Tienchin Ho

Extremism

So I am back from Washington DC. What a busy trip! We met up with so many friends and family in the last ten days that my head is still spinning.

The wedding we attended was full of people who were all involved in the military either directly through active service or as civilians contracted to do military work. It was actually quite awe-inspiring. They were all so genuinely and sincerely doing their best at their jobs. I have never been in a room with so many militarily connected people. My curiosity drove me to ask everyone what their opinion was on the presidential election this year. To my surprise, the majority supported Obama rather than McCain.

During this election campaign season, the media has hinted that Obama does not support the Iraq war and therefore does not support our military. So I was stunned to find that the people who are involved in the military would support him. I have been conflicted about this issue because I feel that as a lay person, I have no way of knowing what the best military strategies for our country are. I have to trust our elected officials to do what's best. It was quite eye-opening to find that those persons who are actually privy to the inner workings of our military choose Obama.

It is always refreshing to be around people who do and see different things in their lives than I do. It makes the world such a bigger place and moderates my views of the world. National Public Radio had a bit today on how being around like-minded people tends to make one's views more extreme. The discussion was about the Republican rallies.

Using the Republican rallies as an example, people at the rally express views and ideas that support the same position. This makes them even more sure that they are right and Democrats are wrong. Plus, in order to be the best Republican you can be, people tend to go to the extreme. So a person proves that they support McCain by not only agreeing with McCain, but by demonizing his opponent.

So although it is good for women who value natural childbirth to find each other, it is also good to be open to women who value technology during childbirth and to the many more who are somewhere in between. This keeps us from going to the fringe ends of the spectrum.

Birth on Labor Day

It has been another three weeks since my last post. During this time I have sat on the talk back panel of BOLD, listened to birth stories at our monthly birthcircle meeting, made two silk dresses for my girls, and am now in Washington D.C. WHEW!

BOLD is the Birth on Labor Day play that presents eight women's birth stories. The stories are all typical of births happening today including unmedicated, non-interventional birth, induction, medicated vaginal birth, operative-assisted vaginal birth and cesarean. I thought the production at the Tower Theater here in Fresno was well done and I appreciate all the hard work that went into it by Childbirth Resource Network. 

Following the play, the audience asked questions of a panel composed of me, a home birth midwife, a pediatrician, and an obstetrician. One of the questions was: How can we create global change in the maternity care system? This question has such strong personal significance for me. I asked the very same question myself on the Lamaze Normal Birth Forum a year and a half ago.

Fueled on by the misinformed article by Atul Gawande in the New Yorker about obstetrical care and Henci Goer's response, I was looking for ways to contribute to the birth advocacy movement. Like the person in the audience at BOLD, I was trying to share how wonderfully life changing childbirth was for me and how it could be the same for them. How can we reach those women when they aren't even remotely interested in attending a play like BOLD? Aren't we just preaching to the choir again and again?

Robbie Davis-Floyd says it best in her book Birth as an American Rite of Passage. Women have different values and beliefs. How each person perceives childbirth depends on these values. Some see childbirth as just another bodily function or a potential medical disaster prevented only by technological vigilance. Others see childbirth as an opportunity for personal growth or a powerfully feminine experience.

BOLD doesn't need to reach every woman. It just needs to be out there for the women who see childbirth as more than a physical or medical event. Women who found their response to childbirth different from those around them need to see BOLD. Midwives, doulas, pediatricians, and obstetricians who find themselves discouraged by clients who seem to miss the point need to see BOLD. BOLD connects the community of people who share common values. We need to preach to the choir because some members of the choir haven't found us yet. They need to know they are not alone.

Resources for Mandarin Chinese

One way to become bilingual is to grow up in a household speaking one language and in a country that speaks another. I am trying to do this with my children, but as an American Born Chinese (ABC) I have not regularly spoken Chinese for years. Now I am making the effort to do this.

In addition, I have searched high and low for resources to help me with this. Most of the resources I find are for adults or high school students trying to learn the language. With the increasing American interest in China, I thought I would share the list of online resources that I have found useful for children.

