Experience and Personal Practice

Personal experience always changes the way you practice in some way.  Anyone who denies this is probably not being 100% honest with themselves.  It’s the nature of us being human, and it’s inevitable because humans (as opposed to future robots?) provide health care, and by and large it’s a very good thing.  This can be seen most obviously because of bad outcomes, which I admit can be a very compelling reason to change your practice.  You see something terrible happen once, and after that, you’re more cautious as a provider.  Sometimes this means you call a cesarean sooner than you would have in the past (if you’re a doctor), or you start antibiotics a bit sooner, or call Peds to a birth which before you would have handled on your own.   And usually it’s like a pendulum, swinging back and forth.  Initially, after a scary experience or bad outcome, you will become overly-cautious and hyper-vigilant, and then, with time, as you see similar situations which result in good outcomes rather than bad, you begin to calm down a bit about whatever it was which was making you so nervous in the first place, and regain your perspective.  It’s not that you eventually grow lax or complacent over time, but more that gradually the personal experience gets integrated into your practice as a whole, so that you’re no longer fearful of it, and yet you have that past experience as part of your wealth of knowledge to draw from the next time you’re facing a similar situation.  It’s small things, like remembering to have a woman pee or empty her bladder before pushing because of that one time when a full bladder caused a postpartum hemorrhage.  In this way, we learn from the mistakes we make and the occasional bad outcome which occurs, and in most cases this makes us better providers

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?

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

Question Kegels?

One of my pregnant patients was asking me the other day about what your vagina is like after giving birth.  I reassured her that the tissue of the vagina and the perineum usually comes together very easily after a delivery, even if she tore, and that the perineum usually heals beautifully after a birth (a midwife preceptor used to joke that if there are two pieces of a perineum in a room they will find each other and stick together, such is the beauty of it).  However, I admitted that the muscles of the vagina are another story altogether, and that rarely do these muscles function again exactly as they did before you give birth without a some (sometimes a great deal of) effort on your part.  And I am personally a perfect example of this.  Let’s just say that even now, 6 months postpartum, things are still not at all what they once were in terms of my pelvic floor.  I guess this is what happens when a baby is crowning for an HOUR and those poor muscles (the bulbocavernosous in particular, I think) get incredibly, incredibly stretched out.  And yay, I didn’t tear, but man oh man–I sort of think I would have happily tore instead if it meant my muscles were just a bit stronger and less stretched out now.  I don’t really want to get into graphic details, but let’s just say that I still have a lot of work to do to avoid having both a cystocele and a rectocele for the rest of my life!

While researching this on the internet, I’ve stumbled upon some fascinating information which flies in the face of conventional wisdom.  Conventional wisdom suggests that kegel exercises are the answer to this sort of pelvic floor weakening problem, and in fact they’re what I have been doing primarily, and have been teaching my patients how to do for years now.  Kegels, kegels, kegels!  However, after reading this amazing post over on MamaSweat where Kara Thom of MamaSweat interviews Katy Bowman of Aligned and Well, I am beginning to change my mind.  Katy is a biomechanical scientist who has done a lot of research into the mechanics of the pelvic floor, and in her radical departure from conventional wisdom, she suggests that squats are the answer rather than kegels.  Naturally, rocking the boat like this has brought with it a bit of a back lash, including this hilarious video aimed at Katy from the “Kegel Queen” (an RN who also believes highly in the merits of kegels); even a year after the initial interview, the debate is still alive and well.

So in addition to kegels, I’ve decided to add some squats to the mix, and I’m even squatting and peeing in the shower each morning (apologize for the potential TMI right there, loyal readers!).  There are also some pretty cool exercise systems out there which can be purchased, as well as physical therapists who specialize in nothing but the pelvic floor, so I’ll keep all of you posted on pelvic progress 6 months from now.  But I’m also a firm believer in sexercises, too!

