Question:  You don’t encourage the right kind of attitude in women regarding childbirth.

Answer:  What is the right kind of attitude in your mind?  Do you feel you have the right or the expertise or the arrogance to dictate what a right attitude is and what a wrong attitude is?  Because we don’t.  Nor do we have any aspirations in that direction.  Whatever attitude a woman has is the right one to us and we are offended for ourselves and all women at the suggestion that we are all same-thinking clones that should have the same attitude.  We are all individuals and we have the right to have that simple fact respected.

Question:  I learned the hard way that midwives are interventionists.  Could you tell your readers what ‘finger forceps’ are? 

Answer:  Midwives are interventionists.  The myth that they aren’t is a self-serving one perpetuated by midwives themselves and by those who agree with their biases or by those who wish it was true.  Midwives intervene for the same reasons other obstetrical caregivers intervene.  Some are cruel and sadistic and they intervene unnecessarily because they can and because no one stops them.  Some intervene unnecessarily because they believe they have the right to use a woman’s body as a teaching tool.  It is never informed consent if you are asking for permission to do anything if the woman isn’t made aware of the possibility of it happening before hand or if you are asking in situations where she is under duress.  It is never informed consent if the woman says NO.  It is never informed consent if the woman feels she will be punished or subjected to substandard care if she says NO.

Some do it to speed up labour or to make a vaginal delivery possible in the first place.   Without these medical interventions by nurses, midwives and doctors more women would lose their lives in childbirth than already do.  Ditto for their babies.  Many midwives feel their interventions reduce maternal morbidity – both physical and psychological (it doesn’t).  We hear hundreds of stories (literally) from women with horror stories about their midwife-attended births, just as we do doctor attended ones.

Finger forceps are when the attending midwife (or doctor – but we have only heard stories about midwives doing this) inserts both hands into the mother’s vagina with her hands positioned so the knuckles meet (for leverage).  She then uses her fingers (and fingernails) to pry open the pelvic area and tear away maternal flesh and tissue.  It is cruel, barbaric, extremely painful on top of the excruciating pain women are already in and it results in extensive damage to the mother.  All the stories we have heard are from women who had this done to them by midwives and without pain relief.

Question:  Is it true that women have bowel movements as they have babies?

Answer:  Yes, about 80-85% of women giving birth vaginally will.  Enemas don’t prevent that.  One of the hospital staff in the labour and/or delivery room with you will clean this up quickly and often women find the pain and the birth so traumatizing they are unaware of this.  You have the right to know this if you choose to give birth vaginally because it is your right and because it will influence who you choose to have as a support person(s) (they will be aware of it) or whether you choose to have a support person.   We have heard many stories of immature support persons thinking this is a funny story to tell friends, relatives and drinking buddies.  One husband we are aware of used his continued silence on this subject as a means of controlling his wife when she asked for money and to prevent her from leaving him. 

Make wise choices when deciding who (if anyone) you want with you.  They are there as an advocate, as support and to speak for you when you can’t.  When you grant them the privilege of being with you they should always treat you with the respect you deserve.  If you have any doubts about this they are not the right choice.

Question:  I found dealing with people after my traumatic birth was almost as traumatizing as the birth itself.  You helped me understand how harmful this secondary wounding is and how it makes healing and coping harder.  I’ve seen lots of references to it in the comments from other women but I think you need to talk about this more.

Answer:  You are right and I’ll do that right now. It is a sad truth that often people do more harm than good.  They are dismissive, indifferent, blaming and shaming and it is often done by people who should know better.  Secondary wounding or re-traumatization involves many of the same behaviours encountered during pregnancy, labour and delivery and occurs when the trauma survivor turns to people, institutions, caregivers, family, mental health or medical professionals for emotional, legal, financial, medical, or other assistance and is met with:

1)  Disbelief, denial, discounting.  [You are told you didn’t suffer near as much as so and so and she isn’t complaining/ What do you have to complain about?/ Don’t be so ungrateful/ You have a healthy baby so get over it/  Why do you want your medical records/ You can’t have your medical records/ Oops, we can’t find your medical records/ You are lying/  You can’t remember properly/ and on and on.]

