The Doula-Added Experience

At the end of pregnancy a woman’s body ushers her precious passenger into the world. Muscular contractions of the uterus soften, thin and ultimately transform the cervix – often called the ‘mouth of the womb’ – into an open gate through which a tiny human can pass.

Yet as eager as a woman may be to meet her new baby she may be dreading labour and birth.

Fortunately this dread can often be resolved well before birth. For many, the key to overcoming fear is to perceive labour and birth as natural processes that are made easier to work with by positive attitudes and with practical strategies.

While the attitude of every mother-to-be is a force influencing whether she faces birthing with confidence or anxiety, including a doula in her birth plans is an excellent strategy.

It may have been my midwife in 2006 who explained to me what a doula was and recommended the then-very-new doula service to me. I was excited to hear that doula support was associated with shorter labours, less medical intervention and fewer Caesareans. But what exactly is a doula?

The word ‘doula’ is derived from the Greek for ‘woman servant’ but a doula today is a trained professional, usually a woman, who provides emotional and physical support during labour and/or after pregnancy. The Doula Alliance of Trinidad and Tobago charmingly describes the doula’s role as “mothering the mother.”

My own mother had been a reassuring presence during my first labour. Her back massage and aromatherapy oils had worked wonders. She had been the unofficial doula for my first birth. But she lived abroad and my concern that she might not arrive in Trinidad in time for the birth of our second bundle of joy was a driving force behind my decision to have a doula.

And so Mags entered our birth story.

In the weeks before our baby’s birth, Mags and I got to know each other and we discussed the natural pain relief strategies she could make available.

Honestly, I was confident about being able to manage the ‘discomforts of labour.’ After all, for my first birth, I’d used certain labouring positions and visualizations from my birth preparation classes and they had worked. I was simply planning to use them again.

But in the end, somewhere in the more intense phase of labour I realised that the strategies I had used the first time round didn’t fit the experience I was going through – and I had no back-up plan. However Mags did. She presented a birthing ball for me to sit on just when I needed it – and later, warm compresses for my back.

She helped keep me focused at that challenging point in labour just before the actual emergence of the baby through the birth passage.

Mags was completing her training when she attended my son’s birth yet her impact was so positive I’ve been recommending having a doula (and Mags herself if she’s available), ever since.

I remember her being not just well-intentioned, as a friend, father-of-the-baby or mother might be, but also skilled and professional. Years later she holds an important place in our birth memories.

Manghanita Kempadoo was our first doula but will forever be part of a positive birth memory! We snapped this photo when she came to visit our newborn in the days following his birth.

Manghanita Kempadoo was our first doula but will forever be part of a positive birth memory! We snapped this photo when she came to visit our newborn in the days following his birth.

Fast forward to 2013. A third pregnancy and another doula – Zara.

This time I was preparing for a homebirth.

A few relatives asked me frankly why I should need a doula. After all, my mother and husband would be available to rub my back and I wasn’t new to the birth process. This was a reasonable question.

My answer is that a doula can identify and use more pain relief strategies than a loving family member. She comes with training, regular experience and she too comes with love. The work of a doula involves intimate work with an unknown woman at unpredictable hours for possibly days at a time. The remuneration is humble so the work is vocational, a labour of love.

Importantly too, a doula can support a labouring mum without excluding other relatives or friends. In fact meeting with my husband to discuss what he felt his involvement in the upcoming birth should be, was something Zara did very early in our relationship.

Though today’s man is often expected to be a key labour support person (once the hospital allows him to be present), and some men do embrace this opportunity, others would prefer to stand-by or be called in after the birth of their baby. Unfortunately men can feel socially pressured to be involved beyond their comfort level.

A doula can help take the pressure off baby’s father by helping him identify how he can participate at his comfort level while ensuring that mother has the support she needs.

Thanks to a few planned “chat sessions” with Zara I was better able to focus on mentally preparing for the birth. Zara made gentle suggestions which in the end I used with no regrets.

She was keen on hypnotherapy as a tool for a peaceful and natural birthing experience and so loaned me a hypnobirthing book and CD that I used in my preparations for the big day.

My birth prep stash! Including some bits on loan from Zara.

My birth prep stash! Including some bits on loan from Zara.

In the end, knowing that my doula could get to my house (or the hospital) in half-an-hour, that she understood and respected my birth plan and would be able to gently advocate for the written plan to be followed (should I be rendered speechless by contractions), gave me great peace of mind. A woman in labour needs to focus on her task at hand – and arguing rationally with medical personnel is hardly a distraction she can cope with effectively.

Our birthing room this time turned out to be our bedroom.

The intense phase of this labour was very brief but Zara was brilliant in helping me to keep calm and reminding me to breathe appropriately. Some people grumble that no-one needs to be reminded to breathe but I breath-hold unconsciously under stress and some people create a panic cycle by hyperventilating, so simple breathing techniques in labour can be useful.

Zara used a light feathery massage which took the “edge off” the final and most trying surges. Ironically, I had been adamant in our pregnancy discussions that light massage is irritating- but what was amazing is that she knew (intuition or experience?) exactly what I needed at moments when I had no access to words.

Overall, I sought and received peace of mind and help with natural pain relief methods from my doulas. However, what doulas offer is much broader in scope. The soothing and coaching to dissolve fear and anxiety, or encouragement provided for a particularly difficult or lengthy labour can be critical in helping a mother to persevere. I’ve had friends who found doula support priceless for labours that took place in hospital or ended in Caesarean births.

Doulas also extend their services to the period after baby’s birth, helping with breastfeeding in the critical early weeks.

Zara De Candole

Zara De Candole

Visiting on Day 12

Visiting on Day 12

To learn more about accessing doula support in Trinidad and Tobago do contact the Doula Alliance of Trinidad and Tobago via Facebook, call The Mamatoto Resource and Birth Centre at 621-2368 or email doulaalliancett@gmail.com.

Birthing and labour memories can be especially wonderful when mothers access the right preparation and support!

First published in the April-June 2014 issue of UHealth Digest, Issue 25

Photos above included for this blog but were not used in the original publication.

www.uhealthdigest.com

But is The HPV Vaccine the Answer?

Is the HPV vaccine the answer to cervical cancer? It was under development when I was a medical student in 1997. I remember first hearing about it and being immediately excited about the possibilities. I had seen the misery of death by cervical cancer and I was aware of the woeful state of Trinidad and Tobago’s Pap smear service so a vaccine that could do to cervical cancer what the polio vaccine did to polio certainly sounded like something to do cartwheels about.

(Pity I never learned to do cartwheels; I’m too chicken now – we become increasingly comfortable with our incompetencies as we grow older).

But now that the vaccine is here and routinely offered in the UK while vigorously opposed by many in the UK, is it the answer we were hoping for?

My short answer is that time will tell.

When I told my darling gynaecologist that I was dedicating myself to wellness education he said cheerily that I could include the promotion of the HPV vaccine in my work.

I gave him an appalled look. I can’t recall the brief interaction that followed but he’s an easy going fellow whose expert opinion I respect – yet we didn’t agree on this.

Individuals, both friends and strangers, (possibly mischief makers amongst those strangers) have emailed me asking me for my view. Should they vaccinate their daughters? Are the concerns about the risks pure hysteria?

It seems likely that some of the vaccine reactions were hysterical and some of the deaths were pure co-incidence. True believers in the vaccine might want to protest that all the reactions and deaths were hysteria and co-incidence.

Let me stress two things:

1)  I am not Anti-Vaccine. My three children follow the standard vaccine schedules. I have declined receiving or giving my children the flu vaccine and the rota-virus vaccine. I simply did not accept that they were necessary. I do not give them pain killers or antibiotics that are not necessary and I do not give them vaccines that are in my humble opinion unnecessary.

