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Unnecessary cuts: Why are American hospitals doing so many episiotomies?

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The routine use of episiotomies has been discouraged for a long time. Yet a recent report by USA Today has found that they are still being done at an alarming rate.

An episiotomy is an incision made at the opening of the vagina and into the perineum—the space between the vagina and the rectum—at the time of birth. The goal of an episiotomy is to enlarge the birth canal, providing more space for the baby to come out.

Episiotomies became very common in the mid 20th century. Providers believed that in addition to speeding up delivery, episiotomies would decrease the risk of vaginal and perineal tearing and injury, decrease the pressure put on the baby's head by the birth canal, and decrease the risk of shoulder dystocias (when a baby's shoulders get "stuck" in the pelvis, leading to a slower birth with high risk for complications).

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The thing is: none of these are actually true.

Researchers have spent a lot of time looking at the differences between routine (meaning that they are standard protocol) and selective (used on a case by case, as needed basis) episiotomies.

Here's what they've found:

When it comes to shoulder dystocias, the problem is not happening in the vagina—the shoulders are "stuck" behind the pelvic bones. A larger vaginal opening does not change this.

Lastly, episiotomies have a significant psychological impact on women—their lasting pain has proven to be a stressor for postpartum women, and I would venture to say that the emotional trauma has lasting effects as well.

Now, it's really important to note that like all interventions, sometimes episiotomies are necessary and really helpful. For example, if a special hand maneuver is needed to help deliver the baby in the event of certain complications, an episiotomy can give the provider more space to perform it. They may also help speed birth in the event that a vacuum or forceps become necessary.

The problem is that, as with many interventions, something that was intended to be used in emergency situations is being used routinely.

The World Health Organization believes that an episiotomy rate of about one out of 10 women may be appropriate, though many providers think it should be much lower still. For example, Kaiser hospitals in Northern California have a 3% episiotomy rate. For reference, I've attended hundreds of birth as a midwife and I have done maybe five episiotomies.

With all of this information then, the findings of a recent investigative report by USA Today are troubling: They found that some hospitals have episiotomy rates of 20 to 40%. A Cochran Review report corroborates this, finding a rate of 28% in some institutions.

To put it bluntly, this an unacceptable.

For a group of professionals who have taken an oath to do no harm, why are we performing an excessive number of harmful procedures? Fear and disconnection are the reasons for this.

Obstetrics is tied (with surgery) for the most commonly sued branch of medicine. And it should be—the stakes are really high. But the constant threat of legal action leads to fear, and it changes the way people work. There is the omnipresent fear that one day, someone will look back at any given birth and say, "Why didn't you do something to prevent this?"

And so we are on a constant quest to do. To speed things up, to use technology, to intervene.

Therein lies the disconnect. We are disconnected from the process of birth that happens on its own, powered by nature. We are disconnected from trusting women. And, we are disconnected from the actual human experience of transitioning into motherhood.

Let me be clear about two things:

  1. Many interventions are necessary. And when they are, it is a tremendously good thing that they exist.
  2. Not all providers are disconnected—most are wonderful, working with the best intentions and most up to date evidence backing their actions.

But the USA Today findings indicate that we urgently need to reevaluate how we are taking care of women.

Now, if you are planning on giving birth soon or in the future, these new findings are probably making you very nervous. Here's what you can do:

  1. Research. Ask your provider (current or potential) what their specific episiotomy rate is, as well as that of the place where they deliver babies.
  2. Remember that you are the "customer." You have a choice. If you went to a restaurant and they served gross food and were rude to you, you would not go back. If you have a medical provider with whom you do not feel comfortable, please do not feel like you have to stay with them. Don't worry about hurting anyone's feelings. Choose discomfort over resentment, and find a new provider.
  3. Get clear and what you want, and talk about it. Over and over again. If not having an episiotomy unless absolutely necessary is important to you, let everyone know. If you are writing out your birth plan, write "episiotomy only in an emergency scenario." When you have your prenatal appointments, talk to your provider about how you feel—if there are multiple providers, it's okay to talk to each of them about it. Don't assume that your message will be conveyed. When you are in labor, let your nurse know. If your nursing care changes shifts, let the next nurse know too. And when you start pushing, say it again. You are a lovely, polite person—don't worry about being "annoying" here. THIS IS YOUR BIRTH.

If you've already given birth and had an episiotomy, you may be completely at peace with it. It may have been necessary, and you may be very relieved to have had the experience that you had. If all that is true, then that is awesome!

