Belly Tales

Forget the Oscars (well, not entirely: Go, Juno, go!); the movie I really want to see is A Walk To Beautiful. Having already won several awards at film festivals around the world, the film follows five courageous women as they travel to the Addis Ababa Fistula Hospital in Ethiopa to find a cure for the obstetric fistulas they suffer from. Fistulas are an opening between the vagina and rectum or the vagina and urethrea which occurs after days and days of obstructed labor. In developed countries around the world, fistulas have become a thing of the past since the advent of cesarean birth (the last U.S. fistula hospital closed its doors in 1895), but in developing countries around the world, it’s still a very grim reality. Incontinent, with either feces or urine dripping from their vaginas, women with fistulas are often shunned by their communities, ostracized and forced to live lives of isolation. The cure for fistulas is a simple surgical procedure, but with access to modern health care often hundreds of miles away, the cure might as well exist on another continent. Just check out some of these facts:

• For every woman who dies from pregnancy-related complications, 20 women survive but experience terrible injuries and disabilities.
• In Ethiopia, there are 59 OB/GYNs and 1,000 midwives for a population of 77 million.
• One woman dies from pregnancy-related complications every minute worldwide; 95% of them live in Africa and Asia.
• More than 99% of The Fistula Hospital patients are illiterate. (The hospital teaches all patients the Amharic Fideles and the Oromiyffa alphabets.)
• Number of patients treated at the Addis Ababa Fistula Hospital every year: 1,200
• Number of obstetric fistula cases occurring in Ethiopia alone each year: 9,000
• Number of new obstetric fistula cases resulting from childbirth occurring worldwide each year: 100,000
• Number of new obstetric fistula cases resulting from childbirth occurring in the U.S. each year: 0.

The movie is playing at the Quad Cinemas in New York City right now, and has recently been extended through February 28th. I’m hoping to see it on Wed., and I’ll certainly write a review afterwards. Good stuff.

(Go Juno, go!)

I cut my very first episiotomy last week. It was my 70th delivery. Somehow, somewhere in the back of my mind I was thinking that my first episiotomy would come after a hundred births, at least….probably more. After all, there are absolutely no advantages to cutting routine episiotomies, and it seems like the reasons you’d actually need to cut one are few and far between. At the same time, I’ve been dreading this for quite some time. Back in January I had a rather scary and traumatic delivery where nearly everything that could have possibly torn on the woman did indeed tear: cervix, perineum (3rd degree laceration), bilateral sulcus tears, clitoris, labia and periurethrea. In retrospect, this had a lot more to do with the woman’s tissue integrity and nutritional status than it did with how I managed (or mismanaged) her birth, but I got some flack from a few of the doctors I work with regarding the blatant lack of episitomy with that delivery (it was a 9lb.13oz. baby, for the record, although none of us were anticipating such a large baby). The woman needed to be brought back to the operating room and sedated in order to complete the repairs, and I was called to the operating room by the doctors to watch some of the repair (I’m not sure if this was their well-intentioned way of teaching me how to do difficult repairs like this, or if it was their way of rubbing my nose in my mistakes, to teach me an altogether different sort of lesson). In any case, the question they kept asking was: why didn’t you cut an episiotomy?

Well, I didn’t cut one because it had never occurred to me that she would tear so badly (and in retrospect, if I had cut an episitomy, I’m pretty sure it would have been a 4th degree laceration rather than a 3rd, especially given how poor her tissue integrity was), and I’ve never seen any reason to cut an episiotomy just because you think it’s going to be a big baby (I’ve seen plenty of 9+ lbs. babies delivered over intact perineums, so why in the world would you actually cut??). Not to mention that the baby delivered so quickly that I barely had time to get my gloves on, let alone pick up a pair of scissors. I told the doctors that I had never cut an episiotomy before. I meant that I had never yet cut an episotomy, not that I never would cut one, but one of the doctors in particular thought that I was stating that I would never EVER cut an episiotomy, ever, and this person was so upset by this that they brought it to the attention of my supervisor. Anyway, to make a very long story short, the cutting (or not cutting) of episiotomies had been on my mind for awhile, and I knew that I would probably end up cutting one eventually, but I wasn’t sure when, and I was dreading it.

