Back in the saddle again!

By The Midwife | Published: September 13, 2011

Friday was my first day back at work on L&D.  I was a little bit nervous about it.  Not that I have forgotten anything or lost my skills over maternity leave, but only that my life had slowed down to match my baby’s pace, and I was worried that I wouldn’t be able to keep up (knowing what our L&D unit is like, and how crazy it can get) when I got back.  Well, I was reminded again that if you’re ever nervous about something, just dive in; nothing beats jumping into the deep end!

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

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

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

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

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

Posted in Complications, Hospitals, Labor and Birth, Vaginal Birth | 1 Comment

Empowering Birth in the Trenches

By The Midwife | Published: September 5, 2011

Welcome to the Empowered Birth Week Blog Carnival
This post is part of the Empowered Birth Week Blog Carnival hosted by Child of the Nature Isle and Betsy Dewey. For this special event the carnival participants have shared their perspective on Empowered Birth. Please read to the end to find a list of links to the other carnival participants.

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

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

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

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

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

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

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

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

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

 


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

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

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

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

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

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

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

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

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

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

Posted in Epidurals, Hospitals, Labor and Birth, Labor Support, Vaginal Birth, VBAC | 7 Comments

One World Birth about to launch!

By The Midwife | Published: August 30, 2011

Just stumbled upon this via a friend on Facebook, and watching the welcome video just sent chills down my spine.  Two passionate filmmakers are creating an interactive, continuously-updated online TV channel focusing on nothing but birth, and the state of birth in our world right now, by interviewing the world’s leading experts in birth and attempting to fuse birth, birth education and film-making.  Their mission is to empower women to believe that they CAN give birth, fully informed of their choices.  Now that’s a mission I can get behind!  Oneworldbirth.net will launch on September 1st; until then, you can watch the website trailer below:

This video was embedded using the YouTuber plugin by Roy Tanck. Adobe Flash Player is required to view the video.

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!

Posted in Birth Stories, Cesarean Birth, Homebirth, Hospitals, Labor and Birth, Labor Support, Midwifery, News, Vaginal Birth, VBAC | Leave a comment

Midwifery Care Associated with Better Outcomes

By The Midwife | Published: August 29, 2011

Via MidwifeInfo, a systematic review spanning 18 years and encompassing 21 studies has found that midwives provide comparable or better care to women than care managed exclusively by physicians.   This finding was part of a larger review focusing on advanced practice nurses (nurse-midwives, nurse-anesthetists, nurse-practitioners etc.), and will be published in the upcoming September/ October 2011 issue of Nursing Economic$.  

    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!

Posted in Journal Articles, Labor and Birth, Midwifery, News, Research | Leave a comment

Why midwives “talk shop”

By The Midwife | Published: August 26, 2011

My husband has been known to complain about this from time to time: get two or more midwives in a room together during any social occasion, and inevitably the conversation becomes nothing but “shop talk”—pregnancy, birth, babies, birth, rotten clinic hours, birth, national politics as pertaining to midwifery, birth, local midwifery jobs, birth, attendings we love and hate, birth, classes we’re taking, birth…you get the picture.  So much so that my husband sometimes tries to weasel out of midwifery gatherings for this very reason (although only sometimes; most of the time he is the staunchest supporter of all things midwife, and has expertly and enthusiastically educated countless dinner guests on midwifery and the midwifery model of care without me even having to open my mouth).

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.

Posted in Labor and Birth, Midwifery | Leave a comment

More Business of Being Born

By The Midwife | Published: August 24, 2011

Back in 2007, I was lucky enough to attend an advance screening of The Business of Being Born in New York City, and I wrote this review of it at the time.  Since then, it’s become widely popular and widely viewed, loudly praised and criticized by opposing sides of the birth debate, and has served as the starting point for thousands of people as they begin to educate themselves about birth and navigate the obstetrical mine-field in this country.  It’s amazing to me how much of a cultural icon this film has become since it’s release—so much so that ACOG alluded to it in its Statement on Homebirth back in 2008 (“Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre.”)—and how this film has served as a lightning rod (re-)sparking endless debate, and bringing awareness to a much larger and more mainstream audience.

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!!

