leader type. Being homeschooled, his leadership has not been supressed to conform to a classroom setting and as such, he doesn't conform well to dry old testament history that he covered extensively in grade school.

After a couple of meetings with our pastor who teaches his class, she suggested we switch gears. Instead of sitting listening to lecture for an hour and a half, having just covered the same material as prep homework, he is instead to only pre-read the biblical text to be covered that day and will be the teachers assistant, doing the board writing, showing journeys on the maps (they are currently covering the exodus) and so forth.

For the first time, he came home so excited yesterday loving confirmation classes! In addition, he talked all the way home about something new. He learned that what we had believed to be the exodus route of the Isrealites through the Sinai Peninsula was indeed wrong.

The Red Sea Crossing shows us that they traveled straight through this area, already occupied by the Egyptians, to the Gulf of Agaba where the read red sea crossing occured (see link for archeological and theological proof).

They then travelled on to Mt. Sinai (Jabal el Lawz) with it's blackened peak.

Mount Sinai was completely in smoke, because the Lord descended upon it in
fire. Exodus 19:18

It has been quite a day of learning and triumph.

Grand Rounds

Grand Rounds up today at Grunt Doc.

MedBlogs Grand Rounds features the best writing about medical topics in the blogosphere, brought to you weekly with rotating hosts.

Medical Journals and Politics

Since talking to Henci Goer way back in 2000 about the concerted effort to misalign natural childbirth for the benefit of "daylight obstetrics" in busy obstetrical practices and hospitals, I have been very wary of the press and even trusted medical journals like the New England Journal of Medicine. In 2002 Henci documented her observations in an article printed in Midwifery Today called The Assault on Normal Birth: The OB Disinformation Campaign.

Today, Red State Moron blogs about a very similar concern reported in the Wall Street Journal, but this time we see the NEJM dipping their toes in the Vioxx scandal. The article explains (emphasis mine),

"Accusations aren't the usual fare of august medical journals, so it's worth trying to understand the publication's self-insertion into the Merck litigation. Its extraordinary decision to publish a critical statement about a Vioxx study it ran years ago is being hailed by trial lawyers as the best evidence yet that Merck played fast and loose with its data. Another way to say this is that the New England Journal is joining the ranks of academic publications risking their reputations as non-partisan arbiters of good science in order to rumble in the political tarpits.

The worry here is that the health community and broader public will soon have one less place to find legitimate "science." These publications have viewed themselves as the gold standard in research, using their peer review processes to build reputations for careful and unbiased science on the leading issues of the day. Any suggestion that these publications have an axe to grind -- whether against corporate America, private markets, or specific drugs -- undermines their standing as neutral arbiters. That in turn makes it that much harder to separate good science from the "junk" version. And that truly warrants an "expression of concern."

As Red State Moron suggests (and I agree), "And this is exactly where I think the medical and science blogs will gain an audience, and perhaps respect. As another way of providing "peer review", and as a means of disseminating the information to the public. Because really, how many of you read the NEJM, The Lancet, or JAMA (to name a few)?" Indeed, how many physicians read their own journals, nevermind the patients they serve?

The Maker's Diet by Jordan Rubin

I rarely take the time to read books outside of homeschooling texts and pregnancy / birth / postpartum related tomes, but this book has been on the back of my mind for a while and I finally have it in my hands to read. I am very impressed with what I have read thus far (granted I am in chapter three only) and it is very much along the same lines as what I have learned and understood about nutrition and the bible, though I am learning tons more.

Rubin's experience with Crohn's was absolutely riveting, if only for that information this book is a keeper. Yet it goes on to explain the basis on which he was cured from Crohn's and how others can achieve health too. I will keep you posted on my thoughts about this book as I continue my reading journey.

Carnival of Homeschooling #2

For all of you who are homeschooling, are wanting to homeschool or cannot for the life of you figure out why on earth someone would want to homeschoool, I have a treat for you!

Similar to Grand Rounds (the best of medical blogs) the Carnival of Homeschooling #1 and Carnival of Homeschooling #2 are compilations of unschooling gems discovered in the blog-o-sphere by A Typical Homeschool. Read and enjoy.

Life with Sleep Apnea

As some of you know, my amazing husband Allan was diagnosed with sleep apnea in 2002. Severe obstructive sleep apnea to be exact. The American Sleep Apnea Association explains:

The Greek word "apnea" literally means "without breath." There are three types of apnea: obstructive, central, and mixed; of the three, obstructive is the most common. Despite the difference in the root cause of each type, in all three, people with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer. Obstructive sleep apnea (OSA) is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep.

