Why Our Problems are Rarely the Problem …

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Understanding yourself is the first key to being a great doula.

The Flowering Brain

… But How Our Brain Makes Us React Often Is

Recently my good friend Murray made an important promise to me and then threatened not to keep it. He agreed to handle his half of the finances in our business partnership for the next two years. Then, three months later he disclosed that he unilaterally decided he would only handle those finances for one year. He had other things he was choosing to spend the promised money on.

Promises made and then not kept are always a challenge for me. I organize my life and my world – not to mention, my brain – around other people keeping their promises. Broken promises seriously compromise my ability to think straight and manage my emotions. How do I know they do that? Because my brain starts generating thoughts of distancing, disconnection, and retribution in an effort to relieve the discomfort my…

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Firing Up the Spark

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Firing Up the Spark

You were so fired up to begin the doula training course and did a lot of reading beforehand. You loved the course, admired the people around you, loved their passion and the spirit of community in your class.  You felt like you were among friends in a room full of people you just met.  You could not wait to get your first client.  You are still a member of a few dozen birth professional social media groups, some good, some less inspiring and some awesome.

Summer came and went.  And here we are, months later and nothing.  You have not even spoken to your fellow students, though, you can see that they have upcoming clients from their posts.  What happened with you?

Life got in the way.  Things got busy.  Priorities shifted.  But the calling and the passion are still there.  And now, you are looking around and wondering how to reignite the fire.

Two decades ago, most trainings happened in your home community under one umbrella organization.  The doulas would have regular, in person, monthly meetings.  The groups became friends and people socialized with their families and everything was centred around birthworkers and the fire stayed lit.  Eventually, some of the doulas would move on in different directions and new doulas from recent workshops would move in.  There was a constant ebb and flow of energy and enthusiasm.  

Today, most doulas, train outside of their home communities with a variety of groups with a distinct difference in the priorities of the work itself. Doulas meet online, attend webinars and virtual conferences. They exchange ideas and opinions online and without tone, feeling, or emotion (unless it gets heated) and feel judged expressing themselves so many stay quiet.  The problem is we can’t go back and there doesn’t seem to be a forward button just yet.

spark-and-fire

The First Step

Each doula must create her own group of people to talk to and rely on.  It sometimes takes a little extra effort to go out and meet doulas in the community.  Finding people who have the same core values and standards of practice can be tough, but those doulas are out there.  Certainly, if they are not, because of where you live, but you know someone who would be great to work with, encourage them to take the course and team up with you.

If you are feeling uninspired and the fire has gone out, reconnect with your trainer or one or two people from your group.  Take the course again or start looking for your people within  your Provincial or State Association.  

Doulas, like midwives, are a global community.  We can rely on colleagues near and far for much of what we do.  It takes a village to raise a doula and some of the villagers need to be within arm’s reach.

The Second Step

Go to a birth.  Find a way.  You don’t need to meet the OBs or the midwives, you don’t have to bring them gifts to remember you. You can, but ultimately, you are looking for pregnant women.  Remember, there are lots of ways to foster connections with potential clients and there are more pregnant people than careproviders.  Put your energy into the right group.  

The spark is there, you just have to to make time to fire it up and keep it burning.

 

Ecstatic Birth: The Hormonal Blueprint of Labor

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Ecstatic Birth: The Hormonal Blueprint of Labor

by Sarah J. Buckley Issue 111 Mothering, March/April 2002

Giving birth in ecstasy: this is our birthright and our body’s intent. Mother Nature, in her wisdom, prescribes birthing hormones that take us outside (ec) our usual state (stasis) so that we can be transformed on every level as we enter motherhood. This exquisite hormonal orchestration unfolds optimally when birth is undisturbed, enhancing safety for both mother and baby. Science is also increasingly discovering what we realize as mothers- that our way of birth affects us life-long, mother and child, and that an ecstatic birth, a birth that takes us beyond our Self, is the gift of a lifetime.

Four major hormonal systems are active during labor and birth. These involve oxytocin, the hormone of love; endorphins, hormones of pleasure and transcendence; epinephrine and norepinephrine, hormones of excitement; and prolactin, the mothering hormone. These systems are common to all mammals and originate in our mammalian or middle brain, also known as the limbic system. For birth to proceed optimally, this part of the brain must take precedence over the neocortex, or rational brain. This shift can be helped by an atmosphere of quiet and privacy, with, for example, dim lighting and little conversation, and no expectation of rationality from the laboring woman. Under such conditions a woman intuitively will choose the movements, sounds, breathing, and positions that will birth her baby most easily. This is her genetic and hormonal blueprint.

All of these systems are adversely affected by current birth practices. Hospital environments and routines are not conducive to the shift in consciousness that giving birth naturally requires. A woman’s hormonal physiology is further disturbed by practices such as induction, the use of painkillers and epidurals, caesarean surgery, and separation of mother and baby after birth.

Hormones in Birth

Oxytocin

Perhaps the best-known birth hormone is oxytocin, the hormone of love, which is secreted during sexual activity, male and female orgasm, birth, and breastfeeding. Oxytocin engenders feelings of love and altruism; as Michel Odent says, “Whatever the facet of Love we consider, oxytocin is involved.”1

Oxytocin is made in the hypothalamus, the “master gland” deep in our brains, and stored in the posterior pituitary, from where it is released in pulses. It is a crucial hormone in reproduction and mediates what have been called the ejection reflexes: the sperm ejection reflex with male orgasm (and the corresponding sperm introjection reflex with female orgasm); the fetal ejection reflex at birth (a phrase coined by Odent for the powerful contractions at the end of an undisturbed labor, which birth the baby quickly and easily);2 and, postpartum, the placental ejection reflex and the milk ejection, or let-down reflex, in breastfeeding.

