Belly Tales

Sometimes birth is not normal. Sometimes there really are complications and problems which need to be dealt with in a hospital setting. Sometimes a medical approach to birth is exactly what’s needed. Sometimes interventions during birth ARE lifesaving. Yesterday was a perfect example of that. I was helping to take care of a woman who was incredibly high risk and had the odds stacked against her in terms of her chance of having a normal, uncomplicated delivery. She was severely anemic, and had been throughout her pregnancy; and not just the usual anemia of pregnancy—no, this was a woman who had a hemoglobin of 6.5 at one point during her 3rd trimester, and a hematocrit of 19%. (To put that in perspective, bear in mind that normal is a Hemoglobin of 12-13 or greater, and a hematocrit of 32-33% or greater.) She had been seen by Hematology several times during her pregnancy and had had numerous anemia work-ups. It all pointed to iron-deficiency anemia, and she was taking iron replacement therapy, but there’s only so much that this can do. At one point during her pregnancy she had been offered a blood transfusion, which she had refused. When she was admitted, her hemoglobin was 7.8 and her hematocrit was 21%—numbers which didn’t demand an immediate transfusion, but which were very concerning given the fact that she was going to give birth, and giving birth means losing blood, and if you’re severely anemic you don’t really have any blood to lose. Our professor used to say that if a woman is severely anemic, she “can’t tolerate” a hemorrhage…which is what…a polite way of saying that she’ll die?

In addition to the severe anemia, she was also preeclamptic. Her baby had oligohydramnios, probably caused by the preeclampsia (unchecked hypertension and poor placental perfusion can lead to intrauterine growth restriction and oligohydramnios, both of which are not good signs). She had protein in her urine, was hyper-reflexive, and was starting to have toxic symptoms (blurry vision, headaches, visual changes, epigastric pain, edema). She was admitted for an induction of labor immediately on account of the oligohydramnios and preeclampsia. To my way of thinking, this was the right call. With preeclampsia, you don’t want a patient sitting around at home with skyrocketing blood pressure—it can lead to siezures if untreated, and the only cure is birth. Similarly, oligohydramnios indicates chronic, long-term insult to the baby, which sadly means that the womb is no longer the best environment for fetal well-being.

This was her second baby. Her cervix was 3 centimers dilated at the start of the induction, so rather than using a cervical ripening agent like cytotec or cervadil, pitocin was started instead. Because she was preeclamptic, she was also started on Magnesium Sulfate, which prevents preeclamptic seizures by causing systemic smooth muscle relaxation. Mag is an awful drug. It makes you weak and hot and sweaty, and it often complicates inductions because it’s hard to induce contractions when a woman is receiving a medication which is causing all of her muscles to relax. Pitocin and magnesium are always at odds with each other. I think a lot of preeclamptic inductions fail because of the magnesium.

Anyway, maybe it was because of the magnesium, maybe it was because her first labor was also a very long, drawn-out labor, but in any case, her progress was very slow. I admitted her on Friday, and she was still in labor when I came back 12 hours later, on Saturday. She hadn’t made much progress; she was only 4 centimeters dilated when the doctor checked her that morning, and was still 4 centimeters when the doctor checked again 3 hours later. Her bag of water was broken by the doctor, an intrauterine pressure catheter was inserted to measure the actual strength of the contractions, and the pitocin was duly increased. And increased, and increased. It got as high as 28 miliunits/min., which was as high as I’ve seen it in a long time. Her contractions were adequte (because of the IUPC, we were counting montivideo units, and yes, they were adequate), but they were always irregular. When I checked her again 3 hours after the IUPC had been placed, she was only 5 centimeters dilated, and it was a tight 5 (I was worried that I was being too generous, and that the doctor would come behind me and check her again and decide that she was still only 4 centimeters, that she hadn’t made any progress, and that she would therefore need a cesarean for failure to progress).

I was really worried about this woman and this baby. I was worried about a severe hemorrhage. She had so many risk factors leading up to it; she was on magnesium, which relaxes the uterus and makes postpartum uterine atony more likely. She had been on pitocin for almost 24 hours, which tires out the uterus and makes postpartum uterine atony more likely. And because she was severely anemic, she couldn’t hemorrhage. She had no blood to loose. I was worried that after another three hours of little or no progress, she would give birth by cesarean, which means that her blood loss would be at least 800 cc. She didn’t have 800 cc to lose.

At least the tracing was always reassuring. I’m sure that if, at any point the tracing had begun to look anything other than beautiful, there would have been an immediate cesarean. Her urine output was always good, her magnesium levels were always on target (never too high or too low), and all of the medications we were giving her seemed to be doing their jobs. The woman seemed to be taking everything in stride, as well. I was amazed by her strength. She never panicked, even when she first found out that she had preeclampsia and would need to be induced. She had an epidural and was comfortable. She slept for several hours at a time, as did the rest of her family (her partner and grandmother, both in their chairs with their mouths open, snoring). She asked a few questions here and there, but for the most part, she seemed to trust that things would be okay. She must have known something that I didn’t. I was worrying plenty for the both of us.

