Breathing in excrement is just a variation of normal!


Sometimes I really fear for the future of midwifery.

It has gone from being a noble profession, saving countless lives and always struggling to save more, to a bunch of clowns drumming up business and always struggling to drum up more.

The amount of stupidity and wishful thinking spewed by these fools is epic. Case in point: a post from the hilariously misnamed blog Midwife Thinking entitled The Curse of Meconium Stained Liquor.

Now you or I might think that the curse is that when excrement is inhaled into a baby’s lungs, it can result in severe respiratory illness and death. But for this midwifery clown, the “curse” is the potential loss of business. But never fear; the all purpose tool wielded by people who profit from homebirth is always available: it’s just a variation of normal!

Letting me repeat that: rather than lose business, Rachel Reed, Midwife (Not) Thinking, simply announces that breathing in excrement is just another variation of normal.

The motivation of the midwife is apparent from the very first paragraph:

Dear unborn baby,

Please consider holding your poo in until after you are born. The big people on the outside get very stressed about your poo and will want to change the way you are birthed if they find any evidence that you have failed to keep it in. Your mother will be told that you are in danger, and will be strapped to a CTG monitor. This will: reduce her ability to help you through her pelvis by moving; prevent her from using water to relax; and increase your chance of being born by c-section. Your mother will also have her time limits for labour tightened up. This may lead to labour being induced or augmented which will put both of you at risk of further interventions. You will be expected to get through your mother’s vagina quickly and if you take too long you will be pulled out with medical instruments…

Imagine that, those evil obstetricians will compromise the birth process for no better reason than to maximize the birth outcome: a healthy, live baby.

But Rachel Reed knows better. She has her priorities in order: it’s more important to have an intervention free labor than for a baby to be able to breathe or even survive.

Rachel is all over this:

MAS is the major concern when meconium is floating about in the amniotic fluid. It is an extremely rare complication – around 2-5% of the 15-20% of babies with meconium stained liquor will develop MAS (Unsworth & Vause 2010). Of the 2-5% of the 15-20%, 3-5% of babies will die. OK enough %s of %s – basically it is very rare but can be fatal.

Apparently both math and logical thinking are hard for Rachel, so let me make it easy for her. One in 5 babies will have meconium in the amniotic fluid. Of those 1 in 20 will become seriously ill (respiratory distress, mechanical ventilation, prolonged NICU stay, risk of death). Of those, nearly 1 in 20 will die. In other words, 1% of babies will have end up with a life threatening illness. That’s not rare. And that illness will kill 5% of those ill babies. That’s not rare, either.

Or, put another way, once a mother learns there is meconium in her baby’s amniotic fluid, there is a 1 in 20 chance of serious complications. And if her baby does experience severe complications, there’s a very real chance that he or she will die. In the US, that means that there are 25,000-35,000 cases of meconium aspiration syndrome (MAS) per year, and approximately 1500 deaths.

I would have thought that anyone with more than two functioning brain cells would recognize that excrement in the lungs is a bad thing, but not Rachel Reed. As far as she’s concerned, it’s not a big deal because:

Meconium is a mixture of mostly water (70-80%) and a number of other interesting ingredients (amniotic fluid, intestinal epithelial cells, lanugo, etc.).

You know what else is 70% water? Battery acid, and I suspect that even Rachel Reed would recognize that battery acid is very harmful.

It’s the other stuff in meconium (intestinal cells, hair, etc.) that makes it dangerous when it ends up in the lungs. What does it do?

This lecture for medical students explains how meconium damages a baby’s lungs:

Decreased alveolar ventilation related to lung injury, ventilation-perfusion mismatch and air-trapping.
• Pneumothorax or pneumomediastinum in 15-30% of cases
• Persistent pulmonary hypertension (PPHN) in severe MAS(increased pulmonary vascular resistance with right-to-left shunting)
• Fetal acidemia
• Chemical pneumonitis
• Surfactant inactivation caused by meconium’s disruption of surface tension

So meconium makes it much for difficult for a baby to expand his lungs, to absorb oxygen and can even lead to a hole in the lung causing it to collapse.

But meconium is not merely an irritant, it is a symptom of another serious problem, lack of oxygen getting to the baby during labor. The baby responds to the severe stress of lack of oxygen with a response similar to “fight or flight”: it defecates.

So there are two reasons to deliver a baby expeditiously once it has defecated in the amniotic fluid. First, the meconium itself is harmful to the baby’s lungs and the more meconium is sucked into the lungs, the worse the harm is likely to be. Second, a baby who has passed meconium is often a baby in distress, and the longer that oxygen deprivation lasts, the more severe the consequences are likely to be. Hence the desire to use whatever interventions are necessary to deliver the baby expeditiously.

This is not rocket science, but apparently it is too hard for Rachel to understand. She offers her bizarre take on meconium aspiration:

So you would think that the sensible thing to do if a baby has passed meconium (for whatever reason) is to create conditions that are least likely to result in hypoxia and MAS. This is where I get confused because common practice is to do things that are known to cause hypoxia, for example:

Inducing labour if the waters have broken (with meconium present) and there are no contractions or if labour is ‘slow’ in an attempt to get the baby out of the uterus quickly.
Performing an ARM (breaking the waters) to see if there is meconium in the waters when there are concerns about the fetal heart rate.
Creating concern and stress in the mother which can reduce the blood flow to the placenta.
Directed pushing to speed up the birth.
Having extra people in the room (paediatricians), bright lights and medical resus equipment which may stress the mother and reduce oxytocin release.
Cutting the umbilical cord before the placenta has finished supporting the transition to breathing in order to hand the baby to the paediatrician.”

The stupid, it burns. It’s the equivalent of approaching the situation of a child drowning in a lake by claiming that the best response is to avoid interventions like rescuing the child and, instead, wait patiently for its body to float to shore. It’s the equivalent of claiming that the “stress” of a frantic rescue with bright lights (oh, the horror!) is more damaging than the lack of oxygen in the child’s lungs.

Rachel’s entire piece is a monument to the stupidity and venality of homebirth midwives, but some parts are more idiotic than others. My personal favorite:

Avoid an ARM during labour so that any meconium present is not known about until the membranes rupture spontaneously …

That statement is a perfect illustration for a new motto for homebirth midwives:

Ignorance is power!

If that’s the case then midwife Rachel Reed is very powerful indeed.

227 Responses to “Breathing in excrement is just a variation of normal!”

  1. anon paediatrician
    February 22, 2014 at 11:49 pm #

    Anyone who thinks MAS is not important has not spent sleepless nights trying to keep these babies alive. By that point, with their baby ventilated, with chest drains, cooled to reduce brain damage, maybe even on ECMO (basically lung bypass machine)….let’s just say that natural birth experience is no longer uppermost in the poor parents’ minds.

  2. Allie
    February 20, 2014 at 10:42 am #

    I don’t understand the part about monitoring being so restrictive. I scarcely noticed the monitor. It was very small and attached by a stretchy, Velcro band. I could move around just fine and it was the last thing on my mind at the time. Are these people even familiar with hospital birth or do they just get their info from TV and movies?

    • LisaL
      February 21, 2014 at 11:42 am #

      They try to scare women away from hospitals right in to their greedy arms.

      • netochka
        May 25, 2015 at 5:34 pm #

        Women get free homebirth midwives in the UK… It’s part of the public service and encouraged in some places.

    • netochka
      May 25, 2015 at 5:33 pm #

      Maybe you had more up-to-date equipment? Because (giving birth in a UK hospital with all the technology etc) I was extremely restricted during my monitored, induced labour.

  3. TG
    February 20, 2014 at 9:53 am #

    i have an honest question. with my son, they broke my water at 6cm, and it was greenish. having read this blog, I got alarmed. but they weren’t worried, and labor progressed as normal (was wearing a fetal heart monitor and they gave me oxygen to wake him up). why weren’t they worried? thanks.

    • Ceridwen
      February 20, 2014 at 1:15 pm #

      Small amounts of meconium are much less of a concern than thick meconium. There’s a grading system involved to determine how serious it is.

    • Anj Fabian
      February 21, 2014 at 11:56 am #

      They were worried. Givin,g mothers O2 is not standard

  4. NursingRN
    February 19, 2014 at 10:59 pm #

    I don’t know about every single patient on our floor unless I’m working in the nursery, but on those days I am in the nursery I can tell you that at least 50% of our babies are born with thin or thick mec. I was going to attempt TOLAC with my daughter- the OB said I could (the one who delivered my son). Well, when my water broke at home, there was mec, more than what there was with my son. I labored for about an hour at the hospital before I noted there were late decels on the monitor, so *I* was the one who said it’s time for the section. Good thing too, she would have probably had a very very bad outcome had I chose to labor. She was born covered with mec, jittery with a blood sugar in the low 40’s (or high 30’s, can’t recall, it was 3 years ago) and when they tried to give her some formula to bring up her blood sugar, she got dusky, desatted to the 80’s and ended up in the special care nursery with a little cannula to give her oxygen. She had aspirated mec. Luckily she got to come up to be with me the next day. So…yeah. I see it a lot. It’s not normal, it’s not rare either! It’s scary and freaks parents out.

  5. Lynnie
    February 19, 2014 at 3:47 pm #

    I know a teenager that still has problems and almost died several times because he aspirated meconium when he was being born and the doctor at the hospital was negligent and didn’t suction him properly. It was a very small town hospital and the doctor was a regular md not a ob/gyn and was apparently young and stupid or something. How I look at it is if something is common enough to happen in my small town of around 1000, it’s NOT that rare at all.

