As an example, very recently for me I had a baby who needed full-on resuscitation after the delivery, and I was absolutely shocked and baffled by it.  It was a full term baby, we’d been continuously monitoring the heart the entire time she was pushing and everything was looking good (up to the last few minutes when the baby slipped under the pubic bone and it become incredibly hard to pick up the fetal heart rate…and granted, a few minutes can make a big difference if the baby’s heart rate was decelerated during those minutes, but overall the tracing had been very reassuring).  She wasn’t even pushing for that long, you would expect everything to turn out well, or at least expect the baby to pick up very quickly after some drying and stimulating….and yet, shockingly, the baby came out blue and needed not just positive pressure ventilation with a bag and mask, but chest compressions as well (which you only have to do if the fetal heart is less than 60 and isn’t picking up, and which most babies rarely ever, EVER need; prior to this delivery, I had seen chest compressions done only two other times in my 8 year career as a Labor & Delivery nurse and now midwife).  The Apgars for this baby were 1 at one minute of life (which means the baby had a pulse, and that was it), 4 at five minutes, and 7 at 10 minutes (which is certainly a decent enough score, if not absolutely perfect).   It was a full three minutes before the Peds team arrived on the scene; I was ventilating the baby while the nurse did chest compressions.  And thankfully, in the end everything turned out well; we resuscitated the baby, the baby recovered nicely and went home two days later perfectly normal, but nevertheless, it was absolutely terrifying.  Afterwards, as we were recovering and debriefing and waiting for our own heart rates to return to normal, the only issue we could see was that the mother had had chorioamnionitis (an infection of the amniotic cavity), and one of the attendings pointed out that he has sometimes seen chorio do that to a baby before.  It wasn’t something I had ever seen before, and chorio had never been something I had routinely called pediatricians to a delivery for in the past, but now it gave me pause.  And the next time I had a woman pushing with chorio (only about a week later), you can be damn sure I called Peds to the delivery, well before the baby actually came out.  With that birth, everything was fine, the baby was pink and vigorous with Apgars of 9/9, and the pediatricians were  wondering why I had called them for something as routine as chorio.  I called because personal experience had made me cautious, and has temporarily changed the way I practice.  The next time I am pushing with a woman who has chorio, I may decide to call Peds again, or maybe I will decide to wait and see.  I suspect that gradually over time it will become less scary again, and become more integrated into my overall practice, but I will always and forever add chorio to my mental check-list of reasons why we may need Peds at a delivery, and will probably make the call based on several factors, like 1) how long has she had chorio, 2) how long has she been pushing, 3) how has the tracing been overall, 4) how high has her fever been etc. etc.   And a full-on resuscitation is now always going to be one of the possibilities I consider with a woman who has chorio (although technically it’s something we’re supposed to always consider with every delivery, and it can and does happen out of the blue sometimes for no apparent reason at all); always, always, from here on out.

But personal experience isn’t always negative, or built upon bad outcomes and our responses to them.  I was writing to a friend the other day about how my practice as a midwife has changed now that I’ve given birth myself, and I also find this very interesting to stop and reflect on a bit.  The most obvious change I can think of is how I handle women in early labor/ prodromal labor. This comes from my own experience of an endless early labor which lasted for nearly 2 days.  I think in the past I was a bit more terse with women coming in to the hospital in early labor, only to be sent home again because they were only 1 or 2 centimeters dilated.  They weren’t in active labor yet, and that was that.  Which isn’t to say I wasn’t sympathetic and sweet about it, but I didn’t spend nearly as much time talking with and encouraging these women as I do now.  Now my heart goes out to them so completely because I can so well remember what that’s like.  It’s not like my contractions were irregular and mild—they were strong and regular and painful to me, at the time.  Albeit they were nothing compared to the contractions that were yet to come, but since it was my first time laboring, I had no idea of what was yet to come, and in the beginning, the early labor contractions were PAINFUL.  I spend so much more time with these women than I ever did before in triage, going through what’s normal and what’s not, reassuring them, talking about what (limited, because nothing really helps that much) comfort techniques they have at their disposal.  I’m even more patient with them, and even more understanding.  In this regard, I think empathy is quite valuable–which isn’t to say that you can’t be a good provider if you haven’t gone through it yourself—but I do think it adds another layer to my care which wasn’t there before.

Strangely enough, though, if I’ve become much more patient with women in early labor, I’ve become much more practical and maybe even a bit tougher when it comes to second stage.  In the past, having never pushed a baby out before, and having no idea what that actually felt like, I was incredibly sympathetic to the agonies of pushing.  I would allow women to say things like “I can’t” again and again during pushing while I calmly and unflaggingly told them again and again and again that they could.  For me, this was the epitome of midwifery care—this spoke to the very root of my calling, helping women to find their own strength in the moments when they were convinced that they had no strength left, helping women to climb the mountain that they thought they couldn’t climb.  However, having now pushed out a baby myself, I feel like I cut to the chase much more quickly during the pushing phase than I ever used to in the past.  I can remember just how excruciating the pushing was, and I know all too well that there’s no cure for the pain except to GET THE KID OUT, and I no longer hesitate to use tough love to help women buck up and PUSH, or hunker down and PUSH, or get to work and PUSH, if it seems like that is appropriate and will be effective.  It’s become another tool in my arsenal.

Granted, there is a time and place for everything, and there are certainly some women who will always need a softer touch, and as a midwife you are always acting like a chameleon; in a way, that’s the hallmark of what good midwifery care is.  Because women are so different and because labors are so different, what works in one situation doesn’t work in another situation. There is no cross-the-board answer.  I can get away with saying something with one woman which I would never dream of uttering with another woman,  based on my personal relationship with that woman, and on who she is and on what is needed minute by minute.  And often the situation itself dictates the tone; sometimes the energy in the room is very high, and you can joke around and be loud and loving and teasing, other times the mood is very subdued and quiet and she is working hard and inwardly focused, and what is needed is a soft touch or a single word.  You have to know how to surf the different energies at different times.  But now, thanks to my own personal experience of birth, I try to get women through second stage as efficiently as possible, to try to keep the pain from being drawn out longer than it needs to be.  Because man oh man is it painful!