Posted in Gynecology, Miscellaneous, Postpartum, Research, Women's Health | 1 Comment

Cooking with Milk

So, my darling boy is nearly six months, which means that solid foods are just around the corner. In preparation for this, I’ve begun to research which foods we should start him out with, baby food in general. Our pediatrician, while incredibly open-minded and holistic in other areas, has actually proved to be a bit conservative in his recommendation of starting off with rice cereal as the very first food. There are some pediatricians which are launching spirited campaigns against cereal as the first food, arguing that it’s just refined carbs, the equivalent of white-bread, and that this trend may actually promote childhood obesity.   So instead of going that route, I’ve decided to try my hand at cooking my own baby food instead.  Armed with a few books (this one, this one, and of course, this one, not to mention this wonderful website) and a bunch of cute plastic freezer cubes, I’ve begun making my own baby food!  On Saturday I made a banana puree which involved sauteing chopped banana in butter and then mashing it.  Quite yummy, reminded my of banana fosters!  Yesterday I baked a sweet potato and then blended it up with….breastmilk.  Yes, it turns out that most of these recipes call for breastmilk, which makes sense given that breastmilk is what the baby has been eating 24/7 up until now, and is still a complete meal in and of itself, full of iron, antibodies and every other necessary nutrient under the sun.  But when I started out on this parenting journey, I never imagined I’d find myself leaning over a blender with my bra down, adding a few squirts to a potato puree in order to get the consistency right.  Wow.  What next?  Guess we’re really cooking with gas milk now.

Posted in Mothering | 2 Comments

Wax Study Revisited

Imagine the following scenario:  a meta-analysis comparing planned homebirths to planned hospital births is published, but it has so many statistical flaws in it that the journal which originally published it goes on to print several letters to the Editor critiquing the flawed research, in order to give the authors a second chance to explain themselves.  This flawed meta-analysis is then roundly criticized by several authors of many of the individual studies used in the meta-analysis, pointing out the ways that the meta-analysis’ findings were based on a faulty a computational tool, numerical errors, mistakes in inclusion/ exclusion criteria and methodological and reporting errors.  Nevertheless, despite the widely discussed flaws in this said meta-analysis, the trade organization for all obstetricians and gynecologists in this country still goes ahead and bases their most recent opinion statement on this very same flawed study.  Sounds improbable, right?  Wrong!

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 SensibilityOur Bodies Our BlogNatureACNM’s responseMidwifery 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.

Posted in Choice, Complications, Homebirth, Hospitals, Issues, Labor and Birth, Midwifery, Politics, Research | 1 Comment

How have midwives touched your life? Share your story for National Midwifery Week 2011!

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.

Posted in Midwifery, News | 2 Comments

Mea Culpa

My dear blog readers, I must apologize profusely for the abysmal state of my inbox!  I have been ignoring it for way too long.  However, for the first time in over a year, I have finally managed to slog through all of the spam and look through my messages (all 2443 of them, most of which were offers for rolex watches, live hot girls, real ambien at half the price, weight loss miracles of all shapes and sizes, and botox cures), but lo and behold, there were also some *real* messages mixed in with all the dross!  Thank you–all of you–for writing to me!  I apologize again for never getting back to you in the past, and I promise that in the next week or so I will be responding to your inquiries and emails, since I subscribe to the theory that a real reply is always better late than never.  Your messages have inspired me!  It’s so comforting to think that I am not actually writing into a void, but that real live people are actually reading this blog.  Thank you so much for taking the time to write, and for reading Belly Tales through the years.  I will continue to write, and hopefully will be much better about tending to my inbox in the future!

Posted in Miscellaneous | Leave a comment

Miles For Midwives just around the corner!

Heads up all New York City midwives, friends of midwives, doulas, midwifery clients, runners, walkers, parents, kids and babies!  Miles for Midwives is next weekend (Saturday, Oct. 1st) and this is always a wonderful (traditionally *gorgeous* autumn) day where participants can run/ walk/ stroll a loop of Prospect Park and then enjoy a Birth and Wellness Fair afterwards, chock full of information and local birth resources.  Proceeds from the event go to support both Choices in Childbirth and the NYC ACNM Chapter.  It’s not too late to register!  This will be my seventh year running it.  Last year I ran it while pregnant; this year I’ll have a baby in a running stroller with me.  Come on out to enjoy a fabulous event and support and celebrate the midwives in your lives!

Posted in Midwifery, News, Women's Health | Leave a comment

Mother of Many

I *love* this video (“Mother of Many” by Emma Lazenby, which also won the BAFTA for Best Short Animation last year).  It so perfectly portrays what the average day can be like for a hospital midwife, from the overwhelming chaos of helping so many women at the same time to the joy at every birth to the quiet satisfaction that comes at the end of the day.  Watching it even makes me tear up a bit.  Enjoy!

 

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

Posted in Birth Art, Good Enough to Share, Labor and Birth, Midwifery | Leave a comment

Back in the saddle again!

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 | 2 Comments

Empowering Birth in the Trenches

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