Your Brain is Green
Of all the brain types, yours has the most balance. You are able to see all sides to most problems and are a good problem solver. You need time to work out your thoughts, but you don't get stuck in bad thinking patterns. You tend to spend a lot of time thinking about the future, philosophy, and relationships (both personal and intellectual).

Thursday, August 30, 2007

Are You SURE You're Bluish? (part 2)

In Jewish religious law, a person is Jewish if his mother is Jewish in Jewish law. That's not as confusing as it sounds. Either she was born to a Jewish mother, or she converted in accordance with Jewish law. In other words, Jewishness is genetic. (That, incidentally, is how one can be a Jewish atheist). In fact, the traditional way of assigning Jewish identity is racist: if a Jew says, of a non-Jew, that he has a Yiddishe kop (a Jewish head), that's a tribute to the Gentile's intelligence. If a non-Jew begins talking about "Jewish blood", Jews know it's time to bar the door and close the window shutters before the pogrom begins. But I digress.

There is another definition that requires some explanation but is important to understand in this story. A "bastard" in Jewish law (mamzer) is the child of an adulterous relationship, not born out of wedlock. There are very significant penalties for being a mamzer, one of which is not being allowed to marry anyone but another mamzer for 10 generations.

Back to the story.

Jewish rabbinical courts consist of three rabbis. Women, children and idiots are not allowed to be witnesses. When we applied for an Israeli marriage certificate, we of course submitted the marriage license signed by Rabbi Lipman in Washington DC. However, the Israeli rabbinate keeps lists of American rabbis they deem sufficiently Orthodox, and Rabbi Lipman wasn't an Orthodox rabbi. That in itself wasn't an insurmountable obstacle. Cohabitation can be one of the three ways a woman is "purchased in marriage" (the language is Mishnaic, not mine). But a Jewish marriage has to be between two Jews. Was I a Jew?

Bring your mother to Israel to testify to her Jewishness, the rabbis told me. No way, said I. My mother was undergoing chemotherapy and could not travel. OK, have her make a deposition before a rabbi we accept. I refused this too, because I knew my mother had a very bad conscience about marrying "out" and the last thing I wanted at this time was to increase her emotional problems. Finally, after much consultation, the rabbis decided my two aunts could make depositions, stating that they definitely knew my grandmother to be Jewish, and my mother was indeed their sister. (Trying to explain this to my aunts was a job in itself, since neither was observant. WTF? Of course Bubbie was Jewish! Nevertheless, it was done.)

Then the rabbis dropped the bombshell: how do we know that your first husband was indeed NOT Jewish? Perhaps he was secretly Jewish, and in that case, since you don't have proof of death, you are still married to him, not having received a Bill of Divorcement according to Jewish law! Bring HIS parents--if you can't find him--to Israel to testify that they are goyim!

This was patently impossible. Bernard had never told his parents, from whom he was estranged, that he'd even married me. The rabbis had cause for concern because in Europe there were children who had been saved from the Holocaust with faked baptismal papers, and his mother might have been one. But it was very important because I was now pregnant with my first child, and unless I could prove, to the court's satisfaction, that my first husband had not been Jewish (and therefore my first marriage was not Jewishly valid), I was pregnant with a mamzer, because the second marriage was invalid.

DH didn't understand the implications; he may be a "kosher" Jew, but he's Israeli, and not a Torah scholar. I collapsed in hysterical tears outside the courtroom. Another rabbi hurried over, thinking perhaps we were having a marital dispute, and when I managed to blurt out a bit of the story, he immediately told us to follow him to the offices of the Jerusalem Chief Rabbi. This rabbi was his secretary. I spent over two hours with Rav Zolti (z"l), and the upshot was he gave me a letter to take back to the court which said, in essence, "solve this now".

The rabbis did, in the following manner:

As stated above, a Jewish marriage is the union of two Jews (a man and a woman, incidentally) and must be dissolved according to Jewish law with a "get" or Bill of Divorcement. However, a marriage between a Jew and a non-Jew is not a valid marriage, and no Jewish divorce is required. So, (Talmudic sing-song with waving finger for emphasis is appropriate here) if we cannot prove that Bernard definitely wasn't Jewish, then, the rabbis reasoned, using the "no women, children, or idiots are legal witnesses" cop-out, we can definitely say that Antigonos isn't Jewish because her aunts' testimony is worthless!