Three hours after my last exam, I was unsure of what to do. I didn’t want to check her again and have to be the one to discover that she was still only 5 centimetrs dilated, and then have to notify the doctor and watch the entire thing get written off as “failure to progress”. On the other hand, we’re supposed to round on the women we’re taking care of every 2 hours, and I was trying very hard to be on top of things; it was already an hour past when I was supposed to check her and write a note. I called my preceptor on the phone and discussed the situation with her. We decided to write a note on her well-being, lab values and fetal status, but defer the exam for another hour, if possible. I hung up the phone and walked to the room, only to discover that the doctor was already there, and had just checked her. She was fully dilated.

I didn’t even have time to marvel over how she’d managed to go from 5 centimeters to fully in 3 hours…not that this is an impossible thing at all (many 2nd time moms do the entire labor in 3 hours or less), but she had been making such slow progress, and her body was battling the magnesium every step of the way. I was so incredibly, pleasantly surprised! I barely had enough time to get my gloves on before the baby’s head was crowning. He wasn’t a very large baby. She pushed him out in 6 minutes, and he began to scream and wave his arms around. Her partner cut the cord. The pediatricians were there on account of the prolonged magnesium exposure in the baby, but everything was fine.

The placenta came out 4 minutes after the baby, and we began to massage her uterus immediately. It wasn’t firm right away, but it firmed up with massage. We ran 40 units of pitocin in 1 liter of IV fluid (we couldn’t give her methergine because her blood pressure was too high, since methergine can cause a stroke if given to hypertensive women) and…please, no heavy bleeding…please, no hemorrhage…please, let it stop….and it did. She lost blood, but a normal amount. She had a small, first degree laceration which we quickly repaired so that it wouldn’t bleed very much.

And that was it. All of those risk factors, all of those hurdles to overcome, and in spite of it all, a normal birth. Even with the doctor in the room. Even with multiple IV lines, and packed units of red blood cells ready and waiting in case she hemorrhaged. Even with an induction that lasted 28+ hours, and heavy medications competing against each other. Even with a midwife that was worried about so many things that could have potentially gone wrong, which didn’t. Even in high risk situations, with all sorts of complications, even with a prenatal course and labor which is anything but normal….normal birth can and does still occur.

Who ever would have guessed that this would be possible: a blood product substitute made from plastic, and which may be available for use in the next few years.  Unbelievable.  What will we come up with next??

I got an e-mail the other day from a colleague at work who was passing on to a whole bunch of us a forwarded e-mail that she had received. Here’s the content of what the e-mail said. It was entitled “Urine Dip”:

Like a lot of folks in this state, I have a job. I work - they pay me. I pay my taxes and the government distributes my taxes as it sees fit. In order to get that paycheck, I am required to pass a random urine test with which I have no problem. What I DO have a problem with is the distribution of my taxes to people who DON’T have to pass a urine test. Shouldn’t one have to pass a urine test to get a welfare check because I have to pass one to earn it for them?

Please understand, I have no problem with helping people get back on their feet. I DO, on the other hand, have a problem with helping someone sitting on their ASS, doing drugs, while I work. Can you imagine how much money the state would save if people had to pass a urine test to get a public assistance check?

Pass this along if you agree or simply delete if you don’t. Hope you all will pass it along, though. Something has to change in this country — and soon!

My colleague hadn’t written this e-mail. It was a forwarded chain letter, and all she was doing was forwarding it to the rest of us. She did ask us what we thought about it, though. My initial desire was to dash of an immediate (and very heated) response to everyone on the recipient list. Cooler heads prevailed, however (I am still a very new employee, and I’m not sure how I feel about making enemies this early in the game), but I did want the opportunity to air my thouughts on this. So hello my delicious little annonymouse blog, aka venting-opportunity-extraordinaire.

What do I think about this? Well, I think it’s a very condescending, priviledged and uneducated point of view. It’s an excuse that people make for not having to care as much about “those people who do drugs” or “those people on welfare” or “those people who sit around on their asses doing drugs while I’m working”. While there are always a few people who are bound to take advantage of a system like welfare or medicaid, I don’t think the majority fall into this group. Ask yourself how you would feel if you were receiving welfare–would you be sitting back on your ass, taking advantage of it, and doing drugs? I think many people are embarrassed and ashamed to be on welfare, but unfortunately, the system focuses on the hand-out aspect of it, rather than on teaching and educating and empowering and giving people the tools and resources they need to get off of welfare. I think it creates a system of dependency and complacency, and I think THAT’S what needs to change.