As well as reaching peak levels in each of these situations, oxytocin is secreted in large amounts in pregnancy, when it acts to enhance nutrient absorption, reduce stress, and conserve energy by making us more sleepy.3 Oxytocin also causes the rhythmic uterine contractions of labor, and levels peak at birth through stimulation of stretch receptors in a woman’s lower vagina as the baby descends.4 The high levels continue after birth, culminating with the birth of the placenta, and then gradually subside.5

The baby also produces oxytocin during labor, perhaps even initiating labor;6 so, in the minutes after birth, both mother and baby are bathed in an ecstatic cocktail of hormones. At this time ongoing oxytocin production is enhanced by skin-to-skin and eye-to-eye contact and by the baby’s first suckling. Good levels of oxytocin also protect against postpartum hemorrhage by ensuring good uterine contractions.7 In breastfeeding, oxytocin mediates the let-down reflex and is released in pulses as the baby suckles. During the months and years of lactation, oxytocin continues to keep the mother relaxed and well nourished. One researcher calls it “a very efficient antistress situation which prevents a lot of disease later on.” In her study, mothers who breastfed for more than seven weeks were calmer than mothers who did not.8 Outside its role in reproduction, oxytocin is secreted in other situations of love and altruism, for example, sharing a meal.9 Researchers have implicated malfunctions of the oxytocin system in conditions such as schizophrenia,10 autism,11 cardiovascular disease,12 and drug dependency,13 and have suggested that oxytocin may mediate the antidepressant effect of drugs such as Prozac.14

Beta-endorphin

As a naturally occurring opiate, beta-endorphin has properties similar to meperidine (pethidine, Demerol), morphine, and heroin, and has been shown to work on the same receptors of the brain. Like oxytocin, beta-endorphin is secreted from the pituitary gland, and high levels are present during sex, pregnancy, birth, and breastfeeding. Betaendorphin is also a stress hormone, released under conditions of duress and pain, when it acts as an analgesic and, like other stress hormones, suppresses the immune system. This effect may be important in preventing a pregnant mother’s immune system from acting against her baby, whose genetic material is foreign to hers.

Like the addictive opiates, beta-endorphin induces feelings of pleasure, euphoria, and dependency or, with a partner, mutual dependency. Beta-endorphin levels are high in pregnancy and increase throughout labor,15 when levels of beta-endorphin and corticotrophin (another stress hormone) reach those found in male endurance athletes during maximal exercise on a treadmill.16 Such high levels help the laboring woman to transmute pain and enter the altered state of consciousness that characterizes an undisturbed birth.

Beta-endorphin has complex and incompletely understood relationships with other hormonal systems.17 In labor, high levels will inhibit oxytocin release. It makes sense that when pain or stress levels are very high, contractions will slow, thus “rationing labour according to both physiological and psychological stress.”18 Beta-endorphin also facilitates the release of prolactin during labor,19 which prepares the mother’s breasts for lactation and also aids in the final stages of lung maturation for the baby.20 Betaendorphin is also important in breastfeeding. Levels peak in the mother at 20 minutes,21 and beta-endorphin is present as well in breastmilk,22 inducing pleasure and mutual dependency for both mother and baby in their ongoing relationship.

Fight-or-Flight Hormones

The hormones epinephrine and norepinephrine (adrenaline and noradrenaline) are also known as the fight-or-flight hormones or, collectively, as catecholamines (CAs). They are secreted from the adrenal gland, above the kidney, in response to stresses such as fright, anxiety, hunger, or cold, as well as excitement, when they activate the sympathetic nervous system for fight or flight.

In the first stage of labor, high CA levels inhibit oxytocin production, therefore slowing or inhibiting labor. CAs also act to reduce blood flow to the uterus and placenta, and therefore to the baby. This makes sense for mammals birthing in the wild, where the presence of danger would activate this sympathetic response, inhibiting labor and diverting blood to the major muscle groups so that the mother can flee to safety.

In humans, high levels of CAs have been associated with longer labor and adverse fetal heart rate patterns.23 After an undisturbed labor, however, when the moment of birth is imminent, these hormones act in a different way. There is a sudden increase in CA levels, especially noradrenaline, which activates the fetal ejection reflex. The mother experiences a sudden rush of energy; she will be upright and alert, with a dry mouth and shallow breathing and perhaps the urge to grasp something. She may express fear, anger, or excitement, and the CA rush will cause several very strong contractions, which will birth the baby quickly and easily.

Some birth attendants have made good use of this reflex when a woman is having difficulties in the second stage of labor. For example, an anthropologist working with an indigenous Canadian tribe recorded that when a woman was having difficulty in birth, the young people of the village would gather together to help. They would suddenly and unexpectedly shout out close to her, with the shock triggering her fetal ejection reflex and a quick birth.24  

After the birth, CA levels drop steeply. The new mother may feel shaky or cold as a consequence. A warm atmosphere is important, as ongoing high CA levels will inhibit oxytocin and therefore increase the risk of postpartum hemorrhage.25

Noradrenaline, as part of the ecstatic cocktail, is also implicated in instinctive mothering behavior. Mice bred to be deficient in noradrenaline will not care for their young after birth unless noradrenaline is injected back into their system.26

For the baby also, birth is an exciting and stressful event, reflected in high CA levels.27 These assist the baby during birth by protecting against the effects of hypoxia (lack of oxygen) and subsequent acidosis. High CA levels at birth ensure that the baby is wide- eyed and alert at first contact with the mother. The baby’s CA levels also drop rapidly after an undisturbed birth, being soothed by contact with the mother.

Prolactin

Known as the mothering hormone, prolactin is the major hormone of breastmilk synthesis and breastfeeding. Traditionally it has been thought to produce aggressively protective behavior (the “mother tiger” effect) in lactating females.28 Levels of prolactin increase in pregnancy, although milk production is inhibited hormonally until the placenta is delivered. Levels further increase in labor and peak at birth. Prolactin is also a hormone of submission or surrender (in primate troops, the dominant male has the lowest prolactin level) and produces some degree of anxiety. In the breastfeeding relationship, these effects activate the mother’s vigilance and help her to put her baby’s needs first.29 The baby also produces prolactin while in the womb, and high levels are found in amniotic fluid, possibly of uterine or placental origin.30 The function of prolactin in the baby is unknown.

Undisturbed Birth

Undisturbed birth is exceedingly rare in our culture, even in birth centers and homebirths. Two factors that disturb birth in all mammals are firstly being in an unfamiliar place and secondly the presence of an observer. Feelings of safety and privacy thus seem to be fundamental. Yet the entire system of Western obstetrics is devoted to observation of pregnant and birthing women, by both people and machines; when birth isn’t going smoothly, obstetricians respond with yet more intense observation. It is indeed amazing that any woman can give birth under such conditions. Some writers have observed that, for a woman, having a baby has a lot of parallels with making a baby: same hormones, same parts of the body, same sounds, and the same needs for feelings of safety and privacy. How would it be to attempt to make love in the conditions under which we expect women to give birth?