Posted in Birth Centers, Education, Homebirth, Hospitals, Labor and Birth, Midwifery, News, Politics | Leave a comment

More mother than midwife, these days

By The Midwife | Published: August 7, 2011

Well into my second month of maternity leave, now, it is finally dawning on me that I am a mother.  You might laugh at this.  Didn’t I know I was going to be a mother, from pretty much the moment the pee stick turned positive?  Didn’t I fully understand that this was the logical outcome of pregnancy?  And haven’t I been a mother for two months now, from the instant our son was born?  Yes, of course!  But there is a huge difference between knowing something logically, and feeling it within you, as part of your identity.  Like peas and carrots.  Night and day.  I haven’t really thought of myself as a mother until very, very recently.  Up until then, while I have been doing plenty of mothering (24/7, including the on-demand breastfeeding and the incredibly sleepless nights), I feel like I have been in shock.  Or else too busy treading water to notice anything but the water, and the need for constant motion to stave off the near-drowning.

But now, suddenly, sometime in the last week, I have found myself walking down the street with the baby attached to me, and feeling like this is normal.  Like this is part of who I am.  That being a mother is one of the ways that I identify myself, just as I think of myself as a midwife, a woman, a wife, a sister, a daughter, a friend.  And there are definitely some moments (fleeting! and few and far between) when this feels normal.  Days when I am taking it all in stride.  But the transition, here, is that I have spent 34 years on this earth without a son, and only two brief months on this earth with a son.  It makes sense that the idea of me as a mother still feels so foreign.

And I was never sure about the mothering part, anyway.  When we were talking about getting pregnant, it was never the pregnancy or the birth that I worried about (not much, at any rate)…it was always the mothering part, the being responsible for a new human being part, the raising a tiny baby into a useful and functioning member of society part.  So much responsibility on your shoulders, and so many opportunities to mess it up, big time!  (One has only to look at articles like this, in the Atlantic last month, to see how easy it is to mess it up, even when trying so very hard to get everything right!)

There are moments when I think that this is all it’s ever going to be: the exhaustion, the monotony (feed, burp, diaper, soothe to sleep, rinse and repeat), the constant cluelessness, the slow dawning on you that life will never, never be the same.  This is all I’ve known of parenting so far, so it’s hard to imagine what it will be like 2 months from now, let alone 2 years from now.  I know, logically, that he will grow and develop, and that gradually it will become more fun and more rewarding.  But for now, this is all you can see.  And you think it will never end.  And to honestly talk about some of the aspects of being a new mother that often get glossed over, there is a sense of mourning involved in all of this: a mourning for your old self, for your old life, for being able to go out whenever you want and stay out as long as you want, for dinners with friends and late night movies and living your life for yourself and your own pleasure, more or less.

But my beautiful son has also just begun to smile as well, in the last few weeks.  It’s one of the sunniest, most freely-given smiles I have ever seen, and he lights up over the simplest things: someone talking softly to him, a long-awaited burp which suddenly makes him much more comfortable, the late-afternoon light dancing through the leaves of a tree.  I know this will sound cheesy, but it is profoundly true: seeing his smile, realizing that he’s not just a small, unresponsive bundle of endless demands but instead a small human being, suddenly makes the sacrifice, the sleeplessness, the mourning, the loss of freedom, the strangeness of motherhood all worth it.  I am hopelessly in love with my son.  Hopelessly?  That sounds too dire.  Hopefully seems more like it.

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Well done, NPR!

By The Midwife | Published: August 4, 2011

NPR has a great series up on their website right now called Beginnings: Pregnancy, Childbirth and Beyond, which explores myriad aspects of pregnancy and childbirth, from cultural, economic, global and scientific perspectives.  Overall, an incredibly balanced and informative series, well worth checking out (I’m especially enjoying the Baby Project, which is a blog following the fate of 9 pregnant women spread throughout the US from pregnancy through birth and the immediate postpartum and newborn days.  (Quite an adventure, and especially poignant given that I’ve just journeyed down this road myself).  Their current post on The Baby Project is a break-down of the different drugs used in L&D, which is fairly balanced, although I think they could have spent a bit more time discussing the risks as well as the benefits of many of the drugs.  The comments are just amazing, though–as if people have failed to notice that this article on drugs is just one very small piece of the overall series, and that equal time has been given to natural childbirth, as well as high-risk situations which warrant different medical approaches.  In any case, well done, NPR!  I am lapping this series up, keep it coming, please!

Posted in Good Enough to Share, Labor and Birth, Mothering, Myth, Folklore and Ritual, Postpartum, Pregnancy | Leave a comment

An Oversupply Issue

By The Midwife | Published: June 17, 2011

When you hear about breastfeeding in the world and the blogosphere, usually it’s either to educate women on the merits of breastfeeding, or to discuss women’s right to breastfeed in public, or to promote breastfeeding in general, or lament the low breastfeeding stats in our country.  We all know that breast is best, but you don’t find much about the actual act of breastfeeding itself—the details of it which can make it so challenging.  And trust me, breastfeeding is challenging!  Despite it being the most natural, obvious thing in the entire world…it’s not instinctual.  It’s a learned behavior, and something which each breastfeeding pair must learn together.  I didn’t quite understand this until now.  I just took it as a given that we would breastfeed (because OF COURSE we would), but the how-to of it wasn’t ever something I even thought about.  Until now.