But if you are concerned about the experience you had:

  1. Ask questions. In the intensity of birth, especially in the event of an emergent situation, there is potential for miscommunication. Call your provider and ask them for a birth debriefing, so that they can go through what happened and answer questions.
  2. Escalate. If you feel that you have been wronged or violated, consider speaking with a local or national patient rights organization. Childbirth Connection is a great place to start.
  3. Find a therapist. It is estimated that 9% of women experience post- traumatic stress disorder (PTSD) after giving birth. So if you are having really difficult emotions regarding your birth, please know that they are real and valid, and you are not alone. Seek out a therapist who specializes in PTSD or women's health (or better yet, both), and get support as you work through this challenge.
  4. Find a pelvic floor physical therapist. If you have lingering pain, incontinence (peeing or pooping when you don't mean to), uncomfortable sex or any other concerns, there is help—this doesn't have to be "the way it is now." A pelvic floor physical therapist can work with you to regain your strength and comfort.

And we have to keep talking about it. Because ultimately this is a human rights issue. We need to do better.

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Pop quiz, mama! How many different types of car seats are there? If you guessed three, you're partially correct. The three main types are rear-facing car seats, forward-facing car seats, and booster seats. But then there are a variety of styles as well: infant car seats, convertible seats, all-in-one seats, high-back booster seats, and backless boosters. If you're not totally overwhelmed yet, keep reading, we promise there's good stuff ahead.

There's no arguing that, in the scheme of your baby and child gear buying lifetime, purchasing a car seat is a big deal! Luckily, Walmart.com has everything you need to travel safely with your most precious cargo in the backseat. And right now, you can save big on top-rated car seats and boosters during Best of Baby Month, happening now through September 30 at Walmart.com.

As if that wasn't enough, Walmart will even take the carseat your kiddos have outgrown off your hands for you (and hook you up with a sweet perk, too). Between September 16 and 21, Walmart is partnering with TerraCycle to recycle used car seats. When you bring in an expired car seat or one your child no longer fits into to a participating Walmart store during the trade-in event, you'll receive a $30 gift card to spend on your little one in person or online. Put the money towards a brand new car seat or booster or other baby essentials on your list. To find a participating store check here: www.walmart.com/aboutbestofbabymonth

Ready to shop, mama? Here are the 9 best car seat deals happening this month.


Safety 1st Grow and Go Spring 3-in-1 Convertible Car Seat

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From rear-facing car seat to belt-positioning booster, Grow and Go Sprint's got you covered through childhood. Whether you choose the grey Silver Lake, Seafarer or pink Camelia color palette, you'll love how this model grows with your little one — not to mention how easy it is to clean. The machine-washable seat pad can be removed without fussing with the harness, and the dual cup holders for snacks and drinks can go straight into the dishwasher.

Price: $134 (regularly $149)

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Baby Trend Hybrid Plus 3-in-1 Booster Car Seat in Bermuda

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When your toddler is ready to face forward, this versatile car seat can be used as a five-point harness booster, a high-back booster, and a backless booster. Padded armrests, harness straps, and seat cushions provide a comfy ride, and the neutral gray seat pads reverse to turquoise for a stylish new look.

Price: $72.00 (regularly $81)

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Baby Trend Hybrid Plus 3-in-1 Booster Car Seat in Olivia

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Looking for something snazzy, mama? This black and hot pink car seat features a playful heart print on its reversible seat pad and soft harness straps. Best of all, with its 100-pound weight limit and three booster configurations, your big kid will get years of use out of this fashionable design.

Price: $72.00 (regularly $81)

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Evenflo Triumph LX Convertible Car Seat

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This rear- and forward-facing car seat keeps kids safer, longer with an adjustable five-point harness that can accommodate children up to 65 lbs. To tighten the harness, simply twist the conveniently placed side knobs; the Infinite Slide Harness ensures an accurate fit every time. As for style, we're big fans of the cozy quilted design, which comes in two colorways: grey and magenta or grey and turquoise.

Price: $116 (regularly $149.99)

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Disney Baby Light 'n Comfy 22 Luxe Infant Car Seat

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Outfitted with an adorable pink-and-white polka dot Minnie Mouse infant insert, even the tiniest of travelers — as small as four pounds! — can journey comfortably and safely. This rear-facing design is lightweight, too; weighing less than 15 lbs, you can easily carry it in the crook of your arm when your hands are full (because chances are they will be).

Price: $67.49 (regularly $89.99)

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Graco 4Ever 4-in-1 Convertible Car Seat

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We know it's hard to imagine your tiny newborn will ever hit 100 lbs, but one day it'll happen. And when it does, you'll appreciate not having to buy a new car seat if you start with this 4-in-1 design! Designed to fit kids up to 120 lbs, it transforms four ways, from a rear-facing car seat to a backless belt-positioning booster. With a 6-position recline and a one-hand adjust system for the harness and headrest, you can easily find the perfect fit for your growing child.

Price: $199.99 (regularly $269.99)

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Graco SlimFit All-in-One Convertible Car Seat

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With its unique space-saving design, this 3-in-1 car seat provides 10% more back seat space simply by rotating the dual cup holders. The InRight LATCH system makes installation quick and easy, and whether you're using it as a rear-facing car seat, a forward-facing car seat, or a belt-positioning booster, you can feel confident that your child's safe and comfortable thanks to Graco's Simply Safe Adjust Harness System.