Audio Learning for Adults:
ChinesePod is a branch of the Praxis language company. Based in Shanghai, their audio lessons are aimed at adult learners of any level. They have a series of lessons called "Baby Talk" full of commonly used phrases for parents to use with children. They keep it entertaining and practical. Lessons are short, divided up by level, have a vocabulary list, and a forum to ask questions. It's also the best resource for modern words like a T shirt or the internet. The main speaker is a native speaker. They also have "assistant" non-native speakers with obvious foreign accents who translate with her. I love listening to it while I am doing dishes or hanging laundry.

Dictionaries
Yellow Bridge
Using the site to search by radical is cumbersome and often fails to produce the character in question. Translating an English word to Chinese works most of the time, but some casual modern terms are missing. The best part of this dictionary is that once you look up a character, you can break it down into radicals and find other characters that have the same radical in it. Looking up a word made up of more than one character is relatively easy in this dictionary.

MDGB
This is the best dictionary to use when looking things up by radical, especially for characters written in simplified Chinese. Using this site to translate from English or pinyin to Chinese is really difficult. It is really useful for converting between the traditional and the simplified form of the character.

Chinese-Tools
This is the best dictionary to see how a word is used in a sentence. Looking up words or characters by pinyin is difficult. It does not have a way to look up characters by radical. It also doesn't give any traditional characters. It does have more modern words in it and closer translations from English into Chinese than the other dictionaries.

zhongwen
This is the easiest dictionary to use for looking up words by pinyin. Looking up anything by radical is a nightmare. Sometimes when I cannot figure out which radical to use to look up a character, this dictionary is the one I use to find a character by stroke number. Unfortunately even this is not easy because the print is so very tiny.

Children's Learning
Better Chinese
This is a site for young learners that carries books, teacher's manuals, workbooks, lesson plans, music, and online games and stories. It is designed for children growing up in non-Mandarin-speaking households, so all materials come with pinyin and an English interface.

ChinaSprout
General store including cultural products aimed at non-Chinese families with adopted Chinese children. They often have things in stock that other sites have run out of. There is a big selection of books and learning materials but very little guidance in what to buy.

YESASIA
This is the place to find contemporary music and movies (DVD, VCD) from Asia and the West in any Asian language. Videos are useful for getting children to hear consistently correct Chinese intonation. Materials are divided up by country of origin and by language spoken or sung. It is not easily searched by categories such as children's movies or bestselling Mandarin pop album. It's best to look for something specific. For example, looking up Strawberry Shortcake will find more results than children's movie.

China Books
This site was started by an English speaker searching for resources for children. Book selection is terrific. It is a large selection, but every book I have gotten there has been well written and well received by the girls.

Asian Parent
Good selection of books with CDs. Also has Disney books and books on CD in Mandarin that I cannot find elsewhere.

Cheng & Tsui
Ceng & Tsui has been a publisher for 25 years of English and multilingual educational materials about Asia. The site has a wonderful selection of textbook series complete with student and teacher books and workbooks, audio, and video. I love their Flying with Chinese series for children although this particular series requires the teacher to read and speak Chinese already.

Chinese FLES
This fascinating site is the Center for Applied Linguistics in Washington D.C.'s site where they are developing a Chinese FLES curriculum for kindergarten and first grade. They also have a google group for discussion among educators.

Mandarin Chinese Immersion

Well, I haven't blogged now for three weeks! So what have I been doing?

Three weeks ago, my older daughter started kindergarten and my younger daughter started preschool. I really want my children to have more music and art in their lives than what schools can provide. So I found a music class and an art class. My older one also has an after-school enrichment singing and dancing class. Of course all this driving more than doubles the amount of gas I was using last year when we often walked to preschool. To top it all off, I am trying to teach both girls mandarin Chinese. We spent a month in San Francisco at the Chinese American International School this summer and I want that learning to continue.

This is what really occupies so much of my time. Learning new poems and songs to teach, making writing worksheets, and cutting out pictures from magazines all take up time. I really wish there were Chinese immersion schools here in the Central California Valley. In San Francisco, there are two public schools that are Mandarin immersion in addition to the ones that are Cantonese immersion. Then there are more that are private schools.

I spend my days speaking entirely in Chinese to the girls. Of course, no one talks to me in Chinese, just English. So in essence, I am talking to myself in Chinese all day. And singing and reciting poetry to myself in Chinese all day. It feels goofy and at times completely futile. It is especially futile when both girls and my husband have looks on their faces that say, "I can't understand a word of what you are saying. Can you please just speak English?"

