Belly Tales

Let’s face it: the economy sucks right now.  We haven’t yet hit rock bottom, and it’s going to be awhile (probably a long while) before things begin to recover.  In the midst of this harsh financial reality, companies and industries are scrambling to find ways to save money.  Birth activists have been trying for decades to convince this country of the benefits of midwifery based on its safety and track record of better outcomes, not to mention improved client satisfaction, but hey, this is America—the only thing people really pay attention to in this country is the bottom line.  So maybe midwifery has finally found the argument it needs to affect actual change.  In the midst of one of the worst recessions since the Great Depression, NOW is the time to increase access to midwifery care because it’s excellent care for a heck of a lot less than what we’re currently spending on maternity care.

In early December, shortly after the nomination of Tom Daschle as Secretary of Health and Human Services (HHS), the Big Push for Midwives launched a campaign to get Mr. Daschle to attend a community meeting on midwifery and its advantages.  Per the change.gov initiative, discussions on healthcare reform will be occurring around the country between 12/15 - 12/31, and Senator Daschle has promised to attend a few of them in person.  Thanks to the Big Push for Midwives, he was invited to several heartland discussions, including this one in Lees Summit, MO.  I haven’t been able to find any updates or reports from this meeting yet.  I’m not sure if Senator Daschle was able to attend, but it’s definitley the sort of discussion he (and the Obama administration) should be listening to. (Was anyone actually able to attend that meeting?  If so, give us an update, please!!  I’ve been searching the internet for reports on the meeting, but I haven’t found any yet.)

As this excellent recent article in the LA Times (Midwives Deliver by Jennifer Block) points out, midwives deliver much safer care for much lower cost:

The most cost-effective, health-promoting maternity care for normal, healthy women is midwife led and out of hospital. Hospitals charge from $7,000 to $16,000, depending on the type and complexity of the birth. The average birth-center fee is only $1,600 because high-tech medical intervention is rarely applied and stays are shorter. This model of care is not just cheaper; decades of medical research show that it’s better. Mother and baby are more likely to have a normal, vaginal birth; less likely to experience trauma, such as a bad vaginal tear or a surgical delivery; and more likely to breast feed. In other words, less is actually more.The Obama administration could save the country billions by overhauling the American way of birth.

It seems like instead of encouraging midwifery care, the opposite is happening.  Birth Centers around the country are closing at a rapid pace, and Medicaid has recently started to resfuse to fund birth center care:

Over the past few years, CMS (the federal agency that runs Medicaid/Medicare) has begun disallowing federal matching funds for state Medicaid payments for freestanding birth centers services. Birth centers have been recognized by CMS (and earlier, by HCFA) as a Medicaid provider type in State Medicaid Plans since 1987. Recently, however, CMS has disallowed such payment by several state Medicaid Agencies, including Alaska, South Carolina, Texas, and Washington State, claiming that it lacks clear statutory authority and direction to do so. CMS has directed its regional offices to stop federal payments to any state for birth center services.

As this article points out, this is going to cause a huge squeeze on birth centers around the country, and we’ll soon be seeing even more of them close unless something is done.  This is an urgent call to action.  The AACB has several resources on their website listing ways to contact your senators and let them know about this issue, including using this lovely flyer which lists all of the important talking points you’ll need when composing your e-mail or making your phone call (calls are preferrable, apparently, since e-mail is more likely to be lost in the midst of all the e-mails on the federal bail-out).  The reason this is so important is that Medicaid generally sets the standard for insurers.  If Medicaid stops insuring birth center care, other insurance companies will follow suit.  Birth centers are a crucial link in many communities, providing quality health care to diverse populations (including women on Medicaid - you only have to look at the work of Ruth Lubic and the Morris Heights birth center to appreciate that), and we need to keep as many of them open as possible.  Not only does it make great health sense, but it saves money too.

And here’s another great cost-saving suggestion: stop insuring preterm elective cesareans.  When I read this article I just about choked.  I can’t believe insurance companies are willing to pay for this when research has consistently shown that there are still a lot of complications with “near-term” infants (babies born between 34 - 36 wks) such as respiratory distress, jaundice, temperature instability (hypothermia), delayed brain development and feeding difficulties.  Forget the fact that a cesarean delivery is several thousands of dollars more expensive than a vaginal delivery; the real damage in this practice is caused by the increased number of preterm babies and the burden of care they demand.  Prematurity and NICU care accounts for one of the largest chunks of healthcare expenditure.  Even the March of Dimes is calling for a decrease in preterm cesareans.

