Planning for altered mental states

On Friday night I helped my sister-in-law while she gave birth. (I had my own baby strapped to my front the whole time, so I wasn’t particularly hands-on, but I helped Skype in the baby’s father who was in England at the time.)

My own labors were unusually easy, and seeing someone go through a more typical labor was eye-opening. This woman is a medical student who’s done her obstetrics rotation, but the pain made a different person out of her. A frightened, exhausted, anguished person.

One childbirth book I read (The Birth Partner, which is my favorite for women giving birth as well as support people) advocates using safe words for pain relief. It gives you the freedom to say “I want morphine” in the heat of the moment when you don’t fully mean it, and if you really mean it you’ll say “eggplant” or whatever and your support people will know to take it seriously. A birth plan is also good for this. In this case, my sister-in-law had asked in advance not to be given an epidural unless she repeatedly asked for one over a period of time, so when she said things like “I want an epidural” and “I want a c-section” her doula and midwife helped her find other ways to cope rather than calling an anesthesiologist.

It felt very strange to watch her in agony, to hear her asking for relief, and to know that the person she had been 6 hours ago and the person she would be in 6 more hours wouldn’t want her to get it. (Women who get epidurals report less pain but no greater satisfaction with their overall experience, probably because the side effects are so annoying.)

For both medical and psychiatric care, some people use some form of Ulysses contract, named for Ulysses who tied himself to a mast to be able to hear the Sirens’ tempting song without following it to his doom. It’s the act of a person who knows they’ll be in an altered state in the future. It’s treating your future self as a different person with different preferences, and forcing them to obey your current preferences.

The last day of her life chronicles Sandra Bem’s plan for her own death after an Altzheimer’s diagnosis, knowing that by the time her mind had deteriorated she would no longer want the death she had planned. My lovely wife in the psych ward is from the viewpoint of the husband of a woman with serious psychiatric problems.

DuBrul introduced me to the concept of mad maps. Like advanced directives for the dying, DuBrul explained, mad maps allow psychiatric patients to outline what they’d like their care to look like in future mental health crises. . . . We started trying to create Giulia’s map by discussing the pills in the medicine cabinet. Under what circumstances would Giulia take them, and how much would she take? I took a hardline approach: No sleep for one night, pills at maximum dosage. Giulia wanted more time before jumping to medication, and favored starting the dose out light.

They’re not failsafe: a birth plan only communicates your preferences, and you should go in with the understanding that you may need an emergency c-section or whatever. A mad map can plot out actions in anticipated situations, but unanticipated situations may throw the old plans out the window.

But I think we’re much better off planning, to the extent that we can, for times when our preferences will be different than they are now. From my coworker who’s set her computer to shut off the internet at 11 so she’ll go to bed on time, to a person planning how they want their death to go, sometimes it’s better for your self-in-the-moment not to have the reins.

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Misc. thoughts on birth

I’m 9 months and six days pregnant, and oxytocin is on my mind a lot.

Oxytocin causes and is caused by an awful lot of things. It’s been billed as the “cuddle hormone,” but it’s basically involved with every step of baby-making. Skin-to-skin contact, and eye contact, increase oxytocin in adults (perhaps helping them bond). As the body prepares to give birth, it produces more oxytocin that stimulates contractions. After birth, the baby’s suckling stimulates the production of more oxytocin which causes the uterus to contract again and stop bleeding—very useful! First aid for after an emergency delivery is basically “keep the baby warm and stimulate the nipples so you don’t bleed out.” Skin-to-skin contact stimulates lactation and helps mother and baby bond after birth. (Not sure if this one is related, but skin-to-skin contact is also considered effective for pain relief in newborns during things like injections.)

Because oxytocin stimulates contractions, synthetic oxytocin (pitocin) is given to start or speed up labor. The natural birth people are concerned with the side effects, which are contractions that are so strong as to be more painful for mother and possibly dangerous to baby. Pitocin is also used after birth to stop bleeding.