2) It’s rare but fatal reactions to vaccines have been known to occur, just as fatal reactions to anaesthetics and penicillin have been known to occur. Nobody says stop the use of anaesthetics or penicillin because of these unlucky deaths.

Would I vaccinate my daughter? If she were 11 now the answer is “no”.  But in 9 years time when she is 11, I do hope that we’ll have enough information available for me to make a decision with confidence.

These are the questions that I hope will be answered by time and by diligent, honest research, record keeping and clinical experience. It may take more than nine years.

a) how many doses are required to achieve immunity? We were told three but more recently we’re told that one is enough!

b) does immunity really last more than five years?

c) are boosters needed?

d) should the vaccine be given to everyone or is it better health economics to give it to groups at higher risk?

e) were all those reported neurological reactions hysteria? Were they within the range of rare reactions that are statistically acceptable

f) does receiving the HPV vaccine make women more careless about going for Pap smears

g) how has HPV incidence changed for groups who were vaccinated?

Why am I not simply running with the vaccine, which after all, is approved by authorities such as the WHO, government health departments and leading gynaecologists?

Well honestly, after you read Dr. Ben Goldacre’s fact-filled Bad Pharma, you might be cautious too. In Bad Pharma, Dr.Goldacre, an Oxonian who wrote for The Guardian and works for the UK’s NHS, points out that transparency, integrity and ethics are not pillars of today’s pharmaceutical industry. Bad Pharma is a disturbing book and if anything, it illustrates just how vulnerable both doctors and the general population happen to be when it comes to making decisions about new drugs and vaccines. There’s misinformation and there’s missing information.

The shocking inside story of how devious, corrupt and unethical the pharmaceutical industry happens to be.

The shocking inside story of how devious, corrupt and unethical the pharmaceutical industry happens to be.

Having induced a healthy scepticism into your thinking I can’t help but mention a technical article I found on line. It was published in November 2010 in the Journal of Vaccines and Vaccination. It’s a 7 page article available as a pdf on http://www.omicsonline.org for readers who can make sense of the medical jargon.

The article is a Review of Gardasil (the main HPV vaccine in use in the USA). It’s written by Professor of Medicine Diane M. Harper who declares her relationship with various pharmaceutical companies in the context of vaccine research. Despite this relationship, her paper is clear that expected benefits remain modest for now.

Could she be underestimating it all? Cellular biology does not always read the research papers. Time will tell.

In the long term discussion of the usefulness of the HPV vaccine, may transparency and the best health outcomes win.

Breastfeeding With HIV, is Breast Still Best? Interview With Expert Pamela Morrison

It is 1995. HIV/AIDS is still adolescent, having burst into world consciousness less than 15 years ago. In upscale Zimbabwe a woman is newly diagnosed as HIV-positive and she is distraught. Her eight month old baby is refusing the bottle. He wants the breast but unknown to him, his mother’s breasts have just been deemed dangerous vessels capable of delivering to him a deadly virus. His mother has no way of knowing if she has already transmitted the virus to her son. Nor does she know how risky it will be to continue nursing him.

She turns to Pamela Morrison, an international board certified lactation consultant in the capital, Harare. But Pamela does not know the answers. Neither do the doctors at the Ministry of Health.

This was the heart churning encounter upon which Pamela Morrison began her quest to have the right answers about infant feeding for women who carry the HIV virus. Twenty years later Pamela continues the mission of counselling and guiding HIV positive mothers, though now with the guide of formal policy and the wisdom of decades of accumulated evidence standing behind her.

I caught up with Mrs. Morrison while she was working and waiting – waiting for the birth of her first grandson. She was not too busy to share with us.

Here in Trinidad and Tobago and the Caribbean, the idea of breastfeeding by HIV positive mums would come as a surprise to many as policy here tells these mums to avoid breastfeeding and use replacement milk formula instead. This contrasts with some resource-poor countries where formula feeding is not a safe option due to formula costs, lack of access to clean water and basic sanitation. In this scenario it is actually safer for a baby’s HIV positive mother to breastfeed her baby, even if she is not receiving anti-retroviral therapy (drugs that suppress the HIV virus, which we will call ART for short). We asked Pamela about this.

“The fact that in the absence of anti-retroviral therapy 85% of HIV-exposed breastfed babies do not become infected has always intrigued researchers. Certain factors in mothers’ milk serve to protect a baby from postpartum HIV transmission and in fact, over 2000 patents have been taken out on the components of human milk, many of which are being developed or genetically engineered as anti-AIDS drugs.”

Pamela lists off several protective components. You don’t have enough fingers to count them all. Breast milk is a living, active substance. Consider human milk oligosaccharides, an abundant component, concentrating on the surfaces of the infant’s gut. There it “serves as a decoy receptor to inhibit HIV binding, a prebiotic promoting the growth of desirable bacteria, and a probiotic to protect against HIV transmission.” Don’t we love it when the good guys win? Pamela tells more, “Then there is bile salt-stimulating lipase, a major human milk glycoprotein, which functions in milk lipid digestion and inhibits viral invasion, including HIV transfer to CD4 T cells. Lastly there have been recent press reports about a host protein called Tenascin-C in breastmilk which was found to neutralize HIV binding, and which helped to explain why the majority of HIV-exposed breastfed infants are protected against mucosal HIV-transmission.”

Yet HIV is sometimes transmitted by breast feeding, despite Mother Nature’s strategies for protecting infants. Without ART and supportive guidance from health care workers this occurs in roughly 15% of cases. By contrast, where optimal ART and health care are received by mother and infant, transmission risk is slashed below 1%, to almost zero. Independent of ART, exclusive breastfeeding makes a tremendous difference to the safety of breastfeeding for babies of HIV positive mothers. Countries with policies that encourage these mothers to breastfeed promote exclusive breastfeeding rather than mixed feeding since mixed feeding makes transmission so much more likely.

Pamela explains, “Exclusive breastfeeding means that the baby receives no other foods and liquids apart from prescribed medicines for the first six months of life. Premature introduction of other foods and liquids to the baby before age 6 months leads to disturbances of normal gastrointestinal flora,[ie the bacteria that are supposed to be in the gut and serve as a guard against harmful bacteria], exposure to dietary antigens, and inflammation resulting from infection with pathogens, all of which result in small sites of trauma and inflammation in the lining of the infant’s gut. When the infant’s compromised gut is exposed to HIV in breast milk the damage allows the virus to enter the bloodstream. Exclusive breastfeeding for six months not only reduces the risk of HIV transmission, it also reduces a child’s chances of acquiring other diseases.”

In Trinidad and Tobago cultural practices include cleaning a new baby’s tongue daily with honey or among Muslims, giving the newborn a taste of something sweet, like a bit of a date that has been pre-chewed. Do such habits undermine exclusive breastfeeding?

“Indeed they do, for the reasons just described and even where concern about HIV is not a factor such cultural practices increase the risk of infection.   It might also be worth pointing out that honey is not recommended for babies under a year because of the risk of botulism. [a rare form of food poisoning that can lead to paralysis and death]. Pre-masticated [pre-chewed] food has also been shown to be a risk factor for HIV-transmission if the person feeding the child is HIV-infected.”