To make my life absolutely crazy this week, I also caught a cold and had a migraine headache which I haven't had in almost a year. I started seeing sparkles and having mild vertigo at music class. Thankfully, I was able to get some ibuprofen down while we was there. On the way home, my older daughter asked to have her window rolled down. Keep in mind it was 100 degrees here in Fresno at the time. Weary and afraid of what the heat would do to the progress of my migraine, I told her, "No, it's too hot outside". She giggled at me and said in perfect Chinese, "Mama, ni yao shuo 'wai mian tai re'!" (Mama, you should say 'it's too hot outside') In other words, she was laughing because in my misery, I had forgotten to stick to Chinese.

Well, that motivates me to keep speaking Chinese despite the dirty looks and the exasperated sighs and the threats from my kids to never play with me again.

The Mind-Body Connection

Thursday I listened to National Public Radio's Morning Edition. The topic was about using meditation to lower blood pressure. Dr. Randy Zusman, director of the hypertension program at Massachesetts General Hospital, recommends relaxation response training for high blood pressure unresponsive to medications. Forty out of 60 patients trained in the relaxation response were able to reduce the dosage of their medications. The downside was that the patients had to persevere in their practice of meditation.

It is refreshing to see the practice of medicine acknowledge the impact of the mind-body connection. Surgery and medications are often the sole focus of medical care in the eyes of both physicians and patients. But the mind and the body are intertwined and treating one without the other is bound to be less successful than treating both.

The field of obstetrics is no different from the rest of medicine. Here too, the mind-body connection is often forgotten. But there are reports in obstetrics that demonstrate how acknowledging this connection can have positive results.

Instead of measuring blood pressure, we can look at how many cesarean sections are done or how long labors last. Oxytocin (Pitocin) and early amniotomy are commonly used to lower cesarean section rates and shorten the duration of labors. Another approach is to use doulas. Doulas are trained birth attendants who provide physical and emotional support to the laboring woman. Doulas have been shown to decrease the cesarean section rate, the use of pain medications, and the duration of labor. In fact, the approach originally published in Dublin shown to reduce the cesarean section rate and shorten labor, now called active management of labor, included strict criteria for admission for labor, early amniotomy, oxytocin, and continuous labor companions.

In the story about meditation lowering blood pressure, I wondered if other outcomes were also affected. Did lowering blood pressure with meditation reduce the risk of heart attack or stroke? Maybe, maybe not. Does decreasing the cesarean section rate and the use of pain medications reduce the risk of mothers and babies dying or being ill beyond the immediate postpartum period? Maybe, maybe not.

Certainly doulas contribute to the care of laboring women in a way that medicines and procedures can not. Consider this blog by a family practice physician about a woman who becomes unresponsive to her birth team and either can't or won't push the baby out. Treatment included oxytocin and a doula. This family practice physician recognized that some things are not explained by physiology alone.

It can be baffling in our society to imagine that a person without a medical or nursing degree can have something valuable to add to such a medical event as a birth. But it shows that birth is more than just a medical event. Few life experiences are as emotionally and spiritually intense as birth and death. By recognizing this, we can improve maternity care in a way that medications and procedures can not.

Exercise During Pregnancy

Read any information on pregnancy and childbirth and you will find a section on the benefits of exercise. ACOG has a practice guideline for exercising during pregnancy that suggests 30 minutes a day.

Most of the advice is pretty obvious.

• Avoid activities where you might fall or get injured, such as contact sports or ski jumping.
• Choose familiar activities.
• Don't involve movements that are jarring or sudden.
• Use common sense.

Low impact activities like swimming or walking are obvious choices. There are also certain conditions which are contraindications to exercise, such as an incompetent cervix or placenta previa (covering the cervical opening).

Some things researchers worry about exercising during pregnancy:

Overheating
Any cause of higher temperatures such as a fever or sauna use is associated with increased risk for having fetal central nervous system problems. So, it is a good idea to keep cool and hydrated during exercise.