2) Blaming the victim.  [You are told you deserved what you got because you were too fat, too old, too weak, not cooperative, too cooperative, too aware, not aware enough, too drugged, not drugged enough, took fertility drugs, didn’t use contraception, didn’t use a doula, didn’t have the right attitude, you are stupid, you are selfish, you aren’t selfish enough, you chose the wrong midwife or doctor, you made your nurse(s) hate you, you chose the wrong support person, you are a hippy-dippy granola-cruncher earth mother, you are not a hippy-dippy granola-cruncher earth mother, you didn’t have a husband, you did have a husband, you need to be punished because you are a woman, you have too much education, you don’t have enough education, you wouldn’t be able to bond properly with your baby if we didn’t treat you like that, you are too rich, you are too poor, etc. ad nauseum.]

3) Stigmatization occurs when others judge the victim negatively for normal reactions to the traumatic event.  It can be in the form of ridicule and condescension (Come on it’s funny, You couldn’t sit for weeks – how hilarious, How could you be so stupid not to know that would happen? Etc,etc,).  It can be about misinterpretation of the survivors’ psychological distress as a sign of mental illness or moral or mental deficiencies (She has hormone problems, I’m sure she must have had mental problems before, Are you sure you haven’t been raped or had depression before?, You must be crazy, I’ll bet you are poor and have poor social skills, etc., etc.).  It can involve implications and accusations that the survivor’s symptoms are all part of her desire for attention, unwarranted sympathy and financial gain.  Stigmatization is about punishing the victim, rather than the offender or the system and in the process denying the victim justice.

4) Denial of Assistance.  [In my opinion you didn’t need pain relief; No one can help you now; It’s not our fault the anesthesiologist went for a long coffee/We were busy and never called them; You needed to suffer to be a good Mom; You can sue us but you won’t win; No one will believe you anyways; If we give you money will you shut up?]

Secondary wounding has a number of causes.  Ignorance, human cruelty, insensitivity, misogyny, burn out*, a belief that people get what they deserve and the cultural belief that everyone is the master of their own fate all play a role.

* Burn out is indicative of full or partial PTSD in many medical workers and emergency responders.  Unfortunately, it is either unrecognized or ignored, by them and by the systems that should be working for them.  The cost of that to patients, to the medical workers themselves and to the business of medicine is staggering.

Question:  My midwife says I will not have any problems and I will not tear apart if I have a vaginal delivery.  Should I trust her?

 Answer:  No.  She is either grossly incompetent or a very big liar.  No one can predict how labour, delivery and the postpartum will go and no one should make these statements.  They put their credibility at risk and they pump up unrealistic expectations.  Childbirth is different for every woman and individual pregnancies for the same woman are different.    Honest obstetrical caregivers will tell you that things can go bad very fast and they, and you, can’t control that.  You have the right to know this and you have the right to know what will need to be done in the event the pain or circumstances don’t go as planned.

Question:  I heard they don’t want to respect a woman’s right to choose an elective cesarean so they can save money.  Do you think that is true?

Answer:  Yes, this has been (and is) used as a reason.   I think most women would be shocked to learn that there is such a thing as a health economist and that they hold a great deal of sway when it comes to maternal experience and the choices women are ‘allowed’ or ‘offered’.  It is disheartening to find out that money comes before a mother’s right to reproductive choice.  The ongoing debate about whether planned cesareans cost more than vaginal births is intense and mired in personal biases.  Some studies show that planned cesareans cost more, some show they cost the same, some say they cost less and are a more efficient use of time and money and some show that they cost the health system less in the long run or if both the medical costs of the mother and baby are considered together.  They can use statistics to back any position.  Any analysis of costs needs to consider all associated costs and this is something those with personal agendas resist.  Economics is also a factor in denying epidural anesthesia for women in labour and delivery as epidurals cost money. 