Pamela is currently based in the UK where formula feeding is the recommended policy for infants of HIV positive mothers. In the UK, as in Trinidad and Tobago, exclusive breastfeeding for the first six months is not a cultural norm. Indeed, far from it. So it does come as a surprise to know that the UK has guidelines for HIV positive mothers who want to breastfeed. The history that Pamela gives us may surprise even more: “It’s currently estimated that 72% of HIV-positive mothers in the UK were born in countries of high HIV prevalence where breastfeeding is the norm and where decisions about infant feeding and weaning are often made by extended family members, rather than by the mother herself. Formula-feeding identifies these mothers’ HIV-positive status to their communities within the UK. Furthermore conditions for safe formula-feeding may not be sustainable for HIV-positive mothers who are also asylum-seekers, or in detention centres. Those deported receive only enough formula for the flight home. [with their infants placed at sudden risk of under nutrition and life threatening infection] Consequently the British HIV Association (BHIVA) and the Children’s HIV Association (CHIVA) held a public consultation to take the views of health providers, mothers and others about whether the guidance prohibiting breastfeeding, should be changed and in 2010 it was.

“Current BHIVA/CHIVA pregnancy management guidelines include recommendations for combination antiretroviral therapy (known as cART) during pregnancy and the option of managed vaginal delivery for women with an undetectable* HIV viral load at term. Thanks to these interventions, mother-to-child HIV transmission is now very low, at 0.1%. The current BHIVA/CHIVA infant feeding guidelines, issued in November 2010 permit breastfeeding in a mother who really wishes to do this.

“The impact of these revisions has been profound. Now it is possible for HIV-positive mothers to discuss their wishes with their clinicians and make evidence-based decisions on which method of delivery and feeding would be safest for them. And then they can receive support to breastfeed as safely as possible if that’s the feeding method chosen.”

This is a welcome relief from the extraordinary scenarios that previous policy led to. “Because such a high percentage of HIV-positive mothers in the UK were born in Eastern or Southern Africa where breastfeeding has very important cultural and traditional significance, when these mothers are advised not to breastfeed it causes considerable stigma and distress. There have been reports of mothers hiding in their bedrooms, afraid to let family and neighbours see them bottle-feeding! Furthermore, in the past, when parents appeared to be refusing planned interventions such as bottle-feeding, it was recommended that children’s social services become involved.”

Devastatingly this meant making legally binding arrangements to “protect” the newborns by removing them from their mothers’ care. In the Caribbean formula feeding carries no stigma but carrying the HIV virus certainly does. In fact, this stigma is such that many HIV positive parents would choose the increased risk of other chronic diseases (diabetes, high blood pressure, breast cancer) to the low risk of HIV, if given the choice of how to feed their babies. So in our society formula feeding the baby of an HIV positive mum seems like the most sensible thing to do. Besides this, the other chronic diseases strike in later life and can be warded off by sensible lifestyle habits. What does Pamela say to this?

“In countries where formula-feeding is commonly practised, it would be fair to say that the culture accepts that bottle-feeding carries little risk to health, whereas the small risk of HIV transmission through breastfeeding tends to be exaggerated. As you point out, formula-feeding is not without risk, even in highly industrialized countries and almost every health outcome is improved for breastfed babies. For instance, a UK study published recently showed that exclusive and sustained breastfeeding could prevent 53% and 27% of hospitalizations due to diarrhoea and lower respiratory tract infections respectively.”

I have witnessed the tragic misery and suffering of infants dying of AIDs in the late 1990’s, before the Prevention of Mother To Child Transmission (PMTCT) programme was established, after which transmission to newborns was sharply reduced. The key tools of this programme were testing pregnant mothers, giving ART during pregnancy and labour and providing formula free of charge for their infants. No matter how we argue that breast is best and HIV is just a chronic disease, it’s a disease that can only be managed by expensive long term use of drugs that do have side effects. Isn’t the small increased risk introduced by exclusive breastfeeding too much risk in a nation where replacement formula has been made available and infant death due to infectious disease is the exception and not the rule?

Pamela is cool, rational as ever. “I think it’s difficult to oppose these arguments. As we discussed, in many industrialized countries, formula-feeding is seen as a perfectly acceptable lifestyle choice and there is the perception that a 1% risk of transmission of HIV through breastfeeding is 1% too high.   The tragedy of the HIV and infant feeding debate is that there is neither a clear benefit to one course of action nor a clear risk to another. In fact it’s quite the opposite: it’s always been a dilemma of competing risks. The best that we can hope for is that each mother can make a decision about how to feed her baby, in consultation with her doctors, who can provide her with enough background research to make an informed choice on the least likely risk to her baby in her circumstances.”

Generally, free and informed choice is the ideal we aspire to. In matters of health and safety though, public policy sometimes dictates the course of action to be urged, sometimes even enforced. The World Alliance for Breastfeeding Action (WABA) supports current the World Health Organisation’s guidelines, urging countries to have one main policy for HIV positive mums (exclusive breastfeeding or no breastfeeding). The guidelines sway counsellors away from placing the burden of choice on mothers.

Pamela says, “The World Health Organisation (WHO), says infant feeding practices should support the greatest likelihood of infant HIV-free survival. WHO believe that national or sub-national health authorities should decide whether health services will principally counsel and support HIV-positive mothers to either breastfeed and receive antiretroviral interventions or avoid all breastfeeding. The decision should be based on the socio-economic and cultural contexts of the populations served including the main causes of maternal and child under nutrition and infant and child mortality.”

Pamela adds that a colleague of hers once suggested that this “should be further tailored to the needs of particular areas – eg in areas of Trinidad and Tobago where economic conditions are such that the population resembles the poorer nations, then child survival might well be best served by a recommendation to breastfeed. Where mothers’ living conditions are more like those enjoyed by mothers in wealthy nations then the recommendation not to breastfeed might be justified. In other words, maximizing child survival will require tailoring recommendations to each mother’s unique and individual circumstances.”  

This of course sounds reasonable and logical but policy change must be guided by hard facts. An article by Anna Ramdass in the Trinidad Express of October 4th 2012 described higher than expected infant mortality statistics for Trinidad and Tobago with progress in reducing these figures lagging behind other Caribbean islands but this article reported no actual proven connections between HIV, formula feeding and death by infectious disease.

Backing away from policy discussions and returning to the sphere of personal choice, now that HIV transmission has been shown to be less than 1% when mothers with undetectable viral loads breastfeed exclusively for the first six months and wean from the breast around baby’s first year, are mothers who know this asking to breastfeed? “Yes, indeed, they are. An increasing number of mothers have become aware of the up to date research results, and seem to be putting two and two together; if – thanks to provision of current anti-retroviral therapy and knowledge about the protective effects of exclusive breastfeeding – breastfeeding in the context of HIV carries such a low risk (stated to be virtually zero) then they are keen to explore with their healthcare providers whether they can safely breastfeed, and they are asking for help to do so.”

Such interest is coming not only from the UK and the African continent but from North America, Australia and from countries as resource rich as Denmark and Germany. As a lactation consultant yourself, you continue to counsel and support clients directly. What would you say is the role of the lactation professional in supporting HIV positive mothers? Pamela Morrison   “I think the role of the lactation professional is two-fold. Firstly, it is to provide information. I receive queries from HIV-positive mothers, or their breastfeeding counsellors from all over the world. They are all searching for enough information to protect individual HIV-exposed babies. Usually these mothers want to breastfeed, but healthcare providers citing out of date studies showing a high risk of transmission are warning against breastfeeding.   I feel that my role is to share with my clients the most up to date information and research that I can find so that they can discuss this fully with their own doctors. Ideally, a decision will be reached that will keep the baby safe, that the mother is happy with, and that the clinician can support. Secondly, if the decision is made for breastfeeding, then the lactation professional can work with the mother to make sure that she “manages” her own lactation in the safest possible way. In this respect, the HIV-positive mother is no different from any other mother in that she needs information about breast and nipple care, about individual variations in her milk production from day to day, and how to be reassured that her baby is getting enough breast milk. Over 99% of mothers have the capacity to exclusively breastfeed their babies, ideally for the first six months- but in the context of HIV exclusive breastfeeding is especially important and it is vital that the mother knows how to avoid and remedy common breastfeeding problems. It is not difficult to help mothers achieve this happy outcome.”