Just saying that makes it feel like some kind of rite of passage. Is that really the case? Does it have to be that way? Do all midwives have to cut an episiotomy at some point in their careers? Are there any midwives out there who have never cut an episiotomy, ever? I feel like in the case of hospital midwifery, the need for episiotomies is probably much more prevalent simply because the large number of interventions create more situations which call for episiotomies (and by this I mean situations which truly require an episiotomy, as opposed to routine episiotomies that are cut simply to speed up the birth process, or for convenience sake, etc., although those certainly occur more frequently in hospitals anyway).

I am learning that the trick about obstetrics has everything to do with making the right intervention call at the right time. I think this might be more true of hospital births than homebirths simply because of the time pressures which are always nipping at your heels in a hospital, and the fact that so many interventions are available in the hospital setting v. the homebirth setting, and that each intervention then begets even more interventions in that notorious slippery-slope fashion. In any case, it all comes down to judgement; to knowing when something is needed versus when it’s superfluous, and this is such a delicate skill to learn, especially because the line between necessary and unecessary can be razor thin, and becuase it often fluctuates and changes throughout the birth, so that something which was unnecessary 10 hours ago when the tracing was gorgeous suddenly seems brutally necessary 12 hours later, when the tracing has changed. The judgement comes in anticipating these changes—at least as many of them as can be anticipated (which, given how unpredictable and fluid birth can be…is not actually that many). And of course, your experience affects your judgement, too. If you’ve seen several serious obstetric emergencies unfold before your eyes, if you’ve ever seen a baby or woman die, if you’ve been sued…your judgement calls are going to be very different from those who have never experienced any of these things.

Navelgazing Midwife was recently talking about this in two of her posts: The Myth of the Vertex and The Gray, Grey Messenger: Trust. Part of what you’re relying on in your care provider—be she midwife or doctor—is her judgement. That’s why she’s there. In the case of homebirth, it’s really obvious: the midwife is the guardian watching from the birth from the corner of the room. So long as everything is progressing smoothly, she won’t lift a finger to intervene, but if things begin to slide off the road of normalcy and something more is needed, you really want her to step in at that time and do what needs to be done. Ideally, in a relationship based on trust, if she says “we need to go to the hospital now”, you’ll believe her and trust her and call the ambulance, because you know she wouldn’t even be suggesting it if that weren’t truly the case. The reason she’s there is because she’s seen hundreds (maybe thousands of births) and she knows when things are normal versus when something needs to be done. The Myth of the Vertex in particular speaks to this. Just because the baby’s head is down does not necessarily gaurantee that everything will proceed smoothly to a vaginal birth. When everything doesn’t go exactly to plan, it’s not a betrayal on the part of the midwife, it’s her responding to the changing circumstances of the birth by doing what needs to be done—recognizing the change, and knowing what needs to happen next. That’s her job. That’s her judgement call right there. That’s why she’s there. That’s what you’re paying her for.

I know this sounds very defensive. To be honest, I feel incredibly defensive about this. I feel like I need to stand up on stump and say: I cut an episiotomy, but here are all my reasons for doing so, and I really think it was what was needed at the time. That’s how strongly I feel about episiotomies. It wasn’t a phony episiotomy. It wasn’t cut just to cut one. I feel like I need to somehow justify this act to the woman, her family, the universe. I didn’t want to cut it! But in this situation, I think she absolutely needed one. She’d been pushing for over 2.5 hours, the baby had been sitting on the perineum at +3 station (i.e. the point where the head remains under the pubic bone in between pushes, and crowning is usually imminent) for the past half hour without crowning, and the baby’s heart rate was really starting to reflect the baby’s exhaustion, with variable decels that were deepening with each contraction into the 60s. She was exhausted herself after a long, hard primip labor. She had had some stadol earlier in the labor, but never an epidural, and she was feeling the burn and sting of crowning but couldn’t manage to push the baby past that point. Even after I cut the episiotomy, the baby still didn’t come out right away. We tried the Ritken maneuver, but that still didn’t bring the baby’s head up and out. Finally, in the end she needed a vacuum to help deliver the baby (and if I hadn’t cut an episiotomy, the doctor would have at this point to apply the vacuum).

