BTCanada

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FREQUENTLY ASKED QUESTIONS
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Q:  I am fully informed about all the short term and long term risks associated with a planned vaginal delivery and I've decided this is how I would like to give birth.  Do you think I'm crazy?

Answer:  No, we most certainly do not.  Our answer would be the same if your question was reversed as well.  BTCanada supports every woman's right to decide for herself which delivery option is best for her without guilt or coercion from special interest groups, family, friends or the medical profession.  As long as she has the unbiased, evidence based information she needs to make her decision our goal of true informed consent for all mothers and mothers-to-be is met.  We fully support home births, water births, hospital planned vaginal deliveries and planned elective cesareans either for a currently accepted, medically acceptable reason or as a maternal request.   Our major goal is to reduce  the trauma associated with childbirth and we believe the prospective mother is the only one who knows how to do that most effectively.  No woman should be forced to give birth in a  way that is unacceptable to her.  Obstetrical care providers should work with women to provide the safest experience for her within her expectations and they should recommend, without judgment, another obstetrical care provider if they don't feel her wishes match their philosophy. 


Q:  I think a vaginal birth would be degrading and humiliating and the prospect of one scares me to death.  Is this normal?

Answer:  This is very normal.  This is a concern we hear about all the time and it is the single biggest reason young women give us for choosing to remaining childless.  It is also a topic deemed too taboo to talk about but that hasn't stopped us yet.  Lack of privacy and dignity, loss of control and extreme pain are the big three we hear about the most from traumatized women.  We have been trained from birth to keep our 'privates' private.  Each day we are bombarded with cultural messages designed to control female sexuality (and to a lesser extent male sexuality).  Every culture does it - some worse than others.  Remember the international brou-ha-ha and general tsk-tsking when Britney Spears showed up at a night club without underwear?  How about the media frenzy and condemnation of 'bad' girl Paris Hilton? 
A vaginal birth (and cesareans where women are denied appropriate covering) go against everything we are taught is bad.  Public and sexual humiliation is an very effective way to hurt people.  Remember the pictures from Iraq during the Abu Ghraib  scandal?  Your fears are perfectly normal and those who insist childbirth is somehow different aren't being honest.

Having said that lets look at the other side of the coin.  There are women who do not feel degradation or humiliation in the vulnerable and exposed positions necessary for a vaginal birth.  They feel natural and empowered.  This, too, is a perfectly normal attitude.

Each woman needs to decide which camp she is in.  If you would be more comfortable with a planned cesarean you should have a planned cesarean.  If you are a woman who feels a vaginal delivery is the best experience then that is what is the best decision.  Some women feel a vaginal delivery is O.K. if their privacy is respected, spectators are limited and they are appropriately draped.  We often hear stories where this was requested but not respected, particularly in a hospital.  Some want to invite people to watch the whole experience.  The bottom line is this issue will not be a source of trauma to you if you know yourself and you make choices accordingly.  No one has the right to force you or shame you into a particular delivery option but you should be prepared for that because there are a lot of people who will.


Q:  I don't want a husband or a partner but I still want a baby.  Do you think childbirth is more traumatic if you are single?

Answer:   No.  The general consensus here is that wouldn't be a factor.  Many women do this and single motherhood by choice is a growing trend.  Reasons for avoiding committed relationships range from bypassing custodial issues, divorce, domestic violence, relationship difficulties and in-laws to being unable to find Mr. Right before the biological clock stops ticking.  Mothers without partners still face discrimination in society and medical personnel are as guilty of prejudice as anyone else.  We do hear stories of single mothers being treated worse by some medical staff and in some hospitals.  Having said that I can say that having a husband/partner is no protection against traumatization.  We hear from plenty of women who would have been better off without them.

If you are considering a planned vaginal delivery we recommend hiring an independent doula (one not associated with a hospital) who thinks like you do.  Independent doulas are more likely to work for you instead of the hospital and they are trained labour specialists.  If you are considering a planned cesarean with a regional anesthesia you are able to speak for yourself and whether you want a doula is a matter of your personal preference.  Use your judgment.  If you feel your obstetrician or midwife is biased against single mothers find another one.

There are a number of on-line information sources that provide information and support for single mothers by choice and those considering it.  They are:

http://www.ChoosingSingleMotherhood.com

www.singlemothersbychoice.org

A recommended book is:


Choosing Single Motherhood:  The Thinking Woman's Guide
by Mikki Morrissette


Q:  This is my first baby. What are my chances of having a spontaneous vaginal birth instead of an emergency cesarean or forceps or vacuum extractor?  What are my chances of not having lacerations or an episiotomy with a vaginal delivery?


Answer:  43% of all deliveries were considered uncomplicated vaginal deliveries in Canada (2002-2003).  They do not consider obstetrical lacerations or other genital tract trauma as a complication.  32% of women who had vaginal deliveries (2002-2003) had complications before or during delivery.  This figure doesn 't include VBACs.  Including those figures would increase that number.  The number of births in Canada around that same time is approximately 330,000.  That amounts to about 105,000 women per year using the conservative estimate of 32%.  The rate of assisted deliveries (forceps/vacuum) averages somewhere around 16-17% of all vaginal deliveries.  That would be a yearly total of about 54,450.  Inductions account for 21.3% of all deliveries.  The average episiotomy rate was 23.8% in 2000-2001.  The rate of assisted deliveries, episiotomies and cesareans vary widely across the country.  There are certain trends.  Where cesarean rates are higher the rate of assisted deliveries goes down.  When the episiotomy rate goes down the rate of spontaneous lacerations goes up. 


You can find all this information (and much more) in the Canadian Perinatal Health Report 2003 available  click here


and in the GIVING BIRTH IN CANADA series published by the Canadian Institute for Health Information found here

They have compiled the available data on costs and associated complications, etc.