Due to the fear of stigma I can imagine an HIV positive mother seeking the support of a breastfeeding counsellor or consultant while withholding her HIV positive status. “Yes, I’ve worked with mothers who I’m almost certain knew that they were HIV-positive but would not tell me. When a mother seeks help with breastfeeding, the lactation consultant or breastfeeding counsellor is extremely privileged to be invited to share in a very intense and special time as the mother gets to know her newborn. But when a mother is being less than frank, it could have a profound impact on her baby’s health and survival. It may not be appropriate for such a mother to be encouraged to go on providing small quantities of breast milk (effectively mixed feeding) if she finds she has trouble with exclusive breastfeeding. Yet we would certainly recommend this strategy to enhance the health of the baby when the mother does not have HIV, but if she has not disclosed her status, this would absolutely be the wrong advice. I want to give individual mothers the very best information, tailored to their circumstances, that I can. I can’t do that unless she’s absolutely open with me. It’s times like this when I would like to see HIV recognized as just one more medical condition, like say diabetes, or Crohn’s disease, rather than something shameful to be hidden.

“Ideally the disclosure about positive HIV status would come at the earliest opportunity so the breastfeeding counsellor can give the mother the information which is most relevant to her and her baby, and so that we can supply references and journal articles etc. for her to share with her doctors.   We are all working for the same goal – a happy healthy mother with a happy healthy baby – and it can be a very positive experience when we all work together.”

  *undetectable viral load or levels refers to extremely low levels of HIV virus in the body fluids of someone who is HIV positive. It does not mean that the person is cured and continued use of Anti-Retroviral Drugs is required to maintain these low levels.  

Pamela Morrison began her career as an international board certified lactation consultant in Harare in 1990. While in Zimbabwe, Pamela also worked as a BFHI Facilitator and Assessor, as well as serving on the Zimbabwe National Multi-Sectoral Breastfeeding Committee and the national BFHI Task Force. She has also served on the World Alliance for Breastfeeding Action (WABA) Task Forces for Children’s Nutrition Rights, and for HIV and Infant Feeding, and the ILCA Ethics & Code Committee. After moving to England in 2005, she was employed until 2009 as a Consultant to WABA. She is currently the ILCA media representative on HIV and continues to do volunteer work for WABA.

This interview was first published by Fresh Start in the December 2014 issue. Here is the link to the original article:

The photograph of Mrs. Pamela Morrison does not appear in the original article. Warm thanks to Mrs. Adepeju Oyesanya, editor of Fresh Start for suggesting it and for the very generous and knowledgeable and meticulously professional Mrs. Pamela Morrison for sharing her time, experience and expertise.

Gene Guns, Code Scramblers and Your Food

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UHealth Digest July-September 2012

Gene Guns, Code Scramblers and Mutant Food

If I said I’d just blasted tomato cells with a gene gun, spraying tiny gold particles

coated with fish DNA (protected with an antibiotic resistant marker gene and armed with a promoter from a cabbage virus), you might be quite alarmed.

If I told you this new tomato was safe, would you want documented evidence of its safety?

Let’s look at the safety concerns that surround genetically modified foods.

We should clarify a few terms before we begin:-

DNA: an extremely long molecule found in cells of most living things, made of repeated and varying sequences of only four units. (The units are known as bases). The sequence pattern varies from person to person and from species to species. Of at least 3 billion base pairs in humans, only 3% represent genes.

Genes: the parts of the DNA molecule that instruct or code for the creation of proteins.

Genetically Modified (GM) food: food or additives from plants or organisms with modified DNA due to laboratory gene insertion.

Genome: the full DNA code common to a specific species.

Proteins: produced from combinations of amino acids. Enzymes, hormones and our bodies’ integrated organ systems all require constant and precise protein production.

RNA: represents the orders of the gene, almost like a manager. These shorter strands are made of base units, (like DNA) and are produced by active genes. RNA specifies the details of amino acid production: if, when and how much.

Transgene:

(i)                the gene sequences created artificially for insertion into a species and

transgene is also used for (ii) the new genes that result after insertion.

Transposons: virus-like structures found within plant DNA that rarely activate in nature. Tissue culture seems to act as a stressor, awakening the dormant transposons into activity, which leads to mutations.

Promoters: in nature promoters are the parts of the genome that help determine which genes should be active at what time. Genes can be switched on or off. When transgenes are inserted they must include a promoter in order for their new function to be activated.

Here’s how unlabelled genetically engineered foods on your grocery shelves are generated:-

How are plant cells grown in a lab?

Plant cells are isolated and grown in tissue cultures. After transgenes are inserted, the cells are replaced in tissue culture, and allowed to develop into new plants. Tissue culture may also be used when cloning the transformed plants.

Unfortunately, plant cells grown in tissue culture suffer several mutations. These mutations alter RNA and protein production.

Transposons are at least partly to blame.

How are transgenes inserted?

One approach is to use a bacterium that in nature causes plants to grow tumours. The tumour producing part of the bacterial DNA is replaced by the transgenes. The transgenes are then incorporated into the plant genome.

Another approach is to coat tiny particles of tungsten or gold with millions of transgenes and shoot them into plant cells at high speed. Only a minority of millions of target cells incorporate the foreign gene.

How are the modified cells separated from the unmodified ones after gene insertion?

The cells are flooded with high concentrations of antibiotics, which kill all the cells – except those with the transgene. How? Transgenes come with ARMS or Antibiotic Resistant Markers genes. The ARM gene protects the transgene cells from otherwise deadly antibiotics. So the modified cells are the ones that survive.

How do scientists ensure precision and consistency when they use a gene gun?

They can’t. It’s impossible to recreate the random process of gene gun particle insertion. Each event creates a different and unpredictable result. Many of the new organisms generated are useless, as the traits sought, even after successful gene insertion, are not always produced.

Successful gene insertion is less than straightforward. Only insertion in specific  areas of the genome will allow the new gene to be activated. To further complicate the process, successful insertions come with their own “side effects”. Think of the side effects as additional changes which were not intended but occur anyway. Just as side effects to drugs vary between unique human beings, gene insertion and the “side effects” vary between cells.

What do we mean by “side effects” to gene insertions?

Since genes determine protein production, the side effects lead to changes in the proteins produced in the new organism. The “What, When and How Much” questions of the plant’s protein production can now have radically different answers.

So cells chosen because of successful gene insertion will have common active transgenes but the other changes to their genome and the insertion point of their transgene would vary.

How extensive are the changes on the original plant genome?

Research shows that the natural gene sequence is disrupted 27-67% of the time. New genomes can have additional fragments of transgenes, re-arranged chromosomes, multiple copies of transgenes and deleted genes. In one study of 112 GM plants, these insertion mutations were found in 100% of the plants!

Why would plant cells respond to foreign instructions?

The use of promoters, such as CaMV (Cauliflower Mosaic Virus) promoter, as part of the transgene, allows the cells’ built-in defence against the activation of foreign DNA to be overcome.

In nature, genes are switched “on” and “off” as needed.  Promoters create a permanent “on” switch so that the plant continually produces the novel protein commanded by the new transgene.