Sleep apnea is very common, as common as adult diabetes, and affects more than twelve million Americans, according to the National Institutes of Health. Risk factors include being male, overweight, and over the age of forty, but sleep apnea can strike anyone at any age, even children. Yet still because of the lack of awareness by the public and healthcare professionals, the vast majority remain undiagnosed and herefore untreated, despite the fact that this serious disorder can have significant consequences.

Untreated, sleep apnea can cause high blood pressure and other cardiovascular disease, memory problems, weight gain, impotency, and headaches. Moreover, untreated sleep apnea may be responsible for job impairment and motor vehicle crashes. Fortunately, sleep apnea can be diagnosed and treated. Several treatment options exist, and research into additional options continues.

In essence Allan stops breathing when he is asleep, an average 28 times an hour to be exact, and the carbon dioxide buildup in his bloodstream signals him to wake in order to open his airway to breathe. In contrast to Olga Sen's description of sleep apnea, you do not wake gasping and choking. Rather you are so fatigued you barely gain consciousness in order to breathe, and then go immediately back to sleep, only to wake again in 2 minutes. I watched this over and over, loud snoring then silence (I would count the seconds) then movement and a gasp of air (and a sigh and prayer of thanksgiving from me), followed immediately by snoring. Over and over as we waited weeks for the appointment with a sleep specialist, the sleep clinic, and finally for the CPAP (continuous positive airway pressure) machine which would allow him precious sleep, REM sleep which he has not had for months.

Though the APAP (essentially a CPAP but with autotitration so the air pressure fluctuates as needed in response to his needs) machine provides him with the precious sleep he needs, it is not without frustration. In essence you are sleeping with a nasal mask on your face, which when sealed against your face (no air escaping) works perfectly. But when you move it is easy to cause a gap which increases the pressure which wakes you... often with dry eyes because of the air blowing in your eyes from the gap. Then there is the hose (from machine to mask) getting in the way or crossing your neck so you wake up from a nightmare of snakes wrapped around your neck. Oh, and lets not forget the occasional interruption from sundry children coming in for one reason or another during the night.

Allan is finding sleep hard again and I am concerned about the effect his shift work as a manager has on his apnea (working anywhere from 7 am to 11 pm), the stress of said job has on his sleep patterns, and the frustrations he has had with our local CPAP dealer who has caused a delay in receiving his new machine for months. His doctor equates living with sleep apnea as sleeping every night in a hospital with the constant interruptions and various medical equipment waking you through the night. I can well imagine, and signed out AMA after my third caesarian because I couldn't stand it. I cannot wait until the new treatment methods in development provide a better solution than is available right now. Until then, the APAP is providing Allan with life and for that I am thankful.

A new boy is born

Congratulations to Dr. Charles on the birth of his first nephew. An eloquent and well written prose of love.

IQ Testing

One question for all of you. If you decided today to take an IQ test today... oh for whatever reason, and it came back as 132 (cognitive destination = gifted which is only 2.3% of the population), what impact would that have on you?

Grand Rounds Today

Grand rounds is posted this morning at the Cinical Cases and Images Blog.

Grand Rounds is a weekly summary of the best posts in the medical blogosphere. Pre-Rounds is an article series about the hosts of Grand Rounds on Medscape.com. Nick Genes of Blogborygmi, who writes the Medscape column, is the founder of Grand Rounds and he maintains the archive.

New Blog called quickening

A great friend of mine, Anne Boyd (who can be found blogging here) and I have been working on a new informational blog called quickening. Our focus is discussing the business of birth and maternal child health.

Birth Biz, where quickening was conceived is an online group at Yahoo!, with 183 (and growing) members.

Come on over, learn with us, and feel free to contribute!

Hail Caesarean

Since I read this on another blog just after Christmas, the words of this woman have haunted me. Here is a woman, already having experienced her first cesarean iatrogenically because of her physician's impending vacation, pregnant and wanting a vaginal birth. I remember those shoes, I was in them not so long ago after my primary caesarean for the very same reason and so wanting a vaginal birth. I was almost assuming it would be so because I couldn't accept the fact that my body was broken, unable to birth my own child. Denial is not a good thing, especially when you have not given yourself time to grieve.

Now this woman is faced with the financial burden of a possible repeat cesarean following a trial of labour vs. the much lower cost of an elective repeat caesarean section. Couple this with her physician's admitted bias (emphasis mine),

That said, my gynae confesses that he is pro-Caesarean himself. Why? Because it is safer for the mother and the child. However, for first time births, he usually discourages it unless the baby is breach (positioned wrongly) et al. For mothers who have gone under the knife, such as myself, he recommends another Caesarean simply because of safety.

