Tienchin Ho

A Lemon Tree and an Experiment

The leaves on our lemon tree have been turning yellow and it only had a handful of lemons on it this past year. I have fertilized and given it extra minerals including magnesium. Now it is finally turning around. My tree book says that sometimes the nutrients are in the soil but the tree cannot use them because the soil is too alkaline. I got a little book from the library that has a children's experiment for determining soil pH. This is the experiment:

Boil chopped red cabbage. Strain it and let it cool. Mix the purple liquid in a jar with the soil. Allow soil to settle in the jar then check the color of the liquid. Pink is acidic. Blue, green or yellow is alkaline. Purple is neutral.

We checked the pH of lemons, soap, baking soda, and vinegar. The girls had a great time and used lots of towels. Of course, I still don't know if my soil is too alkaline or not.

Raising Chickens and Fear of Death

I have spent the last two months building a chicken coop and run. At the end of February, we got six adorable chicks. I joined the BackyardChickens.com Forum and I am chronicling the construction project on a page there.

One day when the chicks were about eight weeks old, I went out to see them by the garden and found a Coopers' hawk stomping on a chick. This contradicts our local zoo's bird show which specifically says that hawks do not attack chickens. Following the attack and the loss of our chick, I read many posts about predators on the BackYardChickens Forum. Basically it comes down to completely confining the chicks to coop and covered run instead of allowing them to free range.

One particularly heated exchange caught my eye. It reminded me of the intense debates about home and hospital births. One BackyardChickens Forum member described free-range chickens as a free lunch. She is baffled by why people cannot understand that "loose chickens get hurt." She places little value of free-ranging itself, saying that her chickens don't "curse me for thwarting their dreams of freeranging adventure.  They don't know about the earthy, groovy, FREE delights of the open range.  They don't know and I don't let 'em and we are just fine!"

In reaction to this post, one Forum member remarked that her chickens had been "locked in fort knox and STILL got killed by a weasel!...if they had been free they would be alive today..they could have flown away from the weasel...please stop judging others." Some Forum posts refer to confined chickens as prisoners. Other suggestions for deterring hawks include keeping a big dog, a turkey or even a pig with the chickens. Crows and magpies chase hawks away. Pigeons and doves provide easier prey. Encouraging these other birds to live in your yard is another way to deter hawk chicken attacks.

I am struck by how different each person's values can be. Like the home birth critics, the free range critics see safety in the coop or hospital. Any poor outcomes are attributed to lacking coop design or hospital expertise. Basically, if you build a good enough coop, your chickens will be safe. If you choose your hospital and obstetrician wisely, you and your baby will be safe. On the other hand, the free range proponents place a high value on not just the life of the chickens, but on their quality of life. Women who choose to birth at home value the whole childbirth experience as an opportunity for personal growth. They are also quick to notice the poor outcomes that can occur even in the hospital.

Of course, my chickens are not my children and I do not mean to equate their importance. But still, life and death situations always seem to bring out a person's most basic value system. Clearly, neither side is right or wrong. Every person must figure out what is most important to them and their family.

We are now used to watching the Coopers hawks and red-tailed hawks circle our yard almost every day. I even felt the wind from one that was chasing a tiny songird over my head as I knelt attaching welded wire to a wooden frame. Both of my girls can identify a hawk from the other flying specks in the sky and run to verify that our chicks are safe. We miss the chick that was killed that day. She was an Easter Egger with a stripe on her head. Still, our chickens run around the yard as they choose.

birthcircle TONIGHT

Tonight's birthcircle meeting is about when birth disappoints.

We are meeting at

Perfect Balance Yoga from 6-7:30pm
5091 N Fresno St #133 Fresno 93710

"The romantic image of a radiant mother, a beautiful baby in her arms, her golden hair lit by the sun’s rays, displayed on the jackets of many birth books is far removed from reality. New mothers are often unhappy. This major life transition is made incredibly difficult by poverty, poor housing, overcrowding, and social isolation. But one reason why many women have low self-esteem and cannot enjoy their babies is that care in childbirth often denies them honest information, the possibility of choice, and simple human respect."

from Sheila Kitzinger on Becoming a Mother

birthcircle: What is a Midwife?

Come meet some real life midwives at birthcircle!

Topic:       What is a Midwife?
Date: Monday    February 9, 2009

Time: 6:00 pm to 7:30 pm

Place: Perfect Balance Yoga 5091 N Fresno St 93710

Midwives vary both in their licensure and in their scope of practice.