For birthing Maia Rose, my fourth baby, I arranged a situation where I felt very safe and very private, and I had my shortest, easiest, and most ecstatic labor and birth–one and a half hours with an 8-pound, unexpectedly breech baby. I believe this birth proceeded optimally because I was totally free to follow my instincts, and because I felt safe and private. Each woman must labor where, and with whom, she feels safest, and my situation would not suit everyone. But it underscores the huge gap between what was ideal for me and my baby, physiologically and hormonally, and the standard care offered in most hospitals.

Impact of Drugs and Procedures

Induction and Augmentation In Australia, approximately 20 percent of women have induced labor, and another 20 percent have an augmentation–stimulation or speeding up of labor–with synthetic oxytocin (Syntocinon, Pitocin).31 In the US, these rates are 19.8 percent and 17.9 percent,32 adding up in both countries to around 40 percent of birthing women being administered synthetic oxytocin by IV during labor.

Synthetic oxytocin administered in labor does not act like the body’s own oxytocin. First, Syntocinon-induced contractions are different from natural contractions, and these differences can cause reduced blood flow to the baby. For example, waves can occur almost on top of each other when too high a dose of synthetic oxytocin is given, and it also causes the resting tone of the uterus to increase.33

Second, oxytocin, synthetic or not, cannot cross from the body to the brain through the blood-brain barrier. This means that Syntocinon, introduced into the body by injection or drip, does not act as the hormone of love. However, it does provide the hormonal system with negative feedback–that is, oxytocin receptors in the laboring woman’s body detect high levels of oxytocin and signal the brain to reduce production. We know that women with Syntocinon infusions are at higher risk of bleeding after the birth, because their own oxytocin production has been shut down. But we do not know the psychological effects of giving birth without the peak levels of oxytocin that nature prescribes for all mammalian species.

As for the baby, “Many experts believe that through participating in this initiation of his own birth, the fetus may be training himself to secrete his own love hormone.”34 Michel Odent speaks passionately about our society’s deficits in our capacity to love self and others, and he traces these problems back to the time around birth, particularly to interference with the oxytocin system.

Opiate Painkillers

The most commonly used drug in Australian labor wards today is pethidine (meperidine, Demerol). In one state, 34 percent of laboring women in 1998 were given this drug.35 In the US, several opiate-like drugs have been traditionally used in labor, including meperidine nalbuphine (Nubain), butorphanol (Stadol), alphaprodine (Nisentil), hydromorphone (Dilaudid), and fentanyl citrate (Sublimaze). The use of simple opiates in the labor room has declined in recent years, with most women now opting for epidurals, which may also contain these drugs (see below).36 As with oxytocin, use of opiate drugs will reduce a woman’s own hormone production,37 which may be helpful if levels are excessive and inhibiting labor. The use of pethidine, however, has been shown to slow labor, more so with higher doses.38

Again we must ask: What are the psychological effects for mother and baby of laboring and birthing without peak levels of these hormones of pleasure and mutual dependency? Some researchers believe that endorphins are the reward we get for performing reproductive functions such as mating and birthing; that is, the endorphin fix keeps us having sex and having babies.39 It is interesting to note that most countries that have adopted Western obstetrics, which prizes drugs and interventions in birth above pleasure and empowerment, have experienced steeply declining birthrates in recent years.

Of greater concern is a study that looked at the birth records of 200 opiate addicts born in Stockholm from 1945 to 1966 and compared them with the birth records of their nonaddicted siblings. When the mothers had received opiates, barbiturates, and/or nitrous oxide gas during labor, especially in multiple doses, the offspring were more likely to become drug addicted. For example, when a mother received three doses of opiates, her child was 4.7 times more likely to become addicted to opiate drugs in adulthood.40

This study was recently replicated with a US population, with very similar results.41 The authors of the first study suggest an imprinting mechanism, but I wonder whether it may be a matter of ecstasy: if we don’t get it at birth, as we expect, we look for it later in life through drugs. Perhaps this also explains the popularity (and the name) of the drug Ecstasy.

Animal studies suggest a further possibility. It seems that drugs administered chronically in late pregnancy can cause effects in brain structure and function (e.g., chemical and hormonal imbalance) in offspring that may not be obvious until young adulthood.42-45 Whether such effects apply to human babies who are exposed for shorter periods around the time of birth is not known; but one researcher warns, “During this prenatal period of neuronal [brain cell] multiplication, migration and interconnection, the brain is most vulnerable to irreversible damage.”46

Epidural Drugs

Epidural drugs are administered over several hours via a tube into the space around the spinal cord. Such drugs include local anaesthetics (all cocaine derivatives, e.g., bupivicaine/marcaine), more recently combined with low-dose opiates. Spinal pain relief involves a single dose of the same drugs injected through the coverings of the spinal cord and is usually short-acting unless given as a combined spinal-epidural (CSE). Epidural pain relief has major effects on all of the previously mentioned hormones of labor. Epidurals inhibit beta-endorphin production47 and therefore also inhibit the shift in consciousness that is part of a normal labor. (This may be one reason why epidurals are so acceptable to hospital birth attendants, who are not prepared, practically or professionally, to deal with the irrationality, directness, and physicality of a woman laboring on her own terms.) When an epidural is in place, the oxytocin peak that occurs at birth is also inhibited because the stretch receptors of a birthing woman’s lower vagina, which trigger this peak, are numbed. This effect probably persists even when the epidural has worn off and sensation has returned, because the nerve fibers involved are smaller than the sensory nerves and therefore more sensitive to drug effects.48

A woman giving birth with an epidural will thus miss out on the fetal ejection reflex, with its strong final contractions designed to birth her baby quickly and safely. She must then use her own effort, often against gravity, to compensate. This explains the increased length of the second stage of labor and the extra need for forceps when an epidural is used.49 Use of epidurals also inhibits catecholamine release,50 which may be advantageous in the first stage of labor; close to the time of birth, however, a reduction in CA levels will, as with oxytocin, inhibit the fetal ejection reflex and prolong the second stage.