The latest release of the Canadian Perinatal Health Report is here:

Canadian Perinatal Health Report 2008 English version

Rapport sur la santé périnatale au Canada 2008

http://www.phac-aspc.gc.ca/publicat/2008/cphr-rspc/pdf/cphr-rspc08-fra.pdf

They do not report all types of genital tract lacerations nor do they differentiate between women having their first babies and women who are having subsequent children.  The cesarean rate figures lump emergency cesareans with planned cesareans which means there is little useful information you can glean from data with respect to these two very different procedures.  Hospital stays for vaginal births do not include time spent in hospital during labour nor do the costs for a vaginal delivery include life time costs associated with childbirth for women, especially vaginal deliveries.  Never the less these are interesting documents and I recommend reading them.

It is unlikely you will give birth to a first baby without lacerations and they are usually more extensive with first babies than second or subsequent babies. 


Q: Do you think I’m a bad mother if I don’t breastfeed?

Answer: No. There are all sorts of good mothers. Some bottle feed exclusively. Some breastfeed exclusively. Some do both.
There are many good reasons women choose not to breastfeed. Painful engorgement, infections, cracked and bleeding nipples, embarrassing leaking, producing too much milk, isolation, being unable to find a private undisturbed spot in public, bite marks (when the little darling gets teeth) and costs. Costs can include a nursing wardrobe, bottles to hold excess milk, nursing pads and nursing bras. It is also impossible for women to hold a full time job and nurse exclusively. Some women have medical conditions that preclude breastfeeding. Breastfeeding also keeps estrogen levels low which keeps the urethral and vaginal tissues thin so urinary incontinence and painful intercourse are made worse. Women are told that breastfeeding is easier and cheaper than feeding with formula but that isn’t true. The biggest problems with breastfeeding happen during the first month (or more) and many women just don’t need any more hills to climb at that point. Breastfeeding may not be all it’s promised to be as well. See Research/Articles for an abstract of one study from Australia that casts doubt on current strongly held opinions. One thing we know for sure is that strongly held opinions in obstetrics and anything to do with babies often aren’t founded on quality, evidence based information.
Women often ask us what to do about people with these strong opinions and the audacity to force their viewpoints on other people. We say avoid them if you can. If you can’t we recommend lying. You read right. Tell them what they want to hear so you can get rid of them and then do things your way. Countless numbers of women do this. The mother is the only expert that counts. No one on this planet cares more about that baby and yourself than you do and you will do the right thing for both of you.


Q: I hate my husband. I can’t be around him without being reminded of my ordeal. His is the only face in my nightmares that is clear. He enabled my torturers and I can’t forgive him or trust him anymore. His attempts to make it up to me don’t make me hate him less. They just make me feel guilty for hating him as much as I do. Have you heard about this from other new Moms? What should I do?


Answer: Sadly, yes, we know about this and we hear it fairly frequently. Avoidance of people, places and situations that remind you of your experience is a hallmark symptom of trauma. So are your nightmares. For some couples a baby changes their relationship for the better but for others the experience destroys what had been a good thing. This is particularly true when he was unsupportive and insensitive during and after your pregnancy and if he helped medical staff hurt you. Often women describe this as either passive or direct assistance in their rape. A committed relationship is based on trust and an understanding that, when the chips are down, your partner will step up to defend you when you are unable to defend yourself. It’s a two way street and it is the bedrock love is built on. When that bedrock turns to mush marriages fail. You’ve had that bedrock shattered. Childbirth is often the first real opportunity in a marriage to test the strength of that bedrock. Dealing with the breakdown of your relationship while recovering from childbirth and adjusting to being a new Mom is overwhelmingly difficult and our heart breaks for you. I can’t tell you what to do and I’m sorry for that. I know you are looking for guidance during this difficult time but we don’t have the right to tell you how to live your life. No one else does either. Only you have that right. Another reason we can’t tell you is we don’t know the right answer to this. Every woman is different. We can tell you what we know ourselves and what other women have done.
Many of these relationships end either right away or in the coming years. Custody issues and financial situations are always an issue and they can be soul-destroying. Some women wait until the children leave home. Some partners come to a mutually agreeable arrangement they can live with. Some women pretend nothing is wrong but are always vigilant about being betrayed again. Some women - given time, space and a reason to believe it won’t happen again - find they can forgive. Some men find childbirth a strong maturing experience and they feel very guilty after the fact that they weren’t a better partner before. And, just like mothers, they often aren’t prepared for how awful things can be. Prenatal preparation tends to downplay the reality and equate natural with ‘good’ or ‘easy’ or ‘not that bad’ when it is often none of those things. There is a lot of pressure on young couples to have the father involved in labour and delivery and this just shouldn’t be. There are reasons why women don’t want them and why men don’t want to be there and I wish that was respected much more than it is. Maternity care should be woman-centred. If the mother wants it to be family-centred that is her choice. None of these things, however, change the past for you.
Trust is like an egg. When they are treated roughly they break. It takes a long time and it’s hard, tedious work but, if you feel the egg is worth saving, it is possible to glue it back together and get something that looks pretty much like an egg. It will never look like the original egg. You have to decide if that egg is worth saving and whether you can live with the finished product. You have an arduous road ahead. I don’t know how you feel about anti-depressants/anti-anxiety medication but they have helped other women in the same situation. You are not a failure or a bad mother if you need this help. I think your immediate worries should be insuring you feel safe, lowering your stress levels and getting adequate sleep. Once you’ve addressed those issues you can think clearly about the other decisions you need to make. We are rooting for you – whatever you decide. The right decision is the one you make.

Q: Is there a cure for PTSD?