Certified Nurse Midwives (CNM)
Some midwives are trained as both nurses and midwives. They are called certified nurse midwives (CNM). Their certification is regulated by the American College of Nurse-Midwives.

Direct-Entry Midwives (DEM)
Other midwives are like physician's assistants or physical therapists. They are not nurses and enter the field of midwifery directly. These midwives are called direct-entry midwives (DEM). Some of these midwives are licensed by professional organizations. Those licensed under the auspices of the North American Registry of Midwives (NARM) created by the Midwives Alliance of North America (MANA) are called certified professional midwives (CPM). Those registered under American College of Nurse-Midwives are called certified midwives (CM).

Some midwives practice without certification or licensure. Often they train as apprentices to established midwives. These are called lay midwives.

The practice of certified nurse midwives is legal in all 50 states. Government regulation of direct-entry midwifery varies from state to state. Midwives licensed by state legislation are called licensed midwives (LM).

Currently 24 states in the United States have legislation for the regulation of direct-entry midwives. Some states have legislation permitting direct-entry midwives to attend births without explicit regulation. Others prohibit direct-entry midwives from attending births.

The CDC report  based on birth certificate data shows that in 2006, about 8% of births in hospitals were attended by certified nurse midwives. It is not clear by birth certificate data how many out-of-hospital births are planned and attended by midwives. Not all midwives attend births. Many have office practices caring for women before and after childbirth.

According to ACNM, the majority of CNMs attend births in hospitals with only 2% in freestanding birth centers and 1.3% at homebirths. By contrast, DEMs have training in out-of-hospital births and most go on to practice in these settings.

Fresno Women's Medical Group

Last week I went downtown to the new Fresno Women's Medical Group (FWMG) location. The historic Van Valkenburgh home at 1125 T street is just across Fresno Street from the UCSF Center for Medical Education and Research. An historic home, original features such as the walls and windows are unaltered, preserving the cosy atmosphere of a home. The office is even able to provide non-stress testing on site. Dr. Gail Newel and Dr. Sharon Kopacz see patients at this location. Dr. Newel is respected as a supporter of natural childbirth. She also spends time in Africa repairing rectovaginal fistulas and teaching the surgeons there how to do repairs.

She and her partner Dr. Kelly Beingesser have had a huge positive impact on my own childbirth experiences for which I will always be grateful. I hope that other women looking for excellent obstetrical care will find them.

Some tips on choosing or changing birth attendants:

Look for local mother's groups with views on childbirth that are similar to your own. You may be able to get recommendations for attendants that also share those values. Some local groups whose members tend to support natural birth:

La Leche League

Fresno AP Mommies

ICAN of Fresno

birthcircle

Changing obstetricians is easiest to do before 27 weeks.

If a service such as vaginal birth after cesarean is not supported by your current provider, you may be able to find another provider who does even after 27 weeks.

Elective Repeat Cesarean Sections

A New England Journal of Medicine article this month discusses outcomes for babies born by elective repeat cesarean section. Here is a link to a New York Times article about the study.

In this study, data on 19 university hospitals was taken from the Eunice Kennedy Shriver National Institute of Child Health and Human Development cesarean registry. The investigators looked at 28,867 patients with prior cesarean sections who had repeat cesarean sections. Patients who had cesareans before 37 weeks were excluded from the study. Those who were in labor or already had spontaneous rupture of membranes were also excluded.

Then, for each case, the investigators determined the reasons for the cesarean section. Only cesareans without a medical reason were considered elective.

Some of the reasons they found were:
multiple gestations
non vertex presentation
major malformations
maternal medical problems such as heart disease or HIV
prior uternie incision that was not low transverse
non-reassuring fetal heart tracing or fetal testing
suspected macrosomia (abnormally large baby)
placenta previa or abruption

There were 13,258 elective repeat cesarean sections done after 36 weeks (46% of all repeat cesarean sections).

Distribution of elective repeat cesarean sections by gestational age:
37 weeks          834 pts     6.3% of all elective cesareans
38 weeks        3909         29.5%
39 weeks        6512         49.1%
40 weeks        1385         10.4%
41 weeks          505           3.8%
>= 42 weeks     113           0.9%

Then the investigators tracked the babies' outcomes.