  6. AlisonCummins
    February 19, 2014 at 10:28 am #

    Wondering how rare MAS and death are. Looked up some numbers.
    MAS rate in infants born through meconium-stained fluid
    2000-2007 (France) 2.29%
    1990-1998 (US) 4.20%
    2002-2003 (India) 15.60%
    Death rate for infants with MAS
    2000-2007 (France) 2.90%
    1990-1998 (US) 4.60%
    2002-2003 (India) 17.50%
    Likelihood of death with MASF
    2000-2007 (France) 0.07%
    1990-1998 (US) 0.19%
    2002-2003 (India) 2.73%
    The difference between the french and american numbers — reduction in both MAS following MASF and death following MAS by about 40% — partly reflects international recommendations on the management of birth with MSAF introduced in 2000.
    I chose to look at Indian numbers because I thought they would reflect good data collection and well-trained staff in a condition of limited resources, so outcomes that could be expected to be better than in american homebirth.
    Modern protocol in a modern, well-staffed hospital: when you see meconium, chances that the baby will be in trouble are about 2%, and that the baby will die are about 0.07%.
    Doing the best they can in a less-resourced hospital: when you see meconium, chances that the baby will be in trouble are about 16%, and that the baby will die are about 2.7%.
    Nobody should ignore meconium in homebirth.

    • Irène Delse
      February 19, 2014 at 12:34 pm #

      Fascinating, thanks! I’m French myself and I wonder where the difference between France and the USA comes in this matter. IIRC, the overall rate of perinatal death in France is not as good as, say, Norway or Sweden, but better than the Netherlands. And you are right about “modern, well staffed hospital” part: even though the NCB movement is gaining in public opinion, nearly all women here give birth either in the hospital, or in a birth center attached to one. And midwives are fully integrated in the medical system: they in effect nurse midwives with a college level education, they work as part of teams with OBs, anesthesiologists, etc. Also, we have universal healthcare insurance with good coverage of reproductive medicine, so even women from poor neighborhoods can have access to hospital birth. (Note that I’m not saying things are perfect here. For instance, hospitals have been suffering from the economic crisis, with lack of personnel, overworked doctors and nurses, etc. And there are sadly political pressure to manage hospitals like for-profit businesses, and other short sighted policies.)

      • Young CC Prof
        February 19, 2014 at 12:42 pm #

        I assume the reason that the numbers in France are better is the dates. The US numbers are 10 years older, and, as AllisonCummins stated, management of meconium has improved in recent years.

        I would imagine that right now, numbers are similar

        • Irène Delse
          February 19, 2014 at 1:05 pm #

          Ah, good point. Thanks.

    • AlisonCummins
      February 19, 2014 at 12:49 pm #

      Note that in India, in a maternity hospital, when meconium is seen there is a 1/37 chance the baby will die.

      That is huge. It is not rare at all.

      • Desi_redux
        March 1, 2014 at 11:41 am #

        It is not rare, indeed. I’m Indian and I chose not to go back home to give birth (for woo-related reasons initially, but the exact opposite reasons when I stumbled on this blog at 6 months pregnant). I know of several cases where meconium was spotted (thankfully in a larger metro hospital setting) and one case where my friend lost his baby because they REFUSED a c-section for his wife (who was NOT given an epidural either) despite requesting the nurses that she was not able to handle labor. The baby was delivered by c-section eventually, but within minutes ceased to breathe and died. No neo-natal resuscitation to the best of my knowledge; it was a fairly big town (Coimbatore) and a pretty big teaching hospital. The doctors indicated that it was due to MAS in the beginning, but then retracted their statements saying it was a “congenital” defect in the heart and lungs. How this was even possible was beyond me.

    • KarenJJ
      February 19, 2014 at 8:57 pm #

      It makes sense having some Indian friends that had a child around the same time I did. They didn’t name their child until he was a couple of weeks old and they were really uncertain about buying a cot prior to birth. Apparently it was normal in their family to get a cot organised while mum and baby were still in hospital, but definitely not prior to the baby’s birth.

  7. Allie P
    February 19, 2014 at 7:18 am #

    My so-stupid-it-burns Lamaze class instructor-cum-doula (highly recommended childbirth class for the white-collar set in downtown DC!) not only counseled our class to LIE to our doctors about our water breaking so they’d let us labor at home longer (because it’s SO EASY for doctors to provide you with accurate and quality care when you are feeding them misinformation!), but she also recommended Castor Oil smoothies to “naturally” induce labor, the better to give us and our ROM babies severe diarrhea. Talk about meconium.

    • GuestB
      February 19, 2014 at 9:31 am #

      Sounds more like Takoma Park to me. I have found most of DC to be non crunchy – thank God.

      • guest
        February 20, 2014 at 11:01 am #

        I live in DC and unfortunately crunch is not limited to Takoma Park.

    • An Actual Attorney
      February 19, 2014 at 12:24 pm #

      Can you name names? I don’t want to get trapped in one of those. Although, even what I hear about Sibley’s in-house class sounds full of woo.

      • guest
        February 20, 2014 at 10:57 am #

        Sibley’s in-house class wasn’t too bad. it may depend on who is teaching it. we had a retired RN who was no-nonsense.

    • Certified Hamster Midwife
      February 19, 2014 at 7:58 pm #

      Wait a second. Does taking castor oil induce bowel movements and cramping in the baby as well, or does it not cross the placenta?

    • areawomanpdx
      February 19, 2014 at 10:38 pm #

      A CBE and doula giving out medical advice? She should be reported somewhere. WAAAAAYYYY out of her scope of practice.If she’s DONA certified, they’ll take away her certification…

  8. Sue
    February 18, 2014 at 9:31 pm #

    What is it about those BRIGHT LIGHTS??

    • February 18, 2014 at 10:14 pm #

      I guess it matters if you’re gestating a Mogwai. ..

      • Amy M
        February 19, 2014 at 6:47 am #

        And if they are born after midnight…don’t want to be nursing them then….

    • February 19, 2014 at 6:02 am #

      All babies look pink in dim light…even when they’re really blue…

  9. guest
    February 18, 2014 at 7:54 pm #

    I realize this is horribly OT, but raw milk and home birth often go hand in hand around here:

    • Trixie
      February 18, 2014 at 9:41 pm #

      Wow. The takeaway for me was: “This chronology can confuse people. They don’t understand how their grandparents who drank raw milk all of their lives never got sick from E. coli. But scientists believe E. coli didn’t pick up the genes that cause human illness until late last century. Now that this disease-causing strain of the bacterium is commonly found in most cowherds, people can, and do, become ill from drinking contaminated milk.”

      • Certified Hamster Midwife
        February 19, 2014 at 8:00 pm #

        My grandparents drank raw milk their whole lives because they owned the cows.

        • KarenJJ
          February 19, 2014 at 8:47 pm #

          Same – my Dad’s parents had cows and his Dad’s parents were dairy farmers (and Great grandpa died of heart disease). Oddly enough neither my Dad nor I can drink milk. We can’t stand it and never have liked it. My son’s the same.

  10. February 18, 2014 at 6:16 pm #

    Every time I see these suggestions that encourage ignorance, I get so upset that I can barely articulate myself. It is so frustrating that these women support and practice willful ignorance and sell it like it is skillful. It really is, or should be, criminal.

    • mollyb
      February 18, 2014 at 7:54 pm #

      I knew I was going to have to have a c-section with my second. Because I was overweight, I was concerned about possible risks. When doing my research, on reputable website, several times I came across advice like “if you’re overweight, a c-section is more dangerous. Here are ways to avoid them . . .” and one piece of advice was to refuse continuous fetal monitoring because you are more likely to get a c-section IF THEY KNOW THERE IS A PROBLEM WITH THE BABY. In what world is that sensible advice? I WANT a c-section if there is a problem with the baby. There is such an acceptance now, even amoung reputable sites, that outcomes like a c-section outweigh outcomes like a dead or brain damaged baby.

      • Jessica S.
        February 18, 2014 at 8:34 pm #

        That’s mind-boggling! How anyone could accept that as sound advice, it’s beyond me.

      • Sue
        February 18, 2014 at 9:34 pm #

        There is a well-known piece of medical fiction that contained survival principles for interns, like:

        ”If you don’t take a temperature you won’t find a fever”.

        This was meant to be black humor – not a clinical guideline!

        • Amy Tuteur, MD
          February 18, 2014 at 10:13 pm #

          I did my internship and residency at the same hospital, The House of God (Boston’s Beth Israel Hospital). The Chief of OB-GYN was Dr. Friedman of the Friedman Curve.

          • February 19, 2014 at 6:04 am #

            Oh, that “other” Beth Israel… [I’m a terrible snob, I know]

            There are three that I know of, one is in Boston, one is in New Jersey, and my alma mater, in Manhattan.

        • jenny
          February 18, 2014 at 10:38 pm #

          out of curiosity, what book is this?

          • PrimaryCareDoc
            February 19, 2014 at 8:52 am #

            Samuel Shem’s “The House of God.”

          • Dr Kitty
            February 19, 2014 at 9:25 am #

            I should mention that at my somewhat eccentric Alma Mater Chekhov’s Medical Short Stories and The House of God were required reading for the medical ethics course.
            I think that is how they justified giving us a BA.

            BTW the medical ethics course was the only course you could theoreticallly fail and still graduate, but they threatened to put (ethics: failed) after your degree if you did…no one failed.