Answer: There are a number of interventions around the world – debriefing, cognitive behaviour therapy, EMDR (Eye Movement Desensitization and Reprocessing), hypnotherapy – but we haven’t seen any hard evidence that any of them work. We, however, applaud every effort in this respect. This serious problem has been ignored for too long. We hear from some mothers who feel these strategies worked for them and others who felt they were hare-brained rubbish. We’ve heard of some who felt better initially but relapsed when the next stressful situation happened. Some people feel that trauma changes the brain physically and chemically and that no psychological intervention could be effective. There is certainly compelling evidence to support permanent changes to the brain after a traumatizing experience but we aren’t sure if the interventions aren’t effective.
‘Debriefing’ gives the woman an opportunity to get information about her experience and express her negative feelings. There is no firm evidence that this is effective at preventing trauma symptoms. When it is done in a hospital setting or done by a member of the same group of people who traumatized her in the first place you have to seriously question the value of this intervention. Often it is the most traumatized women who can’t or won’t talk about their experience to anyone.
Using hypnosis may be effective but some people feel this is just capitalizing on the self-hypnosis that often exists after a traumatic experience. Emotionally detaching and tuning out difficult situations are common PTSD symptoms. Some don’t want anyone else messing with their mind. Again, we’ve heard good and bad about hypnotherapy.
Cognitive behaviour therapy involves exposing the person to the same situation that traumatized them in the first place in a ‘controlled’ environment. We don’t know what that means and none of us has been brave enough to try it. I know this intervention is done with soldiers with PTSD, often with astonishing technology to simulate the sights, sounds and even smells of battle. Just the sound of that makes the hair on the back of my neck stand up. We don’t know very much about CBT but if anyone else does we would love to hear from you.
EDMR is relatively new. We have heard good and bad about this too. Only one volunteer with BTCanada has tried it – and she had to go to the U.S. to do that. There are very few trauma counselors with experience in PTSD from childbirth in Canada. This brave volunteer didn’t feel it was successful for her.
We do know that trauma symptoms usually lessen with time and women develop different coping strategies given time but we don’t think PTSD ever goes away. It hasn’t for any of us and our traumatizing childbirth experiences range from 25 to 6 years ago. People will feel better when there is meaningful acknowledgement and recognition of their situation and when they are treated kindly with respect and compassion. The worst thing anyone can do for anyone with PTSD is trivialize, dismiss and ignore. It is also counterproductive to say you know how they feel when they know full well that you don’t. We think preventing trauma will always be the best ‘cure’.

Q: I’m booked for a planned cesarean for [a variety of reasons]. I’m pretty freaked out. Do you think they are safe?


Answer: This depends on which hospital and who your surgical team is. In a reputable hospital with a competent surgical team (nurses, anesthesiologist, obstetrician and the surgical assistant, infection control specialists, pediatric specialist) they are very safe. We define a reputable hospital as one that takes infection control seriously, does not have an anti-cesarean culture and doesn’t cut costs at the expense of patient safety and comfort. It is important to remember that many factors influence your obstetrical experience, many you likely haven’t considered. Government policies and legislation, insurance/legal organizations, funding shortfalls, unreasonable compensation to doctors for certain procedures, poor hospital/health region management, a shortage of good quality evidence-based research, poor statistical reporting, doctor controlled associations, midwife controlled associations, nursing associations, staff shortages, hospital policies, lack of transparency and accountability, bureaucratic silliness, lack of leadership, sleep deprivation and the inability (because of heavy work loads) to have a life outside the hospital for medical professionals, workplace politics and how ‘whistle-blowers’ are treated are some of the things that impact your experience and this is just as true for vaginal deliveries as cesarean ones. For a better look at how various hospitals (in Ontario) stack up when comparing the same procedures and indicators go to www.hospitalreportcards.ca and click on ‘Indicator Search’. There are a number of indicators (risk-adjusted) and some of them relate to childbirth. This document is called the Ontario Hospital Report Card: 2006 and it was produced by The Fraser Institute. They are planning similar reports for the other provinces. I expect the same results from other provinces as seen in Ontario. You will be surprised at how good some of them do and how very badly others do. You will also be surprised at how pervasive the culture of secrecy and camouflage is in health care. Most hospitals choose not to identify themselves and some of them have a lot to be ashamed of. As an example: The Ontario average number of adverse events associated with cesarean sections is 6.0/1000 cesarean births. The worst hospital in the bunch (104 hospitals total) had a rate of 91.2/1000. This is a sobering statistic. On a positive note 24/104 hospitals reported 0/1000 adverse events. The same risk-adjusted comparison is made for vaginal deliveries as well. The average Ontario rates for obstetric trauma (3rd and 4th degree) vaginal delivery with an instrument was 121.9/1000. The worst hospital had a rate of 370.4/1000. The risk-adjusted average rate for birth trauma to the baby in Ontario is 12.4/1000. The hospital with the worst record for this indicator had 260.6/1000.
Now that I’ve got the bad stuff out of the way I can tell you that we often hear anecdotal evidence from women who had very positive experiences with no operative pain, little discomfort post-operatively (and I’m not using the word ‘discomfort’ where I should be using the word ’pain’), short hospital stays, very kind, compassionate and professional medical professionals, short recovery times and where their bodies returned to normal aside from the scar. This is a testament to how good some people are at their jobs and how some hospitals provide an environment to allow this to happen. We’ve heard some say that the worst part was having the epidural/spinal catheter inserted in their back. Some (like me) didn’t feel this anymore than a regular needle. I think this depends on the skill of the person doing it and your anatomy.

The Albeta and BC reports have been released:

Some highlights of the Alberta and British Columbia hospital report cards published by the Fraser Institute (all figures are risk-adjusted using the same parameters).  Unfortunately the Ontario hospital report card could not be compared as the reporting parameters – ICD codes used - were more comprehensive than the Alberta or BC reports

MATERNAL AND NEONATE BIRTH TRAUMA

 

 

Primary Cesarean Rate 1

Vaginal with Instrument 2

(PER 1000)

Vaginal without Instrument 2

(PER 1000)

Injury to Neonate 3

(PER 1000)

Obstetric Trauma – Cesarean 2

(PER 1000)

Alberta

2006-2007

19.71%

144.1

31.9

6.2

14.2 (observed rate)

British Columbia 2006-2007

22.91%

142.60

29.00

2.54

12.37 (observed rate)

All rates risk-adjusted averages unless otherwise designated.

