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I just got back from the Doulas of North America international conference in Atlanta where I gave a talk called “how OBs think.” The doulas seemed to find the title humorous but they still came to hear what I had to say. I gave the talk because I’ve gotten interested in exploring the scientific data to support physiological childbirth (birth without medical interventions) and I wanted to think through how to introduce ideas to the OB community that might shift beliefs a little. 

So what exactly did I say about how OBs think? First I explained how doctors are trained to think like scientists and how we like scientific evidence to support our practices.  We weigh risks and benefits before making decisions. But we are also human, and under pressure to always get “good outcomes”. We live in a zero tolerance environment, even for very rare unpredictable complications. And we worry about malpractice suits. So risks loom large, and when we weigh risks against benefits most OBs are not convinced that low intervention physiologic birth has specific benefits. This imbalance between perceived risks of allowing labor against the benefits of spontaneous vaginal birth plays a big role in the current high rate of cesarean section.

I gave an example of a typical high intervention hospital labor that ends with intrauterine infection, cesarean section, separation of mother and baby (NICU), and then short term breast pumping but never breastfeeding; Everyone agreed this sort of scenario isn’t that unusual. I asked the question “How did we get here?”  We are supposed to be guided by the principle First Do No Harm, but I think that concept has been subjugated to a risk-based intervention approach to managing labor, without totally understanding all the implications of the management decisions. No mother wants her baby to have problems just so she can have a good birth experience. But that is often a false choice.

Birth is a physiological process and is designed (by survival of the fittest) to go well. Most births shouldn’t require interventions, just support, attention, and a safety net in case of emergency. Birth isn’t just a medical experience. It becomes part of each woman’s personal story. We need to better understand the downstream impact of our obstetrical care: any long-term risks to mother, baby, and future babies from our routine practices; the emotional consequences on the mother and the family of experiencing birth as a medical event; the effects of common practices on breastfeeding and parenting. It sometimes feels like our routines appear justified by community norms, but when they add up they may cause more problems than they solve.

So this is what has been keeping me up at night (when I am not at work being kept up at night by the usual things that keep OBs awake). I’d love to hear other people’s thoughts.

Last week I went to Washington DC for the American Optometry Association, invited to give the keynote for their Women Of Vision women’s networking group. I gave my seminar: Building a Life that Works for Your Family, Your Career, and You, reworked for this audience. I love giving this talk–most recently to the Cleveland Bar Association’s Women in Law section, and the Midwest Veterinary Conference for which I had to learn all about pregnancy in veterinarians, including anesthetic gas exposure effects and veterinary infections! For the optometrists I talked about when is the perfect time to have a baby, and while we all know there isn’t any, we did talk about factors that can guide that difficult decision. We also talked about when and how to disclose the pregnancy at your workplace, maternity leave laws and policies, adjusting to your new job as a parent, communicating with work after the baby, breastfeeding, returning to work, and most importantly work-life balance challenges.

The most fun and satisfying aspect of this seminar for me is always the conversations that develop between the participants. My favorite story this time was from an optometrist who had her office downstairs from her home. She used to run up and nurse her baby between clients but she was running behind one day and was torn about what to do. She finally told her patient that she needed to ask her to wait a bit longer while she ran up to nurse, and the woman invited her to bring the baby down and nurse while they had their appointment…and she did! I love how this seminar opens up discussion for the more seasoned professionals to mentor their juniors in aspects of life outside traditional career mentoring.

After the seminar I did a book signing and got to talk individually with some of the attendees. I received a lovely thank you note from the executive director:

Marge – Please excuse the informality of this THANK YOU!

Thank you for the outstanding presentation at the Women of Vision reception.  The topic was ‘spot on’ and the entire audience was able to relate to your terrific discussion as was evident in the lively post interchange.  I don’t think anyone minded about the ‘Standing Room only’!! Thank you again and we all look forward to your next book.

I hope that our paths will cross again – I enjoyed having the opportunity to visit with you.

Warm regards,                                                                                                                                                                                               Siu G. Wong, OD, MPH                                                                                                                                                                       Executive Director, Women of Vision

This talk seems to be a great ice-breaker for young professional women, and also provides a start to conversation between young members and potential mentors. So if you know of any professional women’s networking events, think of me! I can be reached at mgreenfieldmd@aol.com.

I was interviewed for a new website called Mindful Mama. The thoughtful an thought-provoking site has lots of interesting interactive features, and videos of interviews done at the Controversies in Childbirth conference. Check out four segments from my interview!

Why haven’t I written for this blog in a while? I have been swamped with amazing and challenging adventures! Here’s a few:

I just got back from Controversies in Obstetrics in Fort Worth Texas, a meeting that included talks on Home Birth in the Hospital, International Birth Models that Work, Is There Any Benefit in Low C-Section Rates, and loads of other awesome topics. I got to make a presentation about applying the concept of “first do no wrong” when it comes to hospital routines in birth. The organizers are hoping to make it an annual thing, so I’d keep my eyes open. It was inspiring.

Before I forget: anyone who has had a baby in the past three years is invited to complete a survey. A combined effort between Grassroots advocates and CIMS (Coalition for Improving Maternity Services), the birth survey has three goals: to allow moms to share their experiences, to connect consumers so they can inform each other, and to track intervention rates in different hospitals and birth centers. They hope to summarize their data so everyone can see it, and then keep it updated over time. 