Those of us with good jobs are privileged in so many ways we may not even recognize. How did we get those jobs? Because we have an education. How did we get that education? Because we were blessed with an attitude or an upbringing or a teacher or a mentor or a relative or a friend who believed in us and taught us that education is important, and that it matters. How did we pay for that education? Because we were blessed with scholarships or grants or friends or relatives who could help us out, or banks that had enough faith in our future potential that they were willing to loan us money, and because we were blessed with enough cultural capital to know how to ask a bank for money in the first place. Or because we were blessed with the knowledge that education is worth it, even if it takes you 7 years to pay for every cent of it yourself from your hard-earned paycheck at MacDonalds. How did we get into college? Because we were blessed enough to finish high school; because many of us we weren’t growing up with violence or drug abuse in the home, because most of us had a stable life and a roof over our heads and food to eat and time in the evenings to do homework and someone there who was going to make sure we DID our homework. Of course we had to work for it, and want it, and put in lots of our own hard-earned blood, sweat and tears, but the desire to get where we are right now is something we shouldn’t take for granted, and not something that everyone is lucky enough to have. The “well, why don’t they just get a job?” attitude is a blanket statement of privilege, which fails to acknowledge how difficult it is to obtain a good job, and all the ways that getting an education and therefore getting a good job is a learned behavior, and a cultural gift, and that not everyone is lucky enough to have that passed on to them and instilled in them, especially at a young age.

The other fallacy in this is the fact that drug use is an ADDICTION. What makes people take drugs in the first place? Depression, loneliness, feelings of helplessness and despair? A sense that they’re trapped, that there’s no way out, that life is shit and there’s nothing to do but try to enjoy what little time you’ve got on this earth in any way you can? Trying to belong to a particular group, trying to fit in, trying to feel like you’ve got a community or a family or friends? Whatever the reasons, the decision to habitually use drugs rarely stems from carefree flower-child experimentation or laziness. People who start to use drugs are driven to it because something is pretty damn bad in their life in the first place, and then, once they’ve started….they can’t stop. Hence the ADDICTION part of it.

To make it sound so easy and so simple–I have a job, I don’t use drugs, I take a urine test, so why can’t “those people” do the same?–is a very narrow-minded point of view, and fails to address any of the larger issues; it’s patronising, simplistic and judgemental, at its very core, and because we all know that the majority of people on welfare are certainly not white, it’s also racist at its core. Cutting people off from the help they need by forcing them to take a urine test before receiving public assistance will probably only make things worse, not better, and only addresses the symptom, rather than the root of the problem. The root of the problem is: what is it in this person’s life which drove them to take drugs in the first place, and how can we address that and help that? I don’t believe in free hand-outs either, but drug addiction is not something that people can just stop overnight, no matter how much they might want to (and usually if they’re deep in addiction, they don’t want to anyway), and it’s not something that people can usually do on their own. It’s so easy for the non-addicted to say to someone who’s addicted…well, just stop using, get off your lazy ass and quit doing drugs…but has that person ever stopped to consider just how HARD that is? Have you actually put yourself in the other person’s shoes, and tried to walk a mile in them? Help, compassion, non-judgement and true understanding would go a lot further, in my very humble opinion, than the “get off your lazy ass and quit abusing the government dole” attitude. Respect for “those people” would make a huge difference, too, but if you see “those people” as lazy (and if you see them as “those people” in the first place)…you’re never going to be able to respect them enough to make any kind of positive change.

Where does the midwifery come into all of this? LISTEN TO WOMEN and DON’T JUDGE. Those two lessons, all over again. The respect and the need to be able to put yourself in someone else’s shoes is inherent in that.

Now, the next question is…should I go ahead and send this back to everyone on the e-mail list? What’s it worth? Making a good impression at my new job and not pissing people off right off the bat…or speaking my mind and being upfront and honest about my beliefs, even at the expense of creating work conflict? Aargh, really tough call.

Today I caught my 50th baby! She was born at 4:18 pm to a young woman from Puerto Rico who was absolutely thrilled and excited about her first pregnancy. She was an induction for postdates (per hospital policy, all women are induced if they’re still pregnant at 41 weeks); she’d actually had an incidence of preterm labor earlier in her pregnancy, but now, instead of the baby coming too soon, we had the opposite problem—a baby that didn’t want to leave. Because she was an induction, she was on pitocin, and because she was on pitocin, she pretty much had to stay in bed (again with the hospital protocols…). She was so strong and so tough, though, laboring in bed for the entire afternoon and refusing an epidural the entire time, through every single pitocin-induced, booming, more-intense-than-natural-labor contraction. The only thing she took for pain was a dose of stadol when she was around 5 cm dilated. I think her birth team made a big difference for her. Her mother and the father of the baby were at the bedside with her all afternoon, fanning her and bringing juice and ice water, putting cold packs on her head when she was hot, massaging her legs and arms. I couldn’t get over the father, in particular. He was such a young man (19 years old!), but his maturity was well beyond his years. He knew just when to be attentive, and just when to be quiet and not pester her with questions or ministrations or conversation (during transition, she didn’t want anyone to touch her). When she was pushing, he was so excited by the tiny glimpses of head we were seeing with each push; he couldn’t wait to meet his baby. He kept encouraging her to keep pushing, she could do it, soon she’d have their baby etc. etc. (I barely had to say a word of encouragement, he was doing such a good job of it all on his own). We pulled the mirror out after the first hour of pushing, and this really made a difference for her. Once she could see her progress in the mirror each push was better and better. The baby crowned in right occiput anterior, and she was able to breathe the baby out in between the contractions in such a way that she didn’t even tear her perineum (she did have a small laceration inside the vagina which required 5 stitches, but the actual perineum itself was intact). When the head restituted, the shoulders came out almost transverse rather than vertically. It was almost as if the baby were spinning inside her very roomy pelvis. The little girl (7 lbs, 2 oz.) started crying almost right away, and her beautiful family all burst into tears (especially the young father), which then made me tear up as well (seeing a family cry always gets to me, every time). The father cut the cord. Afterwards, the baby latched onto the breast like a pro and had a very tasty meal of colustrum while I did the small repair. There was no other midwife in the room with me (my preceptor was out at the nurse’s station, within shouting range, but minding her own business). The saying goes that somewhere around 100 babies, you start to get a clue as a new midwife. I guess that means that I have roughly half a clue, right now, but today, for the first time, I felt like…yes, I really am I midwife.