Experience can be both a blessing and a curse, but it’s all of these little moments strung together which makes you a better provider.  This is the reason you seek out providers who’ve been doing this for awhile, who’ve seen the good, the bad and the messy, and have learned how to integrate it into their larger view.  For all my midwife sisters out there, how has your personal experience changed you?

This meta-analysis (Maternal and newborn outcomes in planned home birth v. planned hospital birth: a metaanalysis) by Wax et. al. (also known simply as the ‘Wax study”) is not new.  It came out last September in the American Journal of Obstetrics and Gynecology (AJOG), but the reverberations of this controversial study are still being felt in the birthing community today.  As mentioned above, the flaws in this study have been discussed on numerous blogs and in numerous articles, so there’s no need to re-hash the entire argument here. (For further reading on this, though, check out the following links: Science and Sensibility, Our Bodies Our Blog, Science Based Medicine, Nature, ACNM’s response, Midwifery Today’s response).  To sum it all up, though, I quote from Michal et. al., Planned Homebirth v. Hospital Birth: A Meta-analysis Gone Wrong:

The statistical analysis upon which [the Wax meta-analysis'] conclusion was based was deeply flawed, containing many numerical errors, improper inclusion and exclusion of studies, mischaracterization of cited works, and logical impossibilities. In addition, the software tool used for nearly two thirds of the meta-analysis calculations contains serious errors that can dramatically underestimate confidence intervals (CIs), and this resulted in at least 1 spuriously statistically significant result. Despite the publication of statements and commentaries querying the reliability of the findings, this faulty study now forms the evidentiary basis for an American College of Obstetricians and Gynecologists Committee Opinion, meaning that its results are being presented to expectant parents as the state-of-the-art in home birth safety research.

And that’s really the crux of the issue right there: ACOG has based their most recent home birth committee opinion paper on the Wax findings, despite the fact that the Wax study is so controversial, and has been so loudly contested.  ACOG seems to take the Wax study as gospel truth: “Published medical evidence shows [home birth] does carry a two- to three-fold increase in the risk of newborn death compared with planned hospital births.” (i.e. the Wax findings).  But as you can see above, the Wax findings are anything but conclusive. Couple this with the fact that a recent study in the current issue of Obstetrics & Gynecology (ACOG’s very own publication, aka the Green Journal) found that two-thirds of all of ACOG’s practice guidelines have no basis in science, and we have a very serious cause for alarm.  As one of the letters to the Editor at AJOG pointed out in regards to the Wax Study,  this is the dangerous practice of communicating bad science to the public.  To quote liberally from this letter to the Editor:

These practices are unethical, causing harm through unfounded confusion and fear, and misleading policymakers and the public. The Singapore statement on research integrity represents the first international effort to unify policies, guidelines, and codes of conduct for researchers worldwide.⁴   Accordingly, the AJOG publication would fail on 2 counts: (1) poor quality of the study; and (2) author recommendations made beyond what the data support and outside of their professional expertise. Obstetricians are not the leading professional group in home birth and midwifery-led care, and should not reach policy conclusions in isolation. It is essential to use appropriate subject peer reviewers: in this case midwife and epidemiology experts in studies examining midwifery care and birth setting.

Obstetricians have never been the experts on home birth.  In my own personal experience, I cannot think of a single obstetrician who has even seen a home birth.  Nevertheless, as Melissa Cheyney writes in the  Huffington Post (Why Home Births Are Worth Considering), the Wax study is only serving to fan the flames between the obstetrical/ medical community and the home birth community (I purposely refrain from saying the homebirth/ midwifery community, because I feel like midwives can and do and SHOULD straddle the gap between the home birth community and medicine, offering high-touch, low-tech intervention as we do, and advocating for all women, everywhere, regardless of their birth choices or location of birth).  When home birth is seen as more dangerous than hospital birth by obstetrical “experts”, what then happens to the women and families who still choose to have a home birth?  Are they considered crackpots and lunatics endangering the lives of their babies?  What happens if they need to transfer to a hospital?  What happens if they need to transfer to a hospital but the midwife is reluctant to make the transfer based on the stigma and ostracizing treatment she and the family will receive in the hospital setting?  Will the barriers to midwives choosing to attend home births continue to rise so high that ultimately they can no longer provide this service? And if that happens, where does that leave the women who will still choose to have a home birth anyway, without any medical provider available to attend them?

So long as ACOG’s opinion on home birth continues to be based on poor science, we’ll continue to move further and further away from what this country truly needs: an integrated model of care, where women who choose home births and the midwives who serve those women are backed up by obstetricians and the medical model of care, allowing for safe transfers when needed without stigma, judgement or blame.