Decreased oxygen flow to baby
During exercise, working muscles are using more oxygen than at rest. Faster breathing and heart rate work to meet this increased demand. At the same time, blood flow may be shunted away from the uterus and placenta to the working muscles. Heavy exercise, resulting in heart rate over 80% of maximal heart rate, may be associated with decreased fetal movement.

Women who are later found to have intrauterine growth restriction (IUGR, abnormally small baby) due to placental problems have decreased blood flow during heavy exercise. It is unknown whether these changes in uterine blood flow make any difference to the fetus in the long run.

Fortunately, most women are able to judge whether they are exercising lightly or heavily. So, paying attention to how you feel during exercise is important. Don't overdo it.

Some potentially beneficial things about exercising during pregnancy:

Improved muscle tone, flexibility, posture, and mood
Exercise during pregnancy keeps body and mind healthy. Staying flexible and fit helps the work of labor and childbirth. The postpartum period is draining physically and emotionally; so, optimize both while you can.

Provides insight into the mind-body connection
Physical and emotional health are intertwined. Learning your personal coping methods to stress can help prepare you for the demands of labor. Physical activity reinforces body awareness and mindfulness. The practice of yoga has a special emphasis on the mind-body connection.

Controversial benefits of exercising during pregnancy:

Lowers maternal blood pressure - may prevent and treat pre-eclampsia
Some researchers are concerned that exercise in predisposed women can worsen pre-eclampsia or intrauterine growth restriction. In fact some may recommend bedrest as treatment.

SeonAe Yeo PhD, RN from the University of Michigan has been involved in women's health research since 1995. Her recent work compares stretching exercises to walking for 30 to 40 minutes about three to four times a week. She found that stretching exercises may decrease the risk of developing pre-eclampsia in women with a sedentary lifestyle who have had pre-eclampsia before.

Improves maternal sugar regulation - may prevent and treat gestational diabetes
A small study comparing bicycle exercise to insulin treatment for gestational diabetes showed that both treatments result in similar blood sugar levels and the number of newborns with low blood sugar levels.

Improves maternal posture - may optimize baby's position
Some positions are more difficult for baby to come out than others. The ideal position for birthing is vertex position (head down) and occiput anterior (baby facing back). Some midwives actively help to move baby into this position. Even if your baby is already in good position, maintaining good posture may help to reduce some of the aches and pains.

Resources:

Gail Tully CPM
Online resource developed by a midwife in Minneapolis for defining your baby’s position and recommendations for optimizing it.

Perfect Balance Yoga
5091 N Fresno St Ste 133
Fresno 93710
(559) 222-6212
Conveniently located at Shaw and Fresno streets. Provides a supportive atmosphere where women can share childbirth experiences and an awareness for a variety of childbirth options in addition to the practice of yoga.

San Joaquin Valley Rehabilitation
Hospital & Outpatient Center
7173 N. Sharon
Fresno 93720
(559) 436-3600

• Aqua Moms is an aquatic exercise class for expecting and post pregnancy mothers. The pool is an indoor, warm-water, therapeutic pool (92 - 95 degrees). Mondays and Wednesdays from 5:30 to 6:30. $42 per month. Physician's medical clearance required.

• Mommy Fitness is a land based exercise program for mothers and babies (until they begin walking). It focuses on core stabilization and strengthening with the natural progressive resistance of your baby's body weight. Tuesdays and Thursdays from 5:30 - 6:30. $42 per month. Physician's medical clearance required. You will need to bring a yoga mat, stroller or sling.

Mommy Matters
1010 E Perrin Ave
Fresno 93720
(559) 433-0172

Fig Garden Yoga Studio
6045 N Palm Ave Ste A
Fresno 93704
(559) 222-5100

Coil Yoga
764 P St
Fresno 93721
(559)270-4709

Dystocia and Quality Improvement

Dystocia or failure to progress refers to labors that are either progressing more slowly than expected or not progressing at all. The diagnosis of dystocia is responsible for half of all first-time (primary) cesareans in the United States.

The diagnosis and treatment of dystocia vary from doctor to doctor. For example, most obstetricians agree that cesarean section for dystocia is generally not recommended before the active phase of labor. Despite this, research shows that 15-20% of cesareans done for dystocia were done during latent phase instead. To standardize when a labor should be treated for dystocia, the American College of Obstetricians and Gynecologists (ACOG) published guidelines. As many as 35% of cesareans done for dystocia do not adhere to the published guidelines.