Rachel commented, in response to my Worry-wart = New Midwife post: “I was interested to see in your description how “medical” the treatment of the L&D patients seems to be, despite having a midwife on hand. Any thoughts on that?”

Of course I have thoughts on that!

First of all, this is hospital midwifery and hospital birth. Unfortunatley, you almost have to think of it as a different species of midwifery all together. Because this is occuring inside a hospital, and there are hospital regulations to follow, there are protocols in place which limit the amount of freedom a midwife has to manage her clients in a more traditional “midwifery” manner, and there is a constant push-and-pull of politics and power at play. Who ultimately gets to make the calls? Is it the women themselves, who are educated and empowered enough to demand the kind of birth experience they want? Is it the midwives, fighting and advocating for these women? Is it the doctors, whom the midwives collaborate with? Is it the nurses, who often choose to ignore the breastfeeding-friendly initiative that’s been established in our hospital, and try to bring the baby to the nursery as quickly as possible after the birth in order to limit the amount of work they have to do right after the birth?

Ultimately, it’s a combination of all of those things which impact the overall birth experience. This is a midwifery service located in a very busy urban hospital in a very poor, underserved section of Brooklyn. Our clients are women from all over the world. Many of them are recent, first-generation immigrants, and presumably many of them are here illegally (we never ask). Many of them don’t speak English—they speak Spanish, Urdu, Polish, Hindi, Arabic, French, French Creole and Patois, predominantly. On the whole, many of these pregancies are unplanned. Home situations vary incredibly. Sometimes the father of the baby is supportive, sometimes they’re married, certainly sometimes it’s a planned and wanted pregnancy, but sometimes the woman and her partner are no longer on speaking terms, sometimes there’s a court order against him, sometimes the aunts and mothers and grandmothers of these women will be raising the baby while the woman goes back to finish high school. Planning for the pregnancy and birth is often done under very difficult circumstances. By and large, these women are not showing up to labor and delivery with doulas and birth balls and birth plans, having read all the latest childbirth books and having bought the latest, most ergonomic birth sling. They’re not online, with internet access, reading blogs like ours or doing research about their birth choices. But most importantly, these women are not choosing midwifery care. They’re coming to our hospital clinic because they can get prenatal care for free with us if they don’t have health insurance and they qualify for medicaid and WIC and PCAP. They’re being taken care of by midwives because their pregnancies are predominantly low-risk and healthy, and because the hospital finds midwifery care to be cost-effective and economical, but are these women seeking us out, or looking for the midwifery experience? Not really. And are these women really after a natural childbirth experience? Again, for the most part, not really.

Women generally see one midwife for their prenatal care, but unfortunately, labor and delivery is covered in shifts. It’s a 24-hour service, so there are always two midwives on L&D at any given time of the day or night, but it may not necessarily be the midwife who took care of you during your prenatal care. Which means that when you come to the hospital to give birth, the midwife you know and are familiar with may be there to deliver your baby, but there’s also a good chance that she won’t be. It’s not ideal, by a long shot, but this is the difference between private practice midwifery, which is often a luxury item reserved for those who can afford it, and hospital midwifery, which serves underserved populations with excellent care, but isn’t set up in such a way that the midwives are on-call for their clients.

So, in a hospital setting, where does the midwifery care come in? We don’t have a birthing center, and there really isn’t a birthing center vibe to the place. However, I think the midwifery aspect comes into play in many areas which aren’t immediately obvious because they’re subtle, but I do think it makes a big difference overall. For one thing, the number of women getting epidurals on this floor seems to be much less to me than in other hospitals where I’ve worked as a nurse (and these were all private hospitals predominantly served by private doctors). I chalk the decreased epidural rate up to the increased labor support the women get from the midwives and the nurses. The c-section rate is also much lower in our hospital than it is in many other hospitals in the city (22% last year, v. 30-35% in other hospitals in NYC, and certainly much lower than the national average), and our VBAC rate is much higher than in many other hospitals in the city, as well as higher than the national average (I think this comes from the fact that there is one dedicated VBAC counselor who counsels all the women, and the midwives really work hard to find the op report and talk to women about the benefits/risks of VBAC). Women are allowed to eat clear liquids (juice/jello etc.) during labor, which is a big improvement over many other hospitals where women STILL aren’t allowed to eat anything (and which is still occurring on a regular basis at other hospitals). Women can get out of bed if they’re not on pitocin (again, something which doesn’t occur that often in other hospitals). We push in side-lying or sitting positions, we push with squat bars, we let women push on the toilet or standing (hanging) in a suspended squat.