I caught three babies on Friday.  The first woman was already 6 cm dilated when I got onto the floor.  She had just arrived, and had already been brought into a birthing room, knowing that it was her third baby and that things were moving fast.  She was groaning and sweating when I entered the room.  She was by herself; her husband was at work and her sister was at home watching her other two children.  My heart instantly buckled at the thought of being alone during birth.  There is NO WAY I could have made it through my own birth alone.  I sat on the edge of her bed and didn’t want to leave her side (and thankfully, things were progressing fast enough that there was no time for me to be pulled in any other directions).  The sights and sounds of labor instantly took me back to my own very recent birth.  It was almost visceral.  I could almost feel it in my body like a phantom pain.  She looked at me with the slightly panicky eyes of transition, and I could instantly remember my own transition, vomiting over the edge of the birth tub, sweating and shivering at the same time.  For a moment I wasn’t sure how to even help her; I felt like any comforting words are so inadequate compared to that pain.  But she wanted me to do something, so we talked briefly about what her options were.  Pain medicine, or just getting the labor over as quickly as possible.  She just wanted to be done with it, so I broke her water.  We barely had enough time to get the birth kit open before the baby’s head was visible on her perineum.  Three good pushes and the baby was out at 8:38 am, a 7 lb healthy little girl with a strong cry and a head full of hair.  The mother hadn’t known the sex of the baby in advance, and she wanted the father to help her pick out the name.  She cradled her baby but unfortunately couldn’t breastfeed her immediately because we didn’t know her HIV status (somehow this test had been missed during her prenatal care!) and per hospital policy she wasn’t allowed to breastfeed until the results came back.  I left the two of them bonding and stepped back out onto the craziness of the floor.

The second delivery happened at 3:48 pm.  This mother was a thirteen year old girl who looked as if she were 21.  Her half-sister and mother were in the room with her, and had been with her for nearly 24 hours.  She had come in the day before with sky-rocketing blood pressures, and was currently being induced for preeclampsia.  She was on magnesium, and had been making very slow progress.  When I first examined her in the morning (shortly after delivering the first baby), she felt to be about 5 cm dilated, which was exactly like her last exam four hours ago.  This wasn’t the kind of situation where we could tolerate a slow and meandering induction; the cure to preeclampsia is birth, and we needed her to deliver sooner rather than later because her blood pressure was a bit scary: 160s over 110s (so high that we actually administered 5 mg of hydralazine at the start of the shift to try to stabilize her somewhat).  The attending suggested that we break her water to try to get her labor going, but I thought pitocin might be a better option.  Yes, a midwife pushing pitocin!  However, with a slow, drawn-out induction, I felt like breaking her water at only 5 cm was an invitation for an infection, and that there were other ways to encourage her progress without taking that route.  In my limited experience to date, I feel like breaking the water in a multiparous woman who’s clearly progressing quickly is a sure-fire way to speed things up, but in an adolescent primip, there was no guarantee that breaking her water would do anything.  I argued my case and the attending agreed.  We began pitocin and left her water intact.  She didn’t want an epidural, but she took some stadol twice to help her cope with the pain, and around 1:00 pm when I reexamined her she was 7-8 cm dilated, and the baby’s head had moved down considerably.  I broke her water at that point, and she began to feel like she needed to push around 2 pm.  I checked her again, and hallelujah, she was anterior lip.  We tried some different position changes to try to encourage the lip to recede (including hands and knees–the beauty of no epidural!), and around 3:00 she felt like she had to go to the bathroom (music to a midwife’s ears) and wasn’t able to stop herself from pushing.  She began to push, and almost immediately you could see the baby’s head.  We pushed for about 40 min, and she truly was a superstar, giving birth to a healthy 7 lb 4 oz baby boy!  I kept forgetting that she was only 13 years old, such was her maturity and resilience.

The third delivery happened at 7:31 pm.  This was a woman whom I had been taking care of all day, but I wasn’t sure I would be the one to deliver her.  Her water had broken the night before, and she was contracting on her own when I first arrived onto the floor in the morning.  I only checked her twice during the day.  Once around 10:00 am (she was 3-4 cm dilated at that point) and again at around 4:00 pm when she decided she wanted an epidural (she was 5-6 cm at that point).  Shortly after the epidural, while I was up to my neck in triage, her nurse called me because she was having an excruciating headache.  I couldn’t figure out what could be causing such sudden and extreme head pain aside from the very recent epidural (and I did call the anesthesiologist to have him come evaluate her, since a spinal headache is a known complication with epidurals).  She had asked her family to darken the room, and when I walked in she had a washcloth over her eyes.  Her blood pressures were also rising, so I asked her nurse to draw some preeclamptic lab-work on her just to make sure it wasn’t that (photosensitivity and headaches are some of the toxic symptoms of preeclampsia).   While we were waiting for the anesthesiologist to show up to assess the headache, she began to feel like she needed to push.  I didn’t want to examine her again (with prolonged rupture of membranes, the fewer exams the better), but it was pretty obvious that something had changed and the labor was going much more quickly all of a sudden.  She felt like she needed to vomit, so we quickly got a bucket under her; her family fed her ice chips and fanned her face.  This was getting on towards the end of the shift, and by that point our triage room was overflowing, with pregnant women pacing the hallways and filling chairs in the waiting room.  I left her to return to triage, only to be called back by her nurse again about 10 minutes later.  When I walked into the room, the nurse was hastily opening up the birth kit, and the head was visible on the perineum (so much for checking her again….clearly she was fully dilated!).  It was one of those deliveries where I barely had enough time to get my gloves on before another healthy little boy joined us earthside, all 9 lbs and 7 ounces of him!