Price: $149.99 (regularly $229.99)

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Graco Snugride Snuglock 35 Platinum XT Infant Car Seat

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Making sure your infant car seat is secure can be tricky, but Graco makes it easy with its one-second LATCH attachment and hassle-free three-step installation using SnugLock technology. In addition to its safety features, what we really love about this rear-facing seat are all of the conveniences, including the ability to create a complete travel system with Click Connect Strollers and a Silent Shade Canopy that expands without waking up your sleeping passenger.

Price: $169.99 (regularly $249.99)

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Graco Snugride Snuglock 35 Elite Infant Car Seat

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With just one click, you can know whether this rear-facing car seat has been installed properly. Then adjust the base four different ways and use the bubble level indicator to find the proper position. When you're out and about, the rotating canopy with window panel will keep baby protected from the sun while allowing you to keep your eye on him.

Price: $129.99 (regularly $219.99)

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This article was sponsored by Walmart. Thank you for supporting the brands that support Motherly and mamas.

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Having children isn't always as easy as it looks on Instagram. There's so much more to motherhood than serene baby snuggles and matching outfits. But there's a reason we've fallen so deeply in love with motherhood: It's the most beautiful, chaotic ride.

Every single day, we sit back and wonder how something so hard can feel so rewarding. And Eva Mendes just managed to nail the reality of that with one quote.

Eva, who is a mama to daughters Esmerelda and Amada with Ryan Gosling, got real about the messy magic of motherhood in a recent interview.

"It's so fun and beautiful and maddening," the actress tells Access Daily. "It's so hard, of course. But it's like that feeling of…you end your day, you put them to bed and Ryan and I kind of look at each other like, 'We did it, we did it. We came out relatively unscathed.'"

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And just like that, moms all over the world feel seen. We've all been there: Struggling to get through the day (which, for the record is often every bit as fun as it is challenging), only to put those babies to sleep and collapse on the couch in sheer exhaustion. But, after you've caught your breath, you realize just how strong and capable you really are.

One thing Eva learned the hard way? That sleep regressions are very, very real...and they don't just come to an end after your baby's first few months. "I guess they go through a sleep regression, which nobody told me about until I looked it up," she says "I was like, 'Why isn't my 3-year-old sleeping?'"

But, at the end of the day, Eva loves her life as a mom—and the fact that she took a break from her Hollywood career to devote her days to raising her girls. "I'm so thankful I have the opportunity to be home with them," she says.

Thank you for keeping it real, Eva! Momming isn't easy, but it sure is worth it.

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News

Nannies and early childhood educators do incredibly important work. Parents and children need these workers, they are vital to families and our economy. And they are woefully underpaid.

On average, nannies in the United States make less than Amazon delivery drivers, and day care workers earn less than either.

According to Sittercity's most recent data, the typical hourly rate of nannies in 2019 is $17.50 per hour. According to Amazon, most delivery drivers earn $18 - $25 per hour. And day care workers make only a couple dollars more than they would working in fast food, earning $11.17 per hour on average, according to the U.S. Bureau of Labor Statistics.

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What does it say about our society that we value the delivery of consumer goods more than we value care work?

Yes, parents are struggling to pay for childcare, but those caring for our children are struggling to pay their bills, too, and it is hard to retain talented professionals when there is more money to be made in other fields. "It is stressful. Everybody loves these children, and that's why they're there, but the love can't pay their bills," day care operator Danielle Frank told KSNB News this week.

Frank owns Smiling Faces Academy in Kearney, Nebraska, but the problem of high turnover and low wages in the childcare industry is an issue all over the United States. This isn't a uniquely American issue, either. In Japan, day care workers are desperately needed, the New York Times reports, but childcare workers there earn about a third less than workers in other industries and report struggling to cover the basic necessities.

Back in North America, this week day care workers in Nova Scotia, Canada who are frustrated with low wages have threatened to walk off the job, a move similar to one made by YMCA childcare workers in Chicago last year. "I make $15.50 an hour, and I have a BA in early childhood education with a certification in infants and toddlers," childcare worker Tahiti Hamer told WGN last year.

From Nebraska to Nova Scotia to the story is the same: Parents pay a lot for childcare while workers make very little, even though some licensed day cares require employees to have training in early childhood education, or even a bachelor's degree. And when you've got student loans, maybe carrying Amazon packages starts to look better than caring for children.

According to a recent study by the Indeed Hiring Lab, the childcare industry has two big problems right now.

"As the labor market has strengthened in recent years, more workers need child care. At the same time, growth in interest in child care jobs has slowed," Indeed Hiring Lab economist Nick Bunker notes. He suggests low-wage earners who work in childcare have more options these days, and employers should consider raising workers' pay.