More than any of this is, though, is the midwifery philosophy which is held by the midwives, and which is always at work in the hospital. I’ve been working here for only about 4 weeks, but a lot of that time has been spent advocating for natural childbirth and breastfeeding and trying to find a way to limit the number of interventions performed in labor and delivery. As the midwife, it’s a constant struggle. Sometimes it means jumping through hoops, or presenting patients to the doctors in a such a way which highlights the positive (she’s making change, just slowly…but no, I don’t think she needs pitocin or a cesarean or etc. etc.) and downplaying the negatives. It doesn’t mean changing the facts, it just means fighting and doing everything you can to let a normal birth unfold, even in a hospital. It’s a crazy balancing act, balancing so many different needs and agendas and pressures and desires. I think this philosophy can be seen in the amount of patience which the midwives display, the effort put into offering a humane, hands-on touch, and the deeply held belief that BIRTH IS NORMAL, that women CAN do it, that all women deserve respect and informed choice, that they deserve explanations, that no one is going to just walk in and rupture their membranes without talking to them about it first and making sure it’s okay. To me, the midwifery philosophy, at its very core, means LISTEN to WOMEN, DON’T JUDGE, and return the power of labor and birth back to the WOMAN, where it belongs. We don’t deliver babies, we catch babies; it’s the woman who does all the hard work. It’s the woman who delivers her baby. It’s her body, it’s her baby, and it’s her birth. Women in this hospital are powerless in so many ways, and are often so used to giving up there power. They don’t always ask questions because they don’t realize that they have a right to ask questions—that they can ask questions. The midwifery philosophy at work in a hospital helps to correct this imbalance and inequality, even if only a little bit. So much of midwifery care is education, and education is power.

I’ve recently had a birth which really illustrate these points, and which I’ll write about below, but in any case, I do think the difference is palpable. Yes, it’s hospital birth. Yes, there are lots of monitors and beeping machines, there are hospital protocols which must be followed, women get epidurals (but only if they want them), we use pitocin, there aren’t tubs, and unfortunately no one has time to rub lavendar oil into anyone’s back (simply because this is an incredibly BUSY hospital, and you rarely have time to pee, let alone massage someone during labor), but I think we still provide excellent midwifery care to our clients. Even if it wasn’t necessarily the kind of care they were looking for in the first place, I think that many women find that they really enjoy midwifery care, because we as midwives are trying so hard to give them choices, to help them take control of their bodies and their births, to be able to say no to treatments or procedures they don’t want, and of course, treating them with dignity and respect (again, things which aren’t always in large supply in hospital settings).

Case in point: last week I was taking care of a woman who was laboring with a baby that was Occiput Posterior, meaning that the baby was face up instead of face down, and that therefore the back of the baby’s head (the hardest part of the baby) was up against the woman’s back. OP happens quite frequently during birth, and can make labor a lot longer and more difficult, because it’s not the optimal fetal position for a quick and easy birth. And indeed, this woman was making progress, just SLOW progress. She was 6 cm dilated at 8:00 am when we first came on our shift, then she was 8 cm at 10:30 am (when I broke her water because she was asking for something to speed the process up). She was 9 cm at noon, had progressed to anterior lip at 2:00 pm and was finally fully dilated at 4:00 pm. I was getting really nervous because she was gong so slowly and I was conscious of the hospital pressure which always exists, and which goes something like this: as soon as you’re admitted to the hospital, you better be moving towards birth, and moving at a pretty regular, pretty rapid pace. It was my preceptor that day (a big, loud-mouthed woman who’s been a midwife for 10+ years, possesses loads of confidence-born-of-experience—which I don’t yet possess—and is not afraid to tell the truth, whatever that may be) who was the calm rock of this birth. She’s the one who told me to quit checking our patient, to just sit tight and watch her labor unfold and trust that everything is going the way it should. So that’s what we did.

Because our patient didn’t have an epidural and she didn’t have pitocin going (she just had two fabulous midwives, sitting in her room with her because it was a quiet day), we got her out of the bed and let her sit on the toilet for awhile, let her walk a little bit, but eventually she wanted to get back into the bed, so we helped her back into bed and then helped her roll side to side every 20 minutes or so. Position change is a key to managing OP birth, as I’ve been learning; just keep changing position, and eventually the baby will slowly rotate and work its way into an anterior position (that’s the hope, anyway). Luckily, the tracing was beautiful—we couldn’t have asked for a nicer tracing, with these huge, reassuring accelerations into the 170s with almost every contraction—so we weren’t under a time crunch to get the baby out quickly. Everything was going smoothly, just slowly.

