Empowering Birth in the Trenches

When we think about empowered birth, we most often think about women going outside the system and choosing homebirths or unassisted births.  We think about women who experienced a traumatic birth with a prior pregnancy and are now determined to do it differently.  We think of finding the power and strength necessary to avoid interventions in our high-tech low-touch hospitals.  We think of choosing to birth free of drugs and medications, and welcoming our babies into this world in the softest and safest ways possible.  And certainly, all of this IS empowering, especially since it flies in the face of a birthing industry which has forgotten how to trust both women and birth.  However, when we broaden our definition of empowerment, we can suddenly see that strength and joy and beauty can still be found in even in the trenches of the hospital system, and that empowerment can mean very different things to different people.

Cases in point: as a midwife working in an urban hospital with an under-served, medicaid-only population (some of New York City’s most vulnerable women), empowered birth doesn’t come in the usual trappings.  By and large, we’re not dealing with women who’ve been doing their research and know exactly the kind of birth experience they’re looking for.  The method of delivery, the type of interventions used or not used, the provider attending their birth, the setting, the soul-changing journey that birth can be is often of little importance compared to the much more immediate problems many of these women face: not enough food on the table, abusive partners, unstable housing situations, older children who are uncontrollable, substance abuse, peer pressure, high school (we all know how difficult high school can be!), minimum wage jobs which often involve intense physical labor or oppressive conditions, illegal status…the list goes on and on.  As a midwife working in this hospital, birth plans are not something I’m seeing a lot of (although I have seen one or two!).

And of course, this is a hospital, bound by all of the usual, myriad hospital rules and regulations, some official, well-researched and evidence-based, others unofficial and absolutely asinine.  There are 18 midwives in our practice at this hospital, but we’re employed not because the demand for midwifery care is so high, but because the hospital finds it more cost-effective to hire midwives instead of doctors (midwifery care saves money, after all).  And while it’s a very good thing that our hospital doesn’t have a residency program, the sad truth is that we midwives basically function like residents; we do the majority of the triage, the majority of the admissions, and we’re the ones managing the floor, more or less (in collaboration with our attending physicians, of course, although many of our attending physicians are more than happy to wait in the wings and let us do the bulk of the work, which has its advantages and disadvantages).  I’ve written about this type of hospital midwifery many times before in the past, and it certainly does present its own unique set of challenges and compromises. Nevertheless, empowered birth CAN and DOES happen in this setting, all the time; this is what it looks like:

Empowered birth is the woman who decides she doesn’t want an epidural.  Sometimes she had decided this in advance, but very often this happens in the spur of the moment, as the woman is listening to her body and riding the labor wave.  Sometimes this is decided in the face of (sometimes extreme) family pressure.  I have attended births where the father of the baby or the patient’s mother or some other family member will seek me out repeatedly to tell me that the patient wants an epidural.  This is most often well-intentioned, since the family member doesn’t want to see the woman in pain, but when I go into the room and actually talk to the woman about it, I hear a different story. She’s working hard, but she’s not ready for the epidural yet.  Or, are there any other options besides the epidural?  (In which case, we talk about other analgesics, like stadol, or position change–getting into the rocking chair, for example, and off of her back).  I have been accused by family members many times before of being unfeeling, cruel, selfish, uncaring, but I’m always quick to point out that they’re not the ones in pain, and it’s not their decision to make.  Of course, I’ve also seen this in reverse: a family who’s dead-set on a woman having a natural birth, but a woman deciding that she’s had enough, and would, in fact, like an epidural.  And again, the same rules apply.  If she’s not coping well with the pain, if she feels like she’s at her limit (whatever that limit might be) and would like some relief, she’s welcome to it, even if her family is telling her that she doesn’t need it.  Empowered birth is helping a woman to have what she feels is the best pain coping method for HER birth, and helping to protect her decision, even when no one else in the room agrees with her choices.

Empowered birth is a woman deciding that she would like to have a VBAC, and finding a way achieve this goal come hell or high water.  I like to think that our hospital has a pretty successful VBAC rate, and all of our attendings are very supportive of VBAC (though not always the most patient with a VBAC-ing woman, when push comes to shove), but one of the biggest challenges we face is the fact that our hospital requires a copy of the operative report from the woman’s prior cesarean in order to ensure that her uterine scar is low-transverse (i.e. horizontal), as opposed to a classical (vertical) incision, which has a much higher rate of uterine rupture.  Many of these primary cesareans were done in foreign countries: Honduras, Haiti, the Dominican Republic, Mexico, Poland, Bangladesh, Egypt etc. etc.  Getting a copy of an op report is a laborious process which often takes several months to obtain.  First the woman has to contact her existing family members in her country of origin, who then have to trek out to the local hospital and go through the medical archives to find the report (if it can even be found!), and then send it to either the woman, or to our hospital.  This requires a great deal of time and explanation during prenatal care devoted solely to finding of the op report.  I have had patients go through this finding and obtaining process again and again.  One patient brought me a copy of a report (all in Spanish) which detailed her stay at the hospital after her cesarean but said absolutely nothing about her actual uterine scar.  After translating the report and going through it with her, I told her that she’d have to ask her family to go back to the hospital again and find the actual notes from her surgery, as written by the doctor who had performed it.  Which she did, bringing in the correct report just days before she actually went into labor.  Empowered birth is when this woman is so determined to have a VBAC that she’s more than willing to jump through all of these unfortunate hoops, and then empowered birth is watching her successfully deliver her baby vaginally just a few days later.

Empowered birth is watching a fifteen year old (wo)man up to the task at hand and finally do what has to be done to birth her child. Sometimes this comes only after hours and hours of watching her run from the pain, or refuse to push, or throw the equivalent of an adolescent temper-tantrum; sometimes it’s impossible for her to think about anyone or anything else besides herself for most of the labor. And yet, inevitably, there comes a point in the labor when she realizes that she is the only one who can get herself out of her current predicament, that there’s no other way out except to actually hunker down and do the work.  Empowered birth happens when she finally realizes she’s the one who has to rise to the occasion, and then watching her do exactly that.  And sometimes it comes as a complete surprise—adolescents you’ve cared for during their pregnancies who have been needy, high-maintenance, low-pain-tolerance drama queens can sometimes turn around and  completely bowl you over by their grace, maturity and strength during birth.   Empowered birth is learning (again and again and yet again) to NEVER underestimate an adolescent, just because she is young, and to always trust her.

Empowered birth happens in our hospital when, after a long, two-day induction for oligohydramnios, a woman decides she’s finally had ENOUGH of the wise-cracks and mean comments and general lack of support from her partner, and insists that he leave the room. Empowered birth is that woman claiming her right in that moment to be surrounded only by people who are helpful and supportive of her. And as the midwife in this situation, this sometimes means calling hospital police to make sure that the unwanted party isn’t allowed back in, or providing hospital police with a copy of a patient’s order of protection to make sure that unwanted “guests” can’t just drop in unexpectedly.  Empowered birth happens every time a woman demands nothing but respect and support during her birth.

Empowered birth happens in operating rooms during necessary cesareans when a woman is 100% present while giving birth.  It happens when her face lights up at the very first sound of her baby’s cry.  It happens when she insists on having her baby close to her immediately, with either the partner or family member or midwife holding her baby up to her face so that they can look each other in the eye for the very first time, despite the disapproving look and pursed lips of the anesthesiologist.  Empowered birth even happens afterwards, when she breastfeeds that baby shortly thereafter in the recovery room.