So they sent me to be "converted".

It was less of a problem for me than for DH who, if he didn't rabidly hate the rabbinate before, he does now. I recognize the legal fiction, and the need for it, that the rabbis used. They were forced to work within Jewish law, and in its best tradition managed to find a way around what appeared a nearly-insoluble problem. DH just thought the whole thing was a farce. At the end of the day I merely was dunked in a ritual bath and given a piece of paper which I think I've lost over the years (along with my Israeli marriage certificate, which I haven't lost). The rabbis are happy. Now my daughter's getting married, and because I went through this soap opera she isn't having any problems with the rabbis at all. Her Jewishness isn't in doubt.

But every time the stranglehold of the religious authorities in the areas of conversion, marriage and divorce makes the headlines, I feel sympathetic. On the one hand, it is Halacha--literally, "the way in which one walks"--that has kept the Jewish people a coherent unit throughout more than two millennia, in spite of the most ferocious persecutions. On the other, it takes rabbis of real moral stature to be able to have the guts to adapt the Halacha to current conditions. It's just too easy to fall back on the generations of scholars who went before and not allow any innovations out of fear. Right now there are significant numbers of Russians who would formally convert if it wasn't made so difficult; they have Jewish partners and have chosen to leave the FSU and make their lives here, and there are many Ethiopians who consider themselves completely Jewish but whom the rabbis doubt and it is deeply insulting to them. Once again, a bill is in the Knesset for civil marriage, but that will only divide the religious and the secular even more. It is a very difficult problem.

Tuesday, August 28, 2007

How NOT to Have a Baby

Birdie's Mama doesn't like me.

On her blog she relates the story of her pregnancy, her labor, and the stillbirth that resulted. She doesn't like me because I told her that it was most probably her bad choices which caused the baby to die in utero. OK, I admit being harsh. But trying to exonerate her by commiserating uncritically with her is actually an act of collusion in the tragedy. More than that, I desperately want to jolt her into not endangering either herself or her next baby.

I don't think I'm doing too well. She's now into something called "Mayan Massage" which is just woo, and is already thinking about trying for VBAC even though she's not yet pregnant again.

So, for what it's worth, even though I doubt she will read this (why should she?), let me recap what I know, what I speculate, and what I fear. Perhaps it will be of benefit to someone.

Birdie's Mama chose, in her first pregnancy, to decline being tested for gestational diabetes. An adopted child herself without information about her biological mother, she nevertheless claimed she had no inherited tendency to diabetes. She wrote:
The test is more for women who run a high risk for having GD. I don't fall into
this category, however the concern lies in my being adopted and not knowing my
biological health history. For all I know, my biological parents could now have
diabetes. Nonetheless, even if I am tested there is not any real evidence that
shows treating GD can improve the outcome for mom & baby. So, I am going to
think about it over the weeknd....and make a decision early next week. Of course
the risk of not having the test is growing a larger baby, and in the end not
being able to have a vaginal delivery....that is not an option for me.
But gestational diabetes is not real diabetes at all, and it isn't an inherited trait. Gestational diabetes is a condition of pregnancy where the mother's blood sugar during pregnancy behaves in the same way that it does in true diabetics. However, almost always, it returns to normal within hours of birth. The risks of gestational diabetes are twofold: either the baby is unusually big, with the consequent problems of possibly being too big to go through the mother's pelvis, and also, after birth, having trouble maintaining his blood sugar levels, or the baby is unusually small because the placenta isn't working properly and the baby is being starved of oxygen and food. A baby whose blood sugar levels unexpectedly plummet can convulse, and there can be permanent brain damage as a result since during a convulsion, the supply of oxygen to the brain is interrupted.

Generally speaking, most gestational diabetics can be managed on a diet which keeps their blood sugar levels within normal limits. This has the additional effect of keeping the babies from growing excessively large, and thereby also reducing the chances of hypoglycemia after birth. Some gestational diabetics, however, require insulin (oral diabetic agents are not suitable during pregnancy). The diet has some carbohydrate (carbohydrates are metabolized in the same way as sugar) but it is very limited. Birdie's Mama is a vegetarian. While it is possible, on a vegetarian diet, to get sufficient protein when pregnant, it isn't easy, and the typical vegetarian diet is heavy with carbohydrates.