Ugh. Having just typed all of that out…it suddenly seems pathetic: my sad attempt to try to justify why I cut an episiotomy. I’m sure someone will call me on it and say, bold as brass: she didn’t need one, you were wrong to cut one. Maybe I was. Or maybe I’m making way too big a deal of this? I don’t know why I’m typing all of this out, why I feel the need to hyper-analyze my defensiveness—in essence, defend my defensiveness. I made a judgement call, I cut an episiotomy, I think it was necessary. That should be that. And yet, as a midwife, I view myself as a defender of intact perineums everywhere. I feel like I let this woman down in some way. I feel that so clearly and so strongly, and yet, at the same time I find myself praying that I will always be able to make the right judgement call at the right moment—that in the future, when a woman really does need an episiotomy, I won’t hesitate. I’ll do what needs to be done.

This is a messy post, as Dark Daughta would say. In her book, that’s actually a compliment. I never promised I’d have all of the answers. My response to my first episiotomy has been very complex; it’s kind of taken my by surprise, how much this has affected me. How I feel about it has been varying tremendously from day to day, minute to minute. I promised to chronicle my adventures as a new midwife— the good, the bad, the ugly, the messy….so here you go. I’m still trying to figure out how I feel about this one. It’s all a work in progress.

The American College of Obstetricians and Gynecologists (ACOG) recently issued a Statement on Homebirth which condemns homebirth and all those who are willing to attend homebirth (aka midwives), concluding that only “…the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets the standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.”

Many other websites have covered this topic in exhaustive detail, so I’ll refer you to them in just a moment, but first a few comments of my own. As Rixa rightly pointed out on her blog The True Face of Birth, ACOG’s sudden acceptance of out-of-hospital birth facilities (i.e. freestanding birth centers) flies directly in the face of their earlier November, 2006 Statement on the subject, where they were adamant that the hospital “is the safest setting for labor, delivery, and the immediate postpartum period,” and that “ACOG strongly opposes out-of-hospital births.” I wonder what caused the sudden change of heart? If you recall, during the time, ACOG and the American Association of Birth Centers (AABC) were not on such buddy-buddy terms. In fact, the AACB wrote a scathing denouncement of ACOG’s statement. Opposing out of hospital birth included births that occurred in freestanding birth centers as well as in homes. I guess in deciding to attack homebirth directly, maybe ACOG decided that it would be better off having the AACB as an ally rather than an enemy, and included freestanding birth centers in its list of “acceptable birthing places” this time around. Who knows. There has got to be so much back-room wheeling and dealing and politics involved in all of this that one can only wonder at the motives. But crucially, why must support of freestanding birth centers be at the expense of homebirth?

It’s also interesting to note that the ACNM has yet to issue a response to this. Is that because they’re partly mollified by ACOG’s acceptance of certified nurse-midwives to the exclusion of all other midwives? From the ACOG statement: “For women who choose a midwife to help deliver their baby, it is critical that they choose only ACNM-certified or AMCB-certified midwives that collaborate with a physician to deliver their baby in a hospital, hospital-based birthing center, or properly accredited freestanding birth center.” Making distinctions like that among midwives in our country (CNMs v. CPMs) only hurts our profession as a whole and is going to get the overall profession of midwifery absolutely no where, but I’ve already written about this ad nauseum. And what about the hundreds of Certified-Nurse Midwives/ Certified Midwives who attend homebirths? Dear ACNM: Just because the majority fo CNMs/CMs work in hospitals doesn’t mean that those who work in homes don’t need a response statement from you. You’re still the professional organization for ALL Certified Nurse Midwives and Certified Midwives—even those who perform homebirth. If you won’t stand up for a woman’s right to give birth in a home, at least stand up for the midwives you represent who deliver in homes….even if it means butting heads with your beloved ACOG.