I’ve always been consistently amazed that HMOs, managed care systems and Medicaid haven’t latched onto midwifery with more enthusiasm.  I wonder sometimes if this is because ACOG and the AMA are able to counteract the economic practicality of midwifery care with a tons of lobby money.  The economic angle isn’t anything new.  The Business of Being Born said the same thing in 2007, and Michel Odent, Ina May, Naomi Wolf, Suzanne Arms, Robbie Davis-Floyd etc. etc. have been saying the same thing for decades.  Maybe in the midst of the recession, the message will finally get through: midwifery care is better AND cheaper.

One week after our historic election of Barack Obama as the 44th president of the United States, here’s a very interesting article on what his presidency might mean for Women’s Health (of the non-”airquotes” variety), namely improved access to birth control and sex education (i.e. the federal government no longer funding abstinence-only programs), a reversal of the “conscience” legislation which is now allowing doctors, nurses and pharmacists to legally refuse to perform any service they morally object to, including prescribing birth control, and stopping the global gag-rule which prohibits federally-funded health clinics in foreign countries from performing abortions or even referring women to other facilities that will. It’s all good stuff, and worth checking out (with a nod to Women’s Health News who found the article in the first place).

South Dakota’s Measure 11 was soundly defeated: “South Dakotans have affirmed by their votes tonight that no vague law can account for every individual circumstance. And that is precisely why women and families, not the government, should make these personal healthcare decisions,” said Sarah Stoesz, President and CEO of Planned Parenthood Minnesota, North Dakota, South Dakota.

The New York Times, in the midst of all the election craziness, published an article on new links between depression and premature delivery which have been recently reported in the Journal of Human Reproduction. The study interviewed 791 women and ultimately gave them scores based on how many depressive symtoms they exhibited–the higher the score, the worse the depression. The study found that the higher the score, the greater the risk of preterm delivery, even after controlling for prior preterm deliveries, miscarriage, socioeconomic status, education and other variables. This is particularly fascinating considering that so little is known about how depression affects pregnancy, and vitally important since depression during pregnancy (and the mental health of women during pregnancy in general) are so often overlooked in prenatal care.

The New Space for Women’s Health (formerly Friends of the Birth Center) is having a fundraiser on November 18th at Babeland called Women Come First. The event, which is co-sponsored by Ricki Lake and The Business of Being Born, offers an opportunity to not only raise money for the new free-standing women’s health and birth center in New York City but an exclusive cocktail party and shopping opportunity. Sounds like a lot of fun! I’d be there if I wasn’t already working that day…

Finally, I’m sure this is going the rounds on the internet, but I think everyone, everyone, needs to watch Keith Olbermann’s special comment on Proposition 8:

Last night was a very strange night. It wasn’t that busy, and yet, somehow, neither the other midwife nor myself were able to take a break. The pace was very steady. We kept expecting it to settle down, but it never did. Just as we were thinking “oh, as soon as this woman is discharged, we’ll be able to rest for awhile”, then another woman would walk through the door.

There were two deliveries. One was a grand multip (G6P5005) who came in 9 centimeters dilated with a bulging bag of waters. The other midwife ruptured her membranes at 3:40 am and she delivered at 3:41 am. I love deliveries like that! It’s always amazing to me how QUICKLY a baby can actually exit the human body, when all the conditions are right. It’s as if they’re on a greased slide, and they just whizz on out. If only all births were so quick and easy.

The woman I delivered was 16 years old, having her first baby. She was newly immigrated, and the father of the baby was back in Santo Domingo. She had her mother and grandmother with her, though, and they were a tremendous support team for her as the contractions were picking up, fanning her face and feeding her ice chips. She progressed remarkably fast for a first baby. We forget, sometimes, that teenager’s bodies are meant to give birth, and probably more so at this age than at any other time in their lives. Even though they might not be emotionally ready, their bodies are, and they often open up through labor as if it were the easiest and most natural thing in the world. This girl was having a labor like that.

When I came on at the start of the night she was 4 centimeters dilated and in a lot of pain. We discussed her pain options, but she didn’t think she needed anything just yet, and carried on with the support from her family. Two hours later, she was ready for something for the pain, and was thinking that she wanted an epidural. However, when I checked her, she was a whopping 8 centimeters dilated, and the head had moved down to zero station. I told her she was a superstar, she was doing amazing work and the birth would be really, really soon. I told her that she could have an epidural if she really wanted one, but that by the time she got it she would probably be fully dilated and ready to push, and that an epidural would just slow down the birth in the long run. She didn’t believe me (I can’t really blame her….the contractions were pretty intense at this point), but her mother and grandmother exchanged a look, and both of them rolled up their sleeves. We coaxed her into a sitting position, and her grandmother went behind her, rubbing her back, while her mother continued to fan her face. Less than half an hour later, she was fully dilated (there is a Russian doctor at our hospital who likes to call this moment “fully delighted”), and was pushing beautifully.

