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

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

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

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

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

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

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

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

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

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

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

Happy National Midwifery Week, everyone!  Here in NYC we kicked off National Midwifery Week with a very successful Miles for Midwives 5K run around Prospect Park.  But there’s a lot more going on nationally this week.  First of all, check out Team Midwife.  A $15 donation to Team Midwife will help the ACNM continue to fund its mission of promoting and supporting midwifery care in this country, and as a member of the team you’ll receive a monthly newsletter featuring women’s health news, resources and stories about amazing midwives, a member badge to display on blogs (for those with blogs *ahem*), and action alerts.  Sounds like a good deal, right?  Right!

But more to the point, I want to hear about all the ways that midwives have touched your lives this year!  Part of the way we’re going to increase the number of midwife-attended births is by getting the word out about how wonderful midwives are in the first place.  So share your story! Share it on the ACNM website, and then share it here, too.  How has a midwife changed your life this year?  What experiences have you had with midwives this year?  How has a midwife supported you this year?  Why do you love your midwife?  Let me know!  And let the world know.

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

Through a comprehensive evaluation of the evidence from 21 studies of CNM care, the review concludes that there is high quality evidence that women cared for by CNMs are less likely to experience a cesarean delivery, episiotomy, or severe perineal trauma. Women cared for by CNMs are also more likely to choose non-pharmacologic approaches to manage pain, and they have higher breastfeeding rates.

Are you surprised?  I’m not surprised! I feel like this just confirms what we already knew: midwives establish better relationships, answer more questions, are more sensitive, check all the boxes on the customer satisfactions card…but more than that, they actually deliver better outcomes—fewer cesareans, fewer lacerations, increased rates of breasfeeding and natural delivery.  Of course!  It’s just very affirming to see it in writing.

To read the full review as a pdf file, follow this LINK!

Why all the shop-talk, though?  I was wondering about this today.  I think it serves two purposes.  First, I truly believe that for the majority of midwives, this is a calling.  It’s not just a job, it’s not just something we “do”, it’s something we love, something we all think we were born to do, something which feeds our souls on a deep and primal level.  Midwives LOVE birth.  LOVE it!  I truly feel like I could happily talk about birth for 8-10 hours a day (and honestly, when you’re working a 12 hour shift, you pretty much *are* talking about birth that entire time, educating, teaching, explaining, encouraging, supporting, etc. etc.)  I remember reading an amazing quote once from some obstetrician back in the 1800s saying that if the energy and enthusiasm of women assistants at birth could somehow be harnessed,  the entire profession could be changed, because the passion and enthusiasm of these women was really something extraordinary.  (Does anyone know which quote I”m talking about?  I feel like it must be pretty famous.  And I also feel like he was referring to midwives, basically, without calling them such).  We talk about birth all the time because it’s truly one of our favorite topics, and every birth story is unique and exciting and worth sharing and hearing, so talking shop in this way is one of life’s greatest pleasures.

But I think it serves another purpose too.  When I was a new midwife, I would regularly gather with 4-5 other new midwives once a month for dinner and shop-talk.  This was partly inspired by our love of birth and all things midwifery, but it was also a support group—a way for us to voice our concerns and talk about different situations we had encountered as they came up.  I remember the weight of so much responsibility settling on my shoulders in those first few months.  Suddenly, with no preceptor in the room with me, I was the one calling the shots, responsible for ensuring that the life of both mother and baby were safe while trying to allow for the most natural birth possible to unfold.  It’s a huge weight, and took some getting used to, and those early new-midwife support group dinners were invaluable.  But we spent as much time talking about births that had gone wrong as we did talking about births that had gone right.

Today I had a catch-up phone call with midwife colleague who is also a relatively new midwife (3+ years of experience, similar to me….still seems relatively new in the grand scheme of things, if you ask me), and she shared with me the story of her first true shoulder dystocia which lasted for six whole minutes (an eternity, in shoulder dystocia time!).  She’s just started practicing as a homebirth midwife recently, and what she was describing is one of my biggest fears as a future homebirth midwife.  She took me through the entire delivery, blow by blow: what she did, what she did when that didn’t work, then what she did after that, Gaskin maneuver, woods screw, attempt to deliver the posterior arm, more woods screw etc. etc.  And then what the baby had looked like, progressing from pink faced to blue faced to grey and ashen faced, and then the scary but ultimately successful resuscitation afterwards.  I should say right now, for the record, that thankfully everything turned out fine, and the baby is doing very well, with good arm movement and no other evidence of damage.  And my colleague feels very proud of her skills, after the fact (as well she should–there is no emergency scarier or more challenging than a shoulder dystocia, and it sounds like she did an incredible job with this!)

Needless to say, she had my full attention throughout this story, and I’m so glad she shared it with me.  And this is the other, slightly darker but much more important side of shop-talk: the passing on of valuable information.  Every story we share, the scary ones and bad outcomes as well as the good outcomes, is the sharing of vital information among other birth professionals.  I have not yet experienced a six minute shoulder dystocia.  I hope that I never do, but if/ when I do, I will have my friend’s story filed away in my memory, full of examples of what worked, what didn’t work, and how she got out of that very tight corner.  And even though I might end up using different maneuvers or doing things differently, the more stories like hers that I hear and have tucked away somewhere in my brain, the more I’ll have to draw on when the time comes for me.  Shop-talk gives midwives much-needed tools which they can use.

And actually, I’ll add a third important aspect of shop-talk—when you’re the one with the scary story to tell, every time you re-tell the story, it eases some of the stress and trauma of the experience for you, and gives you a chance to evaluate what happened from a more objective standpoint.  So, in my opinion, shop-talk isn’t idle chatter by any means, but a very important and vital aspect of working in this field.  Which is why whenever there are more than two midwives in the room, it’s not just inevitable, but necessary!  Sorry, dear husband, but you’re just going to have to deal.

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