As Rixa conjectured, maybe all of this is indeed in response to Ricki Lake and Abby Epstein’s documentary The Business of Being Born, which has done a terrific job of raising awareness regarding homebirth. The real question we need to continue to ask ourselves is this: Why is it that America, with all of it’s insistence on hospital birth and safety, still has one of the highest rates of neonatal and maternal mortality among developed countries? That question lies at the heart of The Business of Being Born, and clearly, the American way of doing birth, for all its emphasis on hospitals and safety, has not adequately addressed this. What we need is a statement from ACOG more along the lines of the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM), which both jointly support homebirth, in sharp contrast to what ACOG has churned out (kudos to Rixa for finding and posting this in its entirety). Just read the first few lines of the document:

The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.^1–3

What a refreshingly different point of view. Surely American women aren’t that different from British women? Surely our healthcare systems are not that different? Why can homebirth be safe on one side of the pond, and unsafe on the other? Yeah, you guessed it: one side is actually basing its policy on research and fact, while the other is pandering in fear, uncertainty and doubt. And don’t forget the economics at work here. ACOG is a professional organization supporting and marketing the services of its members: obstetricians. In other words, a lobby. Again as the Business of Being Born points out, the bottom line is always the bottom line. If we had a national healthcare system like the NHS, where homebirth actually translates to increased savings, rather than a competitive profit-driven healthcare system and a surplus of obstetricians, we’d probably be seeing a lot more governtment-funded support for homebirth.

This is the line that really sticks in my craw: “The main goal should be a healthy and safe outcome for both mother and baby. Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.” You selfish, selfish mothers, trying to enjoy your relaxing, all-natural births at the expense of your babies! The mother and the baby have become hopelessly estranged in the minds of American medicine, and the emphasis (and increasingly, the legal rights) of the baby are always seen as more important than those of the mother. Rather than motherbaby, where the two are linked and the health and wellbeing (physical, mental and emotional) of one is dependent on the other, we have fetal rights outstripping maternal rights, in courts as well as in hospitals. Why can’t modern medicine seem to get it through its skull: what’s good for the mother is ALSO GOOD FOR THE BABY. The two are not diametrically opposed. When a woman feels safe, supported and relaxed, she’s able to sink into her labor and allow her birth to unfold in the manner that’s best for the baby, without all of the stress hormones and cortisol, without all of the fear….and more often than not, with stunningly good outcomes.

In any case, you should go read the rest of Rixa’s post on The True Face of Birth ASAP: 10 Responses to ACOG’s statement on homebirth, as well as the other responses cropping up around the blogosphere.

I’ve sort of fallen off of the blogging bandwagon, but what’s the point of a blog if you can’t be political with it? So, with that in mind, we now take a break from our regularly scheduled midwifery for this brief political message:

I’m voting for Barack Obama

I like the fact that he’s run a very clean campaign and refused corporate lobby money. I like the fact that he’s an idealist—people try so hard to call him naive and inexperienced because he’s idealistic and hopeful—but why should we vote for our fears rather than our hope? How deliciously refreshing to be voting for a candidate that you actually like: someone who inspires you and makes you hopeful, rather than voting for the candidate that you dislike the least! There’s an excitement and an energy in his grassroots movement which is sweeping the country right now that’s really got me excited, so much so that I’ve actually given money to his campaign. My donation was then matched by another Obama supporter in California, and we’ve since gotten into an e-mail correspondence. I like the sense that his campaign is driven by hundreds of thousands of little guys like me, and that our combined small-fry donations are actually adding up to a lot.

I think this country needs a radical change in leadership, and while I really like Hillary (I’ve voted for her twice as a Senator), she and her husband have been the darlings of the Democratic party for over 20 years now. Clinton ran on an anti-establishment platform of change in 1992, but now he and Hillary have become the establishment. It’s time for some new blood. It’s Obama, not Hillary, who’s most successfully running on Clinton’s legacy of change.