It's easy to see why the industry has a hard time keeping workers, especially as other lower-wage job sectors (like Amazon delivery) expand. Unfortunately, for many childcare centers, paying workers more is just not doable without some help from levels of government.

And help is needed, not just to ensure that parents have access to quality, affordable childcare, but also to ensure that those providing it aren't living in poverty.

A study out of the Center for the Study of Child Care Employment at the University of California, Berkeley, found childcare workers' earnings are not keeping pace with increases in similar professions or with the costs of childcare and living. "Childcare workers have also experienced no increase in real earnings since 1997, and, as was true in 1989, still earn less than adults who take care of animals, and barely more than fast food cooks. Those who work as preschool teachers have fared somewhat better; their wages have increased by 15 percent in constant dollars since 1997, although their wages remain low. In contrast, parent fees have effectively doubled," the researchers note, highlighting that many childcare workers earn so little they actually qualify for public assistance.

The researchers continue: "While there are no available data to explain this glaring gap between trends in parent fees and teacher wages, it is abundantly clear that families cannot bear the burden of addressing the imperative to provide more equitable compensation for their children's early childhood teachers."

Speaking to the Education Writers Association last year one of the reports' writers, Marcy Whitebook, the founding director of the Center for the Study of Child Care Employment at the University of California at Berkeley, said the problem is that our society devalues the work of looking after and educating children under 5, even though it is as demanding and important as teaching those ages 5 and up.

"Americans aren't used to funding early childhood care and instruction like they do K-12 education," Whitebook said. "We don't look at it as education. And we don't look at it as education everyone should have access to."

That may change in the future, as presidential candidates float plans for universal pre-K and childcare, but right now, having access to childcare is a privilege. And those who are privileged enough to employ a nanny should pay them fairly if they want to keep them, says Elizabeth Harz, CEO of Sittercity. "It's also worth noting that when parents are proactive and offer systems and official paperwork that give nannies protection in the relationship, it goes a long way," says Harz.

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News

It may seem like there are a lot of recalls for kids' products these days, but it's actually a good thing. In some cases, the recalls indicate that companies are being proactive. They're often taking action before the Consumer Products Safety Commission has to get involved, and that's the case for the latest car seat recall.

This week WAYB voluntarily recalled thousands of PICO Travel Car Seats. The lightweight, foldable car seats are a favorite with parents who fly frequently as they're designed for use in cars and planes.

"A small number of customers have experienced a break in the headrest support tubes (the part that connects the headrest to the back of the seat) on their Picos. Each of these customers informed us of the issue directly, and we provided them with a replacement Pico under our warranty policy," the company states.

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There have been no injuries, but "even one warranty replacement of this sort is too many" according to WAYB.

The company says it has reported the issue to the National Highway Traffic Safety Administration (NHTSA) and is working on a recall plan to replace the headrests on affected Picos, free of charge.

If you have questions about your PICO, contact Customer Experience team at 1-888-924-9292 with any questions (phone or text, Monday through Friday, 7am to 4pm Pacific Time), or email us at help@wayb.com.

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There have been a lot of iconic entertainment magazine covers featuring pregnant women over the years. Who can forget Demi Moore's bare baby bump on Vanity Fair or Britney Spears' similar nude pose on Harper's Bazaar?

Pregnant women on a magazine covers is nothing new, but a visibly pregnant CEO on the cover of a business magazine, that's a first and it happened this week.

Inc. just put The Wing's CEO Audrey Gelman on the cover and this is a historic moment in publishing and business.

As Gelman told Today this week, "You can't be what you can't see, so I think it's so important for women to see that it's possible to run a fast-growing business and also to start a family."

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She continued: "It's so important to sort of burst that bubble and to have new images of women who are thriving and working professionally while balancing motherhood … My hope is that women see this and again feel the confidence to take greater professional risks while also not shelving their dreams of becoming a mother and starting a family."

The Wing started in 2016 as a co-working space for women and has grown rapidly. As Inc. reports, The Wing has eight locations in the U.S. with plans for more American and international locations by 2020.

Putting Gelman on the cover was an important move by Inc. and Gelman's honesty about her early pregnancy panic ("I can't be pregnant. I have so much to do." she recalls thinking after her pregnancy test) should be applauded.

Gelman says pregnancy made her slow down physically, and that it was actually good for her company: "I had this realization: The way to make my team and my employees feel proud to work for me and for the company was actually not to pretend to be superhuman or totally unaffected by pregnancy."

We need this. We need CEOs to admit that they are human so that corporate leadership can see employees as humans, too. Humans need things like family leave and flexibility, especially when they start raising little humans.

There are a lot of iconic covers featuring pregnant women, but this one is different. She's wearing clothes and she's changing work culture.

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