1 Defined as all cesarean deliveries for first babies whether they were elective or emergent

2 Defined as 4th degree perineal lacerations

3 Limited definition (see Methodology)

The highest cesarean rate in Alberta (all figures are from 2006-2007 unless otherwise stated) was hospital #99 (all hospital details were censored in Alberta making the huge variation in medical services both a competency issue and a transparency problem in this province) with a rate of 57.88%.  Interestingly enough they were also a hospital with no adverse events (each category as defined by the Fraser Institute and above and is limnited) in the Obstetric Trauma – Cesarean category, no Obstetric Trauma – Vaginal without Instrument and no Injury to Neonates.  They did not provide data for Obstetric Trauma – Vaginal with Instrument.  The Alberta hospital with the highest Vaginal with Instrument maternal injury was hospital #3 with a shameful rate of 601.1/1000, followed closely by hospital #50 at 531.8/1000.  Hospital #50 also had the highest rate of maternal injury in Vaginal Deliveries without Instrument at 115.7/1000 and their primary cesarean rate was 11.01%. 

In BC the hospital with the highest primary cesarean rate was Fort Nelson General Hospital at 36.12%.  Victoria General and Royal Jubilee Hospitals followed closely with a rate of 30.64%.  Fort Nelson’s Obstetric Trauma – Vaginal without Instrument was zero in 2006-2007 but 33.11/1000 the year before.  What happened there??  Fort Nelson did not supply data on Obstetric Trauma – Vaginal with Instrument and recorded no Injury to Neonates.  The same comparison for the Victoria hospital shows a Vaginal without Instrument maternal injury rate of 23.39/1000 for 2006-2007 and a 19.22/1000 rate the year before.  The rate for Obstetric Injury – Vaginal with Instrument was 125.73/1000 and the rate of Neonate Injury was very low at 0.54/1000.  The variation between hospitals and between hospitals in different years is undeniably a competency issue.  This is just a small sampling of the information one can glean from this report.  The full report can be found at 

http://www.fraserinstitute.org/researchandpublications/publications/6756.aspx

for Alberta and 

http://www.hospitalreportcards.ca/bc/

for British Columbia.  The hospitals are named (they were initially censored by the Ministry of Health in that province) in the British Columbia Hospital Report Card.  Alberta Health Services continues to censor hospital information.

 


Hard evidence from countries that do not have an anti-cesarean bias (and generally Canada isn’t one of them) consistently show that planned elective cesareans with a regional anesthesia are predictable and safe. There is even compelling evidence to show it is safer for mother and baby than a spontaneous vaginal delivery. But given all that it is still surgery. Someone is going to cut you open, rummage about inside and then sew you up and you will need to recover from that. A number of us have had planned cesareans (happily) for our second (and sometimes third) babies. This is very common for mothers with PTSD. Most of us had good experiences. Mine was 21 years ago (there have been many improvements since then) and it was a good experience and much better than my first by a long stretch. My obstetrician was way ahead of other obstetricians of the time. The anesthesiologist had me laughing so hard I didn’t even realize they had started operating. Even then I had no post operative pain and I felt good (but tired and slightly drugged) afterwards. I had no problem with stairs or caring for my baby but I kept my activity level very light for the first while to make sure I didn’t hurt anything. I was home sitting in my garden on the third day. The absolute worst part was being in the hospital. I really hate those places. I hope I have eased your worries. Let me know how it goes. Please send me a baby picture. I hope the arrival of your beautiful baby is a joyful experience.

Q: Of the women who contact you who is traumatized the most often?


Answer: In order from worst to least they are: emergency cesarean and operative assisted vaginal deliveries (forceps/vacuum extractor – particularly forceps) are pretty much tied for worst spot. Some poor women have had both. The vacuum and forceps failed after episiotomies were cut and the genital tract damaged and then they are rushed to surgery to have the baby pushed back up and removed surgically and often under general anesthesia. Then comes vaginal deliveries that ended with serious complications (like hemorrhaging, hysterectomy, hospital acquired infections, wound dehiscence, etc.) Then there are spontaneous vaginal deliveries. Then comes planned cesareans where the mother had complications during her pregnancy and felt like a failure (or was made to feel like a failure) when her baby couldn’t be born vaginally. We also hear from a few women who had traumatizing miscarriages and of course, those who have endured childbirth and lost their babies are going to have a very tough time.

Q: All my nightmares aren’t about childbirth. Is that expected?

Answer: Yes. Nightmares after trauma can include terrifying themes related to your childbirth experience. These can be scenes from your delivery and labour or they can be about humiliation, degradation, pain, torture, powerlessness, harm to your baby or other loved ones, disjointed disturbing images that leave your terrified and disoriented, revenge, horrifying dreams where those closest to you are torturing you and any other type of nightmare that you have now that didn’t occur before you had your baby.

Q: I just had my first baby assessment/vaccination appointment with the public health nurse. I’m a good Mom and I have a healthy baby who is growing well but she made me feel like I was unsuitable, inadequate and uncooperative when I wouldn’t submit to her abusive, arrogant behaviour and questioning. I left feeling like a common criminal.

Q: The home visitor nurse just left. She was supposed to remove my staples (emergency cesarean) but she spent the better part of an hour lecturing me about lifestyle choices, hygiene and housekeeping. What possible business is it of hers anyway? My house is spotless. I have no idea why she was so critical. I think she was punishing me for complaining about my hospital experience.