Of course, misogyny plays a big role in this economic behaviour but it isn’t the only factor.  Health systems are strained beyond the breaking point in terms of resource allocation and, since pregnancy related costs are the bulk of costs to health care systems, they make a big target for those wanting to keep costs down or prevent them from going up further.  This is a greater problem for publicly funded systems and is the major reason why most private hospitals worldwide are consistently more progressive; provide better access and more choice than public ones.  You get what you pay for and that is a sad, but realistic, statement that applies to obstetrics just as it applies to any other aspect of life.  When society, governments, medical administrators and practitioners understand they don’t have a society or jobs without mothers perhaps we will see some positive changes about medical spending attitudes and women’s rights and health.  I’m not sure how low the birth rate has to go before that reality sinks in.   

 

Question:  I’ve heard women do not have the legal right to request a planned cesarean in Canada.    Is this true and can they be sued for denying women this reproductive choice?  

Answer:  Technically, yes, this is true.  As far as I know the first country in the world to make it illegal to deny women this human right was Italy.  They did this over a decade ago (1996).  Many other countries around the world do not place barriers on women wanting access to this reproductive choice.  The Society of Obstetricians and Gynaecologists of Canada (SOGC) has steadfastly refused to recognize this right although the American College of Obstetricians and Gynecologists (ACOG) essentially recognized this right in 2003.  Not all obstetric specialists in Canada are affiliated with SOGC.  Many are affiliated with the ACOG (www.acog.org) and they have a ‘Find a doctor’ service on their website that includes those practicing in Canada.  Be forewarned that just because a doctor is affiliated with the ACOG is no guarantee that they will respect maternal choice.  Not all obstetricians associated with the SOGC would deny a woman this choice either.   The key to finding such a doctor is persistence and insistence. 

I don’t have a clear answer as to whether a doctor or hospital can be sued for forcing a woman to give birth vaginally when that is objectionable to her.  I haven’t heard of any test cases but that could be because these things are kept covert and secret.  I know there have been legal precedents using the court system to force women to undertake a cesarean against her wishes. 

Could a woman sue for failure to provide a maternal request cesarean?  I think you need to talk to someone more knowledgeable about the law than I am.  Make an appointment with a lawyer specializing in medical malpractice for an expert opinion on this subject.  I do think that doctors and hospitals expose themselves to liability if a woman refuses a particular medical option (ie: a vaginal delivery) based on unacceptable risks to her body and her baby and then is forced into this option and does suffer these risks.  In Canada, as in most developed countries, a person has the legal right to informed, unbiased information to get informed consent and to ascertain which medical risks a procedure entails and they also have the right to refuse a particular course of action if they feel the risks outweigh the benefits. 

It is the position of Birth Trauma Canada that it is morally and ethically reprehensible to deny a woman the right to reproductive choice and to force her to give birth in a way that is objectionable to her.  This applies equally to both planned vaginal deliveries at the mother’s request and planned cesarean deliveries at the mother’s request.

Question:  Is having a baby (vaginally) like running a marathon?  I have heard this analogy and I’m skeptical. 

Answer:  Skeptical is a very good trait.  Hang on to that.  No, having a baby is nothing like running a marathon.   Having a baby is way, way harder; hurts far, far worse and takes way longer to recover from.   You can train for a marathon in ever increasing increments.  You can stop running a marathon when and if you feel like it.  Running is a good form of physical exercise that will leave you in better shape than when you started.  None of those things apply to having a baby.  The pain after running a marathon is sore muscles and the pain after childbirth includes sore muscles and far more severe stuff.

Question:  During my prenatal class the nurse went on and on about how awful a cesarean would be.  Now my baby is lying sideways and I’m told I need a cesarean.  Now the nurse is telling me that a cesarean won’t hurt, even after and not to worry.  They both can’t be right and I’m so scared and stressed out and I don’t know who to believe.  Please answer quickly.