They looked for:
death
breathing problems
hypoglycemia
severe newborn infection
seizures
hypoxis ischemic encephalopathy
CPR
signs of severe stress
admission to the neonatal ICU
hospitalization for 5 days or more

They found that babies born by elective repeat cesarean section before 39 weeks were at higher risk for having these problems.

babies born at:
37 weeks    15.3% had problems       had 2.1 times the risk of problems compared to 39 weeks
38                11.0%                                1.5
39                 8.0%                                 ----     
40                 7.3%                                 0.9
41               11.3%                                 1.4
>=42           19.5%                                 2.5

The researchers concluded from their study two things.

First, that elective repeat cesarean sections before 39 weeks is common (one-third of all repeat elective cesarean sections).

Second, earlier cesareans have an increased risk of neonatal complications.

So, what does all this mean to a pregnant woman trying to make decisions?
If there are no medical problems, this study suggests that she can minimize the risk of problems with baby by scheduling the cesarean section after reaching 39 weeks.

In real life, however, there are two situations I can think of that make it difficult to apply this study. First, if a woman really wants an elective repeat cesarean section, how does she know she isn't going to go into labor before 39 weeks? There would be pressure to have a cesarean section sooner rather than later to make sure she was really going to get an elective repeat cesarean section. This is the sort of decision that may seem easy for those of us who are not pregnant but can be excruciating for women who are.

Second, this study was based on trained reviewers looking at medical records. Unrecorded conversations between providers and patients may include soft indications. For example, if I tell a mother that baby feels big, I haven't officially diagnosed macrosomia on the record, but I implied it to the mother. This may be the final straw for a woman to decide on an early repeat cesarean. In this study, her case would still be considered an elective repeat cesarean section. The woman, however, may feel her cesarean is medically indicated. She may feel it is better to have the cesarean earlier than 39 weeks to avoid having a big baby. This study suggests that by doing this, the baby will be at increased risk for complications. Given the known inaccuracies of predicting birth weight, I think using the possibility of a big baby as a medical indication for cesarean section before 39 weeks is problematic but more common than suggested by this study.

Nutritional Advice for Steve Jobs

Recently, Steve Jobs wrote a letter to the Apple community explaining his progressive weight loss. I know my bariatric patients would have done almost anything to have his problem. In fact, often people do have nutritional problems after many types of surgeries that involve the stomach. In Steve Jobs case, this was a Whipple procedure. Other examples include the Roux-en-Y gastric bypass and gastrectomies. Even though these are all very different procedures done for different reasons, patients share similar problems following surgery. Most people transition quickly and easily to the changed anatomy, but, some experience a rocky and prolonged period of adjustment.

Some commonly troublesome foods:
soft breads meats
    wheat flour tortillas                 steak
    muffins                                   sausage
    bagels                                    chicken breast
    sandwiches                            lunch meats
    cake                                       hamburger
high calorie liquids eggs
    cream soups     scrambled
    ice cream                                omelets

    milk shakes
    nutritional shakes         fried foods with breading

Some common difficulties with these foods include:

sticks on the way down

waves of nausea

vomiting

cramping pain

dizziness

sweating

People experiencing these problems are at risk for developing nutritional deficiencies which may be reversible or may become irreversible.

Some potential deficiencies:

protein

thiamine (B1)

B6 (pyridoxine)

folate (B9)

B12 (cobalamin)

Patients need to pay particular attention to these nutrients until they adapt to their new digestive tract. Often people turn to supplemental shakes such as Ensure or Slim Fast, but then find that drinking it just makes them feel terrible.

Some sources of nutrition that are less likely to be troublesome:

nuts and seeds beans

peanuts     refried beans

almonds     black beans

nut butters     navy bean soup

cashews     lentil soup
        pumpkin seeds                            hummus dip

pine nuts
fish (not fried)
cheese
plain yogurt (add jam to taste)        

eggs over medium or boiled

bread, cereal, and crackers that list "whole grains" as the first ingredient

Supplements when eating food is just not enough:

Brewer's yeast, whey, rice or soy protein powder

0.5 - 1mg protein per pound of ideal body weight

example: a person with an ideal weight of 130 lbs
                        needs 65 - 130 g of protein a day

thiamine (B1) 100 - 200 mg a day

B6 (pyridoxine) 50 mg a day

folate (B9) 2.5 - 5 mg (250 - 500 mcg) a day

B12 (cobalamin) 1 mg (1000 mcg) a day by mouth or
                                1000 mcg (1 mg) monthly injection

So, although I do not know Steve Jobs and I do not have any personal knowledge about his medical problems, I wonder if he is just having the same problems. In which case, I hope he reads my post.