Of all the home remedies to stimulate labor, nipple stimulation and castor oil are the only ones that work.  (For the record, castor oil is not considered worth it because the ensuing nausea and diarrhea dehydates mother and stresses baby.) Sex should help, in theory, because of both prostaglandins from semen and oxytocin from orgasm. But in practice it doesn’t seem to.

Here’s where the idea that “natural” is safe and “medical interventions” are dangerous really breaks down. Too much nipple stimulation basically gives you a large and unknown dose of oxytocin, maybe much more than the dose a doctor would give you. A few studies on high-risk women doing three hours(!) of nipple stimulation each day for three days concluded it was unsafe, because it was more likely than synthethic oxytocin to bring on dangerously strong or quick contractions. Cochrane seems to think it’s ok if you’re not high-risk, though (and presumably it’s safer if you don’t do three hours a day).

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Another thing on my mind is what tradeoffs to make around pain relief. Last time I planned to labor in the tub and get out for the actual birth because I was concerned about risk to the baby, but when they offered me the chance to stay in the water I was not eager to get out. Lily was born in the tub at the birth center.

There aren’t many sources that strike any middle ground between rabidly pro-water-birth pieces by midwives and rabidly anti-water-birth pieces by obstetricians, but this is one. Cool fact about babies: they practice breathing in utero, breathing small amounts of amniotic fluid. Shortly before birth they stop doing this. Upon moving from a warm fluid environment to the cooler air of the outside world (maybe also because the chest goes from being compressed to suddenly having space), the baby’s life support system suddenly changes, and it switches from getting oxygen through the umbilical cord to taking its first breaths of air.

The reason water birth normally works fine is that the baby is moving from one warm fluid environment to another, and they don’t start breathing until they hit the air. One danger of water birth is if your baby is compromised and takes a gasp earlier than it normally would, in which case it can inhale water. The other reported danger is from unsanitary conditions, like the cases of Legionnaire’s disease from pools of water kept at 98 F for days at a time – a perfect breeding ground. And some of the reported problems from “water births” are things like “woman accidentally gives birth while in the bath at home with no medical care.” Another danger is an overanxious attendant pulling the baby out of the water so suddenly that the umbilical cord snaps—this is a reason I would be sure to have an attendant who is experienced with water birth.

So how common are these problems? Not very. The UK recommends that all women with uncomplicated pregnancies have the option of water birth, and 6% of births there occur in water. It’s considered safe there.

Water birth usually results in less tearing for the mother, and I found it helped a lot with pain. So how do I balance the risk of serious harm to my child with the near-certainty of less pain for me? At first I thought it was terrible to consider any chance of a really bad outcome for my baby in exchange for my own relief.

But consider a parent with a headache who puts their child in the car and drives to the store for pain relief medication. There’s some risk they’ll be in a car accident and serious harm will come to the child. But we’re okay with people taking that small risk in exchange for near-certain pain relief. I don’t know how the risks of bad outcomes vary between these two situations, but it does at least seem that we shouldn’t immediately condemn any possible tradeoff between parent and child well-being.

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If you do any kind of tidying during late pregnancy, people will exclaim, “You’re nesting!” (Most annoying was from the midwife who pushed the exam-room curtain up against the chair where I was supposed to sit and then said I was “nesting” when I moved it out of my face.)

As far as I can tell, there’s plenty of documentation of nesting behavior in pregnant rats, dogs, cats, hamsters, and rabbits but not humans. My mother still talks about her urge to scrub my changing table with Lysol the night before she gave birth, but that’s is the kind of project that doesn’t sound unusual for her anyway.

Part of me wonders if this is just us medicalizing women’s very sensible wish to get things in order while they still have any time.

Birth story

I wrote up the story of Lily’s birth (below the break).  It’s probably not very interesting unless you’re a birth junkie, but I wrote it up because I was looking for this kind of thing when I was pregnant because I needed to hear that it was possible for birth to go well. Most “positive birth stories” seem to be about home births, but obviously it’s possible to have positive births in more typical settings, and I wanted to write about that.

I’ve kept it pretty un-graphic, but it is, y’know, the account of a birth.

Our bodies, our selves?

