Belly Tales

The AMA has recently issued a resolution supporting ACOG’s Statement on Homebirth which agrees that the safest place to have a baby is the hospital, of course, where obstetricians work and get paid.  What’s really awful is that they’re using Ricki Lake’s movie, The Business of Being Born, as a tool to try to pass laws that would mandate that all births occur in hospitals, since hospitals are the “safest” place to give birth.  Nevermind that in this country (at least for now) all women have the right to make their own choices about their bodies and the health care they receive, or the fact that the U.S. has one of the worst rates of neonatal and maternal mortality among developed countries and that (wow, what a surprise) 90% of all our birth occur in hospitals, or that other countries with much better mortality rates wholeheartedly support and embrace homebirth and that there is strong evidence-based research which backs this up.  Nevermind all that.  In this country, it’s money that does the talking, and money which sets the agenda and passes laws….and now, the AMA, with all its money, has unsurprisingly agreed with ACOG’s ridiculous statement.

The Huffington Post has an article up detailing all of the furor, along with a raging debate in the comments section.  Please, if you care about this even a little bit, visit the article and post a comment.  The more comments the Huffington Post receives, the higher the likelihood that they’ll move the article to their “favorites” section, which will keep the article up on their website for days.  The more comments and press this topic gest in the blogosphere and in the media, the more women will hear this message, and the more this subject will become part of our national debate.  Every comment counts!  Here’s the link again: Docs to women: Pay no attention to Ricki Lake’s homebirth

Here’s a lovely birth story to share, my 99th delivery:

We were all expecting a big baby. Her estimated fetal weight from Leopold’s palpation was judged to be approximately 4500 gms. The baby felt huge: fat and happy, and we were all duly nervous, because her first baby was only 7.5 pounds. She wasn’t a large woman, either, but her pelvis felt incredibly roomy, so we were proceeding very carefully, watching closely, wondering if things would progress.

She had an epidural, but even with the epidural, everything was hurting her: her back, her legs, her vagina. With the assistance of her partner, we kept turning her side to side, sitting her up and lying her back down, trying to alleviate some of the pain through what limited position change is available when someone has an epidural. She had cold packs on her forehead and sacral massage. Even so, it wasn’t helping much. She began to feel a lot of rectal pressure and wanted to start to push, but she still had a small lip of cervix in front of the baby’s head, so we breathed with her through her contractions and tried to keep her from pushing. She was really unhappy with us at this point; who wants to breathe when they feel like pushing?? It’s the hardest thing in the world, and she really struggled with it.

The thing is, even though her cervix felt nice and soft, and we could possibly reduce the small lip of cervix in front of the baby’s head, we didn’t want to. With large babies, there’s a lot of danger involved in reducing an anterior lip and bringing someone to fully dilated when maybe they’re not supposed to be. Sometimes there’s a reason for a woman with a large baby not making it to fully dilated. Sometimes it’s a message to you that the baby is actually too large, and it’s a warning that should be heeded. So we let her body work on its own, without forcing it, and eventually, after over an hour of being at anterior lip, the last remaining, stubborn piece of her cervix finally disappeared.

Our concern, of course, was shoulder dystocia, which is without a doubt one of the most dangerous of all obstetric emergencies. With shoulder dystocia the head is delivered but the shoulders get stuck, and you have only minutes to get the baby out before he or she begins to rapidly decompensate on account of the severe cord compression that occurs. There’s a whole list of maneuvers that you’re supposed to work your way through: first you pull the legs back, which helps to widen the pelvic outlet, and then you apply suprapubic pressure, which helps to pop the baby’s shoulder under the pubic arch and get the baby out. If that doesn’t work, you move on to other maneuvers, like Wood’s Screw or the Gaskin Maneuver (named after our favorite midwife, Ina May). You reach your hand in and try to delivery the posterior arm. Even though it’s not the perineum that’s the problem, but actually the bones of the pelvis, an episiotomy is often cut in order to ensure that there’s enough room to get your hands in to maneuver (and in our sick society, if a lawsuit is ever being brought to court on account of a shoulder dystocia, apparently if you haven’t cut an episiotmy, it’s a huge strike against you, since cutting is part of the “standard of care”. I’m not sure that I agree with that, but on the other hand, in such emergencies, you do what you have to do). You empty the woman’s bladder. You pray. You try the maneuvers again if they didn’t work the first time. The clock ticks so slowly, so that miliseconds seem like eons and all you can do is stare at this stuck baby with a face that’s slowly turning more and more purple. Sometimes nothing works. Sometimes you need to break the baby’s collarbone or humerus in order to get the shoulder out. I’ve never had a true shoulder dystocia yet in my short career as a midiwife, but I’ve seen a terrible shoulder dystocia in my work as a nurse, and I’ve heard the stories. It’s no joke. It’s one of the scariest things you’ll ever have to deal with in this profession.