Another hormone also appears to be adversely affected by epidurals. Prostaglandin F2 alpha helps to make a laboring woman’s uterus contractible, and levels increase when women labor without epidurals. In one study, women with epidurals experienced a decrease in PGF2 alpha, and average labor times were increased from 4.7 to 7.8 hours.51 Drugs administered by epidural enter the mother’s bloodstream immediately and go straight to the baby at equal, and sometimes greater, levels.52,53 Some drugs will be preferentially taken up into the baby’s brain,54 and almost all will take longer to be eliminated from the baby’s immature system after the cord is cut. One researcher found bupivacaine and its breakdown products in the circulation of babies for the first three days.55

Another indication of the effects of epidurals on mother and baby comes from French researchers who gave epidurals to laboring sheep.56 The ewes failed to display their normal mothering behavior; this effect was especially marked for the ewes in their first lambing that were given epidurals early in labor. Seven out of eight of these mothers showed no interest in their offspring for at least 30 minutes.

Some studies indicate that this disturbance may apply to humans also. Mothers given epidurals in one study spent less time with their babies in hospital, in inverse proportion to the dose of drugs they received and the length of the second stage of labor.57 In another study, mothers who had epidurals described their babies as more difficult to care for one month later.58 Such subtle shifts in relationship and reciprocity may reflect hormonal dysfunctions and/or drug toxicity and/or the less-than-optimal circumstances that often accompany epidural births–long labors, forceps, and cesareans.

Incredibly, there have been no good studies of the effects of epidurals on breastfeeding, although there is evidence that babies born after epidural have a diminished suckling reflexes and capacity.59,60

Cesarean Surgery

Cesarean section involves major abdominal surgery and increases the risk of maternal death by about four times,61 as well as possibly affecting mother and baby’s health in subsequent pregnancies.62 Cesarean rates are currently 21.1 percent in Australia63 and 22.9 percent–the highest level on record–in the US.64 Obviously there is a shorter or absent labor with cesarean birth, and the peaks of oxytocin, endorphins, catecholamines, and prolactin are absent. Furthermore, mothers and babies are usually separated for some hours after birth, so breastfeeding is usually delayed. Both will also be affected to some extent by the drugs used in the procedure (epidural, spinal, or general anaesthetic) and for postoperative pain relief.

The consequences of such radical departures from our hormonal blueprint are suggested in the work of Australian researchers who interviewed 242 women in late pregnancy and again after birth. The 50 percent of women who had given spontaneous vaginal birth experienced a marked improvement in mood and an elevation of self-esteem after delivery. By contrast, the 17 percent who had cesarean surgery were more likely to experience a decline in mood and self-esteem. The remaining women had forceps or vacuum assistance, and their mood and self-esteem were, on average, unaltered.65

Another study looked at the breastfeeding hormones prolactin and oxytocin on day two, comparing women who had given birth vaginally with women who had undergone emergency cesarean surgery. In the cesarean group, prolactin levels did not rise as expected with breastfeeding, and the oxytocin pulses were reduced or absent. In this study, first suckling had been at 240 minutes average for cesarean babies, and 75 minutes average for babies vaginally born. Duration of breastfeeding was not significantly different for the mothers, and the authors conclude that “other factors” can compensate for deficient hormonal release.”66 Other research has shown that early and frequent suckling positively influences milk production and the duration of breastfeeding.67,68 The authors of the hormonal study above add, “These data indicate that early breastfeeding and physical closeness may be associated not only with more interaction between mother and child, but also with endocrine [hormonal] changes in the mother.”69

These studies not only indicate important links between birth and breastfeeding but also show how an optimal birth experience can influence the long-term health of mother and baby. For example, successful breastfeeding confers advantages such as reduced risk of breast cancer and osteoporosis for the mother and reduced risk of diabetes and obesity long-term for the child. And enhanced self-esteem after a natural birth–a lifelong effect, in my experience–is a solid base from which to begin our mothering.

The connections between events at birth and long-term health certainly deserve more study. (See Michel Odent’s Primal Health Database, http://www.birthworks.org/primalhealth, for a summary of current research.) But we cannot afford to wait for years for researchers to “prove” the benefits of an undisturbed birth. Perhaps the best we can do is trust our instincts and vote with our birthing bodies, choosing models of care that increase our chances of undisturbed–and ecstatic–birthing.

Early Separation

Even in non-interventionist settings, it is uncommon for a baby to remain in his mother’s arms for the first one to two hours. And yet nature’s blueprint for this time includes a specific and genetically encoded activation of the brain and nervous system for both mother and baby. For example, when the newborn baby is in skin-to-skin contact at the mother’s left breast (which is where new mothers in all cultures instinctively cradle their babies) and in contact with her heart rhythm, “a cascade of supportive confirmative information activates every sense, instinct and intelligence needed for the radical change of environment…. Thus intelligent learning begins at birth.”70

For the mother also, “A major block of dormant intelligences is activated” the mother then knows exactly what to do and can communicate with her baby on an intuitive level.”71 This awakening of maternal capabilities is well known among animal researchers, who link it to the action of pregnancy and birth hormones on the brains of mothers who have recently delivered.72 Such intuitive capacities are sorely needed in our human culture, where we rely so heavily on outside advice from books and “experts” to tell us how to care for our babies.

According to Joseph Chilton Pearce (see Note 70), when these activations do not occur within about 45 minutes of birth, “cut off from his mother’s nurturing and with none of the encoded expectancies met, the newborn’s adrenals continue to release steroids in the face of maximum fear and abandonment. The infant screams for a short time and then silence falls.” The damage caused by separation, Pearce writes, is “massive and past the point of repair.” Like Odent, he believes that our current birth practices are psychologically crippling to babies, mothers, and society as a whole, and the evidence in his book Evolution’s End: Reclaiming the Potential of Our Intelligence is compelling.

Optimizing the Ecstasy

The following suggestions will help a woman use her hormonal blueprint and so optimize the experience and safety for herself and her baby.

Take responsibility for your health, healing, and wholeness throughout the childbearing years.

• Choose a model of care that enhances the chance of a natural and undisturbed birth (eg, homebirth, birth center, one-on-one midwifery care).

• Arrange support according to an individual woman’s needs; trust, a loving relationship, and continuity of care with support people are important.

• Consider having an advocate at a hospital birth, e.g., a private midwife or doula.

• Ensure an atmosphere where the laboring woman feels safe, unobserved, and free to follow her own instincts.

• Reduce neocortical stimulation by keeping lighting soft and reducing words to a minimum.

• Cover the clock and any other technical equipment.

• Avoid drugs unless absolutely necessary.

• Avoid procedures (including obvious observations) unless absolutely necessary.