          • Sue
            February 20, 2014 at 1:20 am #

            The House of God ”rules” have been repeated endlessly by overworked junior doctors around the world. Some are very insightful about the reality of that time, but they also reflect the harm and bitterness that can result from young people being given too much responsibility without enough support at a vulnerable time in their lives.

            Most of us therefore don’t condone those attitudes, but there remain some good principles, such as knowing when to do nothing (medically).

          • jenny
            February 19, 2014 at 9:33 am #


        • Dr Kitty
          February 19, 2014 at 2:58 am #

          Shem’s H.O.G also gave us:
          GOMERs don’t die (only young people die).
          The delivery of good medical care is to do as much nothing as possible.

          It is quite obvious the CPMs have taken it to heart.

          • Captain Obvious
            February 19, 2014 at 8:07 am #

            Something like, when you’re tired of rounding on chronically hospitalized neuro patient (stalled labor for 3 days), push them out of their bed so they break a bone so that you can now transfer them to the Orthopedic service (hospital OB service).

          • Dr Kitty
            February 19, 2014 at 9:19 am #

            AKA the “buff and turf” principle.

            I’m hoping the CPMs haven’t read ALL the rules.
            I worry about them discovering either




            It is a good book, but very, very, very black humour. If you think Dr Amy is meen, this book is definitely not for you.

          • smh
            February 20, 2014 at 12:40 am #

            They can always hurt you more!

        • KarenJJ
          February 19, 2014 at 8:52 pm #

          It reminds me of a conversation I had with my immunologist at my first appointment (immunologist had a dry sense of humour).

          Immunologist: “So we’re looking at a possible periodic fever syndrome diagnosis, but we don’t know if you have fevers”.

          Me: “Yep”.

          My family subscribed to the same method of not finding fevers. Ironic considering the ultimate diagnosis was periodic fever syndrome. (I did confirm that my next flare had a fever by actually taking my temperature, no idea why we never did that before – mum used the ‘back of the hand method’ but I do seriously doubt it’s reliability now).

      • February 20, 2014 at 7:19 pm #

        It really does beggar belief. My doctor is hoping she won’t have to section me with my girl (due in July) but it is a distinct possibility due to some pelvic instability issues I have. When I have mentioned this some people have genuinely suggested that I consider giving birth at a birth centre because midwives won’t make me have a c-section. Another genuinely suggested that someone like me, who has pelvic issues, birth at home. They have swallowed the woo; hook, line and sinker.

  11. Wondering
    February 18, 2014 at 5:15 pm #

    What *is* the standard of care (in broad terms) in dealing with a patient whose amniotic fluid contains meconium? Just wondering whether her assumptions about how this situation is typically handled are even correct (I realize you can’t fully describe standard of care in a comment but… broadly speaking (?)).

    • February 18, 2014 at 5:32 pm #

      They can sort of rinse out your uterus w/saline. Outside of that I don’t know what else they do.

      • theNormalDistribution
        February 18, 2014 at 5:36 pm #

        Whaaatt? No way.

        • Anj Fabian
          February 18, 2014 at 8:23 pm #

          Yes way. I had it for my first and frankly it sucked and didn’t change the outcome in the least.

      • Haelmoon
        February 18, 2014 at 6:08 pm #

        The studies for intrauterine infusion did not show any reduction in the risk of meconium aspiration syndrome. All it does is dilute the mec, but it is the mec that gets deep down in the tiny air chambers that matter – even dilute mec can do this.
        Also, some of the problem is related to the cause of meconium passage. I tell my patients “some babies are just impatient and couldn’t hold it in. However, there may also have been an incident (like a hypoxia on) that literally scared the mec (shit) out of them. I want to watch those babies more closely. However, it can sometimes be hard to tell the difference right away, so I would monitor all babies with mec more closely”.

      • Captain Obvious
        February 18, 2014 at 6:29 pm #

        NRP has loosened the resus on light stained mec. But knowing its there early enough allows you to consider an amnioinfusion or at least consider having a ped there at delivery. Especially if they are not already in house (smaller hospitals). Allows them time to get there, as opposed to bagging the baby until one shows up.

    • moto_librarian
      February 18, 2014 at 5:35 pm #

      They monitor the baby closely, often with CEFM. When the baby is being delivered, a NICU team is in the room in case resuscitation is required.

      • Karen in SC
        February 18, 2014 at 5:39 pm #

        Mec was observed when my water broke at 10 cm. I sort of pushed once, a person appeared next to me and said, “I’m the pediatrician.” and my doctor said “PUSH now, get her legs up, etc.”

        Baby was blue and rushed over to the incubator. 5 minute apgar was fine. Breastfed well, smart kid, now in high school. 🙂 That part of the birth was actually pretty amazing, but I don’t dwell on it. I don’t think I’ve told him anything about it.

      • Mishimoo
        February 18, 2014 at 6:23 pm #

        I had very light staining with two, I also had some pitocin to speed things up because I was getting tired. Oh noes, interventions!! (Nevermind that I pre-empted the CNM and asked for it) There was more monitoring and a few extra people hanging out in the room, but that didn’t bother us. Luckily, there was no aspiration and they both had great Apgars.

        • Captain Obvious
          February 18, 2014 at 6:27 pm #

          An OB in the room at delivery in case the mother needs assistance for hemorrhage or whatever and a ped in the room to assess baby in case suction or breathing assistance is necessary. Ina may forbid the OB have to attend both the hemorrhaging mother and the apneic baby simultaneously.

        • Meredith
          February 19, 2014 at 9:40 am #

          I had meconium (which the OB discovered when he ruptured my membranes prior to giving me some Pitocin, so I had already lost at the Most Natural Birth Olympics). A NICU nurse came in for the delivery as a precaution. Everything turned out fine, but I was glad that the safeguards were in place!

    • Medwife
      February 18, 2014 at 10:58 pm #

      If monitoring wasn’t continuous before, we switch to that, and peds is present for delivery in case deep suction is necessary. We don’t suction on the perineum and if the baby isn’t vigorous immediately, to peds for suction and resuscitation it goes. They found that suctioning the nasopharynx actually can cause the baby to gasp reflexively and inhale the mec deeper.

  12. Amy Tuteur, MD
    February 18, 2014 at 5:00 pm #

    OT: Jessica Grose has a terrific piece on natural childbirth in The New Republic

    • Wondering also...
      February 18, 2014 at 5:22 pm #

      I generally get where you’re coming from but why would you care whether a woman wants pain relief or not? Unless pain is stalling labor, does it really matter medically?

      • Amy Tuteur, MD
        February 18, 2014 at 5:34 pm #

        I don’t care whether or not women get pain relief in labor. I do care very much that many women are made to feel guilty for wanting pain relief in labor.

        The natural childbirth movement is profoundly anti-feminist, positing as it does that a woman’s virtue is located in her vagina, uterus and breasts, and that women’s pain is all in their heads.

        • Thanks
          February 18, 2014 at 5:51 pm #

          OK. I am, as the prior commenter observed, new to reading your blog. I am completely fascinated by the NCB pedigogy (if you can really call it that). I definitely think there are poor to average OBs out there whose bedside manner (or lack thereof) drive women into the birthing-in-a-field-alone camp but am also blown away by the fear mongering in the NCB camp. It’s all interesting stuff and I am enjoying your blog though you’re meen.

          • Josephine
            February 18, 2014 at 5:57 pm #

            ” It’s all interesting stuff and I am enjoying your blog though you’re meen.”

            Haha! So mean that she answered your comment quickly and concisely. She’s just awful, isn’t she? 😉

            February 18, 2014 at 11:06 pm #

            After experiencing the insidious meanness and passive aggression of the natural child birth movement, the straightforward “meanness” of this blog feels like a hug and a kiss.

      • moto_librarian
        February 18, 2014 at 5:34 pm #

        Dr. Amy has four children, two of whom were delivered without pain medication. I think you are new here, so here’s a quick explanation. Dr. A. doesn’t care if a woman uses pain relief or not; what she cannot stand are the lies routinely told about pain medication by the natural childbirth movement. No woman should feel ashamed or like she has failed because she chose to have an epidural. No woman should be told that epidurals are dangerous to her baby, that they cause c-sections, that they prevent you from bonding, etc. This is what Dr. Amy is fighting against.

      • February 19, 2014 at 6:09 am #

        It’s really the opposite. IV medication, given too early, can temporarily halt contractions. But once labor is really established, nothing will stop them [the urge to push may be absent if the epidural level is high when there is full dilatation, but it won’t actually stop birth, just delay it since the woman can’t cooperate if she doesn’t feel the contractions at that point and push with them.]

        All the medical considerations regarding pain relief in labor are because of the possible effects of analgesia on the baby. IV medication reaches the baby almost immediately, and depresses respiration but epidural anesthesia, being a form of local, does not impact on the baby hardly at all.

  13. 2boyz
    February 18, 2014 at 4:59 pm #

    As someone who had a baby 5 months ago with just this concern- wow, just wow. I commented yesterday about my precipitous birth. I arrived at the hospital 7 minutes before delivering (not on purpose, if I’d known I was in labor sooner, I’d have gone sooner). My water broke while the resident was opening my legs to check the situation. It was stained, though not thick. Since I was 10 cm, she paged for extra staff, and not a moment too soon, baby was out 2 minutes later. He was in mild distress with an apgar of 5, but the wonderful staff got him suctioned and stabilized- his five minute apgar was 9, they watched him for a few more minutes before they handed him to me.