The CaMV has been shown to switch “on” native genes up and down the length of the plant genome and not merely the transgene that it was meant to promote!  GM foods can therefore have new properties besides the ones intentionally generated. Common transgenes in cotton and corn are those which order the production of the Bt toxin, a bacterial toxin which acts as a self-generated pesticide. Under the influence of the CaMV promoter, these plants produce their pesticide continuously. The orders for pesticide production never get switched off.

The more we know, the more we recognize that we don’t know.

When GM food technology was conceived there was a lot we did not yet know about genetics.

Decades later, despite progress, there remains much to understand about molecular genetics.

We still don’t know the function and potential disruptive possibilities of disturbing large stretches of dormant DNA.

Remember, only about 3% of our genome are functional genes.  Much of the rest of the genome is as yet not fully understood. However, this 97% is vulnerable to gene insertions, deletions and rearrangements when new genes are inserted. The consequences of this are both unknown and unpredictable.

Code scramblers, properly called “spliceosomes”, take RNA generated by our genes and rearrange it. Each arrangement allows different proteins to be produced from the same RNA.

The RNA is a bit like a restaurant menu. Think of the code scrambler as the waiter taking your orders from the menu and ensuring that you get what you want, rather than something else on the menu.

What happens when code scramblers meet the transgene introduced by the laboratory? Is the RNA ever rescrambled to create a new protein that was never intended?

Unfortunately, testing of new GM organisms does not mandate that any new proteins be discovered, measured or tested.

DNA chip monitoring shows that 1 in 20 genes in GM crops are creating increased or decreased proteins compared to the original crops. The argument that GM foods are fundamentally the same as non-GM food is questionable.

Joseph Cummins, Professor Emeritus of Genetics at the University of Western Ontario, has this to say, “The bio-technology industry is based on science that is forty years old and conveniently devoid of more recent results…What the public fears is not the experimental science but the fundamentally irrational decision to let it out of the laboratory and into the real world before we truly understand it.”

Do you find this disturbing? If so, be sure to pay attention to what is happening in the world of GM food. You need to decide if and how you will take a stand.

 

___________________________________________________________________

Sources and recommended reading:

Seeds of Deception by Jeffrey M. Smith and Genetic Roulette, by the same author.

First Published in U Health Digest’s  July-September 2012 edition

http://www.uhealthdigest.com

Should Genetically Modified Food Be Labelled?

Article Published in UHealth Digest April-June 2012 issue

Article Published in UHealth Digest April-June 2012 issue

Should genetically modified food be labelled? That’s a question the Just Label It activists of Vermont, California and 16 other US states hope legislators will answer with a “Yes!” very soon.
Here in the Caribbean, if asked for an opinion on genetically modified (GM) food labelling, most of us would frown, take a deep breath – then confess we don’t know enough about GM foods to really say.
Now consider that we’ve all been eating unlabelled genetically modified foods since the late nineties. These foods are generally unlabelled in the United States. So do we really need to worry?
After all soy protein, soy sauce, high fructose corn syrup (often labelled as corn syrup) find their way into almost all our processed foods. Sausages, burgers and deli meats often include soy or corn by-products. Think, too, about the widespread use of soy and corn oil in margarines, pastries, cookies, snacks and sauces! Today, 93% of soy and 86% of corn produced in the US are from genetically modified crops.

Could GM food just be a merger of human brilliance and technology?

Such a relaxed and optimistic perspective is not shared by consumers around the globe.

The European Union updated its labelling law in 2003, requiring foods with more than 0.9% GM ingredients to be labelled.

This year Hungary destroyed 1000 acres of GM corn. GM seeds are in fact illegal in Hungary!
Similarly, France is seeking to have the European Union ban the only authorized GM crop in Europe, MON810, a modified variety of corn.

The 2010 Eurobarometer poll shows that 65% of Europeans are not in favour of the continued development of GM foods. Some surveys tell us 87% of Americans want GM foods labelled.
Sentiment against GM foods is also strong in nations as diverse as Peru, Japan and Germany.
Is the distrust mere paranoia and fear of change – or is it founded on solid ground?
Often, lack of understanding of the GM issue is fuelled by a sense that it’s all too complex for the average person to understand.

So let’s simplify things, because any issue that affects our health and the ecology of our planet needs to be very clear.

Here are three key things we need to know about GM foods:

1) GM foods or organisms are created when genetic material from one species (such as a bacterium) is inserted into another species (often a seed) to create new properties in the receiving species. The industry has used this technology in an attempt to create superior crops. Drought resistance, pest resistance, longer shelf lives, etc., are sought in the laboratory.

2) The GM industry has been able to get their foods classified in the US as GRAS or Generally Recognized as Safe. They’ve also secured legislation which allows their scientists to decide whether their products are safe or not, relieving the FDA of the responsibility to investigate new GM food products independently.

3) When a gene is experimentally inserted into a new species, scientists eventually get the effect they are looking for. However, other random and unpredictable changes to the original species have been known to occur.

The argument of the GM food industry is that the changes are minor, insignificant and have no impact on health, thus the new food can be classified as GRAS, Generally Recognized as Safe. They argue, too, that with climate change and the expected strain on the planet’s resources, GM bio-technology will better enable us to feed the world’s population.
Yet experts from outside the world of GM bio-technology have raised several alarms.

They protest that the research coming from the world of GM bio-technology has not been peer reviewed by independent scientists. Moreover, leaked internal documents show that the industry is fully aware of health risks which have emerged from initial animal studies, but deliberately masks or hides them.

Such research, as well as some independent studies, is presented very convincingly in Genetic Roulette, The Documented Health Risks of Genetically Engineered Foods by Jeffrey M. Smith. This book is written in such a way that the non-scientist can understand it. Yet it’s full of facts and reliable references. The academic credentials of the scientists and authorities often quoted in Genetic Roulette are presented in the appendix. This is critical as their position is sometimes at odds with that of various regulatory bodies.

None other than Michael Meacher, former UK Government Environmental Minister, writes in the forword to Genetic Roulette, “The case presented is absolutely a smoking shotgun that should stop in its tracks any dabbling with GM foods, whether by individual families, food companies or indeed nations.”

Many experts are also alarmed by the potentially irreversible damage already sustained to the environment, small scale agriculture and organic crop development. They point out that the benefits that the GM industry claimed would result from introduction of its products have never materialized.

Indeed, dairy farmers in the US were made to feel that their businesses would cease to be competitive if they did not adopt BGH or bovine growth hormone to boost milk production. (BGH is sometimes also known as BST). Instead, the cost of dairy farming and the amount of antibiotics administered to cows has taken a leap, as cows experience side effects like infected udders and reduced fertility!
So the Just Label It movement in the US States of Vermont, California and others was born of concerns about health, the environment, and ethics. Championing “the right to know what we are eating,” is a rallying cry of the movement.

If California succeeds in passing this legislation, then the impact is likely to be felt throughout the United States and naturally, here in the neighbouring Caribbean.
On March 12th 2012 the UK’s The Guardian put it like this: “If approved by voters, the California proposition would have a national ripple effect, just as the state’s air rules have influenced the cars that get made in Detroit. The sheer size of the California market likely would prevent most food companies from segmenting products sold in the Golden State from those sold elsewhere; food producers would probably have to put the labels on all their products sold nationwide.”
Nonetheless, while a 2003 poll showed that more than 90% of Americans want GM foods labelled, only 54% said the labels would affect their buying decisions.

However, labelling paves the way for health researchers to be able to trace the effects of this great food experiment in much the same way they do with other additives when health concerns are raised.

Opponents of the GM bio-tech industry hope that labelling will be the first stage in an outright ban of the progress and presence of all or most GM foods and organisms.