• Avoid cesarean surgery unless absolutely necessary.

• Don’t separate mother and baby for any reason, including resuscitation, which can be done with the cord still attached.

• Breastfeed and enjoy it!

One way to ensure minimum interference in the third stage is to practice Lotus Birth, or nonseverance of the cord. This is only compatible with a physiological third stage, and also keeps mother and baby together and secluded in the hours and days after birth. It is the subject of a new book and, having had three Lotus-born babies myself, I highly recommend both the practice and the book.73.

Giving birth is an act of love, and each birth is unique to the mother and her baby. Yet we also share the same womanly physiology and the same exquisite orchestration of our birthing hormones. Our capacity for ecstasy in birth is also both unique and universal, a necessary blessing that is hard-wired into our bodies but that requires, especially in these times, that we each trust, honor, and protect the act of giving birth according to our own instincts and needs.

Dutch professor of obstetrics G. Kloosterman offers a succinct summary, which would be well placed on the door of every hospital birth room:

Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character. The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine–nil nocere [do no harm].74

Notes 1. M. Odent, The Scientification of Love (London: Free Association Press, 1999). 2. M. Odent, “The Fetus Ejection Reflex,” in The Nature of Birth and Breastfeeding (Westport, CT: Bergin and Garvey, 1992). 3. K. Uvnas Moberg, quoted in report of Australian Lactation Consultant’s Conference, Gold Coast, Australia 1998, published in Australian Doctor (July 8, 1998): 38. 4. M. Y. Dawood et al., “Oxytocin in Human Pregnancy and Parturition,” Obstetrics and Gynecology 51 (1978): 138-143. 5. E. Nissen et al., “Elevation of Oxytocin Levels Early Post-partum in Women,” Acta Obstetricia et Gynecologica Scandanavica 74, no. 7 (1998): 530-533. 6. T. Chard et al., “Release of Oxytocin and Vasopressin by the Human Fetus during Labour,” Nature 234 (1971): 352-354. 7. M. Odent, “Don’t Manage the Third Stage of Labour!” Practising Midwife 1, no. 9 (1998): 31-33. 8. See Note 3. 9. J. G. Verbalis et al., “Oxytocin Secretion in Response to Cholecystokinin and Food: Differentiation of Nausea from Satiety,” Science 232 (1986): 1417-1419. 10. P. Feifal and T. Raza, “Oxytocin Modulates Psychomimetic-induced Deficits in Sensorimotor Gating,” Psychopharmacology 141, no. 1 (1999): 93-98 11. T. R. Insel, “Vasopressin and Autism: Is There a Connection?” Biological Psychiatry 45, no. 2 (1999): 145-147. 12. S. Knox et al., “Social Isolation and Cardiovascular Disease: An Atherosclerotic Pathway,” Psychoneuroendocrinology 23, no. 8 (1998): 877-890. 13. S. Sarnyai and G. L. Kovacs, “Role of Oxytocin in the Neuroadaptation to Drugs of Abuse,” Psychoneuroendocrinology 19, no. 1 (1994): 85-117. 14. K. Uvnas Moberg et al., “Oxytocin as a Possible Mediator of SSRI-induced Antidepressant Effect,” Psychopharmacology 142, no. 1 (1999): 954-1001. 15. M. Brinsmead et al., “Peripartum Concentrations of Beta Endorphin and Cortisol and Maternal Mood States,” Australian and New Zealand Journal of Obstetrics and Gynaecology 25 (1985): 194-197. 16. R. S. Goland et al., “Biologically Active Corticotrophin-releasing Hormone in Maternal and Fetal Plasma during Pregnancy,” American Journal of Obstetrics and Gynecology 159 (1984): 884-890. 17. T. Laatikainen, “Corticotrophin Releasing Hormone and Opioid Peptides in Reproduction and Stress,” Annals of Medicine 23, no. 5 (1991): 489-496. 18. M. Jowitt, “Beta-endorphin and Stress in Pregnancy and Labour,” Midwifery Matters 56 (1993): 3-4. 19. C. Rivier et al., “Stimulation in Vivo of the Secretion of Prolactin and Growth Hormone by Beta-endorphin,” Endocrinology 100 (1976): 238-241. 20. C. R. Mendelsen, “Prolactin May Be Stimulus in Fetal Lung Development,” Ob-Gyn News, July 1, 1978. 21. R. Franceschini et al., “Plasma Beta-endorphin Concentrations during Suckling in Lactating Women,” British Journal of Obstetrics and Gynaecology 96, no. 6 (1989): 711- 713. 22. V. Zanardo et al., “Beta Endorphin Concentrations in Human Milk,” Journal of Pediatric Gastroenterology and Nutrition 33, no. 2 (2001): 160-164. 23. R. Lederman, E. Lederman et al., “Anxiety and Epinephrine in Multiparous Women in Labor: Relationship to Duration of Labor and Fetal Heart Rate Patterns,” American Journal of Obstetrics and Gynecology 153, no. 8 (1985): 870-877. 24. This incident is described by Michel Odent in “The Fetus Ejection Reflex,” in The Nature of Birth and Breastfeeding (Westport, CT: Bergin and Garvey, 1992). 25. Manabu Saito et al., “Plasma Catecholamines and Microvibration as Labour Progresses,” Shinshin-Igaku 31, no. 3 (1991): 81-89 (abstract in English). 26. S. A. Thomas and R. D. Palnuter, “Impaired Maternal Behavior in Mice Lacking Norepinephrine and Epinephrine,” Cell 91 (1997): 583-592. 27. H. Lagercrantz and H. Bistoletti, “Catecholamine Release in the Newborn Infant at Birth,” Pediatric Research 11, no. 8 (1977): 889-893. 28. M. Odent, The Nature of Birth and Breastfeeding (Westport, CT: Bergin and Garvey, 1992). 29. Ibid. 30. G. Daniels and J. Martin, “Neuroendocrine Regulation and Diseases of the Anterior Pituitary and Hypothalamus,” in Harrison’s Principles of Internal Medicine, 13th ed. (New York: McGraw-Hill, 1994). 31. Australian Institute of Health and Welfare National Perinatal Data Statistics Unit, http://www.aihw.gov.au, retrieved October 2001. 32. National Center for Health Statistics, http://www.cdc.gov/nchs, retrieved November 2001. 33. See Note 15. 34. See Note 28. 35. Queensland Health Perinatal Statistics 1998, http://www.health.qld.gov.au/hic/1998peri/home.htm, retrieved November 2001. 36. American College of Obstetricians and Gynecologists, Obstetric Analgesia and Anesthesia, Technical Bulletin No. 225 (July 1996). 