So we were nervous, and rightly so. But she was making slow progress, on her own. She began to push once she was fully dilated, but she was tired, and her effort wasn’t great. She lost her fighting spirit, and began to cry, asking for a cesarean, telling us that she couldn’t push any more, telling us she wanted to die. This is all pretty normal stuff for the pushing phase, at least among the women we take care of at our hospital, but it only served to make us even more nervous. The four P’s of labor are the Powers (contractions), the Pelvis, the Passenger (baby) and the Psyche. If any one of those P’s are missing, you’re in trouble, and staring at this huge baby waiting to be born with a mother who’s psyche wasn’t in the best place was very, very worry-making. There comes a point in the labor as the baby’s head is just beginning to peek into view when you can really get a sense of just how big the baby is. You can put a finger on the baby’s crown and then palpate the baby’s rump through the woman’s uterus, and get a true measure with your hands for the first time, and let me tell you….this baby was HUGE.

But she was making progress. Slow progress, but progress. The baby’s head began to come into view during pushes, then would tuck back in again in between contractions. This is called Turtling, and it’s a sign of impending shoulder dystocia, and when we saw this, we really began to wonder what in the world we were doing by encouraging this woman to push. Slowly, though, it became clear that the baby was moving down, and was starting to stay down, even in between contractions. We could still get our fingers in, and could still feel lots of room in the sides and the back of her pelvis, and little by little, she kept pushing the baby down. Soon enough (well, after over an hour of pushing), she began to crown.

I was catching the baby, and was gowned and gloved and ready, running through the shoulder dystocia maneuvers in my mind. The doctor was standing next to me, also gowned and gloved. We had the pediatricians in the room, waiting. The back up doctor was also in the room, plus another midwife and 3 nurses. We had a stool ready, in case someone needed to stand on it to apply suprapubic pressure. We had broken the bed so there was plenty of room to get in close to her perineum, if need be (of all my births so far, I’ve broken the bed on only two deliveries, just to give you an idea). And there we all were, waiting, sweating, watching and waiting.

The head emerged, and it was huge and fat, with these chubby cheeks and tons of hair. I didn’t cut, but instead gave perineal support and pulled the perineum down around the baby’s face as he crowned. And there he was, in all his glory. It looked like she had the head of a young toddler between her legs, that’s how big he was. I don’t know about the rest of the staff, but my heart dropped into my feet when I saw that head. Surely this was going to be a shoulder dystocia. Surely we were all in a lot of trouble.

I let the head restitute on its own without rushing it. The baby slowly turned into ROT, and I thought: well, might at least try to deliver the shoulders, just to see what happens. So I gently applied downward traction, little more, little more…and then, all of a sudden, there was the anterior shoulder!! Just like that. Just like a totally normal delivery. As soon as I saw the top of the anterior shoulder, I applied upward traction to delivery the posterior shoulder, and the shoulders were out. Getting the actual baby out required hooking a finger under each armpit and actually gently tugging the baby free, because this definitely wasn’t one of those births where the baby was just going to slide out. But the baby came quickly and easily, with hardly a pause between the delivery of the head and the delivery of the rest of the baby. He began to howl, wiggling both his arms and fingers (a good sign, indicating that there was no erb’s palsy going on), and we put the baby onto the mother’s stomach, and everyone just sort of stared in amazement.

He was enormous!! Guess how big….just guess. Much bigger than 4500 gms. He was actually 5150 gms. 11 pounds 5 ounces. The biggest baby I have ever delivered, and one of the biggest babies I have ever seen.

Delivered in a hospital, by a midwife, without the slightest whiff of shoulder dystocia. Oh, and one of the best parts: she didn’t tear, at all. Her perineum was intact. There was one nick which was bleeding, which required one stitch, and that was it. That was it!! Such a miraculous, miraculous birth.

Sometimes, briefly, you feel like you’re making progress, that midwifery outreach is making a difference, that people are becoming more educated and informed, and then you read an article like this one, over at Time Magazine, and you realize that you exist in a small bubble where your philosophy on birth is far different than the majority of the country, and no matter how much you talk yourself hoarse educating people about the issues, they’re still going to buy into the myths of birth, hook, line and sinker.