The rest of this woman’s delivery proceeded normally; the placenta came out without any fuss, and I repaired the tiny 1st degree laceration that she had.  Amazingly, her terrible headache also seemed to miraculously disappear as soon as the baby was out, which was a big relief, since spinal headaches are miserable (and preeclampsia isn’t much fun, either; we sent her bloodwork anyway, just to be on the safe side). However, there was a thin but steady trickle of uterine blood which wasn’t stopping, despite the usual postpartum pitocin in the IV bag.  We emptied her bladder with a straight catheter (sadly, when there is an epidural on board, most women have a really hard time urinating on their own), and by compressing her fundus, I was able to extract another 300 cc of clots.  I thought this would do the trick, but the slow trickle of blood would not let up.  This was around 8 pm (shift-change time).  I was exhausted, my own breasts were sore and in desperate need of being pumped (I had only had a chance to pump once, at 10 am, such was the business of my first day back!), and I hadn’t had a bite to eat or drink since noon.  We gave her 1000 mcg of cytotec to try to stem the bleeding, and while her fundus firmed up nicely with this medication, it was still very high in her abdomen (well above her belly-button) which made me suspect that there were still lots of clots inside which needed to be removed before her uterus could contract down like normal and stop trickling.  At this point I called the attending, and thankfully one of the fresh night-shift midwives stepped into the room to help out.   I gave report to the oncoming midwife, who gowned up and put on a pair of sterile gloves, and thankfully took over.  I *hate* to leave a delivery unfinished like this, but it was already 8:30 pm, I felt like my breasts were about to explode, and with my husband away for the weekend, there was no one to relieve our son’s babysitter except for me, so I had to get home asap (as it was, I was an hour late).  When I stepped out of the room, the attending and new midwife were beginning to explore their options in terms of stopping the trickle.  Later that night I received a text from the midwife who had taken over, and in the end, it did indeed turn out to be a bunch of clots which needed extracting.  Apparently, everything had turned out well once those pesky clots were out of the way.

I came home sore, exhausted, exhilarated and desperate to see my little baby boy (who was sound asleep by the time I got home)!  I had never been apart from him for longer than 4 hours since he was born.  Being away from him for a solid 14 hours was a real shock to the system!!!  In a way, I am very grateful that it had been such a busy, crazy day, because it didn’t give me much time to dwell on how much I was missing him, and our babysitter thankfully sent me text pictures and updates throughout the day, which eased the pain of separation somewhat.  I crept downstairs into our bedroom and spent at least 10 minutes staring at him in silence while he slept, just soaking up his sweet, peaceful face.  Then I tip-toed back upstairs to pump.  I nearly fell asleep while pumping.  It’s been awhile since I had had such a hectic day.   Overall, though, it felt really good to be back to work again, and I felt so honored to be attending births once more.  This will definitely take some getting used to, though–a new routine, as both a midwife and a mother.

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I believe that the act of giving birth is in itself empowering, and that birth is capable of transforming a woman even if there wasn’t a lot of forethought or planning put into the where, why and how of it.  When we widen our gaze and look at all the ways that women can be empowered even in situations which don’t, on their surface, look like they are, we see that empowered birth comes in all shapes and sizes, just like women do!  Empowered birth happens whenever a woman decides: this is my experience, my birth, my baby, MINE, and I claim it.

The Empowered Birth Blog Carnival was lovingly hosted by Child of the Nature Isle and Betsy Dewey

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We invite you to sit, relax and take time to read the excellent and empowering posts by the other carnival participants:

Empowered Birthing – Amy at Anktangle shares a simple list of things that support an empowered birth experience.

Little Miss Green’s Home, Water Birth Story – Mrs Green at Little Green Blog shares her (home, water) birth story. Even though it happened 10 years ago, the empowering feelings are the same to this day (and yep, it STILL makes her cry!). This post is also a tribute to her husband who was there mind, body and soul throughout.

Save Birth, Change The World – Toni Harman, mum and film-maker talks about the highs and lows of creating the ONE WORLD BIRTH film project dedicated to helping more women around the world have empowered births.

12 Steps to an Empowered Natural Birth – Terri at Child of the Nature Isle wants to talk to all pregnant women and tell them YES they can have an Empowered Birth! This is her personal 12 step guide.

The Blessingway: a sacred blessing for birth – The Blessingway is a sacred ceremonial circle of women gathered with the intention of blessing and preparing a pregnant woman and her child to give birth. Betsy Dewey describes the beauty and the how-to of a modern Blessingway.

Informed Birth is Empowered Birth – Darcel at The Mahogany Way Birth Cafe tells us why it’s important to take control and be responsible for our own births. She says Informed Birth is Empowered Birth.

An Empowered First Birth – Zoie at TouchstoneZ follows the path she took to her first homebirth and finds she may not have started out as the best candidate for an empowered birth.

And this one to be published on Sept 12th :
Empowered Birth: From the Personal to the Universal – Zoie at TouchstoneZ questions the criteria for what makes an empowered birth and finds she has to let them all go.

My one hope is that they don’t just focus on birth in the developed world (although, granted, we’re desperately in need of a birth revolution here in the developed world), but also tackle some of the ongoing issues in the developing world, too.  I can’t wait to see what comes next out of this! Viva la revolucion!

However, both Ricki Lake and Abby Epstein admitted that there were several more pieces of the puzzle which they couldn’t delve into due to time constraints in their film, and how they really wished they could.  Now, fast-forward to 2011 and it seems like they’re making good on their promise to continue to explore various aspects of childbirth in America with the upcoming release of a 4 part documentary series which continues where The Business of Being Born left off, entitled (pragmatically): More Business of Being Born.  I, for one, cannot wait to see these films and see the debate continue!!

A few weeks ago, during a prenatal visit, a woman pregnant with twins told me she would love to have a home birth, but did not have the $4,000 cash required upfront to do so. She was afraid of potential interventions in the hospital. After a discussion of her fears as well as potential complications that can abruptly occur in a twin birth, she admitted she would prefer a hospital birth if she could maintain some control over the situation. This is not a woman who cares more about the birth experience than the baby, but she was tempted, and in some ways I can understand her concerns. My cousin’s wife had her twin induction halted at 4 cm because the new obstetrician on call did not do breech extractions for second twins. Her only option became cesarean delivery.