37. T. A. Thomas et al., “Influence of Medication, Pain and Progress in Labour on Plasma Beta-endorphin like Immunoreactivity,” British Journal of Anaesthesia 54 (1982): 401-408. 38. A. M. Thomson, “A Re-evaluation of the Effect of Pethidine on the Length of Labour,” Journal of Advanced Nursing 19, no. 3 (1994): 448-456. 39. C. D. Kimball, “Do Endorphin Residues of Beta Lipotrophin in Hormones Reinforce Reproductive Functions?,” American Journal of Obstetrics and Gynecology 134, no. 2 (1979): 127-132. 40. B. Jacobsen et al., “Opiate Addiction in Adult Offspring through Possible Imprinting after Obstetric Treatment,” British Medical Journal 301 (1990): 1067-1070. 41. K. Nyberg et al., “Perinatal Medication as a Potential Risk Factor for Adult Drug Abuse in a North American Cohort,” Epidemiology 11, no. 6 (2000): 715-716. 42. B. J. Myerson, “Influence of Early B-endorphin Treatment on the Behavior and Reaction to B-endorphin in the Adult Male Rat,” Psychoneuroendocrinology 10 (1985): 135-147. 43. C. K. Kellogg et al., “Sexually Dimorphic Influence of Prenatal Exposure to Diazepam on Behavioral Responses to Environmental Challenge and on Gamma Aminobutyric Acid (GABA)-Stimulated Chloride Uptake in the Brain,” Journal of Pharmacology and Experimental Therapeutics 256, no. 1 (1991): 259-265. 44. M. Mirmiran and D. F. Swaab, “Effects of Perinatal Medication on the Developing Brain,” in Fetal Behaviour, J. G. Nijhuis, ed. (Oxford, England: Oxford University Press, 1992). 45. G. T. Liversay et al., “Prenatal Exposure to Phenobarbital and Quantifiable Alterations in the Electroencephalogram of Adult Rat Offspring,” American Journal of Obstetrics and Gynecology 167, no. 6 (1992): 1611-1615. 46. See Note 44. 47. See Note 15. 48. C. F. Goodfellow et al., “Oxytocin Deficiency at Delivery with Epidural Analgesia,” British Journal of Obstetrics and Gynaecology 90 (1983): 214-219. 49. C. E. McRae-Bergeron et al., “The Effect of Epidural Analgesia on the Second Stage of Labour,” Journal of the American Association of Anesthetic Nurses 66, no. 2 (1998): 177-182. 50. A. D. Falconer and A. B. Powles, “Plasma Noradrenaline Levels during Labour: Influence of Elective Lumbar Epidural Blockade,” Anaesthesia 37 (1982): 416-420. 51. O. Behrens et al., “Effects of Lumbar Epidural Analgesia on Prostaglandin F2 Alpha Release and Oxytocin Secretion during Labour,” Prostaglandins 45, no. 3 (1993): 285- 296. 52. R. Fernando and E. Bonello, “Placental and Maternal Plasma Concentrations of Fentanyl and Bupivacaine after Ambulatory Combined Spinal Epidural (CSE) Analgesia during Labour,” International Journal of Obstetric Anesthesia 4 (1995): 178-179. 53. M. Brinsmead, “Fetal and Neonatal Effects of Drugs Administered in Labour,” Medical Journal of Australia 146 (1987): 481-486. 54. T. Hale, “The Effects on Breastfeeding Women of Anaesthetic Medications Used during Labour,” paper presented at Passage to Motherhood Conference, Brisbane, Australia, 1998. (Contact CAPERS bookshop, Brisbane, for abstracts or tape, http://www.capersbookstore.com.au) 55. P. Belfrage et al., “Lumbar Epidural Analgesia with Bupivacaine in Labor,” American Journal of Obstetrics and Gynecology 123 (1975): 839-844. 56. D. P. Krehbiel et al., “Peridural Anesthesia Disturbs Maternal Behavior in Primiparous and Multiparous Parturient Ewes,” Physiology and Behavior 40 (1987): 463- 472. 57. C. B. Sepkoski et al., “Effects of Maternal Epidural Anesthesia on Neonatal Behavior during the First Month,” Developmental Medicine and Child Neurology 34 (1992): 1072- 1180. 58. A. D. Murray et al., “Effects of Epidural Anaesthesia on Newborns and Their Mothers,” Child Development 52 (1981): 71-82. 59. J. Riordan et al., “Effect of Labor Pain Relief Medication on Neonatal Suckling and Breastfeeding Duration,” Journal of Human Lactation 16, no. 1 (2000): 7-12. 60. A. B. Ransjo-Arvidson et al., “Maternal Analgesia during Labor Disturbs Newborn Behavior: Effects on Breastfeeding, Temperature, and Crying,” Birth 28, no. 1 (2001): 20-21. 61. M. Enkin et al., A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. (Oxford, England: Oxford University Press, 2000). 62. E. Hemminki and J. Merilainen, “Long-term Effects of Caesarean Sections: Ectopic Pregnancies and Placental Problems,” American Journal of Obstetrics and Gynecology 174, no. 5 (1996): 1569-1574. 63. See Note 31. 64. See Note 32. 65. J. Fisher et al., “Adverse Psychological Impact of Operative Obstetric Interventions: A Prospective Longitudinal Study,” Australia and New Zealand Journal of Psychiatry 31 (1997): 728-738. 66. E. Nissen et al., “Different Patterns of Oxytocin, Prolactin but Not Cortisol Release during Breastfeeding in Women Delivered by Caesarean Section or by the Vaginal Route,” Early Human Development 45 (1996): 103-118. 67. E. M. Salariya et al., “Duration of Breastfeeding after Early Initiation and Frequent Feeding,” The Lancet 2, no.8100 (1978): 1141-1143. 68. P. De Chateau and B. Wiberg, “Long-term Effect on Mother-Infant Behaviour of Extra Contact during the First Hour Postpartum,” Acta Paediatrica Scandanavia, 66 (1977): 145-151. 69. See Note 66. 70. J. C. Pearce, Evolution’s End: Reclaiming the Potential of Our Intelligence (San Francisco: HarperSanFrancisco, 1995): 178-179. 71. Ibid. 72. J. A. Russell et al., “Brain Preparations for Maternity- Adaptive Changes in Behavioral and Neuroendocrine Systems during Pregnancy and Lactation,” Progressive Brain Research 133 (2001): 1-38. 73. Shivam Rachana, ed., Lotus Birth (Melbourne, Australia: Greenwood Press, 2000), golden@xtreme.net.au. 74. G. J. Kloosterman, “Universal Aspects of Birth: Human Birth as a Sociopsychosomatic Paradigm,” Journal of Psychosomatic Obstetrics and Gynecology 1, no. 1 (1982): 35-41. (Note: A similar version of this article was presented at the Circle of Life Conference of the National Association of Childbirth Educators, Queensland, Australia, April 2001.)