Of course, there are legitimate reasons in specific cases for not following a practice guideline. The ideal compliance rate is unknown. However, if we are trying to lower the 33% cesarean rate in the United States, this may be a place to start. Eliminating cesareans done outside of the guidelines could possibly reduce the 33% cesarean rate to under 25%.

Many birth professionals believe that differences in cesarean birth rates are a result of both patient and physician characteristics.

Dr. Eliott Main, chairman of the department of obstetrics and gynecology of California Pacific Medical Center (CPMC), demonstrates how a quality improvement program can change physician behavior in a way that published guidelines can not. In the program, each physician's cesarean rates and patient specifics are available to all physicians. His reason for this was to dispel the notion that a particular physician's patients are "more complicated than average." By showing that they all had similarly complicated patients and similarly good outcomes but varying cesarean rates, Dr. Main was able to convince physicians to critically examine their own practice patterns. Since implementing the feedback system in 1989, cesarean birth rates have dropped by 25% and have remained so.

In California the average cesarean section rate is 29%. At CPMC it is 19%. In Fresno it ranges from 24.5% to 34.5%.

Bias, Obstetricians, and Home Births

Not all obstetricians agree with ACOG's February 2008 statement reiterating its longstanding opposition to home births. Here are some obstetrician's letters that have been made public on the internet:

Dr. Lauren Plante
Dr. Andrew Kotaska
Dr. Stuart J Fischbein

These obstetricians discuss how ACOG's statement disregards the ethical concept of autonomy, or a person's right to make decisions about their own care, including place of birth and birth attendant.

Birth Action Coalition's website posts the response from ACOG's Executive Vice-President Ralph Hale to Dr. Stuart Fischbein's letter. Although Dr. Hale cites concerns over safety, he provides no evidence that planned hospital births are safer for mother or baby. Instead he refers to anecdotes from other obstetricians to justify condemning planned home births. The problem with using anecdotes is the bias involved.

Referral bias occurs when a referral center sees a different group of patients than those who are not referred. So for example, as a surgeon, almost every patient with abdominal pain I saw needed an operation. From my point of view, most people with abdominal pain need operations. In truth, however, many patients with abdominal pain never got to see me because the first doctor they saw correctly thought that they were unlikely to need a surgeon. The opposite of what I thought was true is actually true. Most people with abdominal pain do not need surgery. Which is why a general surgeon shouldn't be seeing every person with abdominal pain.

In the same way, obstetricians only see planned home births that required transfer to the hospital and further treatment. Therefore, they could conclude that births shouldn't be planned for home. They should be in the hospital. In fact, many planned home births (approximately 85%) never come to the hospital. If obstetricians could experience the uncomplicated home births, they might have a different opinion.

Confirmation bias is a bias to selectively focus on events that confirm what you already believe. For example, if I think that someone doesn't like me, I may notice that they didn't call me. I take this as evidence that they indeed do not like me. Of course, I forgot that they were going out of town that day.

Physicians generally already have a preconceived notion that home birth is unsafe. Caring for or hearing about a home birth transfer to the hospital is often enough to confirm this notion. They stop looking for more information about home births. Hearing about 1000 normal births wouldn't clear the memory of a single terrible complication.

People also confuse how memorable something is with how often it actually happens. This is called availability bias. For example, stories of lottery or casino winners are on billboards and in the newspaper. Losing lottery-ticket holders are not interviewed on the six o'clock news. Seeing ordinary people winning millions makes it seem more likely to happen to me. In reality I am more likely to be killed by lightning than I am to win the lottery.  A tragedy in the setting of a planned home birth is very memorable. Even a single poor outcome makes obstetricians think that complications happen more often with home births than they actually do.

Of course, these same biases exist for those who fear birthing in a hospital. Hmm .... sounds like another blog for another day.

Epidural Editorial

in my previous posts about epidurals, I wrote down the basic facts that most birth professionals agree on. Still, a pregnant woman reading about childbirth has figure out her own plan for dealing with labor pain. This decision depends on each woman's personal values. Values are not the same as facts. Values vary from person to person and from situation to situation. They are not objective truths the way facts are.