Answer:  We feel for you and you are right.  They both can’t be right.   Who do you feel is the most trustworthy?  We often turn off our ability to detect bullshit when we are so scared, and you have every right to be scared, but I want you to consider what you think, and only what you think, about the relative merits of each of their statements.

 First off, the decision to have a cesarean is the only one in this situation.  It is impossible to give birth vaginally to a baby lying in this position.  I am truly sorry about this if your first choice for delivery options was a vaginal delivery.  Secondly, I’m assuming from your complete description that the second nurse works with the doctor who will perform the cesarean and she has inside information about his/her abilities/attitudes and those of the hospital s/he works in.  She knows what they are capable of and their track record.  A cesarean is a straight forward operation but, like all surgery, depends on the training, experience, skill and judgment of the surgical team.  The cesarean she is describing is very possible (and has been for a long time) and should be done like this for all women having cesarean births.  It isn’t always and I think you can imagine how terrible surgery would be in the hands of an incompetent or sadistic surgeon/hospital/anesthesiologist.  The first nurse may only know about this type of experience, although I rather doubt it.  It is more likely she (or the people who pay her salary) has an anti-cesarean bias, which I discuss in the next paragraph.  For your piece of mind, I would suggest you make an appointment with both the obstetrician and the anesthesiologist, outline these valid fears and get their reassurance.  If they can’t offer that SWITCH doctors now.  I know this may be difficult or even impossible at this stage but you need to try.

You are not the only woman subjected to pro-vaginal/anti-cesarean rhetoric during childbirth preparation classes.  We hear from many who needed emergency cesareans and were scared to death of that prospect at the time because that is what they were prepared to expect, only to find out that the procedure was painless and their recovery painless.  That realization makes for a great deal of justifiable anger on the new mother’s part directed at the ‘preparation’ they did get and at the futility of the traumatic experience they had.

Please let us know how this works out for you and if there is anything else we can do. 

Question:  I’m having leg problems and difficulty walking normally still 8 months after the birth of my baby and the OB tells me she has never heard of this.  They didn’t mention this in prenatal class.  Have you heard of this?

Answer:  Your OB is lying.   Damage to the pudendal nerve system during a vaginal birth isn’t the only nerve damage that can happen.  Axonal loss/demyelination of several nerve systems can happen – femoral, peroneal, lumbosacral plexus, sciatic, obturator, radicular – all can be damaged via pressure or stretch induced ischemia (lack of oxygen) during pregnancy and particularly the birth process.  Damage to each of these nerves causes various different postpartum neuropathies.   Sometimes they are seen as motor dysfunction, sometimes pain, sometimes numbness or tingling.  They cause back problems or problems with the lower extremities.  Damage to the peroneal nerve is particularly evident when the legs are held wide apart and flexed at severe angles during pushing, handled roughly by support people and hospital staff, or with the use of stirrups in lithotomy position or squatting and prolonged pushing.  This is something that anyone with an ounce of obstetric sense knows (and your OB has lots of obstetric sense or she wouldn’t be an OB).   It has been a problem known for centuries.  It is something that isn’t as common now as it was in the past because of cesareans for situations likely to cause these problems.  That bit of news doesn’t matter a bit to people like you who have these problems and why should it?   Sometimes these problems resolve, at least in the short term, and sometimes it is necessary to deal with physical therapy, braces and walking devices.  Not telling women these risks in prenatal class is just one of many examples of denying informed request, something we would dearly love to change.

Question:  Is vomiting really something you do when you are in labour and delivering?  I am absolutely terrified of that. I don’t want to act like a baby but this is something I can’t deal with.  Please be honest.  I can’t find anyone else to give me a straight answer.