Sarah J. Buckley is a family physician, an internationally published writer, and a full-time mother to Emma, Zoe, Jacob, and Maia Rose, all born at home. She is the author of Gentle Birth, Gentle Mothering: The wisdom and science of gentle choices in pregnancy, birth, and parenting, published in early 2006. To read more from Sarah J. Buckley, and to order her book, visit http://www.sarahjbuckley.com.

The Anterior Cervical Lip: how to ruin a perfectly good birth

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Great piece on The Anterior Lip.

MidwifeThinking

Edited and update: March 2016

Here is a scenario I keep hearing over and over: A woman is labouring away and all is good. She begins to push with contractions, and her midwife encourages her to follow her body. After a little while the midwife checks to ‘see what is happening’ and finds an anterior cervical lip. The woman is told to stop pushing because she is not fully dilated and will damage herself. Her body is lying to her – she is not ready to push. The woman becomes confused and frightened. She is unable to stop pushing and fights her body creating more pain. Because she is unable to stop pushing she may be advised to have an epidural. An epidural is inserted along with all the accompanying machines and monitoring. Later, another vaginal examination finds that the cervix has fully dilated and now she is coached to push. The…

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Compare and Contrast Certified and Uncertified Doulas

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Compare and Contrast Certified and Uncertified Doulas

This is going to be so valuable for primary careproviders , third party payers and clients. Thank you for spelling it all out.

Doula Baby Daddy

I was reading an online discussion recently about the benefits of doula certification.  There was some discussion about the fees and how some doulas don’t receive referrals from their certifying body which, by the way, is NOT the point of certification.  Then this comment caught my attention:

… where I live most people have no idea what a doula is so certification is irrelevant most of the time.

To me the decision to pursue certification is a no-brainer.  Sure it’s challenging, time consuming, and costly, but in my military mind it’s an outstanding weeding out process that separates the professionals from the amateurs.  A 2012 article which shows favorable results from continuous labor support is popular among doulas.   While it doesn’t distinguish between certified or uncertified doula care, there’s a fun little tid-bit which is often left out that specifically states trained and experienced doula care is best:

Continuous support…

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The Best Netflix Women Film. Ever.

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The Best Netflix Women Film. Ever.

People often ask each other what to watch on Netflix.  I find that I tend to gravitate toward movies that are off the beaten path, foreign films, highly rated and not the usual North American high profile movies.  Today, I was fortunate to find a movie that was women centered and had great societal value.  This is one to show your daughters and your sons and maybe even discuss.  For me, though, it was so needed after a heavy week of watching women duke it out online.  The film was all about women supporting women, women working together for a common goal, women uplifting each other and generally feeling for each other.  Sure, there was a woman who was not ‘with’ the group in body or spirit, but the group still showed her kindness even when she did not return the sentiment.  That’s what community is all about, lifting each other up and coming together on important issues.

Almost two weeks ago, a very active group on Facebook was shut down after an offline incident and the group was subsequently removed by a new set of admins.  The group was primarily women based and the former admins were all women.  The group was comprised of over 12000 women supporting each other, virtually, through conversation and opinions much in the way communities did over a hundred years ago. They did not always agree but they were respectful and supportive. This group, though, was an online community that was bigger than the town that I live in.

As the group disappeared, very quickly, a new group appeared and I joined it believing that it was very much the same as the last: women supporting women.  It took all of ten minutes to realize that it was not at all the same.  The women in the new group, lead by a very vocal group of admins, claimed to support and enlighten fellow members through evidence and research. What I found was a group of women who belittled those who did not think the way they did, who hid behind evidence that supported only their own cause and could not fathom two or three sides to an argument and who used horrid cyber bully tactics to validate their arguments.

I stayed in the group for a week.  I felt like perhaps exploring other viewpoints and other opinions might deepen my understanding of yet another side, another stance.  I felt I had something to learn from them.  And I may not have learned but I was reminded:

 Intolerance breeds contempt.  

Judgement is not just about choices other people make, it is about the threat to our own belief system. 

We start wars by degrading, demonizing and disempowering the perceived threat group.

Cyber bullying is not age or gender defined.

The movie, though, also may not have taught but it, too, reminded me of life lessons:

People generally want the best possible outcomes when looking for solutions or helping others to find this.

We depend on truth in the moment to make the best decisions.

Love and tolerance build trust and friendship.

Controversial topics often have many sides to explore and that is a good thing.

Oh.  And the movie?  La Source Des Femmes.  Netflix.  Definitely put it on your list. Let me know what you think.  

 

Setting Reasonable Fees, Part V

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Setting Reasonable Fees, Part V

Fee Disparity

doula

This fee schedule is based on a woman coming into care at 12 weeks, with a low risk, healthy pregnancy, no interventions through pregnancy, labour, birth or postpartum.  It is based entirely on averages.

Does this fee schedule shock you?

A midwife puts in ten times as many hours as an obstetrician and makes more money for it per birth but an OB sees more people than a midwife per hour.  A doula puts in seven times more hours than the doctor but a good deal less than a midwife.  While the doula is often the most expendable team member, many families say they would never birth without the continuous physical and emotional support of a doula and this service is invaluable.

Midwives are paid per course of care after a woman has been discharged.  Doctors are paid per visit and billing happens following each service.  Doulas ask for their fee upfront with a deposit, and paid in full before the birth.

An OB is an expert, the top of the chain, the resource we need and rely on should problems arise.  Does it seem reasonable for a doula to receive more money than the obstetrician per patient?   Does it seem right for doulas to earn as much as first year midwives?  The answers are yours to ponder.  No one has the answer to the questions other than you.  This profession is currently not regulated.