Here is one set of values:

• Why should I writhe in pain if an epidural can make it go away? Why not take advantage of modern medicine? A man wouldn't have his appendix taken out without anesthesia. A woman shouldn't be expected to endure pain unnecessarily either.
• I am a liberated modern woman who doesn't buy into the idea that a woman's place is to endure pain in exchange for the ability to bring forth life.
• I don't believe that the pain itself has any value. Just because women hundreds of years ago had babies without pain medications doesn't mean they would today.
• I have a choice.

And here's another set of values:

• Why should I use pain medications just because other people are uncomfortable with the noises I make and with me moving around?
• I am a liberated modern woman who doesn't buy into the idea that I have to compete in a man's world to feel worthy. I want to do this because it is not easy. I feel that doing difficult things, even those that are painful, adds value to my life.
• I don't believe that an epidural is safe enough. Just because modern technology developed the epidural doesn't mean I have to use it.
• I have a choice.

As a former laparoscopic bariatric (weight loss) surgeon, I do understand the first set of values. After all, I have seen modern technology do some really wonderful things for people. I am all for women's lib. I owe my career as a surgeon to amazing women who proved to the world that women have something special to offer the field of medicine. I definitely do not believe that women should be punished for having the ability to give birth. The spinal anesthesia I had for my cesarean with my first child worked great.

So why did I choose to have a birth without medications at home with my second child? Well, I understand the second set of values too. I like experiencing all of life. I even want to know the parts that are hard. I like knowing that my body labored and birthed my child. I like that it is an exclusively female ability. And I want to do it myself, without chemicals. Women's lib allows me to make a choice without feeling as if my individual decision may destroy the work of an entire movement.

I think the most important thing for anyone facing this decision is to be honest with yourself. Once you have enough factual information, let your own set of values guide you in what you feel is best for you and your family.

MYTH:
Parenting and childbirth are easy and painless if you could just "do it right."

TRUTH:
No matter what you decide, someone is going to judge you harshly for it and all of your future parenting decisions.

Epidural Side Effects

Informed Consent and Refusal

Watching someone in pain makes those around them want to help. What it means to be helpful depends on the point of view. Doulas and midwives have a tradition of methods for coping with pain that do not involve medications. On the other hand, obstetricians and most nurses are trained to treat pain with medications. Without any training in alternate pain control methods, it would certainly seem cruel to not offer medications.

Before any procedure or treatment, risks, benefits, and alternatives should be discussed. In the heat of labor, however, thoughtful discussions about the pros and cons often do not occur. For most families, learning about epidurals is best done ahead of time.

Mobility
In reality, many women with a “walking” epidural do not walk. A laboring woman may not wish to walk. Hospital safety policies and unintended weakness due to the epidural may prevent her from walking. As few as 20% and as many as 80% of women in studies actually walk with an epidural.

Having an epidural also prevents a woman from using warm water in a tub or shower as a labor aid. A woman with an epidural may need more help changing positions in bed, squatting, or trying to use a birth ball or bar. By dulling nonpainful sensations and discouraging positional changes, an epidural may allow the baby to come down the birth canal in a less than optimal position or keep a woman from knowing when to push.

Dystocia
Epidural anesthesia can slow a labor down. Most obstetricians agree that oxytocin should be used to augment the uterine contractions when this happens.

Hypotension
Epidural anesthesia can cause a laboring woman's blood pressure to drop about 10 - 30% of the time. Low blood pressure, hypotension, can threaten the blood flow and therefore oxygen flow to the baby. The treatment is to raise the blood pressure with intravenous fluids and medications.

Both a slower labor and low blood pressure can convince the birth team that continuing to labor is dangerous, leading to a cesarean section.

Other Side Effects
The narcotic in the epidural commonly causes itching that may be treated with further medications. Epidural-related fevers can also trigger an evaluation of both mother and baby with longer hospital stays. Epidural anesthesia is also associated with problems passing urine that can be relieved with placement of a bladder catheter. Finally, spinal headaches lasting days after the epidural is removed can be incapacitating.

Medications to treat unwanted side effects from epidurals are sometimes given preventatively before a side effect actually occurs. Since treatments of unwanted effects of epidurals are considered part of the original informed consent discussion, the treatments are usually just given without additional discussion with the family.