Answer:  Yes, vomiting is something that is so common in labour and delivery that you should expect it.  So is hyperventilating.  Severe pain, distress and fear will do that to anyone.  Vomiting is also something that can happen during a cesarean if ephedrine isn’t given as a prophylactic measure or soon enough as your blood pressure goes down during regional anesthesia and surgery or if systemic opium derivatives are given (they can cause terrible itching too) during recovery but a good hospital/anesthesiologist/obstetrician/ knows this and can account for that easily.   Vomiting is also very common during and after general anesthesia. 

I don’t think you are a baby at all.  No one likes to vomit. You shouldn’t be ashamed of your fears.  Our fears are part of who we are.

Question:  I was looking at a website that claims to want improvements in maternity services but they don’t seem too mother-friendly to me.  They seem the opposite to me and if you don’t want the kind of birth they advocate then you are wrong.

Answer:  Therein lies the crux of the problem, doesn’t it?  There are women (and men) who feel strongly that they have all the answers but, of course, they don’t.  No one single person (or organization) EXCEPT the mother herself knows what the best way to give birth is.   Every woman is an individual and should be treated as such.  There is a lot of chest-beating out there about the ‘best way’, the ‘only way’, the ‘normal way’ but the truth is that, for every person or organization that gets on their soap box about what they think women should subject themselves to, there are other people who think, justifiably, that they are loopy, offensive and just plain wrong. 

My advice to all prospective mothers is to cut through all the bias and crap out there (and there is so much) by deciding whether what someone is saying sounds true to you.  If they sound loopy or offensive it is because they are, to you at least and it is your opinion that matters.  They aren’t going to sound any less wrong when labour happens.  On the other hand, for some women, what these groups are saying is comforting and makes perfect sense. 

Value yourself and what you want.  Be prepared to defend yourself against anyone (and switch immediately) who doesn’t value what is important to you.  You need to put yourself at the pinnacle of the obstetrical hierarchy, not at the bottom.  I wish that wasn’t necessary but it is.  It makes pregnancy more stressful when you have to do this.  This is why BTCanada strongly suggests women do their research, make their decisions and talk to obstetrical caregivers before they decide to get pregnant.  Your options are limited afterwards.  Someday, maybe, women can decide, without guilt, shame or coercion, the best delivery option for them and to have that delivery option provided in a way that is both safe and meets her individual needs. Hospitals, birth centres or home birth midwives need to be more upfront and accountable with their statistics and to report all morbidity and mortality in an un-biased way instead of ways that support their positions.  Women can’t be expected to make informed decisions if they aren’t given access to complete and unbiased information.  That day is not here yet but we see steps in the right direction.  I think there is reason to be optimistic, although we have been criticized for being naïve about this.  They have a good point.  Time will tell.

Question:  I’ve been told by a psychiatrist that I can’t have PTSD because I don’t want to harm my baby and because I’ve never been sexually assaulted.  I feel betrayed because I relate to post traumatic stress symptoms so much. 

Answer:  I don’t keep records but there are two things that jump out at me about what I do with Birth Trauma Canada.  They are:

1)  The overwhelming majority of women who contact us with horror stories about their traumatic childbirth experiences are those with vaginal deliveries and planned vaginal deliveries that ended badly.

2)  The overwhelming majority of these women have never been abused, sexually or otherwise, in their life before their childbirth experience.  Labour and a vaginal delivery (and cesareans where the mother is terrified of surgery, treated disrespectfully or where there was an inadequate level of pain relief) are enough on their own to cause post traumatic stress injury.  Indeed, the majority of women who give birth will have trauma symptoms.  It is worth mentioning that depression is a common and expected trauma symptom.

It is quite possible – in fact it is the majority – to have post traumatic stress from childbirth without displaying a desire to harm your baby and without having a prior traumatic experience.  What you have been subjected to is punishment by psychiatry.  I don’t want to diminish the very real negative consequences of a vaginal birth to those who have survived sexual assault nor do I want to diminish the fact that a woman’s baby can act as a trigger to post traumatic stress symptoms.  Both these things happen. 