I took a breastfeeding class last week.  Yes, I actually took a class. And I’ll be attending it again this coming week as well.  This from a midwife, someone who has taught countless other women about breastfeeding, and who has helped countless women get a good latch with their brand new baby.  But there’s a big difference between helping a newborn (as in, minutes-old) baby latch for the very first time versus addressing the myriad difficulties and complications which come up over the course of time: the engorgement, the first growth spurt, and then what happens after the first growth spurt.  There’s much to be said for getting a baby onto the breast in the first hour of life, but as a midwife you’re not doing much lactation support at 3 weeks of life.  Maybe a bit more at the 6 week postpartum check-up, but in between birth and 6 weeks, a lot of breastfeeding happens, and a lot of challenges arise.

Case in point: for me, my challenge is oversupply.  I have a huge oversupply problem!  Who would have guessed that I would be such a milk goddess??  Whenever I thought about potential breastfeeding snafus, I always thought about undersupply.  It didn’t even really occur to me that oversupply could be a problem.  But it can indeed  be a problem.  A very challenging problem, in fact.  So, I will speak to this for a bit, since I now have first-hand experience with it (and maybe someone else wants to write a guest article about first-hand experience with an undersupply problem?).

This is what oversupply looks like: ever since my son’s growth spurt, my breasts have been painfully full.  When he tries to latch, he has a hard time getting his little mouth to even indent the breast, and then when he does, the milk flows down so quickly it completely overwhelms him, and he ends up pulling back and choking.  This has made his latch very painful for the past few weeks.  In an attempt to stem the overwhelming tide of milk, he’s been pursing his lips and using a much smaller latch than he was the first two weeks, which has led to him sucking little grooves into my nipple and turning the nipples black and blue.  I keep trying to get him to use a wider latch, but inevitably he closes his mouth to a smaller diameter again, and I can’t really blame him.  I would do the same, too, if the milk was flowing so quickly into my poor mouth.  During let-down, my let-down has been so forceful that I have actually sprayed him in the face with milk, like a shooting milk geyser!  Poor guy, how is he supposed to drink from a breast that is out to get him like this?  Every feeding has become a wet and sticky mess.  By the end of it, I’m covered in milk, he’s covered in milk (bring on the baby acne!) and my clothes are covered in milk.  Forget trying to nurse in public at this point, there is no way we can be discreet at this point.  Every feeding feels like a pitched battle against the exploding milk fountain of doom!

Then, there are the digestion issues.  Because the milk is flowing so fast, he ends up gulping a lot of air.  Despite frequent burp sessions, his little belly is full of air by the end of the feeding.  He’s also become a really fast drinker to try to cope with the let-down.  He may finish the breast in about 10 minutes, but it hasn’t satisfied his urge to suck yet, so he continues to try to suckle at the breast for another 20 minutes or so.  And because he’s drinking so quickly, and filling up so quickly, he’s not always getting to the hind-milk at the back of the breast, which comes at the very end of the feeding.  I just found out that hind-milk is crucial to improving his digestion.  If he’s getting enough hind-milk, he digests everything more slowly, and the poop is mustard yellow and much easier on his G.I. tract (less gas, less explosive poops, less fussing).  If he’s not getting enough hind-milk, everything digests much too quickly, with a lot more gas and fussing involved, and comes out green instead of yellow.

I went to a breastfeeding class last week, and this is the advice I was given: first, try more upright feeding positions, where he’s sitting up or across my chest but I am leaning back so that his head is over the breast, rather than under it.  This will make the milk have to work against gravity, which might help slow the flow down.  I was pumping a little bit before feeding him to try to soften the breast somewhat and make it easier for him to latch.  The lactation consultant advised to stop pumping immediately, because this was just encouraging more milk production!  Instead, I can manually express just a bit, if I have to, but if at all possible I should just let him eat directly from the breast, and supposedly that will help regulate our supply/ demand more quickly.  She advised I continue with the frequent burpings, and that if he finishes the breast quickly but still wants to suck, I can offer him a pacifier or clean finger to suck on instead, since continued sucking helps with his peristalsis and may also help him digest the milk more easily and spit-up less.  She suggested that I could also try block feedings if I wanted to in an effort to make sure he gets enough hind-milk (this is where I offer him the same breast for 2—or more—feedings in a row, so that I know for sure that the breast is completely drained and that he got the hind-milk before moving on to the other breast).  However, other advice is suggesting that maybe block feedings are not the best idea, since this increases the risk of mastitis and may eventually lead to undersupply (see the link below from Nurtured Child).