While I was in Fort Worth at the meeting, I was interviewed by Sarah Kraft for her upcoming informational and networking website mindful-mam.com, so keep your eyes open for that posting. They are launching on Mother’s Day with a series of videos called Rites of Passage. Should be available on Youtube as well.

Before I left for Texas, I got to participate in a podcast for PregTASTIC. The whole session was about pregnancy and work. Their format is charming: a group of moms talk together about how their pregnancies are going, then someone comes in with a special topic (this time me on pregnancy and work) and answers questions and they all talk. You can download the podcasts for free on Itunes and listen whenever you want. I took one with me to Hong Kong on vacation and it made the plane trip go…well not quickly but faster than it would have.

I have lots more to say, but I’ll have to save it for later. Don’t forget to tell your friends and family (and doctors and nurses) about The Working Woman’s Pregnancy Book. A great baby shower gift for co-workers and other busy moms!

An article from today’s WSJ online column “The Juggle” says that moms do better if they take off time before the baby comes. Havng interviewed over one hundred women for The Working Woman’s Pregnancy Book, I’d say new moms are split on this issue. Here is what I have learned:

Pros for taking leave before you are due:

• Some women’s jobs are not manageable at that point in pregnancy (think airplane pilot, telephone line service technician)
• Some pregnancy complications preclude working, like gestational hypertension and pre-eclampsia 
• Some women feel so uncomfortable by the end of pregnancy that working either isn’t possible or is just too much
• And from the medical literature: Exhausted moms are more likely to have cesareans than moms who are well-rested

Cons–in favor of working up until labor when possible

• Taking time off up front usually diminishes maternity leave allowed after the baby arrives
• Many women who are used to working get bored and irritable when not busy
• If your delivery date isn’t scheduled (and most aren’t) you don’t know how many weeks you are taking off ahead of time–stopping work at 37 weeks may mean a planned 2-3 week leave turns into 4-5 weeks as your due date comes and goes

The comments online after the WSJ article reflects these arguments, and then some. I am so glad to see these discussions coming out into the open!

What do you think?

Many pregnant women choose to fast at some point in time, usually for religious or cultural reasons. With Ramadan and Yom Kippur around the corner, it seemed like a good time to post some guidelines on fasting in pregnancy. I couldn’t find research on the effects of one-day fasts on pregnancy, but there are several studies on fasting during Ramadan, which is done from sunup to sundown for one month. This year, the Islamic calendar timing of Ramadan coincides exactly with the Western calendar month of September. Yom Kippur is October 8-9.

Is fasting safe in pregnancy?

Resarch on fasting during Ramadan doesn’t show lasting problems for the mother or baby. When ultrasound is used in the third trimester, the babies of fasting mothers are less likely to exhibit normal fetal breathing movements. No one knows if that is a problem, but studies on birth weight and on intelligence later in life are reassuring. My understanding is that Islamic laws don’t require women to fast while pregnant; they are able to make it up by fasting at another time. But many mothers-to-be want to fast because it is meaningful to them. Observant Jewish women are typically advised to fast during the most important holidays. In all religions, allowances are made for fetal and maternal health.

If you plan to observe your holy days by fasting, make sure your doctor or midwife knows that you plan to fast, and exactly what that means—how long you will fast, whether you may drink water, and what rules govern your options if you start to feel poorly. Fasting can be dangerous if you are already dehydrated from nausea and vomiting of pregnancy, or if you have a medical condition like diabetes. If your practitioner objects to your fasting, follow his or her medical recommendations. Remember that the most important outcome is a healthy mother and baby!

Here are guidelines to follow to keep safe if you are going to fast during your holy days:

• Hydrate beforehand. The most likely reason to feel unwell while fasting is dehydration. If your fast is from sunup to sundown, be sure to eat well and drink a lot of fluids before sunrise. Protein and fats will keep you energized longer than carbohydrates will. If you are fasting for 24 hours, hydrate as well as you can for a day or two before the fast.
• Keep cool while fasting. Getting overheated will dehydrate you more quickly.
• Rest, to conserve energy and fluids.
• If you feel lightheaded or dizzy you must at least drink fluids. If your brain isn’t getting enough blood flow and oxygen (the cause of lightheadedness) the baby may not be either. Lie down right where you are if you feel faint, and drink until you feel better. If plain water doesn’t work, you may need something with nutrition in it, like juice or food.
• If you start to have uterine contractions (a balling up or tightening feeling, or the sense of menstrual cramps) you must drink some fluids. Dehydration can lead to preterm contractions and potentially preterm labor. The most sensitive time in pregnancy is the last trimester. If contractions don’t stop with rest and fluids call your doctor or midwife or go to the hospital.
• Break your fast gently with water, sports drinks, or dilute juice. Carbohydrates like crackers or toast typically go down easiest, and fatty foods are most difficult to digest. Eat a small amount first and see how you feel before filling up.
• And most of all: listen to your body! Your body is a good barometer of how the baby is doing. If you feel terrible, that probably isn’t good for your baby, either. Adjust your intake so that your baby gets what is needed.

 A version of this article was originally published in the Al-Sahafa Newspaper, September 2008 issue.