Q: I had the first well baby/vaccination appointment. My baby is longer then ‘normal’ and lighter than ‘normal’. The bitchy public health nurse looked at me as if I wasn’t feeding my baby. I’ve been up every three hours for the last four months feeding him. Please tell me I’m not a bad Mom.

Q: I felt judged and assessed. Why do they think they have the right to be such bitches?

Q: I got a terrible infection after I had my baby and the nurse made me feel like it was my fault but I did everything I was told to.

Answer: You are good mothers. We spend a lot of time being outraged and appalled by the stories we hear from mothers about their experience with hospitals, nurses, doctors and midwives but we are equally enraged by these stories as well. All these women have encountered the infamous Nurse Nazis/Baby Gestapo/Maternity Police. Often they meet them the first time they have their baby vaccinated but many women encounter them during pregnancy, labour/delivery, and post partum recovery. When I speak to a group of women I can consistently bring this subject up and know immediately who the mothers are and who are not. The mothers are the ones nodding their agreement and recognition. Mothers warn daughters, friends warn friends and it has been going on so long in this country that we hear from grandmothers that warn granddaughters about the narrow-minded, belligerent, self-righteous public health workers who further traumatize new mothers. They interrogate. They look for child abuse where none exists, they use guilt and coercion to get their way, they ask personal, completely irrelevant questions, they invade privacy, they have strong opinions that aren’t based on quality evidence and sometimes not even common sense, they pontificate and moralize about ‘unsuitability’, ‘respectability’, and their perceived opinions on the new mothers’ ‘cooperation’ and ‘coping abilities’. They abuse their position of power and they erode any remaining trust mothers have in medical professionals. They make good mothers feel inadequate. They have an unwillingness to accept that there is more than one right way to be a good mother. Mothers are justifiably reluctant to admit experiencing the psychological damage done by childbirth because they don’t want to be discriminated against. Mothers are justifiably reluctant to talk about the physical damage done during childbirth because they don’t want to be labelled as weak. They are afraid of being branded as bad mothers and having that stigma part of their record (and records are kept). Women are afraid they will take their babies away. These stories make our blood boil and they could fill a book.
Not all maternity caregivers are like this. Some are very pro-mother and understand that respecting her privacy and being supportive and kind to Mom are the best ways of supporting both her and her baby. We hear from pre- and post- natal caregivers who choose this field because, they too, have experienced the psychological and physical damage of childbirth and they genuinely want to help other women. They understand and despise this form of mother-bashing because they have also experienced it. It is what the job is supposed to be about. The mother should be treated like the valuable, important person she is. Unfortunately, the bad ones have polluted the reputation of the good ones and the good ones are treated with the same level of mistrust and suspicion as the whole profession because mothers don’t know who they can trust. Even if the public health sector acknowledged their appalling behaviour, apologized for it and weeded out all the bad apples tomorrow it would still take years to overcome the suspicion. This should be done, though. Improvement has to start somewhere.

Infections after childbirth are common and they are not your fault. To blame people for them is inordinately cruel. Well over 90% of all infections after childbirth happen after discharge and that isn’t because of anything the mother did or didn’t do. It just takes a couple days (and sometimes longer) for the initial infection received in the hospital – or at home – during delivery and subsequent surgical repair to manifest as symptoms. These symptoms – pain, redness, swelling, flu like-symptoms – are difficult to differentiate between what you can expect even without an infection after a vaginal delivery. Hygiene after delivery is important and it will minimize the risk of external wound infections but it won’t reduce your chances to zero. All the external hygiene in the world is not going to prevent infections that stem from internal infections. These result primarily from peri-operative aseptic conditions during labour, delivery and the immediate post partum and you have no control over that. These are things nurses, doctors, midwives, medical students and infection control specialists in hospitals control. This is true for cesarean section and vaginal deliveries. Some hospitals and health regions have dismal infection control track records and some have infection rates that are extremely low. Countries around the world who publicly report infection rates in various hospitals see an immediate decrease in infection. It’s been said that public accountability and transparency works better than penicillin at reducing infection rates in hospitals and that is true. Canada has a long way to go in terms of public accountability and transparency. Other countries are way ahead of them. In Canada, only the most atrocious cases make the news.
Urinary catheters increase your risk of urinary tract infections – especially if they were inserted or removed roughly and without proper aseptic technique. IV infections result for the same reasons. Vaginal examinations and internal fetal monitoring devices increase your risk of infection by introducing outside micro-organisms to the vagina and the normally sterile environment of the uterus. They also push normal flora from the vagina into the cervix and uterus. Membrane rupture increases your chance of infection by increasing the amount of time you don’t have an intact amniotic sac to keep the uterus sterile. These are the major reasons the infection rate after an emergency cesarean is higher than the infection rate after a planned cesarean. Everyone has billions of bacteria living in their digestive tracts. Having open wounds close to the anus and rectum will increase the risk of infection. Many bacteria have an amazing capacity for reproduction. One can become two in 15-20 minutes and they grow exponentially from there. You do the math. It doesn’t take very long for one to become a whole bunch. Many bacteria are also motile which means they can move on their own given a moist environment and they get that in the genital area or the cesarean incision if it isn’t kept dry. Bacteria need a source of nutrition and lochia provides that. Most pathogenic bacteria also have the ability to grow without oxygen. Until you are fully healed the increased risk of infection remains.
I hope I’ve made you understand why infections aren’t your fault and why you shouldn’t feel guilty or a failure about them. I also want you to get immediate medical attention for them if you get one. I know how difficult it can be to seek more medical attention after you are back at home but infections can have devastating consequences if they are not treated promptly and effectively. These consequences range from intense pain and more surgery to severe permanent maiming. Antibiotics are often effective early treatments.

Q: I would like a copy of my hospital records and I’d like to make a complaint. How do I do this?