Then, once she’d been pushing for about an hour, one of the doctors stormed in (having just finished a c-section) and threw a little hissy fit, right in front of the patient: why is this woman STILL pregnant?!? Why haven’t you started pit? What are you guys doing in here? Start pit! This is ridiculous. Etc. etc. Nevermind the fact that he hadn’t been paying attention to her all day; she was a midwifery patient, and we had been managing her, but now that it was 5:00 pm and he was signing off to the oncoming doctor he suddenly wanted her to have been delivered ages ago (I guess it looks bad to the oncoming doctor that he’s had a patient all day who still hasn’t delivered yet? Again, this is part of the hospital pressure mentality which says “as soon as you’re admitted to the hospital, you better be moving towards birth, and moving at a pretty regular, pretty rapid pace”). This doctor kept saying: she was 6 cm at 8:00 am, what are you guys DOING in here?? She should have had her baby already!! etc. etc.

And to be honest, I was absolutely, 100% cowed and terrified. As a new midwife, in my near-constant state of terror, I have very little confidence in myself or my management skills, and unfortunately this translates to a whole lot of fear right now; fear of birth, fear of doing something wrong, fear of making a really big mistake etc. etc. If it had been me alone in that room, I probably would have burst into tears. I had already been wondering to myself if we should have started pitocin. But no, thankfully my preceptor was in the room with me, and she very calmly, tranquilly and firmly told the doctor to chill his pants. She basically said: we’ll start pit if you absolutely insist (he is the doctor, after all), but she’s having an OP baby, she’s making progress, and things are fine and NORMAL in here, so please leave and let us do our thing. And what do you know…he left! And then we started pit (and actually, for what it’s worth, the incoming doctor got into an argument with the outgoing doctor at the board, stating that our patient probably didn’t really need the pitocin. If her contractions were enough to get her to fully dilated, albeit slowly, then they were probably enough to get the baby delivered.) But anyway, we started pit, and she pushed and pushed and pushed. And here, I think if she’d had an epidural, she wouldn’t have been able to push that baby out, but thank goodness she didn’t have an epidural so she could really feel the urge to push with each contraction, and eventually the baby did a long-arc rotation and was born from right occiput anterior at 5:39 pm, screaming his head off, and voila!….a totally normal labor and birth.

Would that birth have been different if she hadn’t had midwives taking care of her? Yes, I think so. Maybe she would have had an epidural, and been unable to push her baby out. Maybe a different provider would not have accepted her slow progress, and started pitocin on her a lot sooner. Maybe someone else would have considered her lack of progress as “failure to progress” and she would have been taken to the back for a cesarean. Maybe if no one had gotten her out of bed, or sat with her in the bathroom while she pushed on the toilet (something the midwives have to do, because the nurses won’t take responsibility for the patient if she’s off the monitor, so unless the midwife is in the bathroom with her or walking with her, they don’t let her out of bed), maybe if she hadn’t been walking and changing position so much, maybe that baby wouldn’t have rotated. Who knows. The point I’m trying to make is that midwifery care, admittedly in a somewhat altered and modified form, is alive and well in a hospital setting. Unfortunately, there are just more rules to conform to, more egos and personalities to manage, more pressure and time-crunch, and there isn’t that lovely, private-practice one-on-one kind of care which is one of the hallmarks of midwifery care in other settings. Is there still a lot of things which can be changed? Yes, of course. Is there still a lot of things which are far less than ideal in our set-up? Undoubtedly. But I think the midwives are giving excellent care to our patients, in the best way we can, and I think it really does make a difference.

A few weeks ago, Dark Daughta over at One Tenacious Baby Mama asked me for a contribution to her new weekly series entitled Reloaded, which happens every Sunday and features old posts that are worth posting and reading a second time (oldies but goodies, as she calls them). She wanted posts that I was particularly proud of, “something that really kicks ass analytically, politically” etc., and I quickly discovered when I was combing through my old posts that I don’t really have much in the analytical/ political/ highly opinionated/ kick-ass vein. It seems that my blogging style overall tends to be of the objective-news-reporting variety, or at best the highly-researched highly-factual variety; in other words, the variety that is so factual and evidence-based that no one can really argue or disagree with what you’re saying; in other words, the risk-free variety. Which is good to know about yourself, I guess, because it then prompts a bunch of really good questions, like: WHY AREN’T YOU TAKING MORE RISKS? Why aren’t there more highly opinionated, highly political, highly analytical, highly kick-ass posts on your blog? What are you scared of? Pissing someone off? Causing controversy? But really…is there any other point to a blog than opinion? If all we’re after is the news, we’ll read newpapers and news sources, thank you very much. Blogs are supposed to comment on things. So, good to know. Note to self: enough with the reporting on things. Get commenting instead. Go out on that limb. It’s about time, don’t you think?

Anyway, I sent Dark Daughta a few posts. One on the Keeper (still one of my proudest feminist and environmentalist statements), one on the UK’s new birth agenda (Maternity Matters), and two on female circumcision (Circumcision or Mutiliation? and Further Thoughts on FGM).