In the US, supporters of the industry argue that labelling is unnecessary on the grounds that GM foods are safe. They warn that food manufacturers will be forced to find new sources for ingredients, turning agriculture and the food industry upside down. All costs, they argue, will be passed onto the consumers.

As usual, health, economics, agriculture and public policy are all knotted together.

Which perspective will win over the lawmakers? Follow The Just Label It campaign on Facebook to find out.

Back home in the Caribbean, your local politicians, farmers and grocers will only care about this issue as much as you do.

Further recommended reading:

http://www.organicconsumers.org and Seeds of Deception by Jeffrey M. Smith

– Dr. Amanda Jones, Wellness Educator.

Sources:
http://www.vpirg.org/news/h-722-passes-out-of-committee/

http://eatdrinkbetter.com/2012/03/06/new-connecticut-bill-seeks-gmo-labeling/

http://www.organicconsumers.org/articles/article_25180.cfm

http://wakeup-world.com/2011/11/11/support-californias-gmo-food-labelling-ballot-nov-2012/

http://en.wikipedia.org/wiki/Genetically_modified_food

http://freegankolektiva.wordpress.com/2012/01/05/gm-food-controversies-what-people-want-and-what-european-commission-does/

http://www.trueactivist.com/france-asks-eu-to-halt-monsanto-gmo-corn-approval/

http://www.trueactivist.com/hungary-destroys-all-monsanto-gmo-corn-fields/

http://www.huffingtonpost.com/joshua-rosenthal/4-reasons-to-celebrate-no_b_758346.html

Seeds of Deception by Jeffrey M. Smith

Genetic Roulette, the Documented Health Risks of Genetically Engineered Foods by Jeffrey M. Smith

http://www.guardian.co.uk/environment/2012/mar/12/californian-campaign-labelling-gm-food

http://www.bio.davidson.edu/people/kabernd/seminar/2004/GMevents/NH/NH.html

http://www.monsanto.com/newsviews/pages/food-labeling.aspx

This article was first submitted to and published by UHealth Digest in the April-June 2012 issue.

http://www.uhealthdigest.com

Did Our Daughter’s Birth Follow Our Birth Plan?

She was remarkably calm. She nursed and slept and was unperturbed by the activity and conversation around her.

She was remarkably calm. She nursed and slept and was unperturbed by the activity and conversation around her.

Well I did promise to let you know didn’t I?

Yes, yes and yes. We had a memorable home birth and I’m grateful to my mother, our doula Zara, my husband, the NHS, the midwives and of course to God, for the birth memories and the safe delivery of our precious little girl.

It was just after 11pm when I spoke on the phone to the midwife assigned to come to see me. Our baby was born by Express Delivery at 12.22am. Prior to 10.50pm or so my surges had been coming one every half-an-hour so though I had often said during the pregnancy that it might be an intense and short labour, I really hadn’t quite anticipated that it would have been as brief as an hour and a half!

One item on the birthplan was completely scuttled though: I was unable to use breathing and controlled pushing in the second stage of labour because my uterus simply pushed the baby out for me when it was good and ready- in what must have been one contraction!

We were all taken by surprise! She was on the bed below me and I perceived wrongly that thus far only her head had been born – then I looked down to see a tiny, wet human being and an umbilical cord.

Later I realised that my mother had “caught” her while the midwife was scrambling (comically my husband thought) in her suitcase for her gloves and equipment.

You might remember my concerns, previously posted, about having a physiological birth for the placenta (ie allowing the afterbirth to emerge without the help of any medication).

I was worried that a physiological birth of the placenta, though natural, might cause me to have greater blood loss. This turned out to be untrue and in fact in the days that followed the subsequent blood loss (known as ‘lochia’) has been less than with my previous births where I used the conventional syntometrine injection to speed up the delivery of the placenta.

The placenta itself was birthed just 20 minutes after the baby it had nurtured. Not bad.

And we did wait till the cord stopped pulsing before cutting the cord. My concern here, echoed by the medical fraternity, was that this approach might lead to an increase in physiological jaundice for the baby. (ie jaundice which follows birth and is self-resolving and not associated with any illness).

The reverse turned out to be true. The physiological jaundice lasted nearly two weeks for my previous babies whose cords were cut earlier – but seems to have been less profound and a bit faster to resolve this time around. So much for fears of overtransfusing blood from the placenta! Thankyou again to Mrs.A who reassured and encouraged me to take this approach! And to Zara who suggested it!

Why A Birth Plan? Why Prepare for Birth? Can Birth Be Exhilarating?

The first time the subject of writing a birth plan came up I was in a small birth preparation class in 2003.

We were all planning hospital based births and if I remember correctly we were all going to have the service of private obstetricians.

There was some unease about having a birth plan, about speaking up and about challenging the status quo.

For me though, the unease created by not having a birth plan is much worse.

Fear of labour, fear of being unable to cope, fear of unknown and possibly uncomfortable interventions should not govern our labour and birthing experiences.

Sadly though, this is often exactly what happens.

I remember a few years ago sitting with a table of 7 or so other women, most of whom had given birth before and one of whom was an obstetrician. We were having tea with a jolly tablespread and talking “girl talk”, having quite a few laughs.

I could find not one woman who could agree with me that birth was a positive, empowering and exhilarating experience.

And yet this positive perspective is typically the experience of the woman who overcomes her fears during pregnancy, prepares for birth and creates a birthplan.

In the absence of preparation we become victims of the unknown. We seek and embrace the medical establishment’s paternalistic approach, where we are the patient and doctor knows best. And yes, the doctor does know best when your body is unable to get it right. This is why women rarely die in childbirth: the medical establishment is great at the emergency interventions that save the lives of mothers and babies.

But for the vast majority of women, fear itself can inhibit the process of labour.  A lack of knowledge about how to listen to our bodies’ labouring cues and respond to them in the most appropriate way, slows rather than facilitates labour. Our fears, our tensions, our panic lead us to request the epidurals, the injections, the first steps on the path that reduce our abilities further. As we limit our bodies more we require even further medical rescue. Soon it is the hospital and the doctor who deliver the baby as we allow ourselves to be reduced to powerless vessels rather than birthing mothers.

Still, birth does not always go according to plan. And it’s important to accept that birth is a process of “letting go”, not of control and management. So all the preparation in the world cannot guarantee that all will go just as you imagined or perhaps intentionally visualised if you included hypnotherapy in your birth preparations!

BUT, and this is a big but, when you explore the birthing process during pregnancy and recognize that for many of us, if only we are relaxed and focused and able to summon the coping mechanisms within that enable us to manage the very primal processes of labour and birth, we will be able to work with our bodies to birth without intervention and without fear.

As for the empowering and exhilarating experience, in the absence of excessive stress, the endorphins you generate during labour will seal your memories as they did mine:

Birth Can be Exhilarating!

Wish me all the best!

Having said so much to you I will be now obliged to tell you after the birth just how it all went, won’t I?

Compare With My Old Birth Plan From 2006

Compared to my 2013 plan this older plan includes more explanatory detail and a more legalistic tone, or maybe it’s just a more formal tone.

Some sound advice from my doula ensured that I wrote a brief plan this time. She reminded me that the midwives and other health care providers for this labour may not have met me before nor read my birth plan in advance, so being concise would be key.

For my previous births, because the choice of midwife and obstetrician was pre-planned, we had the opportunity to sit in an office in advance of the labour and discuss the details.