As a child, many of us heard the slogan, “My body belongs to me” as part of a campaign against sexual molestation. It’s a pretty fundamental concept: you decide what to do with your body, who touches it, all of that. Autonomy and self-determination don’t get more basic.

In the weeks around my daughter’s birth, I’ve been thinking about all the ways your body does not belong to you.

When you’re a child, other people control almost everything about your physical world. My daughter doesn’t control when or what she eats, who touches her or how. She’s powerless over almost everything about her physical world.  (For example, she’s made her opinion of baths extremely clear, but I overrule her.)

Later in childhood, you have more autonomy. There are still rules about your body — eat two more bites; don’t run in the halls. And perhaps there are still people touching you in ways you don’t want. But with luck, you have a lot of control right now. Every day you gain more skill, coordination, and enjoyment in the things your body can do.

And then you start to share your body. With luck, this new vulnerability is still under your control, a gift of your body to a lover for mutual enjoyment.  And sometimes that opens a whole new can of worms.

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Choosing to become pregnant is choosing to give up your body in a lot of new ways.

First there’s the process of using sex as a means to an end. Not that people don’t use sex all the time as a means to some kind of end, but when you’re trying to procreate the project-ness of it can become especially intense. And while you wait to know the results of each attempt, there are those half-months of precautions that end with disappointment that it didn’t work and relief that you can have a beer now.

Once it takes, your body is no longer just your home, not just a source of pleasure for your lover, but the site of creating another body. I found the process of being someone else’s life support to be overwhelming at times. I was responsible for creating the body another person would have for the rest of her life. Everything I breathed, ate, and did affected her forming cells.

For nine months there could be no decoupling, no chance to make decisions that affected only myself. I yearned to be able to lie on my back without cutting off her blood supply. I craved bagels with lox because I knew they were forbidden. When I was sick with a stomach virus, every pound I lost was terrifying to me as I thought of her starving.

Aside from sharing your body with another person, when you’re pregnant your body becomes a kind of public property. As you begin to show, your body becomes a topic of public conversation. Strangers discuss how you look, how big/small you are, how low/high you are carrying, how well/tired you seem. People quiz you about your symptoms and moods; they advise you about everything from moisturizers to what to do when your water breaks. Your whole life becomes baby-themed. I stopped watching the prenatal yoga videos that referred to my belly as “your precious baby;” I wanted to forget my precious baby for 20 minutes and just work my own body.

At the same time, I was amazed by how perfectly my body was able to accomplish its task. We can do in vitro fertilization; we can do cesarean birth; we can do all kinds of medical work to repair and regenerate the body. But the actual creation can only be done inside another person. Without any conscious effort, my body took a single-celled organism and made it into a human being.

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As birth approaches, your relationship with your lover shifts yet again. In John Donne’s fabulous poem “To His Mistress Going to Bed,” he tries to persuade a woman to get naked. He urges her:

As liberally as to thy midwife show
Thyself; cast all, yea, this white linen hence.

It’s a cheeky line, and one that came to my mind repeatedly during the midwifery-filled week of the birth. As far as I know, there’s never been a culture before ours where men participated so much in birth. Donne was hoping for nudity, but I wonder if he really had midwifery-level exposure in mind. For a man to actually be at a birth in anything other than an emergency capacity would have virtually unthinkable at the time.

When he accompanies a woman giving birth, a man is in for new levels of graphic detail. Seeing your partner naked in bed is different from seeing her on the exam table as the midwife is peering into the speculum.

We are taught to shield men from this level of knowledge. Better to preserve a little mystery; don’t spoil it by letting him see you vomit or poop or bleed. Don’t let him hear you howl like an animal. But in childbirth, the last shreds of privacy and dignity vanish.

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Even now that my body separated from my daughter’s, it is still very much hers. My days and nights are dedicated to keeping her fed, warm, and clean.  (I wrote most of this post two weeks ago but only now had a spare hour to edit it.  She’s strapped to my chest and hopefully asleep for another few minutes.)

My body is still a means of production; my milk is more perfectly suited to her needs than any food we can manufacture. As the years pass, my body will go from being her dairy to her transportation to her playground. As her body gains autonomy, so will mine.