    It seems he didn’t aspirate and was totally fine except for those first few minutes, and he’s fine now. It seems the distress was caused by the extremely fast labor, so nothing had to be done to get him out- he came out FAST. But having seen first hand how scary the mec situation can be, yeah, this midwife is an idiot. Meconium is nothing to mess around with.

    • Danielle D
      February 18, 2014 at 6:09 pm #

      +100! I commented way down below. To recap: my baby aspirated meconium and recovered very well thanks to a speedy delivery and the the pediatrics team. All was well. But seeing him born totally limp (his apgar 0 at delivery, but 9 or 10 at 5 mins) dispels any illusion I could ever be tempted to have that this is a small matter. The thought of him being delivered by a not-yet-alarmed midwife and needing emergency attention as he did, and maybe not getting it as quickly/well is terrifying thought.

    • Captain Obvious
      February 18, 2014 at 6:33 pm #

      Sure beats days of ECMO

    • February 19, 2014 at 12:58 am #

      It is often forgotten that extremely rapid labors and precipitous deliveries have their own risks. Glad everything is OK.

  14. Amy M
    February 18, 2014 at 4:53 pm #

    I skimmed through her site, and sure enough found the: “don’t cut the cord if the baby isn’t breathing right away because it’s supplying oxygen!” She’s supposed to be a trained midwife, like CNM-level, no? She had a whole thing about allowing the baby to gently transition to breathing, while getting o2 from the placenta, and had a few videos of people gently patting really floppy babies. Maybe I’m too overprotective, but if my baby wasn’t breathing, I’d be freaking right out and wanting the medical providers to be providing immediate medical care, not standing around hoping the baby decides to breathe in its own time. I’m pretty sure that most people don’t remember any “interventions” that were administered to them at the time of their births, so I wouldn’t be worried about the long-term trauma of the baby being suctioned or resuscitated.

    • Jane Lucas
      February 19, 2014 at 1:40 am #

      She is a fully qualified midwife (the equivalent of a CNM) and she is a university lecturer teaching future midwives!

      • KarenJJ
        February 19, 2014 at 1:47 am #

        What the heck are they teaching midwives at uni? In the UK there was an academic chemist?/pharmacist? that was FOI’ing the course notes of some university courses (naturopathy or similar) and blogging about them (David Colquhoun? I think?). I wonder if some university midwifery courses need the same treatment?

          • KarenJJ
            February 19, 2014 at 2:11 am #

            Oh great… She’s Australian… Reminds me of Hannah Dahlen – an academic midwife that is mostly practising homebirths.. Midwifery in Australia is heading downhill too. Same as NZ.

        • KarenJJ
          February 19, 2014 at 2:14 am #

          OK David Colquhoun is definitely not the person I was thinking of..

        • Dr Kitty
          February 19, 2014 at 6:14 am #

          Was it Edzard Ernst?

          • KarenJJ
            February 19, 2014 at 6:22 am #

            No, unfortunately not. It’s driving me nuts now. I’ll have to go google-crazy later.

          • Dr Kitty
            February 19, 2014 at 7:14 am #

            I’m sure it’s not Ben Goldacre either, but I love this link:

            A job advertisement from a company that makes a magical head-lice repelling badge with a multi-coloured unicorn on it (no, really).

            The company’s response to the question “How does it work?”

            “Without a comprehensive understanding of technology e.g. that used in space travel, it is not really possible to provide a very satisfactory answer.”

            Translation “We don’t know/it probably doesn’t/give us your ££ suckers!”

          • AmyP
            February 19, 2014 at 5:55 pm #

            That reminds me of a conversation I read about recently between an interviewer and a guy who worked on Star Trek. Roughly paraphrased:

            Interviewer: How does the science of the transporter work?

            GWWOST: Very well, thank you.

          • Certified Hamster Midwife
            February 19, 2014 at 8:07 pm #

            The difference being, GWWOST wasn’t selling transporters that he swears really work if you believe in them hard enough.

          • Sue
            February 20, 2014 at 1:23 am #

            Could have been David Colquhoun – I think he is a pharmacologist.

      • Amy M
        February 19, 2014 at 6:56 am #

        Ugh, I am a total layperson when it comes to birth, but even I can figure out how a placenta works. I see it like this: A placenta acts as a big old filter, allowing o2 and nutrients to pass through from mom’s blood supply. Once baby is out, uterus is still contracting, and now there’s all this space! So, big contraction, right? Which causes what to happen to the placenta usually? It detaches, right? Am I correct so far? Because the baby should be breathing and doesn’t need it anyway. So if the organ that lets the o2 through to the baby is no longer attached to mom, where would this o2 be coming from that Rachel Reed is claiming is still sustaining baby while it adjusts to the outside world? Any o2 already in the system has circulated and isn’t really recyclable, and the placenta cannot get o2 from the atmosphere. Maybe I should go on here website and ask.

  15. Jessica S.
    February 18, 2014 at 4:38 pm #

    I’m thinking this quote from Rachel’s post: “This is where I get confused” actually belongs at the very beginning of her post.

    And I can’t speak for anyone else, but I think the reason I don’t want the baby to poop is because of the serious risks it poses TO THE BABY, *not* the risk of altering HOW THE BABY IS BORN. That a midwife can gloss over that fact tells me she shouldn’t be considered an authority on delivering babies. Let’s hope other prospective clients arrive at a similar conclusion.

  16. AnotherGuest
    February 18, 2014 at 3:10 pm #

    This makes me so sad. Rachel Reed’s nonsense is just the kind of thing I used to believe. It promises that all will be OK as long as you keep those doctors away. I feel so very sad for the women and babies whose lives will be put at risk by reading stuff like that.

    • Are you nuts
      February 18, 2014 at 3:44 pm #

      That’s why sites like this one are so important. Well-intentioned moms get sucked in by this stuff all the time because women claiming to be medical professionals lie to them.

  17. Certified Hamster Midwife
    February 18, 2014 at 2:24 pm #

    I am asking this in all seriousness: why should a midwife care? Don’t their clients prepay and not get a refund if they transfer to the hospital?

    • Trixie
      February 18, 2014 at 2:25 pm #

      Well, you’ve got to be at least a little worried about repeat business and word of mouth.

      • Certified Hamster Midwife
        February 18, 2014 at 2:27 pm #

        That’s true. If they get a “medwife” reputation , that hurts business.

        • February 19, 2014 at 1:01 am #

          Frankly, I wouldn’t want that kind of business. I’m a “medwife” and proud of it, having seen too many catastrophes and near-catastrophes in my career.

      • Young CC Prof
        February 18, 2014 at 2:46 pm #

        True. If you transfer every time something MIGHT be wrong, you get about 40% of your clients transferred and most of the unhappy. If you wait and see, you wind up with a 10% transfer rate and an, I don’t know, 1% disaster rate. If you properly coach your clients beforehand, the disasters will believe that things would have turned out just as badly in the hospital, only without your kind hand to help them through.

        Overall, being reckless = more satisfied clients.

    • Mel
      February 18, 2014 at 3:11 pm #

      Many require additional money to continue care at the hospital – so transfers add more $$ to their bottom line.

  18. February 18, 2014 at 2:04 pm #

    Now that I am officially a midwife I can say that these cases are just a variati-GIVE ME YOUR MONEY *cough cough*- of normal. Geez don’t know where that came from!

    • Certified Hamster Midwife
      February 18, 2014 at 2:27 pm #

      Congratulations! Will you be my backup midwife for the next time a hamster gives birth in your community?

      • Mel
        February 18, 2014 at 3:32 pm #


        I’ve never had a hamster – let alone one who gave birth. I’ve read some blogs on the internet, though and fully believe in the dangers of interventions – damn those tweezers! There are so many traumatized pups who never realized their full glory.

        Can I be a back-up hamster midwife, too?

        • Jocelyn
          February 18, 2014 at 3:44 pm #

          CHM, I think I’d like to be a back-up hamster midwife too. I’ve been a hamster doula before. I was there for my brother’s hamster when she was in labor. I gave her lots of encouragement and she had a lovely, natural with thirteen pups. Sure, she ate every single one of them later that day, but that’s not the point, is it?

          • Certified Hamster Midwife
            February 18, 2014 at 3:56 pm #

            Eating babies is just a variation of eating the placenta. Welcome to the CHM sisterhood!

          • theNormalDistribution
            February 18, 2014 at 4:20 pm #

            I wonder if there’s always something disturbed going on when a hamster eats her baby, or if some of them are like “I made food!”

          • Certified Hamster Midwife
            February 18, 2014 at 5:41 pm #

            They tend to eat the babies when they’re scared, threatened, or there’s something wrong with the babies. I think the evolutionary logic is that if something scary is coming, it’s a predator. The babies can’t get away, but the mom can, and if anyone’s going to get sustenance from the babies, it should be their mom.

            That, or hamster pup brains are really tasty. Might be a little of both.

          • Amy M
            February 18, 2014 at 6:05 pm #

            Mice do it too sometimes. Also, mice anyway, come into heat immediately after giving birth, so if that litter doesn’t make it, there’ll be another along in 3 wks, (just like the bus!) I’ve been in charge of (mouse)breeding colonies in previous jobs, and there have been occasional breeding pairs that ate all their babies, so I think those individual mice were just really bad parents. One pair tended to get some really pretty colors—sometimes they’d let the pups live long enough to grow fur before they ate them. Jerks.

          • theNormalDistribution
            February 18, 2014 at 6:13 pm #

            Damn nature you scary!

          • Mishimoo
            February 18, 2014 at 7:30 pm #

            There’s a song about that: “Come To Australia” by Scared Weird Little Guys

          • Mishimoo
            February 18, 2014 at 6:14 pm #

            Rats do it as well sometimes, which is classed by the breeders as a bad mother, so they generally don’t breed her again.