I recently received a phone call from a woman 2 hours away who had planned a home birth for her second baby after having an easy first birth. When the fetus, which was anticipated to be a little smaller, was found to be a breech, the midwife sent the woman to the local obstetricians. They would only deliver the fetus by cesarean delivery. The midwife offered the woman a home breech birth, but admitted she had only delivered one breech (stillbirth) in her career. The woman appropriately questioned the safety of this, and was referred to us. She met the criteria for our vaginal breech protocol, and had an easy vaginal breech birth in our hospital. Unfortunately, this is becoming a rarity. A colleague of mine in another state watched the residents she was supervising emotionally bully a young woman and her mother into a cesarean delivery. The young woman had a rapidly progressing active labor with a normal-sized frank breech fetus. Had the residents been open to the idea, my colleague easily could have taught them how to deliver a vaginal breech.

The running joke in our community is that the only way to get a vaginal birth after cesarean delivery (VBAC) is to have the birth at home. Unfortunately, this is a reality rather than a joke. Our small community hospital, owing to regional liability insurance constraints, stopped allowing VBACs in 2002 after many years of  successfully offering them. This has led many women to risk home birth rather than travel to a tertiary care center to attempt VBAC. I recently counseled a woman against having a cesarean delivery who had a BMI of 52 and who arrived in active labor at over 35 weeks of gestation with two previous successful VBACs. I spent the following months defending that recommendation, despite her considerable operative risks and high likelihood of success.

Recent news and media excitement about the benefits and increased safety of home birth over hospital birth have made the former seem like a very attractive alternative. A growing notion among women in our region, and perhaps across the country, is that hospitals and obstetricians are a more risky option than lay-home midwives for birth. Although my initial reaction is disbelief, perhaps we should look at how we, the  obstetricians, contribute to this trend.

Each of these women deserves an honest discussion about the fetal and maternal risks of each birthing option. However, our lack of experience as obstetricians colored by our fear of liability is narrowing women’s choices, and sometimes motivating them to ignore fetal and maternal safety in an effort not to be coerced into unnecessary interventions. I sense a mounting tension, because many obstetricians do not have the willingness, time, or skills to provide maternal choices.

I believe we are at a crossroad in maternity care in this country, and I am saddened that obstetricians are considered the culprits. Our contracting skill set as obstetric providers, as well as the prevailing risk-adverse culture among physicians and hospitals, have given support to home birth. We can all agree that VBAC, twins, and breech should not be managed at home, yet we frequently demand complete control of the situation and eliminate some appropriate choices in the hospital. I understand that it can be very unnerving to be ultimately responsible for the outcome, as we are, and yet pushed into situations outside of our comfort zones. However, our unwillingness to budge in these situations is causing us to lose the battle regarding what is really important to most obstetricians: safety for mothers and babies.

Certainly, we can be proud of the dramatic decrease in maternal mortality in the last century. But, despite the highest per capita expenditure of health care in the world, infant and maternal mortality rates in the United States are higher than in all of western Europe. We have the third-highest cesarean delivery rate in the world.

According to a recent study, nearly half of all primigravidas attempting vaginal delivery are induced, and half of cesarean deliveries for dystocia are done before 6 cm of dilation, presumably before active labor. It is amazing how many women begging for elective induction change their minds when told it doubles their cesarean  delivery risk.

We need to draw lines around patient safety, but must they be so rigid? Most midwives know from experience that Friedman’s curve is too strict. A recent study validates that knowledge. I sincerely hope it is taken seriously. Expectant management of ruptured membranes at term has been declared unsafe and of no benefit. The study that settled the question did not account for the number of vaginal examinations women received, and group B strep was not treated, both important variables. Most women do go into labor in 24 to 72 hours. The Cochrane systematic review concludes that, because the differences in outcome are not substantial, women need to be given the appropriate information to make a decision. This very rarely occurs in the hospital setting. The Term Breech Study closed the door on vaginal breech delivery even for the lowest-risk women in most obstetricians’ minds (including the residents I mentioned above). This, despite the opinion of the College that it may be appropriate in carefully selected situations. In any case, vaginal breech delivery is not completely avoidable, and should not be relegated to the history books with vaginal delivery for previa and high forceps.

Our mission has become more difficult in the last 20 years as mothers have become older, heavier, and of lower parity. Many women, admittedly, do have unrealistic expectations. Although I am eternally grateful for the obstetric skills I learned in residency, I have been amazed in my 14 years of practice to see much of the dogma I also absorbed disproven with experience and patience (both my own, my colleagues’, and the midwives I have worked with in the hospital setting). Collaborative practice with midwives is a good start, but in order for obstetricians to be more than providers of cesarean deliveries (a thankless and, in most cases, technically simple procedure) we need to have conversations with our patients that are not one sided and allow for true informed consent. Many of the obstetric disasters we have all seen and which color our  perspective (which David Grimes has called “numerators in search of denominators”) are at least in some part iatrogenic if examined deeply enough. That failed induction for convenience with early artificial rupture of  membranes and chorioamnionitis. The first cesarean delivery done at age 15 after 2 hours of pushing with an epidural that then leads to the fifth cesarean years later, and then accreta and life-threatening hemorrhage, are both typical examples. We need to recognize and own those aspects of obstetric management that are driving our skyrocketing cesarean delivery rate but having no positive effect on maternal or infant morbidity and mortality.

Admitting what is truly evidence based versus what is tradition and culture is a good start. It is essential that we offer real choices to our patients. We need to recover and disseminate the skills that make obstetrics an art and a privilege. Seek out mentors skilled in forceps, vaginal breeches, and breech extractions before it is too late. Then learn to be patient, so that you very rarely need to use them

I find this letter to be very brave and commendable, and while this may sound strange, I am actually really proud of ACOG for publishing it in the first place.  Kudos to Dr. Fineberg for writing this, especially given that she may very well experience a backlash from her colleagues for even suggesting that VBACs, vaginal breech deliveries and vaginal twin deliveries (with breech extraction for the second twin) are things which OBs should be offering their clients, let alone her suggestion that OBs may be partially responsible for driving women with complications to seek homebirth in the first place.