On the other hand, greater detail was required because my obstetrican and private hospitals in Trinidad were much less confident and enthusiastic about home births or out-of-hospital births with midwives rather than doctors in attendance, than hospital and staff are here in England. In fact at the hospital where I booked in here in the UK, homebirth was advertised on the antenatal waiting room’s newsboard with lots of photos and thankyou letters from enthusiastic mothers and the the hospital’s website including a section with questions and answers about homebirths.

Another point of interest is that some of the practices I felt I wanted respected (like the opportunity to spend time with my baby immediately after birth) and the option to eat and drink during a normal low-risk labour, were not always regarded as routine in Trinidad hospitals at the time. The reverse is true at our local hospital in the UK which has the distinction of being considered Baby Friendly by UNESCO’s standards. This also added to the drive to write a more detailed birth plan.

Our original plan in 2006 had been to have a homebirth but our midwife had to cancel her support due to a personal situation that arose close to the delivery date. We were unable to find a suitable alternative midwife at this point.

Here is the birthplan we wrote in 2006 (with names and places omitted for privacy). Of interest, I see that I had given the business of avoiding a laceration by gentle pushing in the second stage enough thought so as to include it in my birth plan. Of course so many years later I’d forgotten what I’d learned and in 2013 the same thought seemed ‘new’ all over again.

For me this illustrates why preparation for birth is important even if you’ve given birth before. There are things you forget that could serve you well if you keep them in mind during your preparation!

Birth Plan for infant of Amanda Jones 2006

Our plan is based on a desire for as natural a birthing process as possible since we believe this is in the interest of both mother and baby.

We do recognize that should complications occur, intervention or changes in plan may need to be discussed and implemented for the benefit of baby and/ or mother.

The following elements make up our birth plan. Please review and if there are no adjustments to be made, your signature below would indicate your support of this plan.

PREFERRED INSTITUTIONS AND CAREGIVERS

 

1)    We have chosen A Centre and X Private Hospital as the institutions of our choice for a vaginal delivery, considering Nr. D of A will be available as our midwife up to 24/08/2006, Nr.L of A will be available as our midwife from 25/08/2006 and Nr. C of X Hospital may be available as our midwife over the general period during which birth is expected.

2)    In the event of need for a Caesarean Section we have chosen Z Medical Centre (transfer from A Centre) or continuing on at X Hospital as the institutions of choice.

3)    In any event should an obstetrician be required then we have requested Dr. QV as the covering obstetrician. If circumstances in an emergency require urgent cover by another obstetrician in the interest of time then of course this is agreeable to us.

FIRST STAGE

4)    Dr. QV, Nr. D (or Nr. L) and Nr. C would be informed when mother suspects labour has started.

5)    The quiet phase may be spent at home unless there is reason to believe there may be foetal distress, a rapidly progressing labour, extensive traffic, extremes of weather etc.

6)    If membranes rupture at home mother will inform Dr. QV to arrange for review by himself or one of the above mentioned midwives, whichever is most practical at the time. In any event the midwife to attend to the birth will also be informed.

7)    If examination reveals clear liquor, no cord is felt and contractions have not started or have just started and are still mild, or cervical changes suggest the active phase of labour is not likely to begin for some hours, mother will be allowed to be at home with arrangements for review when the active phase is suspected or after an interval specified by the caregiver performing the evaluation.

8)    If (6) does not apply, mother will seek admission to _______ when the active phase of labour is suspected by strengthening contractions lasting five or less minutes apart, for more than an hour- or before if heavy traffic or other obstacle is anticipated.

9)    At ____________ mother will be allowed to eat light items such as crackers, plain biscuits, small bits of light fruit or drink clear fluids if hungry or thirsty in the first stage of labour unless there is reasonable suspicion that a Caesarean birth is likely.

10)                       Augmentation of labour to be avoided by artificial rupture of membranes or use of syntocinon. A gradually progressing labour will be preferable to mother than a speedier one, once foetus is doing well, in the interest of reducing the need for pain relief or other interventions.

11)                       Mother will have the freedom to labour in different positions within the assigned room or cubicle.

12)                       Mother is striving for a labour without analgesia through varying labour positions, massage, quiet prayer and meditation, conscious efforts at relaxation during contractions, conscious efforts to breathe without hyperventilating or taking breaths that are too shallow or too deep and through support of those in her company.

13)                       Continuous electronic foetal monitoring only if medically indicated.

14)                       Father of baby, maternal grandmother and doula to be allowed in the assigned room or cubicle.

15)                       Should an induction of labour be medically indicated once the cervix is ripened and membranes ruptured, mother would like a trial period to allow for the possibility of labour proceeding naturally thereafter without use of syntocinon infusion.

16)                       Routine enema on admission is preferred; catheter for bladder emptying if full bladder obstructing labour,  shaving at would-be episiotomy site are all welcome if deemed necessary by staff.

SECOND STAGE

 

17)                       Availability of a birthing stool if available is requested as it may be required to facilitate birth should mother want to squat for the second stage.

18)                       Presence of father of baby, maternal grandmother and doula is requested during the second stage.

19)                       Unless the assigned room or cubicle is inappropriate for the second stage of labour, mother is requesting to remain in this room for this stage. This is chiefly so that mother and baby can spend more extended time together without being rushed due to the need to prepare the birth room for another client but also for continued focus between the transitional and second stages.

20)                       Mother experienced a midline posterior laceration with her first birth perhaps partly due to insufficient maternal preparation for stretching the perineum. Having made more efforts this time, re perineal massage and Kegel’s exercises, mother would like to manage  stretching of the perineum by avoiding voluntary pushing once crowning has begun and using controlled breathing instead while the uterine contractions push the baby to gradually stretch the perineum. Routine perineal support by midwife/ (obstetrician if attending) is anticipated.

This is in the hope of avoiding a severe laceration or episiotomy. An episiotomy if a severe tear is imminent, is of course preferable, even without lignocaine if time does not permit. Minor superficial tearing would be preferable to a deeper episiotomy on the other hand.

CAESAREAN SECTION

See notes (2) and (3) above.

21) Dr. QV is our surgeon of choice unless awaiting his arrival poses significant risk to mother or infant.

22) An epidural rather than general anaesthetic, would be preferable once the attendant anaethesist agrees that this is an appropriate option under the circumstances. Circumstances include provider experience and of course expediency etc.

23)Presence of maternal grandmother of baby and doula may be requested if epidural is being applied. (Father believes he will prefer to wait outside)

25) If hospital policy or emergency circumstances do not allow for presence of maternal grandmother and doula at Caesarean birth (or only allows for a more limited additional presence) then this is to be respected.

INFANT FEEDING

WE HAVE PURPOSEFULLY SELECTED INSTITUTIONS WHOSE POLICIES WE BELIEVE SUPPORT EXCLUSIVE BREASTFEEDING AND THE PRACTICES BELOW:

25)                       Infant and mother to be given time together immediately after birth, to allow for skin-to-skin contact and latching-on in the “golden hour”.

26)                       Mother and infant to be together unless medical circumstances dictate otherwise

27)                       Infant to be put to the breast with the support of baby’s father, maternal grandmother and attending doula if mother has experienced a Caesarean Section, unless anaesthesist advises otherwise re drugs in maternal circulation. Mother does not need to be fully awake for this to take place and indeed would prefer that these efforts be made even if she is not capable of holding baby in a fully alert state.

28)                       Anaesthesist to advise how soon infant could be put to the breast based on drugs in maternal circulation.

29)                       Anaesthesist to be advised that exclusive breastfeeding is planned so this can inform his choice of drugs, once these will also have the required effects for the existing circumstances.