Some of our greatest presidents have had very little Washington experience. Abraham Lincoln served only one undistinguished term in the House before becoming president. “Looking at the 19 presidents since 1900, three of the greatest were among those with the fewest years in electoral politics.Teddy Roosevelt had been a governor for two years and vice president for six months; Woodrow Wilson, a governor for just two years; and Franklin Roosevelt, a governor for four years. None ever served in Congress.” [1] Even Clinton himself came in with gubernatorial experience, but not a whiff of congressional first-hand know-how.

I’m impressed by Obama’s history of being able to unite both sides of the aisle and craft true bipartisan legislation. I like his constancy and his character; when you actually look at his record (short though it might be), you quickly realize that he’s someone who sticks to his guns. I like the fact that he’s been opposed to war in Iraq from the start. I’d much rather vote for someone with good judgement and little experience than someone with lots of experience but judgement calls which they’ve since regretted. “Obama is an inner-directed man in a profession filled with insecure outer-directed ones. He was forged by the process of discovering his own identity from the scattered facts of his childhood, a process that is described in finely observed detail in “Dreams From My Father.” Once he completed that process, he has been astonishingly constant.” [2]

I think Barack Obama is more electable than Hillary Clinton. This is partly because I know many people—Republicans, Independents, and even some Democrats—who don’t just dislike Hillary….they DESPISE her. I don’t know why, I don’t understand it, but I know that it’s a very personal, deep-seated hatred, and that many people feel this way about her. My number one goal is to get a Democrat in office as the president, and I feel that a Hillary nomination will be a blessing in disguise for the Republican party. They’ll sling mud, they’ll get dirty, they’ll draw upon that strange RABID Hillary hatred, and maybe they’ll win because of it. I don’t want to give them that chance. I think that Obama has the potential to reach out and win the vote of not only Democrats, but Independents and *even* some moderate Republicans. He’s running a campaign that’s trying to beat the Red State/ Blue State mentality, which isn’t something that Hillary (who’s too firmly entrenched as a Democratic bastion) can transcend. As for the question of whether or not he can withstand the Republican mud-slinging machine….well, Hillary hasn’t exactly been kind to him, but she hasn’t been able to dig up anything on him yet. Maybe because there ISN’T anything to dig up.

Finally, I don’t think it’s possible for America to fall much lower in the esteem of the international community. We need a new face, a new message to be sending to the world to redeem our great country from the ravages and stupidity of the Bush years. I feel that Obama, as a relative unknown, is best poised to start with a clean slate in the opinion of the world. Barrack HUSSEIN Obama—fathered by a Kenyan, growing up in Hawaii and Indonesia, attending a Muslim high school—offers an opportunity to rebrand the face of America in the eyes of the world which Hillary just can’t match. [3]

I like Hillary. When this election started last year, I was pretty certain I was going to be a staunch Hillary supporter to the end. The fact that I’m voting for someone else instead really surprises me. I’m a strong feminist, and I do think the time is ripe for a female president. However, I don’t think she’s the right candidate. I think she’s more divisive than unifying in this current climate, and I think the Republicans will have a field day with her record and her history (anyone in the mood for an ugly recap of the Monica Lewinsky affair or WhiteWater? I’m certainly not!! ). I think Obama offers a new start and a new opportunity to actually get beyond the partisan divide which has been the crux of Baby Boomer politics. If Hillary ends up winning, I’d be happy to vote for her in the general election, but I think Obama is the better choice.

So there you go: that basically sums up why I’m voting for Barack Obama. I’d love to hear your thoughts on this!! Who are you voting for, and why? And if anything I’ve said helped tip your hat into the Obama ring, go give him $20 at www.barackobama.com and join his grassroots movement—you too can have your donation matched by someone in another state who is believing, just like you.

[1] NY Times Op-Ed 1/20/08

[2] NY Times Op-Ed 12/18/07

[3] The Atlantic: Goodbye To All That