Cesarean births are not “safer”. Numerous studies have demonstrated, again and again, that cesarean births carry more risks than vaginal delivery, and these risks multiply with each cesarean birth. Sure, the woman in this article had a “safe” and uncomplicated primary cesarean, but no attention is given to what happens when this same woman comes back for her second or third repeat cesarean—how difficult it is to perform surgery on the same site, to cut through scar tissue, how the risks for abnormal placentation such as placenta previa or placenta acreta increase exponentially with each cesarean, how the risk of hemorrhage increases dramatically. There’s also no discussion about how painful recovery from a cesarean is compared to recovery from a vaginal delivery, and how statistics have shown that this poorly affects bonding and breastfeeding rates in women who’ve given birth by cesarean. (Not to mention the fact that the motivation for elective cesareans for many women is a fear of pain, and in fact, the entire process is often much more painful, for a much longer period of time, post cesarean).

Vaginal delivery can, for example, lead to future incontinence and pelvic damage, while babies born by C-section may suffer from respiratory problems because of not being exposed to certain hormones during the birthing process.

Where is the author, Alice Park, getting this information from? How come there are no articles or references cited? I thought we were well beyond the argument that cesareans prevent pelvic floor damage. While injury to the pelvic floor can and does occur during vaginal delivery, it’s often caused by practices such as episiotomy, vacuum-extraction, forceful pushing and lithotomy position during deliveyr, all of which can be (and are being) minimized during vaginal birth. Routine episiotomy, for example, is now by and large a thing of the past. Furthermore, there is no conclusive evidence which demonstrates that cesarean section prevents pelvic floor damage. To quote from What Every Pregnant Woman Needs to Know About Cesarean Section (2006), published by the Maternity Center Association:

Is vaginal birth in and of itself harmful? It is common to hear that “vaginal birth” causes pelvic floor problems. Of hundreds of studies examined, however, not one attempted to avoid or limit the use of practices that can injure a woman’s pelvic floor to try to determine whetehr vaginal birth itself plays a role. It is wrong to conclude at this time t hat the cause of pelvic floor problems is giving birth through the vagina….

Is “vaginal birth” the culprit in the high levels of incontinence that women experience later in life? Studies that take a longer view find that new problems with urinary incontinence that appear after birth lessen over time. These problems tend to completely disappear by the time of menopause. Older women experience high rates of incontinence, but this appears to be due to other factors. For example, excess weight and smoking play a role.

Does cesarean section prevent incontinence? Routine cesarean section would only prevent continuing symptoms of incontinence in a small portion of birthing women. For most women, it would pose numerous risks without benefit. And it would offer no protection against experience incontinence in later years. As no research has found that vaginal birth itself causes incontinence, there are more sensible ways to prevent these problemss: 1) avoid when possible the use of birth interventions that can injure the pelvice floor, and 2) focus on keeping a healthy weight, avoid smoking and other risk factors.

(Still not convinced? Check out the following studies:

[1] Shorten, A, Donsante, J. & Shorten, B. (2002) Birth position, accoucheur and perineual outcomes: Informing women about choices for vaginal birth. Birth, 29(1), 19-27.

[2] Terry, R, Westcott, J, O’Shea, L., & Kelly, F. (2006). Postpartum outcomes in supine delivery by physicians versus nonsupine delivery by midwives. The Journal of the American Osteopathic Association, 106(4), 199-202.

[3] Soong, B., & Barnes, M. (2005) Maternal position at midwife attended birth and perineuam trauma: Is there an association? Birth, 32(3), 164-169.)

The point being, I can’t believe such a mainstream publication could write such an imbalanced, one-sided and poorly researched article. I think I feel a letter to the editor coming on!