30)                       Cup feeding to be done by infant’s maternal grandmother and/or father if feeding is deemed necessary before breastfeeding can be initiated, but only if breastfeeding cannot be initiated. Staff will need to teach relatives how to cup feed infant.

31)                       If baby needs nursery care, baby to be brought to mother for comforting and breast feeding as needed.

32)                       Baby is not to be given fluids through artificial teats in the interest of avoiding nipple confusion.

We do appreciate your kind consideration of the above. We are praying for a safe and memorable birth.

Amendments to Birth Plan III

In the end, after my last discussion with Mrs. A (my amazing midwife) at 35+ weeks into my pregnancy, I felt I needed to change my original birthplan very little.

The new words are highlighted in bold and italics.

Under the section ‘Home Birth Plan’

  • Natural delivery of placenta unless heavy vaginal bleeding requires syntocinon injection.
  • Natural delivery of placenta unless heavy vaginal bleeding requires syntocinon injection or other medical indication

Under the section ‘Birthing Centre Plan’,  I’ve eliminated my preference to give birth in the birthing pool of the birthing centre but in the final plan I do ask for intermittent monitoring if I do have to be on the labour ward after all, and not treating a breech presentation in itself as an indication for an episiotomy.

Compare the original Birthing Centre Plan:

  1.      I would prefer to use the birthing centre if baby is found to be in a breech position in advance of the labour –  since local home birth policy does not allow for home birth with this presentation

2.      I would prefer to use the birthing pool facility for the active phase of labour

3.      In the event of a breech presentation I would prefer not to have an episiotomy unless baby is at risk (prolonged second stage)

4.      I would prefer not to have continuous monitoring or be transferred to the labour ward as long as all indications are that labour is progressing smoothly

5.    All other factors as for Home Birth Plan,

with the amended one:

1)      I would prefer to use the birthing pool facility for the active phase of labour

2)      In the event of a breech presentation I would prefer not to have an episiotomy unless baby is at risk (prolonged second stage) or other medical indication

3)      All other factors as for Home Birth Plan

I’ve added the following to the ‘Labour Ward/ Emergency Care’ part of the plan:

I would like to be as mobile as possible during labour, with intermittent monitoring to be used once this is effective.

The original draft plan can be read at: https://staywellfireyourdoctor.wordpress.com/2013/06/03/my-draft-birth-plan/

The preceding post describes some elements of my discussion with Midwife Mrs. A which lead me to amend the plan and can be read at: https://staywellfireyourdoctor.wordpress.com/2013/06/05/adapting-my-birth-plan-after-consulting-with-mrs-a-the-midwife/

Adapting My Birth Plan after Consulting with Mrs A the Midwife

Mrs A is truly amazing. Her name actually begins with ‘M’ but I’ll call her Mrs. A so you can remember how amazing she is.

(Mrs. EQ would have done equally as well as she’s very high in the EQ department).

She was due to do a home visit with me at 2pm and I overslept, waking up at 1.55pm. So when the doorbell rang  I answered it with my hair all over the place- as I’d been hoping to quickly moisturize it and comb it before she got to my house. Wishful thinking! I have a mass of curly, bouncy hair that I’ve been growing out, so no wonder she looked astonished!

Anyway, what I thought might have been a 20 minute visit took just over an hour. Clinic visits usually take 10 minutes but there’s something informal about a home visit with Mrs. A.

Like my dear obstetrician back in Trinidad, she makes you feel you have all the time in the world, so you do remember to ask all your questions.

In the end we concluded that so far I do continue to have a green light for a home birth. (Yaay!)

I was too hurried to show her the draft birth plan but I did resolve the uncertain issues through the discussion.

(You may remember when I posted the draft I reminded everyone that your own draft should be done in consultation with your health care provider!)

Issue #1: The option of a vaginal delivery for a breech presentation (which at the moment I don’t have as baby is head down and unlikely to flip over at 35 weeks) is definitely wide open but hospital policy will require intermittent monitoring at the very least and this on the labour ward. I will be free to labour as I like unless this interferes with effective monitoring.

Why not ease the labour and delivery with a water birth?

Mamatoto is a birthing centre in Trinidad

Mamatoto is a birthing centre in Trinidad

Well, Mrs A explained, because labour and delivery of a baby in a breech presentation is a bit more difficult than the usual head-down (cepahlic) presentation, the labouring mum needs to listen carefully to her body and immersing in water blunts the signals that the body wishes to give her. Remember the discomforts of labour are often a clue to use a more comfortable position to facilitate baby’s descent and the work of the uterus.

What about the long list of complications more likely with the breech vaginal delivery? (This is not to say that many a breech vaginal delivery has not be perfectly uncomplicated and beautiful!) Mrs. A said the most common problem is that the baby may need a bit of resuscitation. Welllll, even though this is often just simple “bagging” which can be done at home (stimulating the lungs by inflating them using a mask and bag of air that the midwife squeezes), I agree I’d want to be at hospital in this case – in the event it turns out to be a little more serious than that.

(now remember all this is theoretical and exploratory: I am almost certainly not going to have my baby flip over into a breeched position at this point!).

But what of the undiagnosed breech? The one that is discovered during the home delivery when the midwife notices a bum or a foot as the presenting part when mum and her uterus are pushing baby out?

Ah, the old phrase I remember from medical school days: “Hands off the breech!” Allow the mother to birth the baby and be ready with your bag and mask in case you need them. The mother and baby will not be served at this point by attempting a transfer to hospital. It’s simply too late.

How often does this happen? Very, very rarely. Yes, I know that’s not a statistic. LOL.

But this is what I’m rejoicing about: I actually have a choice. I was not told that delivering a breeched baby is routinely considered too risky by the vaginal route and I have no choice but to do a Caesarean. Now I accept that if there were other factors, diabetes of pregnancy (gestational diabetes as it’s called) and a baby who was Large for Dates for example, Mrs. A might have said, ‘Because of these factors a Caesarean birth will be safer for you,’ but the message was that taken by itself, a breech presentation does not always require a Caesarean birth.

I’m sure some obstetricians will not agree!

Issues #2 and #3

Should we work with a delayed clamping of the umbilical cord and a physiological birth of the placenta?

(These concerns were raised in my very last post). While I felt I wanted to research this matter in detail it was interesting that Mrs. A was very confident  that delayed cord clamping and physiological birth of the placenta (‘physiological’ meaning without the routine syntometrine injection given in hospital) appears to be routine practice for home births under her supervision!

She says at homebirths she and her team have been routinely delaying cord clamping until the cord stops pulsating and allowing the placenta to birth naturally

Well look at that!

I seem to remember that natural expulsion of the placenta often takes an average of half an hour but I forgot to ask her if this is likely to be reduced with a home birth of a third baby.

Would the transfer of additional placental blood to the baby by the pulsing cord lead to more physiological jaundice?

She says she has not seen any evidence that more babies have more physiological jaundice (self resolving and not disease related), as a result. She is interested though in another observation: that it seems as if the lochia (ie the post partum blood flow) is much reduced in mothers who use this method.

So that’s enough now. I’m sold. Mrs. A is confident and happy with delayed cord clamping and a natural expulsion of the placenta so I am too.

After all, which of us is experienced with home births?

Now I owe  you further explanations, I know. Now you might be more curious about the aforementioned risks of a vaginal breech birth and what the medical recommendations for cord clamping and expulsion of the placenta happen to be, since they are not in agreement with some of the opinions emerging from professional community midwives.

So, hopefully, between continuing to prepare the house for our new arrival and other routine business, I just might be able to share a few posts on the subject.

But I’m getting wiser now. *Sigh*.So no promises! I’ve broken enough since I started blogging and serving my facebook page!

 

 

 

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