          • Zornorph
            February 18, 2014 at 5:02 pm #

            It’s made of people! Soylent Green is made of people!

          • Captain Obvious
            February 18, 2014 at 6:40 pm #

            Showing your age with that reference. Birth warriors, come out and plaaa aaay

          • anion
            February 18, 2014 at 8:01 pm #

            I LOLed.

            How hard do you think it would be for your cervix to open with the Baseball Furies standing there staring at you? Would lots of scented candles help?

          • Zornorph
            February 18, 2014 at 9:32 pm #

            That was the creepiest part of the movie!

          • Zornorph
            February 18, 2014 at 9:31 pm #

            I still have nightmares about the lips of the DJ in that movie. Fun fact, she later was the host of the TV show version of Where In The World is Carmen Sandiego.

            February 18, 2014 at 11:13 pm #

            As long as she found the process of eating the babies to be personally empowering, the outcome was of secondary importance.

      • Zornorph
        February 18, 2014 at 5:01 pm #

        Well, I’ve midwifed (midhusbanded?) dogs twice. One had 4 pups and the other 7, so that’s 11 ‘catches’. I think that gives me some good qualifications, even if I don’t have any ‘mama wisdom’.

        • Certified Hamster Midwife
          February 18, 2014 at 5:07 pm #

          You have bitch wisdom, though.

          ETA: Also, single parents have mama wisdom and dad wisdom. That’s how it works.

          • Karen in SC
            February 18, 2014 at 5:42 pm #

            CMH, I’ve often wondered if you are discussed on NCB forums. Or if some of our hamster discussions freak out them out. Now ask me if I care.

          • Certified Hamster Midwife
            February 19, 2014 at 8:21 pm #

            I used to post as Barren Spinster, but I remember saying once, “if a midwife’s job is to sit in the corner and knit, well, I was in the other corner reading when my hamster gave birth, so that makes me a Certified Hamster Midwife.” I liked the name, but it probably confuses people when I use this account to comment on other sites. As I do.

            As the first designated CHM, I award the credential, which covers four-footed mammals up to 120 pounds and livebearing fish.

            If you want to attend human births, you have to watch a lot of ’80s TV and obtain the Pablo Certified Midwife (PCM) credential from The Bofa on the Sofa.

        • theNormalDistribution
          February 18, 2014 at 5:14 pm #


          Not unless male dogs gave birth to those pups.

          • Certified Hamster Midwife
            February 18, 2014 at 5:43 pm #

            That’s right – the etymology is that the “wife” refers to the woman giving birth, not the attendant.

            There are some male CNMs in the world.

        • Josephine
          February 18, 2014 at 6:01 pm #

          I’ve been present for the birth of four kittens. Between the two of us we could pretty much open up shop immediately, eh? The family dog actually gently licked the sacs off each kitten so maybe I could offer some sort of cool, new interspecies participation service. Like birthing with dolphins, only more convenient. Yep, for $250 additional I will personally have a sweet-natured Scottish terrier lick your baby clean during those first few minutes of skin to skin time.

        • February 19, 2014 at 1:02 am #

          Presumably you have “papa” wisdom :-))

        • Certified Hamster Midwife
          February 19, 2014 at 8:10 pm #

          Does that count as eleven catches, or two? These are things I should probably know before I go handing out CHM credentials.

          Ah heck, let’s call it eleven.

      • February 18, 2014 at 11:08 pm #

        OF COURSE! I support ALL hamster birthing choices

        • Certified Hamster Midwife
          February 19, 2014 at 8:11 pm #

          Except tiny, tiny C-sections. And eyelash curler forceps.

  19. Are you nuts
    February 18, 2014 at 2:04 pm #

    “Of the 2-5% of the 15-20%, 3-5% of babies will die. OK enough %s of %s – basically it is very rare but can be fatal.”
    Math iz harrd.

    • February 18, 2014 at 2:06 pm #

      math is an intervention

      • Young CC Prof
        February 18, 2014 at 2:15 pm #

        Math is a tool of the patriarchy.

        • Carolina
          February 18, 2014 at 2:54 pm #

          I wish my high school calculus teacher had accepted my “other ways of knowing.”

    • Mel
      February 18, 2014 at 3:28 pm #

      In case any math phobic NCBers are reading, here’s an easy way to do the math without tears.

      Pick a large number. I use 100,000 since the state I live in has roughly that many births per year. Convert each percentage to decimals by dividing by 100.

      Out of 100,000 babies, 15% will have meconium staining.
      100,000 x 0.15 = 15,000 babies with staining.

      2% of the 15% develop MAS.
      15,000 x 0.02 = 300 babies with MAS

      3% of the 2% of the 15% die.
      300 x .03 = 9 babies who die of MAS

      So, yes. Fatalities caused by MAS are rare – but babies die from this every year. I doubt the rarity of the tragedy is any comfort to the grieving families.

      • Young CC Prof
        February 18, 2014 at 3:33 pm #

        And of the 300 with MAS, how many would have died if they didn’t get medical attention immediately after birth? That 3% rate is with treatment!

        It’s a common logic fail among naturalists. Almost everyone survives this disease, therefore you don’t need to treat it. Meanwhile, “almost everyone” did treat it…

        • The Bofa on the Sofa
          February 18, 2014 at 3:55 pm #

          The chance of dying in an 8 mile car ride if you are sober and wearing a seatbelt is something like 1 in 10 million, or more.

          Therefore, seatbelts aren’t necessary.

          You know, when you put it that way, it very clearly makes no sense in the least.

        • theNormalDistribution
          February 18, 2014 at 3:55 pm #

          I wish I could upvote this twice. It’s something that should be pointed out way more often than it actually is.

          • The Bofa on the Sofa
            February 18, 2014 at 3:58 pm #

            (upvote this comment if you think Young CC Prof’s comment needs two upvote)

        • February 18, 2014 at 6:12 pm #

          Exactly. I wish I could upvote 8000 times. Why is this so hard for people to understand? It’s the same with anti-vaxxers.

  20. AL
    February 18, 2014 at 1:59 pm #

    Another idiotic comment:
    “I have hardly ever suctioned a baby on the peri as I prefer to let
    gravity do the job, or just give them another ‘perineal sweep’ wipe to
    ensure the mouth and nose are clear of excess goop before they take a
    big breath. They are usually fine.”
    Ummm, my boy was born face up…so gravity “did it’s job” and made it easier for him to breathe in the mec.

    • Aussiedoc
      February 18, 2014 at 4:06 pm #

      Ah well that’s ok at least – our guidelines say not told suction or wipe on the peri anymore to prevent gasping – so as to avoid mec going into the airways before bub can be transferred to a resus table intubated and have airways suctioned. The theory being if its on the outside, itll be in their mouth too. The number of times I’ve been the paed resident saying ‘please don’t stimulate the baby’ to the midwife is numerous :).

      Having said that I doubt this woman knows anything about resuscitating a baby,

    • auntbea
      February 18, 2014 at 8:31 pm #

      Oh. Well if they’re *usually* fine then there’s nothing to worry about!

  21. Coraline
    February 18, 2014 at 1:53 pm #

    This part of her letter caught my attention: “This may lead to labour being induced or augmented which will put both of you at risk of further interventions.” Risk of, what? Further INTERVENTIONS? As in, “puts you at risk for further interventions…which are used in order to SAVE you and your mother’s life…” right? I mean, seriously, you’d think “interventions” are the worst possible thing in the world. Even avoiding a baby’s death is less important than avoiding an intervention! PURE craziness!

    • Danielle
      February 18, 2014 at 2:50 pm #

      This language drives me crazy too. An “intervention” is simply an action taken by my health care provider to prevent harm and to help me deliver my baby. Collaboration in birth, if you will. This is only a problem if I believe there is some sort of inherent good in me delivering the baby with as little aid as possible (in which case, why not cast my husband and midwives from the room as well! They might intervene!)

      The intervention may carry risks of complications – which must be compared to the risks of inaction or alternative actions that might be taken. But the intervention is not in itself negative.

  22. Dr Kitty
    February 18, 2014 at 1:46 pm #

    There is a place for normalising pathology.
    I do it all the time, when I decide not to worry about isolated mild elevations in GGT or isolated low basophil counts. I know that “normal ranges” are rarely definitive yes/no cut offs, and that clinical judgement is required in their interpretation.

    The Thinking midwife wants mec to be like a slightly high GGT, just one of those things you don’t need to worry about.
    It isn’t, it is more like a potassium of 5.8 or a sodium of 127-something you really can’t ignore, even if you decide not to do very much about it other than watch and wait and monitor vital signs.

    • Young CC Prof
      February 18, 2014 at 1:49 pm #

      The statistician would say that if you draw blood from a normal healthy person and measure 30 different things, it’s to be expected than one or two will be slightly out of range. Doctors who actually know what the tests mean know which deviations are probably meaningless, which should maybe be followed up on, and which are definitely a problem.

      • Dr Kitty
        February 18, 2014 at 1:53 pm #

        Thank you for putting what I was trying to say so much better! 🙂

      • KarenJJ
        February 18, 2014 at 6:11 pm #

        It happens to me frequently. I get six monthly blood draws looking at different levels. There’s almost always one that is slightly out of range. It’s never the same one and the main ones looking at inflammation are always within normal range (which is the main concern of my specialists as it shows that my chronic condition is being well-controlled) so my doctors tell me not to worry about them and why they’re not concerned.