I think we need to understand about the ‘fluidity’ of psychiatry and psychology.  What is considered truthful changes with time and with the people involved.  Psychotherapy is best considered an art.   And some artists aren’t very good at what they do.  It is why it is so important to choose carefully if you are looking for a mental health professional to help you deal with birth trauma.  Some can do far more harm than good.

Every once in a while the American Psychiatric Association (APA) gets together, by committee, and decides what will and will not be considered for their latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM).  The DSM was first published in 1952 and there have been 5 revisions since then.  The current one is referred to as DSM-IV and it was published in 1994.  They are working on DSM-V and that is slated for release May 2012.  This is the definitive resource for those in the mental health field.  Are they the best ones for the job?  Probably they are.  No one else has their level of expertise but they are, by no means, infallible.   Post Traumatic Stress Disorder wasn’t designated in the DSM until 1980.  It wasn’t that PTSD wasn’t around before.  The information necessary to make that diagnosis has been around for centuries – it just wasn’t picked up on by the very people whose job it was to do that.  In 1980 it was determined by the APA that PTSD could only be a diagnosis if the trauma was ‘outside the normal human experience’.  Therefore, psychological injury from combat was considered outside the normal human experience; psychological injury from childbirth was not.  It would be another 13 years before they accepted that childbirth could cause PTSD.  Again, it wasn’t because the information wasn’t there – it had been for centuries as well – it was because the people who should have known better didn’t.  Logical assessments of what constitutes a justifiable trauma didn’t happen.  How they could determine that war was outside the experience of normal human experience for the most war-like species on the planet is beyond me.    My point is that, just because mental health experts say something now, doesn’t mean it is true or that it won’t change in the future.  If you need further proof of that read some of the past revisions of the DSM (you will need a strong stomach) or consider other mistakes the APA has recently made.  They, at one time, felt homosexuality was a mental illness.  They also recently made statements that infer that women who don’t like sex are mentally ill.  This will come as a shock to all those happy, celibate women out there.  This position has garnered much ridicule and I expect a full about face on that as well.

 

Question:  I was told I was ‘lucky’ because my injuries were extensive but first degree.  The nurses laughingly called them ‘skid marks’.  These ‘funny’ injuries have caused me untold pain and distress.  I’ve been diagnosed, finally (I’m 17 months postpartum) with vaginal stenosis.  This is caused by scar tissue after vaginal birth.  Sex is impossible because it is too painful and I couldn’t even get a finger into my vagina.  My husband left because I was told it was all in my head and he believed them.  Good riddance, I say.  I’m supposed to come in over several weeks for freezing needles into my vagina and a series of dilators inserted into my vagina.  If that doesn’t work then I need to have vaginal surgery.  Needless to say neither of these prospects is what I want and I just want to give up.  Can you tell me if these freezing needles hurt and if there is another way to fix my problems without what this doctor is telling me?

 

Answer:  You aren’t lucky and this isn’t funny.  Vaginal stenosis is an underestimated problem after vaginal births.  Some people form scar tissue more than others after tissue damage.  Sometimes this narrowing of the vagina happens because the reconstructive surgery after vaginal birth was done badly.  To answer your questions I asked another Mom who has experience with this.  Actually your letter mirrors exactly what she experienced too.  This is her answer.

 Yes, those needles are painful.  The dilators were used on me and caused bleeding and more pain.  I had the surgery –mine was called a vestibulectomy – and it was a terrible experience, very painful, very humiliating, and took several months for the pain to subside to the point where I could have sex again without hitting the roof because of pain.  The surgery wasn’t a complete success but I’m not sexually active anymore as this ended my relationship.  I feel so sorry for this woman.  It is a terrible thing to happen.

Those last two sentences say it all from my point of view as well.  I am so sorry I can’t suggest any other recourse for you and I am so sorry this happened to you.