I’ve been looking up some other resources about oversupply on the web.  This is what I’ve found so far, which has been very helpful:

Kellymom.com – great resource for all things Breastfeeding.  I just added it as a permanent link under the Breastfeeding section.

Nurtured Child: Managing Oversupply (written by a LLL leader), which discusses frequent switching of sides rather than block-feeding as a way of dealing with it.

At the moment, we’re skipping the block feedings, I’m doing manual expression when needed, and just letting the little guy eat directly from the breast when he’s hungry.  And hoping that the supply/ demand issues will sort themselves out soon.  But no, it’s not easy.  Even with too much milk, there are still challenges.  I will keep you all posted!

 

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Sebastian’s Birth Story

By The Midwife | Published: June 7, 2011

Awhile ago, during the pregnancy, I joined an online forum with other women who were also pregnant and due in May, and this group of women became my “due date club.”  About halfway through our pregnancies, we decided to do a bead swap, where most of the women of the group decided to send each other a bead, often with a wish/ blessing/ quote attached to it, and we were then able to make necklaces out of all of the beads we had received from the other women.  I must admit, my necklace was a huge source of strength and comfort for me!  While I was in labor I wore the necklace the entire time, and clutched it in my fist while I was pushing.  Thinking about the other women who were also in labor at the same time, or who had just had babies/ or were just about to have babies was a really helpful thought for me during the thick of it.  And now that nearly all of us have given birth at this point, this group of women is also proving to be an invaluable source of support through the tricky new parenting/ postpartum days.

One of the women from this group was also willing to share her birth story here on Belly Tales, so with her permission I am going to post it. Her name is Katie, and she gave birth to a beautiful son, Sebastian, at home in a birthtub.  This is their birth story, written by Katie:

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I had a lot of nervousness going into my third birth. Mostly I was nervous about the length of labor, tearing, shoulder dystocia and some other things. My second birth was my first home birth, and it was great; however, there were a few complications, all of which were handled marvelously by my midwives. At a blessingway that my friends threw for me, I was asked to tell about my ideal birth, so I did. I was nervous to say things like” it was short,” or “I didn’t tear.” I did, though, and I just hoped it would turn out that way.

Both of my boys were born after their due dates, so I was sure I had 40 weeks before I would have my baby. I worked hard to get all of my writing done so that I could relax for a week before the baby came.

On Monday morning, May 9, when my husband Michael’s alarm clock went off, I told him I’d been having some regular contractions for a bit, and since I’d been having contractions on and off for a couple of weeks now, he reminded me that they were probably just Braxton Hicks warm-up contractions. I agreed. After a while, I got up and went to the bathroom. I noticed, though, that I had lost my mucus plus, so I knew that these contractions were different.

I kept about with my morning plans, though. I went to eat breakfast with a friend, and on the way, I called my midwife to let her know that I thought maybe I was in early labor. After breakfast, I was going to go to the YMCA to walk to the track and help move things along, but since my midwife was in the area, she decided to come over and see how things were progressing. She checked me around 11 a.m. and said that I was almost four centimeters dilated. I was shocked. My contractions were about four minutes apart, and they weren’t even that painful. She told me to try to take a nap that afternoon. She also told me that she had another mom in labor, which made my heart sink. That mom was also about four centimeters dilated as well.

After she left, I decided to take Atticus to lunch on his way to preschool. He enjoyed that, and when I dropped him off, I told his classroom assistant that I would likely have the baby later tonight, as I was four centimeters. She looked at me in complete shock, like, “Why are you driving and walking around right now?” It cracked me up.

When I got home, I did lie down, and I tried to sleep, but my excitement was too overwhelming. I knew I needed to conserve energy at that point, so I just grabbed my laptop and watched some TV shows on Hulu to keep me distracted. I watched the most recent episodes of “The Office,” “30 Rock” and “Parks and Recreation,” in that order. By the time I got to the last TV show, I had to pause the show during a contraction, get on all fours and rock through the contraction. It was becoming more intense. Atticus came home from school, and he watched me labor for a bit. He asked a lot of questions.

I called my midwife and told her she needed to come again. She got there around 5 p.m., and checked me again. I was only at a 4 ½! I was sure I was further along as the contractions at this point felt more intense. I was discouraged and thought that I was in for a repeat of August’s slow labor. Plus, her other mom in labor was at six centimeters, and I felt so nervous that I wouldn’t get to have my midwife at my birth.