So I speculate: did Birdie's Mama have undiscovered gestational diabetes? The fact that the baby weighed over 9 lbs (4 kilo) at birth suggests it but does not prove it. If Birdie's Mama did have gestational diabetes, her diet was almost certainly higher in carbohydrates than it should have been, and therefore she exacerbated her own problem. Whoever told her that gestational diabetes poses no risk if untreated was wrong. The risks are real, and substantial. And one of them is intrauterine fetal death. But Birdie's Mama didn't want to even think about the possibility: "it isn't an option". I won't think about it, therefore it can't happen. Birth, after all, is normal; complications come from medical interventions. Trust your body.

Birdie's Mama published, throughout her pregnancy, photos of herself. There is a photo, taken at 31 weeks, which strongly suggests polyhydramnios. This is a situation where there is excessive production of amniotic fluid. The uterus looks "large for dates". I won't go into the various methods of estimating gestational age by height of the uterine fundus because nowadays most women have repeated ultrasounds during pregnancy, and this is more accurate (indeed the amount of amniotic fluid can also be measured this way). Polyhydramnios is a warning of many possible problems. If--IF--there was polyhydramnios, it was either missed or not even noticed by Birdie's Mama's health care providers. She also gained much more weight during her pregnancy than was advisable.

Apparently, as far as I can tell, Birdie's Mama's antenatal care was supervised by certified nurse midwives without reference to a doctor. In the blog it is noted that she was scheduled to see one at 32 weeks, but she does not say if she went to the appointment. She arranged for the birth itself to be attended by a doula and a midwife who was not a nurse. At times Birdie's Mama seems to confuse the two kinds of attendants, and she quotes, at one point, completely fictional statistics regarding the use of doulas in labor ("50% less C/S") When I checked the links to the both the doula's and the midwife's. website, neither site was operational.
Birdie's Mama also wanted a home birth, preferably a water birth.
our going to be peaceful and quiet (soft
meditative music)....relaxed, candlelit and romantic.

I have very strong reservations about home birth in the US. There are no national standards for midwives. In some states, they are illegal. In others, only certified nurse midwives are legal, and in still others, "licensed" midwives (meaning they have had some training but the type of course varies widely) are allowed, and lastly there are states where anyone who attends a woman in labor can call herself a midwife. Moreover, there are no nationally agreed criteria for who is suitable for home birth; no form whatsoever of emergency backup, no requirement that the parturient woman should be within a certain distance of a medical institution with the facilities to offer emergency care to mother and baby on a 24/7 basis.

Criteria in the UK have changed in the thirty years since I studied to be a midwife at Cambridge. Back then a woman having a first baby could not have a home birth, because it was not possible to know whether she could put a baby through her pelvis or not. Ultrasound has made that less of a risk, since both the size of the baby's head and the weight can be reasonably estimated and the diameters of the pelvic inlets and outlets can be measured. As Birdie's Mama came closer and closer to her due date, it is impossible to know from her blog whether she had ultrasounds to estimate fetal size at all. She passed her due date, and obviously was oblivious, as were her health care providers, of the risks of postmaturity (placental insufficiency which causes the baby to have no reserves for the stresses of labor)

In the event, engagement happened in the 38th week. Apart from that, there is little information in the blog about her status until a brief mention, in her 41st week, that she has lost her mucus plug and thinks she is beginning to go into labor. Even though she added details to her blog after the birth, all that is certain is that she had contractions for 24 hours. Whether these were real contractions, whether she had any cervical dilatation at all, what station the baby's head was at (whether it was actually descending through the pelvis), we don't know.

She writes that her midwives listened to the fetal heart every half hour or so. It's better than nothing. But a heartbeat can be within the normal 120-160 bpm range and the baby can still be very stressed. That is why intermittent fetal monitoring is done in the hospital; to see whether the baby's heartbeat is showing normal beat to beat variability. If it is absent, if the FH is always the same rate, this is not a good sign. By the time there are decelerations, the baby is now actively distressed. Moreover, it is often very hard to hear the baby's heart beat without electronic equipment (did the midwives have a doppler?) during contractions. If the baby's heartbeat is 80 between contractions, that is a very serious matter indeed.