        • Sue
          February 20, 2014 at 1:30 am #

          Yep – and ”normal range” is a bell-curve with cut-offs – so some ppl at either end are physiologically ”normal” too.

    • Are you nuts
      February 18, 2014 at 2:15 pm #

      Which is why I am very happy to pay my OB/Gyn to help me make medical decisions, rather than relying on google, a message board, a midwife with an online degree, etc.

  23. February 18, 2014 at 1:36 pm #

    It boggles my mind. I read parts of Gloria Lemay’s blog last night (she was bemoaning high cesarean rates) – and there might not be enough brain bleach in the world. Getting your health information from a convicted baby killer who also has a contempt for the justice system and did not finish high school strikes me as a recipe for harm. I believe in free speech, but have come to the conclusion that child birth education classes and even doulas should be regulated – far too many disseminate napalm grade stupid.

    • Anj Fabian
      February 18, 2014 at 4:05 pm #

      The birth choicers complain about cesareans like SOB complains about babies dying.

    • Jenny R.
      March 2, 2014 at 10:44 pm #

      “napalm grade stupid” too true, and n’er more elegantly said. I’ll be stealing that turn of phrase. 🙂

  24. guest
    February 18, 2014 at 1:31 pm #

    Thank you for this. I was planning a vbac but had my second c-section after my water broke, revealing the presence of meconium. When labor didn’t start after 8 hours my doctor recommended the c-section. I agreed, but during my painful recovery, at times wished I had waited to see if labor would start. I didn’t realize just how dangerous the meconium could be.

    • Coraline
      February 18, 2014 at 1:56 pm #

      I have gotten the same dose of reasonable thinking reading Dr. Amy’s blog. Just when I start to worry about something (usually something ingrained in me from my time adhering to the NCB movement), I read Dr. Amy and immediately my perspective shifts into the things that REALLY matter — my, and more importantly my BABY’s, health and well-being.

  25. Mel
    February 18, 2014 at 1:27 pm #

    I made the mistake of looking around on her blog. My head is spinning.

    I do realize that following her method of re-normalizing pathologies could make my teaching job much easier.

    Consider the following situation. About 6 years ago, we had a school where the average incoming reading level for 10th graders was 6th grade. Roughly 1 in 10 students was reading at 2nd grade or below. We responded by revamping the entire English curriculum, buying/writing wider reading level materials for content area classes, tutoring groups after school and taking classes outside of the day on teaching ELL students. It was a crazy amount of additional work outside of ‘traditional’ teaching duties. It worked, too.

    But, boy, we could have saved a ton of time. We accepted that the test data was an accurate representation of the students’ reading level. OBVIOUSLY, reading at a 6th grade level – or not being able to read at all – is just a variation of normal for 10th graders. We didn’t NEED to do anything! After all, the only person who is negatively affected by an inability to read is the brainwashed student. If they just think positively, they can succeed without reading….

    • auntbea
      February 18, 2014 at 8:36 pm #

      Why even bother to test? It will just open the door for people feeling they ought to do something. Obviously we should just try to limit the situations in which students ever have to read.

    • fiftyfifty1
      February 18, 2014 at 9:01 pm #

      Thanks for doing what you do.

  26. Deena Chamlee
    February 18, 2014 at 1:24 pm #

    These women who are victimized by homebirth are actually trauma bonding. Yes there is a syndrome such as trauma bonding where abuse survivors from childhood, any abuse sexual emotional or physical, are drawn to abusers subconsciously.

    I recommend all victims to read:
    Facing Co Dependency by Pia Melody. And read as much as possible in regards to trauma bonding. These readings will empower you from being a victim into becoming a survivor.

    • KAndrews
      February 18, 2014 at 4:09 pm #

      That is very true Deena. As if these families need additional trauma, pain and humiliation but that is what happens.

      • Deena Chamlee
        February 18, 2014 at 4:29 pm #

        I know Kristine I am leaving the profession. And I myself am an abuse survivor hence I understand the pathology and the pain. Many many years of looking at me and still it isnt easy to see grooming through manipulation, the exploitation is only known after the shocking abruptly discarding. You keep sharing as so will I because the experience will began to loose its power through our shares.

        • KAndrews
          February 18, 2014 at 11:58 pm #

          I am sorry to hear that you have been traumatized too. You are not going to be practicing anymore??

      • Deena Chamlee
        February 18, 2014 at 6:03 pm #

        MKristine I am sorry for your pain. And please believe me when I say I understand.

  27. February 18, 2014 at 1:14 pm #

    I suppose that if one thinks that meconium aspiration is a variation of normal, so is amniotic fluid embolus…

  28. batmom
    February 18, 2014 at 1:11 pm #

    How crazy. I have a couple of NCB-friendly books, and all of them are very clear that breathing in poo is a bad thing — not just because breathing poo is bad for the lungs, but because a fetus that is pooing is a fetus that is stressed.

    How out there do you have to be to say it’s better not to know? Maybe that’s why they keep catching all these babies that were fine until they were born dead.

  29. MeconiumMom
    February 18, 2014 at 1:00 pm #

    There was meconium in the amniotic fluid when my son was born at the hospital at 39 weeks (actual – IUI baby), and things turned out OK BECAUSE i had fetal monitoring (not constant – and I was allowed to labor in the tub!) and Pitocin when I stalled out at 3 CM. If I hadn’t had pitocin, i would have probably ended up with an emergency c-section. And I shudder to think of what could have happened had I tried to birth at home. One of my best friend’s daughters had MAS at full term and was in the hospital for 6 weeks or so. It’s seriously scary stuff with some long-term issues even if baby survives birth!

    • netochka
      May 25, 2015 at 6:02 pm #

      You were allowed to go without constant monitoring? How come? Is it not standard where you are? We had yellow fluid with a spontaneous rupture of membranes, and that triggered immediate synto (=pitocin) induction with continuous monitoring and a rushed ventouse delivery, though there was no distress with baby at any time, thankfully.

  30. auntbea
    February 18, 2014 at 12:58 pm #

    I don’t understand how any of those would cause hypoxia.

    • Young CC Prof
      February 18, 2014 at 1:02 pm #

      They don’t. Hypoxia is caused by compression of the umbilical cord or a problem with the placenta.

  31. Jessica
    February 18, 2014 at 12:49 pm #

    An infant in my city died last year after aspirating meconium. I don’t know all of the details surrounding his birth, only that he was born in a hospital with a Level III NICU, and very shortly thereafter transferred to the pediatric children’s hospital two hours away, Despite surgery and the ECMO, he died. He was five days old. I don’t even know the family and my heart broke when I heard about it.

    He had some of the best treatment available and it wasn’t enough. Meconium aspiration is no joke and it’s not something to take lightly. Those babies aren’t just abstract numbers – they are people who lived, died, and are buried, and whose families carry the weight of that for the rest of their lives. How disrespectful that stupid midwife’s article is to those babies and those parents.

    • Young CC Prof
      February 18, 2014 at 12:55 pm #

      Actually, if you scroll down to the comments, one of them came from a mother who lost a baby to MAS. The response from the author:

      “Please don’t be sorry for posting. Unfortunately meconium aspiration can cause death as I state in the post. This is why it is important to
      reduce the chance of the baby becoming hypoxic and inhaling during
      labour and birth if there is meconium in the fluid. For some babies this
      will not be possible to prevent. I am sorry that you lost your baby and
      it is important that you can share your story without apologising. x”

      In other words, she would try to prevent intrapartum hypoxia by making the mother feel less stressed, and if that fails, oh well, some babies aren’t meant to live, practice the art of letting go.

      • Mel
        February 18, 2014 at 1:40 pm #

        I started looking at some of her other topics – induction of labor; amniotic fluid volume. Gak.

        In most topics, a mom writes in about how she did exactly what NCB required in that situation and lost the baby.

        She’s also more than willing to hazard guesses about the motivations of OBs after the fact, but totally unwilling to respond to questions people have about current pregnancies….

  32. Julia
    February 18, 2014 at 12:42 pm #

    This makes me so mad. A friend’s baby had MAS and things turned out OK in the end *only* because of an emergency C-section and the NICU. But they didn’t know for a day or so if the baby was going to make it. Because of her experience, when I was about to give birth, I chose the hospital with a level 3 NICU over the one with the nicer single rooms. How can Ms Reed live with herself?

  33. AL
    February 18, 2014 at 12:33 pm #

    I find Rachel’s post completely offensive considering my oldest was a mec baby who did aspirate the mec. Luckily we were in the hospital, and we were only in the NICU for a week. The moments after his birth when a team of 20 rushed into the delivery room were probably the scariest moments of my life. He did suffer from pneumothorax on his left lung, was under an oxygen hood for 2 days, and had oxygen support for three days via nasal cannula, and was on antibiotics via IV for a week to prevent pneumonia. We were told that there was the possibility that he could have seizures and permanent brain damage. LUCKILY because I was in the hospital with such great care, my baby is now a very smart and thriving (sometimes drives me crazy) 4 year old. For her to trivialize this is absolutely horrific.

    • AL
      February 18, 2014 at 12:35 pm #

      And this is after a very normal, text book pregnancy and relatively easy delivery, with the sudden complication of mec aspiration at the very end of it all. Can’t plan for this s**t! (No pun intended).

    • Danielle
      February 18, 2014 at 3:12 pm #


      My sentiments match yours. During my long, non-progressing labor, my son went into distress & he aspirated meconium. The
      OB and the huge team flagging him got him out faster than I ever thought possible (hello magical vacuum!). A wonderful pediatric team resuscitated him. I won’t ever forget how terrified I was, waiting for that limp baby to cry.