I was curious to see what Dark Daughta would think of them. Leave it to Dark Daughta to not only think about them, but to write an explosive 1000 word treatise as well. She picked my posts on female circumcision, of course, and then ran with them. Ran is a polite word for what she did. More like smacked the posts upside down, flipped them inside out, and then shook all of the loose change out of their pockets. She took everything I had thought after my first encounter with a circumcised woman, and all of the conclusions I had come to at that time (and this had involved a lot of thinking back then, trust me), and managed to turn all of those thoughts, all of those culminations of thought, absolutely, irrevocably, upside down. In the space of just one post. Leave it to Dark Daughta to challenge the hell out of you.

Just a few highlights, here:

Dear Student Midwife:I’m glad that you’re asking yourself questions about how best to proceed. …Maybe examining the culturally based and biased and ofttimes downright racist, response of many privileged feminists who were not born into cultures where genital circumcision is practiced might offer some much needed space inside which there might be less emotionally and politically charged room for a true examination of the issues.There is a power relation here. Are parents in western societies hunted down and denied access to safe male circumcision? Why is the WHO advocating for this procedure when there is a fast growing segment of the male population that is crying out against it?

When male circumcision of babies who can’t make the choice for themselves is enshrined as a part of at least major world religion, are health care practitioners strategizing about how best to stigmatize grown men who present penises that are mutilated? Are feminists of conscience refusing to sleep with men who are circumcized? Are we looking on them with pity and defining them as mutilated? Are we strategizing about how best to divest them of custodianship of their sons so that we can keep them safe from circumcision? Is anyone noticing that the actual side effects of male circumcision…besides those that go horribly wrong…are minimal because these surgeries are done by skilled practitioners in sterile settings?

I don’t agree with either kind of circumcision. But I can’t fail to notice that one is filled with shame and stigma heaped on those who experience it, while the other is thought of as a throwback that should be done away with but is still tolerated and executed in hospitals.

Being useful is definitely not going to include making any circumcized wimmin feel uncomfortable and on the spot about the decisions of their parents. So, labeling a woman’s cuts “mutilations” without checking to see what if anything she says about her own genitalia will go a long way to making a practitioner seem like a judge and not as someone a woman can potentially confide in or turn to.

Because really, the shock and the unfamiliarity with the view below is ours, not theirs. If we’re gonna pay lipservice to accepting the anatomy of the vulva, we’re going to need to work at really understanding and respecting that wimmin come in all sorts of configurations for all sorts of reasons.

This “who is civilized” and “who is babaric and uncivilized” binary split that serves the west/the north, giving our cultures a much needed oppressive ego boost needs to GO!

Yowsa. And those are just the highlights. I’d highly reccommend that you go and read the rest of the post, because she writes with so much passion and conviction, and has this incredible way of phrasing things in ways that I would never, ever think of.

Now, how do you respond to a post like that? I didn’t even know where to start. First I had to do a lot more thinking on the subject, which I’ve been doing for the past several days and nights. I wrote an e-mail response to her, which she published in last Sunday’s Reloaded V which started to flesh out some of my thoughts. And now I find myself here again, having done yet another 180 on the subject (my apologies for repeating some parts of my e-mail, but this is pretty much where my thinking is at right now).

I think Dark Daughta is right on a lot of counts. There is indeed an inherent racism/ oppression in a viewpoint which has decided to call one form of ritual cutting “mutilation” while at the same time leting so many other types of cutting fall under the category of “circumcision” or some other word, and therefore under the umbrella of cultural acceptability (male circumcision, labioplasty, clitoral hood piercing, episiotomy etc.). I can see how that is indeed our culture (and by that I mean western culture) taking its own viewpoint on what constitutes a healthy vulva and setting it forth as “right” and “correct” and that anyone else who does anything different to their vulva (especially something brutal or harmful and something we as a culture don’t fully understand) is therefore wrong and backwards and oppressed and brutalized by their own culture…and that this “mutilation” is therefore a form of violence against women. This viewpoint then lays the groundwork for our invasion of their culture; in other words, this viewpoint basically gives us permission to enter their culture and tell them what’s right and wrong, and that they have to stop this cultural practice. And many huge, big name organizations like UNICEF, the World Health Organization, the US Dept. of State, Amnesty International, USAID etc. etc. have all issued policies and statements which call for an end to this practice, and have programs or policies in place which exist to help educate and save these women from their fate.

Calling something “mutilation” implies, by its very nature, that those who are “mutilated” need to be saved. That makes sense, and I see that now, but I had never before thought of it in those terms. So further thinking on this is prompting me to start to refer to this ritual as “circumcision” again rather than “mutilation”. I do appreciate that my view of what constitutes a healthy vulva is certainly not everyone’s view, and who am I (or who are we?) to decide what is or is not the right kind of vulva? Why is labioplasty or clitoral hood piercing okay, while female circumcision is not? And what would happen if circumcision was done well, by medically-trained people using sterile instruments, sharp instruments, making clean, hygienic cuts? So many of the problems inherent in this practice comes from the scarring and infection which is secondary to the cuts themselves. If there was no scarring, if there was no infection, would the damage be less? As Dark Daughta pointed out, female sexuality stems from a lot more than the tiny nub of flesh which is the clitoris. If the clitoris is removed, but in a clean and precise manner, using sharp, sterilized instruments (rather than a rusty tin can or a piece of glass etc.), would women be able to retain a higher level of sexual functioning? I never, ever would have thought that an underground feminist movement to provide clean, hygienic, medically-trained female circumcisions is not that far off from what feminists were doing in the 70s with their underground abortion clinics to provide clean, hygienic, medically-trained abortions, but yeah, I do see the similarity.