Answer: Recent changes to access to information make this possible now. In the past women were denied access to their own medical files. If you would like a copy or access to your case notes and other medical records (and your baby’s) the first step is to request them from the hospital you delivered at. The first step to acquiring your doctor’s records is to ask them. If you are met with spin, disingenuous behaviour, feigned ignorance or bureaucratic stonewalling (and you can often count on this) you can contact the Office of the Information and Privacy Commissioner for your province or territory for assistance. I’ve provided a list below. Each region has different legislation and full access can still be blocked. If your request is not honoured after that you should contact a lawyer. You can find a good one by checking out The Best Lawyers in Canada. This is a yearly publication and you can find it at www.bestlawyers.com. Keep records of all correspondence, keep your own journal of dates, requests, etc. and make sure everything you do is in writing.

Complaints about your care or experience should be addressed to the appropriate individual in charge of that for each hospital (or Health region) and that will vary from hospital to hospital. Phone, let them know you would like to lodge a formal complaint and ask who to address it to. Be prepared for more spin, lip service and rhetoric. We’ve had women receive the same form letter from experiences three years apart. If you feel your case wasn’t listened to and your restitution wasn’t adequate find a lawyer. Sadly, they listen to lawyers far more than they listen to mothers. We wish it wasn’t so and maybe someday it won’t be but right now it is. You should also know that your chances of winning a law suit against a hospital or doctor are slim. They pay high insurance fees for the express purpose of having very good lawyers defending them against such events. Be prepared to be treated very badly and to pay dearly for the experience. You need to be very angry and committed to consider this. BTCanada will support you and speak for you in a court of law if you choose this route.  An excellent thesis outlining exactly what you can expect before, during and after litigation can be found at:

http://ir.lib.sfu.ca/bitstream/1892/8419/1/b18293530.pdf


“In Their Own Words” The Effect of Medical Negligence Litigation on Women Receiving Health Care: The Case of Obstetrics and Gynaecology, Marilyn Jennifer Jones, National Library of Canada ISBN 0-612-16938-3

Having a copy of your medical records allows you to check for completeness and omissions. It can help you understand what happened and it can fill in events where you were dissociative and/or where you have no memory. It can provide much needed answers about the drugs you were given (and when) and the procedures that were done (and when).

Office of the Privacy Commissioner of Canada
www.privcom.gc.ca

Office of the Information Commissioner of Canada
www.infocom.gc.ca

Office of the Information and Privacy Commissioner for British Columbia
www.oipc.bc.ca

Office of the Information and Privacy Commissioner of Alberta
www.oipc.ab.ca

Office of the Information and Privacy Commissioner of Saskatchewan
www.oipc.sk.ca

Health Ombudsman of Manitoba
www.ombudsman.mb.ca/phia.htm

Information and Privacy Commissioner/Ontario
www.ipc.on.ca

Commission d’accès à l’information du Quebec
www.cai.gouv.gc.ca/index.html

Office of the Information and Privacy Commissioner (PEI)
www.assembly.pe.ca

Office of Ombudsman (New Brunswick)
www.gnb.ca

Office of the Information and Privacy Commissioner of Nova Scotia
www.foipop.ns.ca

Office of the Information and Privacy Commissioner for Newfoundland and Labrador
www.oipc.gov.nl.ca

Office of the Yukon Ombudsman and Information and Privacy Commissioner
www.ombudsman.yk.ca

Nunavut Information and Privacy Commissioner
www.info-privacy.nu.ca

Northwest Territories – Dept of Justice
www.justice.gov.nt.ca/ATIPP



Q: Do you know of any alternative remedies for anxiety and panic and insomnia? I don’t want to see a doctor and I don’t want to answer embarrassing questions at the pharmacy.
Q: Do you know what a doctor will prescribe if I tell them I’m having nightmares, depression and panic attacks?

Answer: The alternative remedies we know about include:
- valerian root
- L-theanine
- jujube seeds
- magnolia bark
- melatonin
- St. John’s Wort (for depression)
- Alcohol
- Marijuana (this is common in Canada but still illegal so tread lightly)

Women also take a number of vitamin supplements that are helpful with anxiety and stress. These include vitamin B complex (usually marketed as a stress formulation) and magnesium. It’s always a good idea to take a multivitamin and many women also supplement with Vitamin D and Omega 3, not because these things help stress/trauma symptoms per se but because it is common for trauma victims to have poor nutrition. They either don’t have an appetite or they only eat comfort foods.

Kava kava is used as an effective alternative anti-anxiety treatment but it is mired in controversy and may (or may not, depending on who you believe) have serious side effects. It will be difficult to find and likely impossible to import.
Research each of these items before making your decision.

For those willing to see a doctor/pharmacist we include the following:

Medications for Anxiety Disorders

Medication can play a useful role in treating anxiety disorders and may be used in conjunction with other forms of therapy. Anti-depressant and anti-anxiety medications are often used to ease symptoms so that other therapy can go forward.

Common Medications

Chemical Category &
Brand Names

Target Anxiety Disorders

How It's Thought to Work

Benefits

Drawbacks

Benzodiazepines:

Ativan
Dalmane
Librium
Restoril
Tranxene

Centrax
Klonopin
Paxipam
Serax
Valium
Xanax

GAD
Panic Disorder
Social Phobia
Insomnia

Enhances the function of GABA.

Fast-acting, with most people feeling better in the first week and many feeling the effects the first day of treatment.

Potentially habit-forming; can cause drowsiness; can produce withdrawal symptoms.

Beta Blockers:
Inderal
Tenormin

Social Phobia

Reduces effects of adrenaline.

Fast acting; non-habit forming.

Should not be used with certain pre-existing medical conditions, such as asthma, congestive heart failure, diabetes, vascular disease, hyperthyroidism, and angina pectoris.

Azaspirones:
BuSpar

GAD

Enhances the activity of serotonin.

Effective for many people; less sedating than benzodiazepines.

Works slowly; can't switch from benzodiazepines immediately.