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And then, as I grow older, my body will again leave my control.

Jeff’s mother is very sick. She’s a midwife who was well enough on the day of the birth to coach me in using my body, to catch her granddaughter’s body as it slithered into the world. The next day, she was hospitalized herself. The family’s joy in the new baby is mingled with dread of what comes next for her grandmother. It’s terrifying to all of us that her body can sabotage her whole being like this. It’s awful to watch a person fall captive to debility and pain.

I desperately hope that my daughter dodged the family’s genetic bullets.  I hope she lives long enough in good health that I’m not around to see her body or mind fail her.  But I know it’s part of the deal sooner or later. To be human is to live in a body, a body we never fully control. We can choose to share it, use it to connect with others, and even to create life. And eventually we become dependent on other people to care for our bodies, as we were in the beginning. At some point we will all lose each other as our bodies fail.

Until then, I hope she loves being in her body.  I hope she gets as much joy from it as she can.

Pregnancy/birth links

Given how many trends have changed since my mother and grandmother gave birth, I like to fantasize that it doesn’t matter what I do because the recommendations will change in another few years anyway.  My mother wasn’t supposed to eat fish because of mercury; now you’re supposed to eat fish because of omega-3 (but only certain ones) but avoid rice because of arsenic (except not really?).

But despite the dizzying changes in recommendations, I do actually try to find out what the evidence shows.  PubMed and the Cochrane Collaboration have become my best friends.  If you have any questions about anything related to health, I recommend them as a starting point.  (I admit to only reading the summaries, but many of these are meta-reviews rather than individual studies so I hope any methodological problems have already been caught by the authors.)

I also highly recommend Scott’s Biodeterminist’s Guide to Parenting.

And now for some things I didn’t know before starting this adventure:

• Popular herbal remedies probably don’t help during pregnancy, and some of them are harmful.  Ginger for nausea is the only one that looks good.
• Cocoa butter does not prevent stretch marks.
• Is it worth it to do pelvic floor exercises during pregnancy?   It seems to make a difference in the first six months after birth, but not after that.
• There’s a big debate about whether epidurals are the best thing to ever happen to women or an evil meddling by the medical industrial complex.  (Interestingly, access to more drugs in labor was considered a feminist issue in the early 20th century, whereas now you’re viewed with suspicion if you don’t Trust Your Body enough to do birth without assistance from an anesthesiologist.)  This Cochrane overview concludes that epidurals usually help with pain and don’t produce a lot of differences in terms of health outcomes (for example, they do not change your chance of having a cesarean).  And yet maternal satisfaction is unchanged.  I’m guessing this is because people don’t like pain, but they also don’t like being hooked to lots of monitors and being unable to use their legs properly.
• Perineal stretching seems to work for reducing tearing.
• Self-hypnosis during labor doesn’t have much evidence for it.  Various drugs, immersion in water, relaxation, massage, and acupuncture look better as pain relief methods.
• You would probably like to have a doula if you can afford one.  Better yet, insurance should cover them.  “Women who received continuous labour support were more likely to give birth ‘spontaneously’ . . . . were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labours. Their babies were less likely to have low five-minute Apgar scores. No adverse effects were identified.”
• The lying-on-your-back-with-legs-in-the-air position that’s standard for hospital births does not seem to make a lot of sense.  Throughout the pregnancy, they tell you not to lie on your back because it cuts off blood flow, and then they have you do it for 12 hours during birth?  It makes it easier for other people to see what’s going on, but it means gravity is not helping you.  I thought it was pretty clear that upright positions are better, but the evidence is more mixed than I thought.
• If you’re going to breastfeed, you should keep taking fish oil after birth.

Founts of knowledge:

Parenting with Evidence
Expecting Science

Assorted other links:

• A due date calculator that tells you your odds of going into labor by a particular date.  Note that it’s based on normal distribution, not an actual data sampling.  I did find it helpful for planning activities, though.
• The motherlode of pregnancy-related Wikipedia articles.
• I love these images.

Name ideas:

• Behind the Name has actual etymologies, not the euphemistic ones most sites have.
• Name Voyager graphs the popularity of names over time.