      He was OK; he needed breathing assistance for less than a day and spent 4 days in NICU. By Reed’s standards, “see, everything was fine!” Well, yes, he rebounded very nicely and luckily for us he didn’t suffer a life-threatening infection.

      But he rebounded nicely because my doctors recognized that
      my baby was in distress and got him out fast. Then they lept on my limp baby like every second counted. Then the monitored him closely. All this requires my providers to believe that meconium in my waters is a problem!

      In fact, my exact change with the OB was like this: “There is meconium in your water.” Me: “Oh no, This is a problem right? Is it a big problem?” Him: Its a problem.”

      Here’s what I don’t want to hear: “Oh no, nothing to be worried about! Just relax!”

      What could have happened if I had been at home, and
      assumed that hours of labor with little dialation was just a variation of
      normal? What if my providers thought that the meconium my waters was not a big deal? It’s a chilling thought.

  34. PrimaryCareDoc
    February 18, 2014 at 12:16 pm #

    This comment is the worst:

    I just gave birth on 10/4 at 5:09 in the morning, after my water broke without contractions and large amounts of meconium chunks at 11pm on 9/30. My midwives did a fetal check every day to make sure there was no stress as contractions picked up and slowed down. Contractions finally hit steady midday 10/3 and at about 1am 10/4 finally entered active labor. Four hour active labor, half hour pushing for a first time, “high risk” momma, with several days broken water and meconium…I was blessed to be under the care of awesome midwives; I would have been sectioned for sure instead of having such an awesome birth!! As her head came out there was a thick chunk of meconium across her face too and the midwife just swiped it away in the water. She popped out two pushes later and went straight into my arms with banshee screams. Not a thing wrong with her!

    This midwife let this woman labor for 5 days with thick mec??? My head just exploded. She was “blessed to be under the care of awesome midwives?” No, she was cursed and just lucky as hell.

    • Mel
      February 18, 2014 at 12:17 pm #


    • Dr Kitty
      February 18, 2014 at 12:23 pm #

      Let her labour and *birth in water* with thick mec and PROM. Way to raise the risk of MAS and chorioamnionitis.

      The sooner there are agreed midwifery standards of care for OOH birth the better.

    • moto_librarian
      February 18, 2014 at 12:30 pm #

      And it’s idiots like this that make other women think that they can experience the same sorts of complications and come through with healthy babies.

    • The Computer Ate My Nym
      February 18, 2014 at 12:32 pm #

      When I went into labor and had ROM, there was mec in the fluid. The conversation with my CNM went like this,
      “I just had ROM and there’s meconium in the fluid.”
      “You’re sure it’s meconium and not just the mucous plug?”
      “Hospital. Now. I’m calling them and will meet you there.”
      I consider that an example of a midwife quite a bit more awesome than the one described above.

    • Danielle
      February 18, 2014 at 3:16 pm #

      That is terrifying!!!

      • Danielle
        February 18, 2014 at 3:25 pm #

        To elaborate: 1. She went four days after her water breaking without delivering? 2. Meconium in fluid from day 1 and they don’t worry. 3. They only checked on the baby’s condition once PER DAY?

  35. Dr Kitty
    February 18, 2014 at 12:14 pm #

    Dear midwife
    I do not like labour. I am having my oxygen cut off for a minute every three minutes.
    I would like it to stop.
    Please get me out.
    Because I can’t write, I’m hoping you pick up on my wishes which I am trying to communicate through the medium of poop and my heart rate.

    So I really hope you’re checking my heart rate and have noticed that I’m swimming in poop and have decided to take steps to shorten the duration of the distress I am being subjected to.

    In short: I don’t like this, get me out now.


  36. Jocelyn
    February 18, 2014 at 12:12 pm #

    Both of my babies had meconium staining in their water. Anyone know if this is a coincidence, or if my next baby is likely to pass meconium as well due to something about my body/labors?

    • Spiderpigmom
      February 18, 2014 at 1:04 pm #

      I’d suggest you discuss it with your OB rather than with total strangers over the internet, who do not know your medical history and who may or may not know what they’re talking about…

      • Jocelyn
        February 18, 2014 at 1:37 pm #

        Yeah, I know, I just thought I’d throw it out there. 🙂

      • Carolina
        February 18, 2014 at 2:46 pm #

        This is a little unwarranted. People ask these sort of questions all the time on this blog. I’m sure she’s not going to base any decisions on what people tell her here.

        • Jessica S.
          February 18, 2014 at 4:22 pm #

          No kidding! I ask questions here, but I’m sure as hell going to ask my doctor, too. I’m pretty sure Jocelyn is of the same mind. 🙂

      • Siri
        February 19, 2014 at 10:46 am #

        It’s ok; fiftyfifty1 is an obstetrician. They must be; they assisted the birth of my last baby via this blog. Didn’t charge me a cent either 🙂

    • fiftyfifty1
      February 18, 2014 at 9:26 pm #

      Most likely coincidence as mec happens in about one out of every 5-6 births. That said, it is much more likely to happen in babies past their due dates and the longer you go past, the riskier it is. Some women have tendencies to go past their due date, and if that is the case for you you might want to talk to your provider about the pros and cons of induction.

  37. tamara
    February 18, 2014 at 12:07 pm #

    this seems to also be a problem with the 39 week rule a lot of babies being born with severe respiratory distress and pneumonia because of the fact that they we’re push to stay with in utero beyond their normal delivery date hence the baby poops in the amniotic sac& breathes it in. And this could actually cause septic shock for the newborn and kill them. so its not only a situation that the baby is being pushed beyond their term limit but they are also putting these babies in danger a further review of the studies of infant mortality or newborn mark mortality one should also review the amounts of death caused by sepsis and respiratory problems by breathing in the meconium. this is something that I am trying to research but of course I don’t have the credentials to get the actual numbers.

  38. slandy09
    February 18, 2014 at 12:07 pm #

    *head desk*

    Two of my mom’s babies passed meconium during labor. We now know she had cholestasis and one of the complications of cholestasis is…meconium passage and fetal distress! Luckily, she gave birth with competent providers and they took the proper measures, and both babies (one of them was me) were just fine.

    I hate it when people act like meconium in waters isn’t a big deal. It is!!!!

    • Mel
      February 18, 2014 at 12:15 pm #

      My sister-in-law spent the first few weeks of life in the hospital with meconium pneumonia. She’s fine now, but was badly touch and go for several days.

      According to my mother-in-law, the least helpful part was when she was undergoing a tubal ligation while sis was still in NICU. MIL had severe blood clots during the pregnancy and was warned that a future pregnancy would kill her. While she was being prepped, she mentioned to an aide how sick her daughter was. The nurse said “Are you sure you want your tubes tied? If this baby dies, you won’t be able to have another one.” MIL said “Well, if I have another baby, we’ll both die.” She held it together until the aide left, then cried.

  39. Young CC Prof
    February 18, 2014 at 12:03 pm #

    A small sampling of what I “love” about that article:

    Post-dates babies release meconium because their digestive systems are mature (not because they are stressed and suffering from deprivation due to a failing placenta.)

    Claiming that only 3-5% of babies with meconium aspiration syndrome die while ignoring the fact that most hospital-born babies at risk for MAS receive immediate and aggressive respiratory help. What’s the death rate for MAS without treatment?

    “Encourage the mother to let you know if she is concerned about her baby
    in any way over the next 24 hours (eg. feeling hot, noisy breathing,
    etc.)” Because new mothers know exactly what newborn breathing is supposed to sound like. It’s not the EXPERT’S JOB to keep an eye on the baby for the first few hours after birth and make sure he’s adjusting to life on the outside, especially the lungs. And, by the way, newborns with life-threatening infections often have lower rather than higher body temperatures.

    And just as a side note, I can’t stand the use of the word “birthed.” It’s “born” if the baby is the subject of the sentence and “gave birth to” if the mother is the subject. Stop trying to make a normal English word more special.

    • moto_librarian
      February 18, 2014 at 12:09 pm #

      When our eldest went to the NICU for TTTN, neither my husband nor myself ever really heard what was wrong with his breathing. Nurses pick up those subtle cues because they are trained for it. New parents (and even parents with more than one child) are not. I’m glad that my boy was being observed by professionals.

    • Mel
      February 18, 2014 at 12:10 pm #

      Plus, even if a post-date baby is not stressed due to a failing placenta, they’ve still been growing at a fast clip. The baby may well be large enough to make a vaginal delivery tricky or impossible. Far better to monitor closely and *gasp* intervene if needed…..

      Thank you for sharing the “birthed” annoyance. I work with mostly ELL students who occasionally – and totally naturally – make that mistake. I get very irritated when native speakers do the same thing.

    • Trixie
      February 18, 2014 at 12:42 pm #

      It is acceptable to use “birth” as a verb, in fact it’s been in use that way for a long time. But I agree the way they use it is icky.

      • February 18, 2014 at 1:12 pm #

        I regret that I disagree most strongly. “[To] birth” is NOT a transitive verb; not in English, anyway. I want to “disappear” people who use “birth” as a verb.

        Antigonos the grammar Nazi

        • theNormalDistribution
          February 18, 2014 at 1:33 pm #

          I am a terrible grammar Nazi. I correct my mother-in-law’s grammar all the time (she has a masters degree. And is a retired TEACHER, so come ON!)… Okay, I have only corrected her a few times but the rest of the time I fume silently about it.