Even more fascinating to me, though, are the commentaries which are going up on The Unnecesarean right now, all written by a collection of different obstetricians who are willing to step forth and give their unvarnished opinion on the true state of things (and huge kudos to them, as well!).  Here are links to their articles:

Lamenting the System, by Dr. Jill Arnold

Lament in Stereo, by Dr. Lauren A. Plante

A Comeback for VBAC?, by Dr. Poppy Daniels

Another Obstetrician’s Lament, by Dr. Gustavo San Roman

An Obstetrician’s Hope, by Dr. David Hayes

The VBAC comments I found particularly compelling, given the sorry state of VBACs in this country right now (see my post below on the new NIH Consensus Guidelines).  The sad truth is, VBACs are no longer being offered as a viable option simply because of politics and a growing culture of fear (aided by our culture of litigation) which states that just because uterine rupture is (occasionally, super rarely) possible, there needs to be 24-hour on-call anesthesia, and an obstetrician on-call ready to brandish a knife at the drop of a hat…and because of this (occasional, super rare) risk, it’s better to not offer VBACs if you don’t have these emergency measures in place.  Nevermind the increasing risks associated with repeat cesareans, the growing rate of cesarean complications, placenta percreta/ acreta etc. etc.  But Dr. Poppy Daniels has addressed this on The Unecessarean more eloquently than I have time to right now, so I’ll let you follow the links.

Besides, I have much more exciting news to share! Stay tuned for a very personal birth story, coming up next!

A consensus panel of 15 non-advocate representatives (i.e. not lobbyists) from different disciplines (obstetrics, gynecology, pediatrics, maternal and fetal medicine, midwifery, clinical pharmacology, medical ethics, nursing, anesthesiology, risk management etc. etc.) got together and performed a thorough literature review and listened to presentations by experts, and then drafted the consensus report, posted above.  Pretty nifty, given the amount of information they had to wade through, and the fact that not all of the research available is good research.  I really liked the fact that the statement divides all of its research up into “High Grade of Evidence”, “Moderate Grade of Evidence”, “Low Grade of Evidence” and “Insufficient Evidence”.  My only complaint is that there isn’t actually a reference list at the back of the statement, and none of the research papers they are discussing are actually cited, so it makes it much harder to find and look at the research yourself.

And what does it say?  Basically, that the VBAC rate is still plummeting, and more research is needed.  Big surprise there.  The VBAC rate has been plummeting for decades, ever since its record high in 1996 of 28.3%.  It also seemed to suggest that ACOG could play a much bigger role in encouraging the practice of VBACs again, but maybe that was just my wishful thinking.

The statement begins by systematically reviewing the evidence behind the short-term and long-term benefits and harms of trial of labor v. repeat cesarean from the perspective of both mothers and babies.   Some of the benefits of trial of labor for mothers includes a decreased risk of maternal mortality when compared to repeat cesarean (high grade of evidence).  There is also a lower risk of hysterectomy (moderate grade of evidence), lower incidence of placental complications with future pregnancies, such as placenta previa, and placenta accreta/ increta/ percreta, (moderate grade of evidence), and shorter hospital-stays, with possible decreased risks of DVT (low grade of evidence).  Among the risks of trial of labor for mothers includes incidence of uterine rupture (moderate grade evidence), which is increased if there is a classical incision, i.e. a vertical uterine scar (however, there was only low-grade evidence to support this).  It’s also interesting to note that there was insufficient evidence to support the claim that repeat cesareans help avoid future pelvic floor dysfunction.

From the babies perspective, the perinatal mortality rate and neonatal mortality rate were observed to be lower in babies receiving repeat cesareans as opposed to trial of labor (moderate grade of evidence), and slightly higher rates of hypoxic eschemic encephalopathy in babies receiving a trial of labor (low grade of evidence).

To my way of thinking, though, the more important part of this statement is the fact that it also looked into many of the non-medical factors that are influencing the declining VBAC rate, such as professional association practice guidelines (ACOG’s 1999 Practice Guideline on VBAC being a big one), hospital and health-insurance policies, and professional liability concerns among physicians and hospitals.  I have heard my OB colleagues joke among themselves that the only bad cesarean is the one that isn’t done.  The general outlook that I have observed seems to be that doing a cesarean is always the right way to go from a medical-legal perspective; cesareans are perceived as being safer, by doctors and patients, no matter what the situation, and if in doubt, it’s better to err on the side of doing a cesarean than not.  This attitude can be found all over the place.  To quote a comment made by an obstetrician on KevinMD.com: “You never get sued for doing a cesarean section, you get sued for not doing one. So given the scenario with a questionable fetal heart rate tracing where any “expert witness” can find fault with, (even if there is none) I would rather perform a cesarean section than not. It comes down to a matter of staying in practice and making a living.”

The last Practice Guideline that ACOG has issued on the subject came out in 1999, and reversed its prior encouragement of VBACs, instead saying that women should be “offered” (rather than “encouraged” to have) a trial of labor if there are no contraindications, but basically asserting that it’s a personal decision, and can be decided on between doctor and patient on a case-by-case basis.  The 1999 Practice Guideline also stated that trials of labor should only be done in hospitals ready to respond to emergencies with on-call physicians always available to perform an emergency cesarean, as well as 24-hour on-call anesthesiology coverage (a standard which many rural and smaller hospitals find very difficult to comply with).   It’s important to note that this recommendation was rated as a Level C in the ACOG Guideline (i.e. based on consensus expert opinion, with no hard evidence to support it).  Nevertheless, many hospitals and providers have cited the lack of these emergency provisions as the reason that they no longer offer women trials of labor.