Ultimately, the doctor will have the highest annual income followed by the midwife. While there should some parity for services between midwives and doctors, where does the doula sit in that paradigm?

The choice is up to the doula.  It is not up to the other maternity professionals and it is not up to the other doulas in, or outside, of the region.  It is up to each individual  doula.  As an independent business owner, understanding your business expenses, your cost per birth and what the region will support is how you set your fees.  But understand this, midwives have been lobbying for pay equity in Ontario for a very long time.  If the doula’s fees are reaching the level of junior midwives, there are going to be fewer referrals from our biggest support network and that’s also a reality.  A living wage as a labour support person is entirely attainable however it must come from a thoughtful place of understanding the big picture of your life, your services and your community.


This post is the last of a five part series.

Setting Reasonable Fees, Part IV

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Setting Reasonable Fees, Part IV

Continuous Support & Fees – A Guide for Doulas

Stats.jpgOne of the key components of all studies that support doula care is the continuous presence of the labour support professional.  That means the doula is there for the entire labour, whether it is four hours or twenty four hours.  This is the job we sign on for.  If for some reason, we cannot fulfill the hourly obligation, then we have the option to call in a back up doula to maintain continuous presence.

Some doulas are learning that this model is not viable from a financial perspective yet we have to realize that this is the type of care that was repeatedly researched and found most beneficial in the reduction of interventions.

There have been a great many discussions and lively debates about leaving a woman with an epidural, going home to get some rest, and returning when the client is in further need of our services.  The problem is that a woman with an epidural often has the need for emotional support, side effects from the epidural, does not sleep soundly or for long and sometimes things change ridiculously quickly after the epidural is administered and not always in a way that is anticipated.  Some doulas are also discussing their departure during unplanned cesareans and the return hours later, or even a day later, for postpartum support but again, without a magic crystal ball, you can’t foresee what type of care will be needed for the mother or her partner.  The key in the research to providing positive outcomes is continuous emotional and physical support and on occasion, this will mean sitting in a hallway alone.

Utilizing language that stipulates a timeline for supportive presence is dangerous for some parents and perfectly understandable and legitimate to others; you must know your audience and be able to adapt. As a doula, you can not predict outcomes or needs based on those same outcomes.  In addition, in 2015  The Doula Group in Ontario Canada reports an overall epidural rate of approximately 34%, a cesarean rate of 12% and the births that were more than 12 hours were only 11%.  A whopping 20% were in four hours or less. Doulas do not refund for those very short labours, and thus we do not charge extra for those that go longer but that is only the policy of this particular group. As an independent contractor, you get to decide how you want to be paid, but understand this: the benefited outcomes of a doula’s service is based upon continuous presence.

This five part series on setting fees is an aide for the new doula to understand all that goes into setting a reasonable fee that you feel is the best for that particular doula.

 

What I Love About Birth

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What I Love About Birth

“There is something to be said about people who love birth and the birth process.  The passion birthworkers feel, and the way we are drawn to a profession involving pregnancy, labour and birth is a true calling that not everyone can embrace.”

I love working with a mother who is strong and sure of what she wants.                                                                                                               I am the gatekeeper, the reminder that she has a goal.

I love working with a mother who needs some help figuring out a birth plan and what her deepest desires could be.                                                                                                                                                                                                             I am the key to unlocking things she already knows.

I love working with a woman’s partner who is her rock.                                                                                                                                                                                                             I am the extra hands.

I love working with a woman’s partner who needs guidance, reassurance and ideas.                                                                                                                                   I am the source of information.

I love working with the nurse who says, “I am so glad you’re here.”                                                                I feel like we make a great team to help this woman have the best birth memories.

I love working with the nurse who pretends I don’t exist.                                                                                                         I see this as a chance to really shine; it challenges me to win them over.

I love working with midwives who appreciate the dual role we play.                                                        I find those births are light, happy and relaxed and that makes mothers feel the same.

I love working with obstetricians who called me and said, “Please take this client on.”                       I know the doc believes we can ease a mind and provide support in ways they cannot.

I love the magic of the movements of birth and how it all comes together.

I love “we did it” moment when the baby is born.

I love the look on a parent’s face when they see their child for the first time.

What are your favourite things about birth?

Being a Badass Doula

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Being a Badass Doula

How to Be a Badass Doula in 2 Easy Steps

badass

  1. Post a Birth Video to Facebook.
  2. Have Someone from FB Take it Down Because it Violates Community Rules.

We posted a fantastic birth video of a woman standing in her kitchen, catching her own baby standing up.  It was just over one minute long.  She was wearing a bra and birthed unassisted.  The video was filmed from a bit of a distance, there were no full-on yoni shots.

If you have been in the birth world a while, or you are fairly new to it, you have probably heard the buzz that Facebook removes photos of birth and breastfeeding as it violates community rules for nudity yet all the photos from the Sports Illustrated nude, body painted athletes were posted last month. It happened again a few weeks ago when  Kim Kardashian showed her post pregnancy body in a photo with the “important bits” blocked out.  Apparently, she had nothing to wear and the “internet broke” because of it.  We are not sure if the video was just simply removed or if it was actually reported.  Facebook does not provide that information.

There is also something to be said about the power of a woman’s body, and not just their appearance, that Facebook does not want to share with the general population.  Women at their finest.  Women being women.  Women being mothers.  Women loving their children.  Women’s power.  Women’s wisdom.  These are all censored.

Birth art from a historical perspective is documented in Aztec, Egyptian, Greek and Roman times.  In all medium, in all cultures, birth is portrayed as a reverent, respected and powerful event.  What will be left of our times that will show birthing and breastfeeding mothers as powerful?

The photos below were taken at the Vatican Museum and the  National Art Gallery in Ottawa, Canada.  Depictions of women feeding their babies is not new either.

What are you going to do about the censorship that continues on Facebook and Instagram? How will you make a difference to what art history pieces of our times are given to generations to come?  There needs to be a change of culture but it seems like the only ones that are noticing the differences are people already actively involved in providing birthing services. The general public sees birth as gory and gruesome but watches horror and psychological thriller moves.  The average pêrson thinks breastfeeding should be done in private but publicizes their own eating patterns on Instagram. There is something not right in going on in North America when it comes to birth and breastfeeding.

Watch the video.  Comment below.  Is it worthy of censorship?  Tell us your thoughts.