          But I have to admit, I think sometimes using words or punctuation incorrectly can add meaning that you just can’t express with proper English. I have argued with other grammar Nazis over this exact thing. Not sure if your example counts, but it certainly is quirky. I wouldn’t want to disappear that literary device from the language.

          That said, the “birthed” thing is just ignorant and the person who says it just sounds dumb. I’m gratified to see we can all agree on that.

          • Trixie
            February 18, 2014 at 1:42 pm #

            I think the takeaway is that anytime you say, “never in the English language does x happen,” you’ll find that somewhere there is a population that uses x exactly as they aren’t supposed to. That’s the beauty of English, infinitely flexible and always changing.

          • NoLongerCrunching
            February 18, 2014 at 1:43 pm #

            I’m a grammar Nazi too, but I think one of the great things about language is how it’s always changing, resulting in “correct” having a fluid meaning. This results in some weird phenomena, such as the fact that “literally” is now defined also as “not literally.” While I will fight to the death to keep atrocities like “your meen” out of our language, I like words like “birthing,” because it’s an interesting example of how our language is evolving all the time.

          • Trixie
            February 18, 2014 at 1:45 pm #

            People get way too upset over the verbing of words.

          • NoLongerCrunching
            February 18, 2014 at 1:47 pm #

            Well, for those of us who can’t math, being good at grammar is a nice consolation. 😉

          • Trixie
            February 18, 2014 at 1:49 pm #

            I personally am enjoying the evolution of “because” into a preposition.

          • NoLongerCrunching
            February 18, 2014 at 1:50 pm #

            We also have this to look forward to:

          • theNormalDistribution
            February 18, 2014 at 1:53 pm #

            I disagree. What I find interesting and valuable is the obvious intentional misuse of language. I think the incorrect use of language that stems from ignorance that eventually makes its way into what is considered “correct” (for example “irregardless”) is a fucking travesty. And, no. “Literally” does not mean “not literally”. That’s not evolution of language. It’s hyperbole.

          • Trixie
            February 18, 2014 at 2:02 pm #

            When evaluating whether a new language phenomenon is good or bad, it’s useful to ask whether it aids clarity or destroys clarity. Thus, I will fight against “infer” and “imply” being used interchangeably, because they have useful and distinct meanings. But “birth” as transitive verb is perfectly clear, and you can make a solid argument that it’s less clunky and more logical than “give birth to.”

          • NoLongerCrunching
            February 18, 2014 at 2:07 pm #

            Good point. What do you think of the constant misuse of “comprises” and “is composed of”? People just can’t seem to get it right. But to keep this on topic, it seems like homebirth advocates love weasly words like “rarely,” “often,” “can be safe,” etc.

          • Trixie
            February 18, 2014 at 2:20 pm #

            I don’t think that use of “comprise” is incorrect. It’s been used that way for hundreds of years.

          • theNormalDistribution
            February 18, 2014 at 2:31 pm #

            And one day, ‘infer’ and ‘imply’ will go the same way.

          • Trixie
            February 18, 2014 at 2:32 pm #

            They’ll have to pry them from my cold, dead hands!

          • theNormalDistribution
            February 18, 2014 at 2:48 pm #

            Haha. Well, that’s how I feel about ‘comprised’ and ‘composed’. I think we agree on the evolution of language to increase clarity and add meaning. But you have to admit, the composed/comprised and infer/imply issues are essentially the same. One day your beloved infer/imply will go the way of composed/comprised, and you will become me: an angry pedant who writes numerous rants to strangers on the internet about minor changes in language that are arguably correct.

          • theNormalDistribution
            February 18, 2014 at 2:29 pm #

            I agree. As I said, I don’t have a problem specifically with the type of misuse that “birthed” would fall under. But ‘birthed’ specifically is awful for other reasons. I explained that in a reply to the post you’re commenting on.

          • theNormalDistribution
            February 18, 2014 at 2:21 pm #

            What makes using “birthed” so objectionable, I think, is the change of focus from something that happened to the baby to something the woman did. A baby was born. The woman birthed a baby. I’m pretty sure the word comes from ‘bear’. As in, how many children did she bear? The baby was born (borne by the mother). Birth is something women have had to bear. An involuntary, uncontrollable, unpleasant experience that they must get through. But NCB types don’t bear children, no. Their bodies know what to do and they have control. Unlike the rest of humanity, NCB mothers are active participants in the birth of their children. Their babies aren’t born. They’re birthed. By them.

            I don’t like “birthed”. I don’t like the focus on mom over baby, and I don’t like the illusion of control where in reality, there is none. It’s wishful thinking to say you birthed your baby and it will mislead women who are looking for that sense of control.

          • Trixie
            February 18, 2014 at 2:31 pm #

            Oh, I completely agree that in the context of NCB language, it’s creepy, for all the reasons you state. My quibble was just that it is, in fact, a word.

          • KarenJJ
            February 18, 2014 at 6:21 pm #

            I find it convenient. The word “birthed” or “birthing” in any article I’m reading raises my guard against potential BS by a good 450%.

          • Sue
            February 20, 2014 at 1:36 am #

            Yep – and double it for ”Mama”

        • Trixie
          February 18, 2014 at 1:34 pm #

          It shows use as a transitive verb in my dictionary as well as several online dictionaries. Perhaps it falls under a regional difference, but it is, in fact, used.

          • auntbea
            February 18, 2014 at 2:14 pm #

            I think it was used far more often as a transitional verb several generations ago.

        • Trixie
          February 18, 2014 at 1:39 pm #

          This one has a better explanation.

    • fiftyfifty1
      February 18, 2014 at 9:30 pm #

      “Post-dates babies release meconium because their digestive systems are mature ”

      There is some truth to this. That’s what we learned in training anyway. “Babies pass mec sometimes because they are stressed, but sometimes just because they can”.
      Doesn’t make it any less dangerous though….

  40. Mel
    February 18, 2014 at 11:58 am #

    The stupidity of the entire blog post makes my head hurt.

    Who starts with a rhetorical appeal to an unborn baby to not defecate? Why are you appealing to the most helpless/least powerful person in the whole damn charade?

    Here’s my rewrite:

    Dear midwife,

    Please don’t kill me. I’d really like to live. It’s not like I’m gonna remember how I was born…..



    • Houston Mom
      February 18, 2014 at 12:28 pm #

      I think if Baby was aware and could communicate, he/she would be asking directions for the quickest exit, i.e. c-section.

      • Jessica S.
        February 18, 2014 at 4:30 pm #

        Yes, this!! Can you imagine? I’d take anything but being shoved through a dark, tiny canal. That said, it’s pretty remarkable that we can be born that way and it’s shocking to me that worse things don’t happen more often. A testament to research and technology. I don’t understand for a single second how anyone can think delivery a baby is perfectly safe.

      • Jenny R.
        March 2, 2014 at 8:16 pm #

        you mean someone WOULDN’T want to linger, blind and helpless, in a crushing environ to choke/suffocate on dirty poop fluid? But that sounds like a blast! Fun for the whole family; they should make that experience a theme park all its own. 😉

    • Jennifer2
      February 19, 2014 at 8:35 am #

      Dear baby,
      Please don’t show any signs of distress during labor. If you do, those meen doctors will make mama have a c-section instead of whelping you in a kiddie pool full of bloody, poopy water like nature intended. Now, I’m not saying you can’t feel a little distress (remember, this is about me, not you). Heck, birth is probably a stressful thing. I remember this one time your dad and I went camping and we were checking out a cave and one of the tunnels was a bit tight and I got a little stuck. It was kind of scary! So you might feel a little scared coming out, but that’s okay. Just be strong and don’t let the doctors know you’re afraid. They can smell fear. Kind of like dogs. And sharks. Anyway, just be cool, kiddo. Mama wants a pain level of 5 (enough to prove I’m tough, but not so much that I start wanting an epidural), a quick labor, and no tearing. Is that too much to ask?
      The woman who grew you, is going to birth you, and who will sacrifice her every happiness (well, not EVERY happiness) to show the world what a good mother I am, a/k/a Mama

  41. anne
    February 18, 2014 at 11:57 am #

    Sometimes I wish these midwives would go dunk themselves in a poopy toilet and try breathing for awhile. : (

    • Trixie
      February 18, 2014 at 12:45 pm #

      Maybe MANA should hold a mec dunk tank fundraiser.

  42. February 18, 2014 at 11:43 am #

    I had 3+ mec. It was really scary.

  43. moto_librarian
    February 18, 2014 at 11:42 am #

    I loathe this midwife. My second child had light mec in his waters, and you can bet your butt that I was concerned about it. My CNM was too, and she made sure that the NICU team was assembled when I began pushing. My son went into very real distress while crowning. The CNM said, “we have to get him out now,” and I heard the nurse ask if she should page the OB Emergency Team. I pushed as hard as I could in the absence of a contraction, and he rolled out of his umbilical cord. They cut his cord immediately and handed him to the NICU team. And I lay there, waiting to hear him cry and asking repeatedly if he was all right. The attending doc said he was just a bit stunned, and with vigorous stimulation, deep suction, and O2 via CPAP, he was stable and in my arms in about 20 minutes.

    I often think about this whenever I heard midwives yammering about how “babies know when to be born.” After nearly two weeks of prodromal labor, our son was born at 38 + 5. Clearly, labor stressed him, and I am glad that he was born when he was. I see no reason to gamble on the health of a child that you have carried for 9 months.

  44. Susan
    February 18, 2014 at 11:29 am #

    What’s more normal than death?

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