In it’s conclusion, the NIH consensus report directly addresses this issue:

Given the low level of evidence for the requirement of “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.

We now know so much more about the causes of uterine rupture and the safety of VBACs than we did 20 years ago when the practice was first encouraged.  We know that the use of prostoglandin induction agents such as cytotec and cervadil were a chief cause of uterine rupture, and that women with low-transverse uterine incisions actually have a pretty low rate of uterine rupture.  With this in mind, it’s probably time for ACOG to finally issue a new Practice Guideline on VBACs.

A last comment about the NIH report: they left a laundry list of critical gaps missing from the research, highlighting the places where more information is desperately needed, which was nice to see.  They also issued a few choice words about the “cesearean as best defense” mentality:

We are concerned that medical-legal considerations add to, and in many instances exacerbate, these barriers to trial of labor.  Policymakers, providers, and other stakeholders must collaborate in developing and implementing appropriate strategies to mitigate the chilling effect the medical-legal environment has on access to care.

I couldn’t agree more!  Thank you, NIH, for a well-written and informative report.  Maybe this will help swing the momentum back in favor of VBACs again!

Even so, 25 weeks is extremely premature, right on the cusp of viability.  She was moved to L&D this morning because she had begun to contract regularly again, and was feeling increased pressure.  We were able to hold her off for most of the day, but one of the doctors did a sterile speculum exam towards evening in order to visually assess the cervix (vaginal exams are avoided as much as possible when a woman has broken her water, since they tend to increase the risk of infection), and all the doctor saw was a head of hair, without any cervix covering it at all.  A vaginal exam afterwards quickly confirmed what she had suspected: the patient was nearly fully dilated, and the first twin had moved far down into the pelvis, to nearly +1 station.  Initially we thought she might need a cesarean, but a sonogram quickly confirmed the first twin was vertex (obviously…this was the twin that was presenting) and that the second twin was very nearly vertex (more transverse, but with the head still sloping downward).  After consulting with the MFM and attending pediatricians, the decision was made to attempt a vaginal delivery, since one of the risks of extreme prematurity is cerebral hemorrhage in the fetus, and pushing a tiny, head-first twin back up through the bony pelvis in order to deliver through the abdomen was sure to cause more damage, rather than less.  Nevertheless, she was taken to the OR for the delivery just in case a cesarean was needed after all.

All hands were on deck, and the OR was packed.  The attending OB physician was there, the back-up attending was also there, and I was there. We were the delivery team.  Two attending pediatricians, 3 pediatrician residents, and 2 neonatal nurses were also there, divided into two groups–one for each tiny twin.  We had two warmers ready for the twins, two isolettes, two laryngoscopes, two sets of everything.  The anesthesiologist was present and on standby in case we needed to put the patient under general anesthesia for an emergency cesarean.  There were also 3 L&D nurses on hand; one scrubbed and ready to assist in a stat cesarean, and the other two as runners/ circulating nurses.  And a medical student, who was observing (with the patient’s permission)–and holding her hand, and feeding her ice chips.

She was nervous, naturally.  This was her first pregnancy, she’d never pushed before, and she still wasn’t feeling the contractions very strongly (one of the hallmarks of preterm contractions is that they tend to be painless).  We set the sonogram machine next to the patient, and the back-up attending used it throughout the birth to help assess the position of the second twin (twin B), as well as the fetal hearts of both twins throughout the pushing.  We gave her reassurance, helped hold her legs, got her into a good position, and then asked her to push.  Amazingly (well, not really, given how small these babies are, and how low in the pelvis the first twin already was), it took only a few strong pushes before the tiny little head was starting to crown in the vagina.  Before we knew it, the first tiny twin was out, a red little girl weighing only 1 lb 6 oz.  I helped deliver the head and quickly clamped and cut the cord; the attending OB handed the tiny baby to the waiting peds team, and they instantly got to work, intubating and ventilating her tiny little lungs.  She never cried, but she was nice and pink, and waving her little arms and legs around.  Within minutes she was intubated and stabilized, and the team quickly moved her to the NICU.  Meanwhile, we were concentrating on twin B.

The back-up physician was applying steady fundal pressure on the uterus, helping to hold twin B in a vertex position and guide her into the pelvis.  After a few more contractions, the uterus began to close around twin B and push her down into the pelvis.  Once she was engaged, the OB attending broke the second amniotic sac, and we asked the mom to begin to push again, which she did with renewed energy (having gotten a brief rest after the delivery of twin A).  About 10 minutes later, twin B was also crowning, and again, we quickly delivered the baby, clamped and cut the cord, and handed the twin to the second peds team.  She as another tiny little girl, this time 1 lb 8 oz, and again, doing as well as could possibly be hoped for at only 25 weeks gestation.  Once she as stable, she too was moved to the NICU, and the OR began to clear out a bit.

It’s quite an amazing sight, to see two umbilical cords presenting.  We waited for awhile, and slowly the cords began to lengthen as the placenta separated from the uterus.  About 15 minutes after the delivery of Twin B the placenta came out–much larger than a singleton placenta, with two cords and two separate amniotic sacs (di-chorionic/ di-amniotic).  Once the placenta was out, we all breathed a sigh of relief.  A quick exam showed that the woman was intact (not surprising, given how tiny the babies were).  We cleaned her up, took out the foley catheter we had put in just in case she needed a cesarean, and transferred her to the recovery room, where her family was waiting. And there you have it: a remarkably straightforward vaginal twin delivery at 25 weeks gestation.  Not exactly something your average midwife gets to see everyday, but certainly something I felt very lucky to have been able to experience.