"Honestly speaking, it poses less stress for the doctor as well because we are worried for you, if your wound might rupture, which is very messy. The decision is ultimately still up to you to go elective or vaginal," he told me.

What the hell?! So let me see, I would rather risk mine and my baby's life to give my physician less stress? Let us look at the consequences of an elective caesarean from ICAN shall we?

Risks to the baby from elective cesarean section

• Babies delivered by elective cesarean have an increased risk of neonatal respiratory distress syndrome (RDS), a life-threatening condition, and other respiratory problems that may require NICU care.
• Babies delivered by elective cesarean have a five-fold increase in persistent pulmonary hypertension (PPH) over those born vaginally.
• Babies delivered by elective cesarean are at increased risk of iatrogenic (physician caused) prematurity, usually related to failure to conform to protocols for determining gestational age prior to delivery, or errors in estimating weeks of gestation even with the use of clinical data. Prematurity can have life-long effects on health and well-being, and even mild to moderate preterm births have serious health consequences.
• Babies delivered by elective cesarean are cut by the surgeon’s scalpel from two to six percent of the time. Researchers believe these risks to be underreported.

Risks to the mother from elective cesarean section

• Up to 30% of women who have a cesarean acquire a postpartum infection. Infections are the most common maternal complication after cesarean section and account for substantial postnatal morbidity and prolonged hospital stay.
• Other serious complications for women undergoing cesarean include massive hemorrhage, transfusions, ureter injury, injury to bowels, and incisional endometriosis.
• Women who undergo cesarean report much lower levels of health and well-being at seven weeks postpartum than women who have vaginal births.
• Women who undergo cesarean section have twice the risk of rehospitalization for reasons such as infection, gallbladder disease, surgical wound complications, cardiopulmonary conditions, thromboembolic conditions, and appendicitis. Rehospitalization has a negative social and financial effect on the family.
• Women who undergo cesarean section report less satisfaction than women having vaginal births.
• Women undergoing cesarean are at increased risk of hysterectomy in both the current and future pregnancies.
• The maternal death rate is twice as high for elective cesarean as for vaginal birth.
• In subsequent pregnancies, women with a prior cesarean have higher rates of serious placental abnomalities which endanger the life and health of the baby and the mother.
• Women are rarely told that a cesarean places future babies at higher risk.
• After cesarean section, women face higher rates of secondary infertility as well as higher rates of miscarriage and ectopic pregnancy.

The only true risk of a vaginal birth after a caesarean is the risk of uterine rupture which is 0.7%. Messy indeed for the physician but rarely life-threatening to either mother or baby. From ICAN's white paper, Issues and Procedures in Women's Health Vaginal Birth After Cesarean (VBAC), "The chance of death for a mother is 7 times higher when delivered by c/section versus vaginally." This alone is why I chose, chose, to have a vaginal birth with each of my children. Though I did end with a caesarean with the next two for different reasons, my fourth was indeed a vaginal birth with no complications at all.

Down Syndrome Revisited

Down Syndrome has been in the news a lot in recent weeks. The Washington Post reported on First Trimester Screening for Down Syndrome in November and many other reporters have followed suit. My thoughts on Fetal Testing for Down Syndrome looked at the true impact of testing outcomes and Red State Moron had this to say. Now a new report is out through AP, this one at ABC News that has found Down Syndrome more common (emphasis mine):

Down syndrome in the United States is more common than previously thought,
at one case for every 733 live births, according to a new
government report containing what are regarded as the most reliable estimates
yet on the prevalence of 18 types of birth defects.

Previously, Down syndrome, a type of retardation caused by a genetic
mutation, was estimated to occur in a range of one in every 800 live births to
one in every 1,000.

I am absolutely stunned that if 85% of pregnancies are terminated (Red State Moron and I found two studies citing this) after only a positive Down Syndrome screening, then the statistics of 1:733 is way off and indeed Down Syndrome is much more common than the report leads us to believe.

Online Learning

I love online learning, but then it comes naturally to me as a long-time tekkie, married to someone who is even more of a tekkie than I! I have been learning online since the internet became available and now there are so many great resources, so many great online classes and so much to learn! That is why I am so excited about the Global Birth Institute's new online classroom for training workshops for the certification programs they offer. It isn't really new, the Perinatal Diploma class has been using it for some time for their distance learning component, but it is new for the workshops. It is an excellent option for the many women in rural and remote areas of Canada who contact me on a regular basis asking what their training options are. I look forward to spending some time in "class" as an instructor and student, if you are interested in become a prenatal educator, doula or lactation counsellor, I hope to see you there too!

Big Jar Mayonnaise Mama

Though I don't have nearly the progeny of either Cheryl or Barbara, I am very proud to be a Big Jar Mayonnaise Mama!