Monoamine Oxidase Inhibitors (MAOIs):
Eldepryl
Marplan
Nardil
Parnate

Panic Disorder
Social Phobia
PTSD
OCD

Blocks the effect of an important brain chemical, preventing the break-
down of serotonin and noradreniline.

Effective for many people, especially for patients not responding to other medicines; 2 to 6 weeks
until im-
provement occurs.

Strict dietary restrictions and potential drug interactions; low blood pressure, moderate weight gain; reduced sexual response; insomnia.

Serotonin Reuptake Inhibitors (SRIs):
Celexa
Desyrel
Effexor
Luvox
Paxil
Prozac
Serzone
Zoloft

Panic Disorder
OCD
Social Phobia
GAD

Affects the concentration of serotonin, a chemical in the brain thought to be linked to anxiety disorders.

Effective for many people; 2 to 6 weeks until improvement occurs.

Nausea; some can cause nervousness; sexual difficulties.

Tricyclic Antidepressants (TCAs):
Adapin
Anafranil
Elavil
Janimine
Ludiomil
Pamelor
Pertofrane
Sinequan
Surmontil
Tofranil
Vivactil

Panic Disorder
PTSD
OCD

Regulates serotonin and/or noradreniline in the brain.

Effective for many people; may take 2 to 6 weeks until improvement occurs.

Dry mouth, constipation, blurry vision, difficulty urinating; dizziness, low blood pressure; moderate weight gain; sexual difficulty.

Anticonvulsants:
Neurontin

Social Phobia

Affects GABA.

May take 2-4 weeks to work.

Sedation.

Medicines used to manage anxiety disorders are grouped based on their chemical properties.
Most anxiety disorders respond best to a combination of medication and other treatments.

www.healthyplace.com

 


Q: I had no idea that women suffered such damage to their genital tracts during childbirth. I’m a 28 year old, educated woman thinking about having a baby. I feel like such a fool being so naïve. I’ve never heard of this. When I confronted my friend (who recently became a Mom) about this she didn’t want to talk about it. She asked me to talk to you instead.

There are a lot of things women aren’t told about. This is one of them. The extent of the problem is usually glossed over during prenatal classes or not mentioned at all by midwives, obstetricians or childbirth educators. It is never real informed consent when women are deliberately deceived about these (and all other) risks.

Obstetrical lacerations (and we are using the plural because that is what most women can expect) can be perineal (the area between the vagina and anus), cervical, labial, vaginal, periurethral and clitoral. They are categorized according to depth. First degree lacerations involve the skin and the vaginal mucosa (the layer of tissue under the skin but before the connective tissue and muscle). Second degree lacerations (the most common and what most episiotomies are) are deeper and involve the skin, vaginal mucosa, fascia (connective tissue) and muscle. Episiotomies are often described to women as ‘a little cut’. This is a lie. Third degree lacerations involve all of the above as well as the external anal sphincter and fourth degree lacerations tear completely through from the vagina to the inside of the rectum. They sever both the external and internal anal sphincters. All genital lacerations sever nerve endings and blood vessels, some worse than others. A thorough visual assessment of your entire genital tract occurs after you deliver the placenta. Surgical instruments are used for this. Bruising, abrasions and 1st and 2nd degree lacerations are often considered ‘minor’, ‘of no consequence’ or ‘trivial’ by obstetrical caregivers. Surgical repair of genital tract trauma is usually done for 2nd degree and worse but sometimes for first degree as well. Women are often told they need a ‘couple of little stitches’. This is a lie. The number of stitches varies according to damage but it usually isn’t fewer than 20-25. It is often many more. These repairs are difficult because the tissue is so badly damaged (it has been referred to as trying to sew wet marshmallows together) and must be done by a skilled person. It often isn’t. 3rd and 4th degree injuries require even more surgical skill and a large percentage of them fail. All surgical repairs of the genital tract have the mother in the lithotomy position (on her back with legs in the air and widespread) usually with her legs strapped into the stirrups. They require strong lighting to visualize the work that needs to be done. A lot of damage to the pelvic floor (occult damage) can’t be visualized. Surgical reconstruction of the genital tract and subsequent recovery is sometimes seen by women as just as bad, or worse, than labour and delivery. Anesthesia for this procedure ranges from general anesthesia, full epidural or local freezing (like what a dentist uses). Often freezing and the epidural you had for delivery (if you had one) are combined. Local freezing involves several needles into the vaginal vault. We hear many stories, past and present, where women were not given adequate (or any) anesthesia during this surgery.

Cesarean incisions also sever blood vessels and nerve endings. They use a cauterizing knife to make the initial incision to minimize blood loss and cesarean scars don’t have the same level of sensation as non-scarred areas because of nerve damage at the incision site.

Q: It took me way longer than 6 weeks to heal from the vaginal birth of my first. Am I unusual? Is this my fault?