This past Monday was the craziest day I have ever worked in my 3+ years at my job, hands down, which is saying a lot because we’re actually a pretty busy hospital, and given that several nearby hospitals have closed recently and this past summer we got the contract for staffing the MIC clinics in our neighborhood, our volume has been going up lately.  The problem isn’t really the volume, though.  The problem is space, or lack thereof.  On Monday, for example, we actually did not physically have enough space to do our job correctly.  By the end of the day, triage was overflowing, there were at least 4 people waiting to get onto beds/ monitors and be seen, and we had no more rooms inside to put anyone.  The recovery room was full of women who were either triage patients or patients waiting to be admitted.  There were several women awaiting inductions–all for good reasons, such as diabetes or oligohydramnios or postdates–who couldn’t even start their inductions because again, we had no free rooms to put them into.  Thankfully there were a few empty beds on the Antepartum unit, so we admitted them and sent them to Antepartum to spend the night, with the hope that in the morning we could move them back over to Labor& Delivery to begin their induction.  If we had 6 triage beds, for example, instead of only 4, we could have done more about the backlog of patients waiting to be seen.  If we had 10 LDRPs (labor-delivery-recovery-postpartum rooms, i..e rooms equipped for births) instead of only 6 rooms, we would have had space to put some of the inductions.  If we had a few more quiet rooms (smaller isolation rooms which aren’t fully equipped for birth, but are good rooms for antepartum patients who need continuing monitoring, or patients on magnesium, or being kept for observation) instead of only 2, we also might have fared better.  But, what are you going to do when your unit is just physically too small to meet the demands of all of the incoming patients?

And don’t get me going about staffing.  2 midwives per shift.  That’s it.  2 midwives to take care of….8 laboring women, 8-10 women to be triaged, 4-5 women to be admitted…my head was aching and my brain was spinning by the end of the shift.  I literally didn’t know where to start or what to do first, there were so many equally imperative tasks awaiting my attention.  We also could have used a few more nurses too (there are generally 10 nurses per shift, but a few had called in sick).  The advantage to being a nurse instead of a midwife, though, is that as a nurse you are only assigned to 2-3 patients, and that’s it.  As the midwife, I’m responsible for the entire floor.  We could really use 3 midwives per shift, honestly.  Easily.

The icing on the cake came when EMS wheeled in a multiparous woman huffing and sweating in active labor, who was very clearly going to be delivering shortly.  And still, we didn’t have a triage bed or a LDRP to put her in.  She labored in the hallway with a small screen around her for about 2 hours while we hustled a recently delivered woman out of her LDRP and transferred her over to Postpartum.  When I checked the woman in the hallway shortly before the end of the shift, she was 9 centimeters dilated and about to begin pushing.  We didn’t have time to fully clean the newly vacated LDRP.  Instead, Housekeeping cleaned the bed only, we threw on a clean set of sheets, and got the woman into the bed, while the rest of the room remained dirty.  Not ideal, by any stretch of the imagination.  This was around 7:50. Our shift was finished at 8:00 pm.  I went to the board to give the poor, inundated nightshift midwives report.  I told them room ## was about to deliver, she hadn’t even been admitted yet, but one of them should get in there ASAP (which she did; we gave the rest of the report to the other midwife, who looked like she was about to cry).  I wish I could have stayed longer and helped out, but honestly, after 12 hours of such intensity, I felt like I was about to drop.  Thank god for shift changes and fresh midwives!

I had Tuesday off.  I slept until noon.  I was working again on Wednesday.  And let me tell you, one single day off is not nearly enough time to recover from the kind of exhaustion that a shift as crazy as Monday can create.  It’s not just physical exhaustion (although there is plenty of that); it’s mental exhaustion, too.  It’s trying to balance the information and histories and stories of all of these women in your head at the same time, keeping track of so many patients, and then figuring out who needs attention first; it’s taking histories and writing up admissions and putting in orders for nurses, and getting requests from nurses for such-and-such patient down the hall while you’re trying to admit such-and-such patient in triage and find the doctor so you can present such-and-such patient to her because you think she needs yadda yadda, and you forgot to put the orders in for that other patient who needed an expedited HIV test, and then there’s a sudden deceleration in room ## so you have to drop everything you’re doing, run into the room, check the patient, turn her on her side, put in and IUPC or ISE as needed, call the attending, present the patient to him (dredging the  information up through a cloud of other patients…was this the one who was being induced for oligo, or the one who had come in ruptured for 2 days who’d been on pitocin all afternoon?), and then as the decel recovers, grabbing her chart, writing a quick note about what you just did, then heading back to triage again to try to pick up the admission where you’d left off, except that a different nurse is now tugging on your sleeve telling you that the patient in ## feels like pushing, and can you please come check her? That’s the kind of exhaustion I’m talking about.

And I wish I could say Wednesday was loads better.  It was a little bit better.  Slightly less frenetic, slightly less overwhelming, but only slightly. At least we weren’t overflowing, with too many patients and not enough beds to put them on.  But even so, I had three deliveries, and the other midwife had three deliveries too.  6 deliveries in 12 hours is not exactly a slow day.  The very first delivery of the day was a woman who came into triage fully dilated and ready to push.  Again, not a single LDRP to put her in, so we brought her to the operating room and we did the delivery in there.  That was at 8:50 am.  The next delivery I did was around 1 pm.  The last delivery was right before I left, at 7:30 pm.  Welcome, Antonio, Jayden and Natalia! And at least we got to eat lunch on Wednesday, and sit every now and then.  Big improvement over Monday.  But seriously.  And then clinic on Thurs and Friday…which is certainly easier than Labor & Delivery, but still not exactly a piece of cake.

It was a killer week.  Truly.  And don’t think I’m complaining, since I do really, honestly, unabashedly love my job….but only trying to explain how amazingly, gut-wrenchingly exhausting it is.  I have 4 days off now.  I feel like I will be sleeping for most of it.