Without getting into a huge amount of detail here…I had a new OB patient recently who came in for her initial visit and eventually told me that she wasn’t sure who the father of the baby was….becasue she had been raped by four men. She had gone to a different hospital immediately afterwards and had had a rape kit collected, and had already been through one round of testing for STIs and HIV, all of which had come back negative. The semen analysis is still pending. She’s been seeing a therapist weekly since the rape, and has the full support of her very large family. Because of her religious beliefs she will be continuing with this pregnancy and plans on giving birth in early September at our hospital. I was stunned, and didn’t even know where to begin with her. I talked a little bit about how rape and trauma can come up again during pregnancy, and especially during birth, but she’s only 10 weeks pregnant at the moment, so I didn’t see any point in getting into that deeply just then. I suggested that we could talk a lot more about it as the birth approached, and she agreed that that sounded like a good idea. We talked a little bit about postpartum depression, and depression in general, and I made a very thorough assessment of her support system and resources, and they all seem ample. In addition to the therapist she’s currently seeing at the other hospital, she was also visited by our social worker, so that additional resources at our hospital can be offered to her as well. I asked a few very broad questions about what she was thinking or feeling about the pregnancy, but she didn’t want to talk about it very much, so we moved on to other topics. And then we did the actual physical exam. She had as much control over the process as possible. We made a deal that whenever she felt uncomfortable or scared or uncertain, all she had to do was say “stop” and I’d stop. So that’s what we did. My assistant held one of her hands (her other hand was between her legs and on top of my hands as I guided in the speculum) and we gently talked her through it. She would tense up, say stop, then we’d stop, let her collect herself and calm down, and then when she was ready, we’d guide in the speculum another half inch. We went inch by inch. It took about 10 minutes total to get the entire speculum in, then I collected the samples and removed the speculum as soon as possible. She actually seemed to handle it amazingly well (I was close to tears).

I can only imagine how birth, which can be so traumatic in its own right, can bring up so many terrifying memories and associations with trauma and rape. Birth is another situation where she can potentially feel vulnerable and exposed, in a situation that she can’t really control, experiencing pain, perhaps feeling helpless and angry and powerless (and keep in mind that this will be a hospital birth and not a woman-on-her-own-turf-at-home-birth). So here’s my question to all you midwives and doctors and nurses who’ve been doing this a lot longer than I have, and who have probably been present at births with women who have a history of trauma or rape (or women who have survived rape or trauma and gone on to birth yourself). Do you have any suggestions? When it comes closer to the time of the birth, what should we focus on? I have many thoughts about where to start: avoiding vaginal exams during the birth, offering early pain relief if desired (maybe a prophylactic epidural before the strong contractions even begin), letting her dictate when and how to push, making her environment as calm and serene as possible…what else am I missing? Any good books on this topic? Any posts that you’ve written which I should read? Anything at all would be helpful, because I still have another 8 months of prenatal care with this woman prior to her birth, and I want to try to make it as healing and empowering as possible (or, at the very least, not compound the trauma with more trauma).

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 been sick as a dog for the past three days, for the second time this season (I was so sick right before Thanksgiving that I actually lost my voice and had to call in sick to work…something which I NEVER do).  Luckily I’ve had the past 3 days off to recover, but I’m due to be back at work again tomorrow, and I’m not sure how my voice will hold up.  I keep coughing up icky green stuff, and I feel like this is potentially moving into my lungs.  I’m so rarely sick!  It must be all of the chronic stress of being a new midwife which has absolutely blitzed my immune system.  Joy.  At least I’m over the contagious part of it, so that when I’m at work tomorrow I won’t be getting pregnant women ill as well.

In any case, I’m not up for writing much of anything, but I found another amazing video over at Sage Femme’s, and thought I’d share it too.  It’s been up at Sage Femme’s for awhile, and I’ve seen it before, but since I only just recently learned how to embed You Tube videos, might as well polish the new skills, w00t!  This one is ultimately brought to you by the folks over at International Cesarean Awareness Network.  Just goes to show what a bogus diagnosis “cephalo-pelvic disproportion” (CPD) often is, and what a VBAC can accomplish when it’s actually allowed to proceed (which is why the declining VBAC rate is an absolute tragedy).  Baby heads are made to mold, and pelvises are made to stretch.  Given enough time and patience, I believe that almost all babies, regardless of size, will make their way into the world.   And just look at the triumph on these women’s faces.  Talk about blowing a raspberry to the entire technocratic fear-based model of birth!

I just discovered the most amazing videos over on You Tube about a traditional midwife working in Mexico. I’m sure many of you have probably seen them already, but I was just blown away!! It’s amazing to watch the way she uses her hands to massage, assess, palpate…turn a breech baby. A midwife’s greatest tool is her hands. I wonder how many of the women I see in the clinic come from traditional midwifery practices like this. American midwifery must seem very different to them. At it’s heart, I think the respect and tenderness and kindness to pregnant women remains the same, but we could learn so much from traditional practices like this. It makes me want to quit my job, fly down to Mexico and study with her for a year. In any case, enjoy!

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

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

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

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

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

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

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

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

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

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