My midwife’s assistant arrived around 5:30 or 6, and she and Robyn, my midwife, went outside to discuss what they would do. When they came back, she said that she was going to stay with me and send her assistant to the other mom. She also called my friend and midwife, Mary, to stay with us and be with me when and if Robyn needed to go to the other mom.

During this time, Michael started filling the birth pool, so when that was done I got in it. The water was definitely not hot enough for me, so he started boiling pans on the stove to fill it with hotter water.

During this time, my contractions stayed three to four minutes apart, but I needed a lot of help getting through them. I had to hold someone’s hand through each one. I would either blow my lips out like a horse through the entire contraction, chant things like, “I am strong,” “I am bigger than this” or “it’s ok” over and over again. I tried some of the same visualizations I used for August’s birth, but they didn’t work for this one, so I made new ones. I also told myself that I could do anything for a minute. I stayed in the pool for a couple of hours, just working through the contractions like this and thinking I had a very long way to go.

At one point, my midwife told me that she thought I was a lot further on. So, when Mary arrived around 8:30ish, she wanted to check me again, because she thought the baby would be born very soon. I was shocked to hear that. When Mary arrived, she checked me, and I was dilated to an 8 or 9 with a bulging bag of water. I could not believe it. I was sure I was going to be laboring all night. How in the world could I be that far along? I felt like even though my contractions were very painful, they weren’t even that close together yet.

We decided to break my water, and as soon as that happened, I felt tons of pressure, and knew that it was very close. My midwife helped stretch my cervix through two or three contractions, which, of course, was painful, but I knew it meant the end. That was about 8:45. Atticus and my mom joined the rest of us in the bedroom. I liked that Atticus was there. He just stood next to Michael and watched everything.

I couldn’t believe how quickly I felt the need to push. He was right there, and I could tell. During my next contraction, I started pushing his head out, and it really hurt. I kept saying that it hurt. I said I couldn’t push anymore. So, the midwives said it was ok to just breathe and pant a bit, which I did. It still hurt, but at that point, that felt better than pushing. I still could feel him moving down, though.

It was intense, and at one point, I saw Atticus run away, and that made me sad, but I knew it was probably best at that point. While he was crowing, the midwives remarked on his black hair, so I put my hand down and felt it. I could not believe that that was my baby’s head and that I would meet him soon. That made me want to push harder.

Throughout my pregnancy, I had expressed to my midwife how I didn’t want to tear as much as I did last time. While I was pushing, she was using oils to help me stretch and putting a lot of pressure on my perineum. While it was happening, though, I was sure I was tearing, because it was so intense and painful.

After his head was out, the midwife checked for cord, and then I start pushing the rest out. It felt like it took a while to come out, but now, when I look at the pictures, I see that it was less than a minute. As soon as he was out, I grabbed and just loved on him. I was so relieved it was over, but I was also so happy to be holding him. And I just couldn’t stop staring at his hair! There was so much of it! He also looked so small, as August was almost nine pounds, and this baby looked teeny-tiny compared to that. I kept hugging him, and the other people in the room reminded me to check to see is he was a boy or girl.

I knew he was a boy as soon as I saw him, and my suspicions were confirmed as soon as I looked. I had wanted a girl, admittedly, but when I saw him, I didn’t care one bit that he was a boy, and I thought about how great it would be to have three little boys, and how cute they all would be together.

I got to stay in the tub for a few minutes. I was still crampy, and I tried to push the placenta out, but it wasn’t coming yet, so I decided to get out of the pool. I didn’t want to cut the cord yet, so Michael helped me stand up, and my midwife held the baby close to me so that he could stay attached for a bit longer.

I tried to nurse him to help the placenta detach, but he was so quiet and just not really interested. I gave a few good pushes, though, and it finally came out. After some inspection, my midwife said she didn’t think that I would need stitches. I was in complete and utter shock. I was also thrilled.

My midwife had been in contact with her assistant who was with the other laboring mom, so she had to leave to be with her, which was fine with me. I was just so thrilled that she had been able to be at my birth. After she left, Mary helped me get cleaned up and settled in bed.

The next day we named our boy Sebastian Michael. He weighed 8 lbs, one ounce and was 20 ¼ inches long.

I still can’t believe that everything I wanted for my birth came true: no tearing, no shoulder dystocia/easy passage and relatively short(er) labor. I feel quiet lucky.

 

Posted in Birth Stories, Homebirth, Labor and Birth, Vaginal Birth | Leave a comment