The baby came down quickly and was delivered 11 minutes after she was fully: a beautiful little girl with a really tight nuchal cord which had to ultimately be clamped and cut in order to allow for the birth, and a compound right hand that extended as the baby delivered and unfortunately tore the girl’s left labia, leaving a tender, open gash. The pediatricians were there to check on the baby due to the moderate meconium which had been in her amniotic fluid, but the tracing had been overall reassuring (we’re calling this Category II now…has anyone else moved onto the new NICHD guidelines? Our hospital has finally made the switch officially, despite the fact that these guidelines have been around and endorsed by nearly everyone [ACOG, AMA, ACNM etc. etc.] since 1997, but I must admit, I’m still finding it a bit strange) and the baby came out vigorous and screaming, waving her little pink arms around. An altogether beautiful and uneventful labor and birth, which took less than 5 hours in total. You couldn’t have asked for a nicer first birth than that.

The eventful part came next, unfortunately. Everything was looking good. I was checking her perineum (intact! the only tear was the labial laceration) and waiting for the placenta when there was suddenly a pretty forceful gush of blood. I figured it was a sign that the placenta was starting to seperate, so I gave a gentle tug on the cord, and the placenta quickly began to descend. Instead of coming out with the shiny, fetal-side showing first (Shultz presentation) it came out maternal-side first (Duncan presentation) and I immediately noticed that the membranes had been completely sheared off on one side. There was a thick tendril of trailing membranes which were still firmly attached somewhere up in the uterus, and were taut and unmoving when I tried to gently tease them out by spinning the placenta a bit. Rather than tearing the membranes and losing them, I cut the placenta away and put a ring forceps on the trailing end of the membranes, so that at least we had them. I quickly inspected the placenta and saw that there were hardly any membranes present, only the cotelydons of the placenta, and the cord. Which meant that most of her membranes were still inside, either retained or trailing, I wasn’t sure which yet. And all the while she was gushing blood.

We moved pretty quickly. I called the attending doctor, we asked the family to step out a moment, and started the IV pitocin running. I gave fundal massage and felt absolutely no fundus! I couldn’t find it anywhere (later on, the attending pointed out that that is exactly what an atonic uterus feels like…as if there’s nothing there). The attending began to remove the rest of the membranes by traction, gently teasing and working them down. We administered methergine, then hemabate, and finally 1000 mcg of cytotec rectally. We started a second IV line and used a catheter to help quickly drain her bladder. I was doing firm fundal massage all this time, and finally, after what seemed like quite some time, but was really about 8 minutes, I began to feel a hard, firm fundus balling up under my hand, and the bleeding had slowed down to a trickle. The doctor had managed to extract what looked like the rest of the membranes, and his sonogram later confirmed that the uterus was empty. And then, just as quickly as it had started, the bleeding stopped. The total loss was estimated to be between 800 - 1000 cc. But once the trailing membranes were finally out, and the fundus was finally firm, she was absolutely fine. I repaired the labial laceration, cleaned her up, and helped her breastfeed her beautiful girl.

Her hemoglobin and hematocrit dropped pretty precitously when we checked her CBC four hours later, but it was still in the range of normal (10.0/ 30%), so in the end she didn’t need any kind of blood transfusion. In fact, I’m still kind of astounded by the entire thing. It’s as if a huge emergency had been averted, and yet, at the same time, it felt really routine. We drill our hemorrhage protocol pretty regularly on our unit. It was really nice to see that when push came to shove, we were able to go down the steps of the protocol one by one, and amazingly (or perhaps not), they worked just the way they were supposed to, and lo and behold, the bleeding stopped! Nobody panicked, the nurses were prepared, the doctor was calm. Everyone knew what they were supposed to do, and we just did it.

Afterwards I was waiting for the shaky post-adrenaline terror feeling that often comes after emergencies, but it never came. It made me think about how far I’ve come in my first year as a new midwife. A year ago, this would have probably left me crying or near tears, shaking in the chart room, totally freaked out. Instead, I finished the paperwork, checked her bleeding again (it was fine) and carried on with the rest of the non-stop night. I guess this is what midwives do. They don’t panick, and they stop the bleeding, and that’s that. It was just a hemorrhage kind of night.

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.