Was it normal that I did not feel my baby m0ving at all during lab0r? The
morning that my lab0r had begun and then stalled I mentioned that I had not
really been feeling her move to one of our hom3b1rth m1dw1ves, as I did feel
little concerned about this, but she told me that this was normal. She
said that
when my body is c0ntr@cting that the baby "bears down" and does
not really

What incredible balderdash! Of course babies move during labor. Sometimes less than before, but they do move. Birdie's Mama was right to question. She also began to wonder whether the "excruciating pain" she felt was right. Any woman who has had a baby can tell her that it is no picnic. So much for the romantic side of labor. Labor is not only hard work, it hurts.

The "midwives" put her on her side. There is no mention of oxygen in the blog. They then called the backup midwife (by implication a CNM) rather than alert the hospital that they were bringing Birdie's Mama in with probable severe fetal distress and to prepare for all emergencies. The hospital, in any case, was a small community one without an obstetrician in the house all the time, and possibly no neonatal intensive care facilities. The "three minute" trip, because of weather conditions, took longer (it always does; and getting dressed, etc. eats up the time as well. This is one of the reasons that countries with organized backup facilities for home births work on a concept of bringing the "hospital to the home" rather than the other way round). The nurses at this hospital were obviously unprepared for this type of occurence.

What Birdie's Mama describes as chaos, and as a situation where no one knew what to do is not entirely fair. (I can't think why she was told to go into knee-chest position). Writing after the event, there is an element of wanting to assign blame as a way of relieving guilt (she becomes much more critical of the hospital later on) Not being a medical person, she didn't fully understand what was going on. But there were delays that would not have happened had she been laboring in a well-equipped and staffed hospital. Further, she seems to have had some kind of seizure on the operating table, but I suspect it was a panic attack--certainly not surprising.

In short, her baby was born dead. There was some question whether the baby's heartbeat was actually heard in the hospital, or whether what the nurses heard was the maternal pulse. How long the baby had been in distress is unknown. One has to wonder whether the "midwives" actually heard the fetal heart before deciding that Birdie's Mama should go to the hospital. It's quite possible that what they heard was the maternal pulse. The placenta looked "normal" (no reason why it shouldn't actually) and nowhere is it noted that an autopsy was performed before the baby was cremated when dead three days.

I think Birdie's Mama's antenatal care was not adequate. She was obsessed with the effects of "toxic" substances on her fetus and eating only "organic" vegetarian foods, but certainly the choice of birth attendants was not sensible; these were not medical professionals. The question of whether a home birth should have been attempted is controversial. I'm not convinced that she was a low-risk patient who should have had even a trial of labor at home.

For the past few months she has been wallowing in grief. It is always tragic to lose a baby. It's my opinion that she needs professional counseling (and her husband probably does too). As grief gives way to anger, the next stage of grieving, her anger is increasingly directed outward at the hospital. Understandable, but not really correct, given the circumstances. Her most recent posts discuss the possibility of trying for a VBAC in her next pregnancy. She thinks this is possible because of the type of Caesarean Section she had. Wrong. It depends on a number of factors. VBACs, when the reason for the C/S was fetal distress are possible; if the reason was failure to progress in labor/cephalopelvic disproportion (baby too big to pass through the pelvis) it is not, whether fetal distress was a factor or not. Since babies tend to be some ounces bigger in each subsequent pregnancy, this may be a major consideration.

Right now she has become enamoured of something called "Mayan Massage". I haven't got a clue what this is, but since her uterus long ago reentered the pelvic cavity and cannot be massaged at all abdominally, I can't think what organs other than the intestines are being massaged and what effect this has on adhesions (present, if at all, within several weeks of the operation) or on the position of the uterus or its ability to house a pregnancy. It is a total waste of time, and money, although a massage is an enjoyable way of spending time, I'll grant you that.

In short, next time round Birdie's Mama should get competent, professional medical care during her pregnancy, and accept it. She should choose a hospital not because it's homelike or comfy, but because it contains all the facilities needed for all events connected with birth, uncomplicated or complicated. The idea that hospitals just want to make people suffer as much as possible is absurd. Unlike minimally-trained homebirth "midwives" who bleat on and on about having beautiful and "spiritual" experiences, hospital staff have only one top priority: the safe delivery of mother and baby. That is, after all, the whole point of giving birth.

I wish Birdie's Mama consolation for her loss, and the wisdom to make better choices next time--and I'm sure there will be a "next time".