Answer: No and no. The six week nonsense is complete fiction. Most women, especially with their first, take far longer for the pain and then discomfort to subside completely. For many it never does. We’ve heard from women who have pain from their episiotomy scars decades after they gave birth. Health problems associated with delivery are very common in the first year and beyond. Back problems, painful sex or diminished sexual sensation, neuralgia, altered body image, pain in a tear(s) or episiotomy site(s) and a wide range of health problems triggered by the staggering physiological changes and abuse your body takes during labour and delivery exist in most women after the birth of a child. Neuralgia is nerve pain caused by nerve damage or nerve entrapment. It can be chronic or intermittent. It can cause pain in the lower back, legs, feet, lower torso and genital area.
Incontinence is very common after a vaginal delivery. For the first several days you will require a sanitary pad or other incontinence product for both lochia and urinary leakage. A 2001 study revealed some startling statistics about how common urinary incontinence was six months after delivery in women who delivered their first child. At six months it is unlikely this problem will go away (actually many feel if it hasn’t resolved in three months it is permanent). 5% remained incontinent after an elective cesarean, 12% after a cesarean and labour, 22% after a spontaneous vaginal birth and 33% after a vaginal forceps delivery. [Farrel S.A. et al Parturition and Urinary Incontinence in Primiparas Obstet Gynaecol 2001: 97(3) 350-356.]
A study involving all births (not all primiparous) in 5 hospitals in Quebec showed that, three months after delivery, 3.1% were incontinent to stool and 25.5% were incontinent to flatus. 1.8% had anal incontinence with labour and then a cesarean, 2.9% had anal incontinence with vaginal births without visible anal damage and 7.8% had this problem with visible damage to the anal sphincters. 10.7% of all primiparous vaginal deliveries had visible anal sphincter damage. [Eason E et al Anal Incontinence after Childbirth CMAJ 2002: 166(3): 326-330]
Both these studies relied on questionnaires. There is no better way to get information but it is a fact that 20-30% (and often more) of post natal women cut ties with the medical profession and never answer questionnaires. Many traumatized women do this. It is likely these numbers are on the low side. These numbers will also increase over the next months or years as these women age. The rate of pelvic organ prolapse follows the same time-line.
Surgery to correct pelvic organ prolapse in the U.S. resulted in direct costs to the health care system of 1.012 billion dollars in 1997. {Leslie L et al Cost of Pelvic Prolapse Surgery in the United States Obstetrics & Gynecology 2001; 98; 646-651] This type of surgery is most common in menopausal women. This does not include costs to the woman in lost wages, pain and suffering, lost quality of life, incontinence supplies, diagnostic tests, drugs used to treat incontinence, or pre-operative therapies (like vaginal cones, physiotherapy for pelvic floor damage, pessaries, etc.). Nor does it reflect the majority of women with incontinence who live with the consequences and the stigma without seeking operative solutions. In Canada (1993) the genitourinary costs to the health care system were $3,034,000. Total pregnancy costs were $2,715,000 and total costs of ‘perinatal conditions’ were $883,000. [Health of Canadians – The Federal Role October 2002]
It is really no wonder that women are the highest users of anti-depressants and anti-anxiety drugs in Canada – and elsewhere. Of all diagnoses in Canada, depression and anxiety rate 4th and 5th. Normal pregnancy supervision ranks 8th. Depression and anxiety accounted for 14,207,000 patient visits in Canada in 2006. 65% of all visits for depression were women. 29% of these were women between 20-39 years of age. 56% of these visits were women aged 40-64. 68% of all diagnoses of anxiety were women. 28% of these were 20-39 years of age. 49% of the women diagnosed with anxiety were aged 40-64. [IMS Health Canada, Top 10 Diagnoses in Canada, 2006] Without the discrimination most women face if they admit psychological problems during their post partum these numbers would be much higher. Many just tough it out because the stigma only makes their lives worse.

Q:  Do you think female or male doctors/midwives are best?

 Answer:  Many women feel less inhibited with female caregivers, especially if those caregivers have biological children of their own but the truth is that women can be bullies and jerks too.  We know there are good and bad in both sexes.  It is also true that some of the best defenders of human rights for women have been men.  The best decision is the one you make.

Q:  One of the comments was about a scopolamine regimen.  What is that?

Answer:  Scopolamine is a drug that causes retrograde amnesia – that is it causes amnesia before and after it is given.  Modern women know it better as a date rape drug.  When given with morphine it causes something the obstetrical community called ‘Twilight Sleep’.  During the 1940’s, 1950’s, 1960’s (and well into the 1970’s in Canada) the majority of women gave birth this way.  Morphine isn’t very effective at alleviating the pain of childbirth nor can it be used at very high doses because it seriously depresses the baby’s respiratory system.  Women were strapped (because they were usually writhing in agony) onto delivery tables in the lithotomy position, routine episiotomies were cut and their babies were delivered for them, usually with forceps.  They would have no memory of this.  Twilight sleep was eventually deemed too barbaric and relegated to one chapter in the very shameful history of obstetrics.

In hindsight we have no problem seeing this as truly barbaric because, well, it was but it was seen as a safer and more humane than natural childbirth or childbirth where ether or chloroform were used to alleviate childbirth pain.  It wasn’t just the medical community that were instrumental in making Twilight Sleep a reality.  Women lobbied hard for this as well.  They were promised they would have a nice nap and they would wake up with a smiling nurse who would hand them their baby.  This was seen as a vast improvement over the suffering women experienced previously.

 

Q:  I’ve heard they put hidden cameras in maternity wards.  Please tell me this isn’t true.

Answer:  They do have surveillance cameras in many maternity wards.  Where they are located and how hidden they are varies from hospital to hospital.  They are usually found on the ceilings. 

The other hidden cameras you need to worry about are those used by medical staff and anyone else the hospital allows to watch your labour, delivery, reconstructive surgery and recovery.  These photos and videos are very seldom taken with genuine consent from the woman and often they are taken without her knowledge.  They are taken from open doorways and from behind barriers and draping.  They are taken when women are incapacitated by pain and exhaustion, when they are drugged with substances that cause amnesia and when they are unconscious.  These images are published, copied and shared.  Women have no copyright control nor do they profit from the use of these images.  The practice is creepy and unethical.  It is also frequently done.  It speaks volumes about how little regard there is for maternal autonomy and privacy. 

Click here for a news release concerning these images taken in the obstetrical ward at the Misericordia Hospital in Edmonton, Alberta from 2002-2010.  The 3600 photos and 2 videos (of reconstructive surgeries after vaginal delivery) plus identifying information were copies of originals still kept at the hospital.  The hard drive they were on ‘went missing’ and Covenant Health (the Catholic health care organization who runs Misericordia) has issued an apology.  Apparently they feel very sorry now they have been  caught.  The hard drive disappeared from an employee’s desk and hasn’t been seen since January 17, 2011. 


 

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