I wrote in a comment on my first post that “I undrstand that there are a lot of cultural and personal reasons involved in choosing [male] circumcision, and I don’t feel like it’s my place to say.” So if I can so graciously back out of the debate when it comes to males, why can’t I do the same with females? To say that these girls aren’t educated about the pros and cons of the procedure, that they’re forced into it by their parents and their culture at a young and vulnerable age (usually at puberty), and that they therefore aren’t making informed consent doesn’t hold up, either, because the same can be said of male circumcision. Baby boys are absolutely, positively NOT making an informed decision when it comes to having their penises cut or not. It’s a decision that their parents are making for them for many different reasons, just as it’s a decision that the culture/ parents are making for the girls who are receiving female circumcision. And I ask again: what right do I have to step in to this decision-making process and tell someone that they’re wrong, or that this decision is wrong? I have no right whatsoever.

Now, before someone comes along and rips into me, let me just make this very very clear: I am not advocating female circumcision, nor am I advocating male circumcision. I am not condoning either practice, nor am I saying that they’re both fine and acceptable, and that they should continue unhindered. All I am saying is that it’s not my place to judge these practices, and it’s not my place to make these decisions. Since I’m not a member of a culture that practices female circumcision, the rich cultural context with which this practice resides is lost on me. The shame or humiliation someone of that culture might feel by not being circumcized and therefore not being a full participant of their culture is something I’m never going to be able to empathize with. And I am questioning whether it is right for our culture (Western culture) to go on huge “Stop Violence Against Women” campaigns in cultures which are not ours, in contexts which we don’t fully understand (and probably can never fully understand).

I do think that these practices need to stop. But I don’t think that the impetus for changing this is going to come from us (from the West), and I don’t think it should. If it’s going to change, it needs to come from within; from women and advocates who are of these cultures, who understand the context, who can see the patriarchy at work in such acts, and who want to rise up against it. And when they do, we as Westerners can and should support them with all of the resources our rich, privileged cultures afford us.

I guess the only sticking point I still have at this point is the following: if you’re a member of a culture, and if it’s all you know, and if you’re never exposed to anything else, you will never have the objectivity necessary to ever question or rise up against these practices that you have seen and been a part of since birth? And maybe that is where an organization can step in and offer education to members of these cultures; ideally, the education should come from members of the culture themselves. I think the folks over at RAINBO are on the right track, and if we as Westerners want to support the education of women (and therefore indirectly the hope that eventually these practices might stop), we can do this by supporting organizations like this.

As far as being a practitioner, the take-home lesson here is once again very simple, and very difficult to fully learn: LISTEN TO WOMEN, and DON’T JUDGE. How is it that I can see this so clearly on issues like abortion, where I absolutely, 100% feel that it is not my place to say, and that since I’m not carrying her baby or walking in her shoes, I have no right to judge at all….and yet issues like female circumcision still bring about huge, heaping amounts of judgement? As a white woman from a privileged background, I’ve been trying for awhile to own my privilege, and see the way that this affects my point of view on everything. This is a difficult, never-ending task, and while I feel that I’ve managed to own this on several more obvious issues, this is an issue I hadn’t even picked up on. I guess the ultimate, life-long goal for every evolving human soul is to continue to move towards a state of less and less judgement. To become as close to non-judgemental as you can possibly be. I say possibly, and “close to” because I think being non-judgemental is an impossible goal. Our psyche, our sense of self, our identities, our culture, our experiences and background and upbringing, everything we use to know ourselves as who we are–all of this is based on judgements which we have formed through living, judgements which we have consciously or unconsciously absorbed, and I think it’s impossible to seperate yourself from them. I am not using this as an excuse. Moving towards a more non-judgemental state requires very close and painful examination of those life experiences and background and upbringing and culture. It requires seeing the ways that your life experiences and culture has potentially prejudiced you, seeing the ways you are privileged, seeing the ways that power affects your identity–power you have, or don’t have, or have in some areas but not others. It requires seeing where you come from, seeing the way that this has formed your world view, and then seeing the way that this outlook affects how you see others. That’s a huge part of becoming less judgemental.

The LISTEN TO WOMEN and DON’T JUDGE take-home message means that all future encounters with women who have been circumcized will involve calling it circumcision, following her cues, and letting her talk or not talk about it, as she desires.

Anyway, those are my thoughts on this subject at this moment in time. Granted, I will continue to think, and I’m sure my thoughts will continue to evolve. I’d be really interested to hear what others think about this as well. It is a very sticky subject, and it’s not about to get any more clear any time soon.