The Newborn Hearing Test

Partial or complete hearing loss delays or prevents language, cognitive, and social-emotional development. Groups such as the National Association of the Deaf advocate testing before three months of age and starting family-centered intervention by six months of age. Without automatic testing, the average child with hearing loss is not discovered until over two years old. Parent and physician observation do not usually detect hearing loss even if profound.

To find infants with hearing loss sooner, California requires hospitals with intermediate or intensive care nurseries to offer testing before a baby goes home. Usually the test is done with the infant asleep in the nursery separate from the parents. Testing can also be done as an outpatient at a hospital or a physician’s office. Testing requires informed consent. Insurance companies may or may not cover newborn hearing tests. There are no good studies that show that testing every infant leads to better long term outcomes.

Two types of testing are available, otoacoustic emissions (OAEs) and auditory brainstem response (ABR). OAEs use the sounds that are reflected back from the ear to check for problems with the structures of the ear such as the eardrum, the ear canal, and the hair cells. A small probe placed in the ear records sounds from the ear over time. OAE testing can be done with the infant in your lap or nursing as long as baby is not vocalizing.  The equipment for OAEs testing is much less expensive than that for ABR testing.

ABR uses electrodes similar to those used for brain EEGs and cardiac EKGs. These stickers send information back to a computer that monitors brain activity in response to sounds. To have a normal ABR result, the outer ear structures, the auditory nerve, and the auditory pathways in the brain must all function. ABR testing requires baby to be very still.

Here is one home birth mother's point of view on newborn hearing tests.

In Fresno you can get outpatient hearing tests at these locations:

Community Regional Medical Center
Newborn Audiology
Tammy Vawter
2823 Fresno St, 3rd Floor
Fresno CA 93721
(559) 459-2807

Children’s Hospital of Central California
Audiology Services
(559) 353-6801

Valley Pediatric Medical Group
7130 N Sharon #101
Fresno CA 93720
(559) 436-8606

Central California Ear, Nose, and Throat Medical Group
1351 E Spruce Ave Suite 100
Fresno CA 93720
(559) 432-3303

The Gaza Strip

"... I am not defending the Arab excesses. I wish they had chosen the way of non-violence in resisting what they rightly regarded as an unwarrantable encroachment upon their country ... Let the Jews who claim to be the chosen race prove their title by choosing the way of non-violence for vindicating their position on earth..."

    - Mahatma Ghandi 1938

Gaza is a strip of land designated by the United Nations for Palestinians who were displaced during the creation of Israel in 1948. It is bordered by Israel on the east and south with the Mediterranean to its north and Egypt to its west. A wall of barbed wire and concrete along its borders surrounds the 1.5 million people of Gaza. The movement of food, fuel, and medicines to Gaza has been restricted in the form of a siege. The seven mile western border with Egypt is also closed although smuggling occurs through underground tunnels. There is often no electricity or clean water. Many in Gaza are homeless or live in refugee camps. In the last 72 hours, more than 300 people in Gaza have been killed and more than 1000 injured.

Each year the United States grants over 3.5 billion dollars of foreign military funding to the Near East, an area immersed in war for the last century. I am saddened by the violence. No matter what history or politics preceded this, we are connected to each other as people and the tragedy belongs to us all.

birthcircle

After a terrific year of meetings at the Big Barn, birthcircle will move to a new location, Perfect Balance Yoga at the corner of Fresno and Shaw. I am grateful to Joanne for sharing her wonderful studio space and appreciate her strong sense of community support for women.

Birthcircle provides a supportive environment for women to share stories of pregnancy, childbirth, and motherhood. Meeting topics are suggestions to start the conversation. Any concerns or stories women bring to the meeting are welcome.

Date: second Monday of each month

Time: 6:00 pm to 7:30 pm

Place: Perfect Balance Yoga 5091 N Fresno St 93710

2009 Topics:

Jan 12: Have the Birth You Want

Feb 9: What is a Midwife?

Mar 9: When Childbirth Disappoints

Apr 13: Birth Stories: Open Session

May 11: Pregnancy and Size

Jun 8: Motherhood: Now Who Am I?

Jul 13: Birth and the Law

Aug 10: Birth Stories: Open Session

Sep 14: Monitoring During Labor

Oct 12: What is a Water Birth?

Nov 9: Sex and Childbirth

Dec 14: Birth Stories: Open Session

Babies-in-arms are welcome.

Hope to see you in 2009 Year of the Ox 牛年！