Sunday, August 9, 2015

Obstetric Violence (trigger warning)

We sat at her kitchen table drinking coffee. The sky was a clear blue with a gentle breeze. As often happens, when women hear that I am midwife, she wanted to share her birth stories with me. When this happens, I try to listen attentively and remain open to their sharing. Her children are 50 and 51, yes born very close together, 11 months apart to be exact. As she tells her stories, she becomes visibly upset and even agitated. For her, these things happened yesterday. In my experience, this is a crucial part of dealing with birth trauma; it always feels so current, the pain is often just below the surface. She is angry and confused, still not understanding the things that happened to her. She remembers very little, just snapshots really. She was "drugged" and felt out of her body, something "cold and hard" was placed inside her to "pull" out her children. She was treated "like an animal" there was no compassion. The next day, she had bruises and abrasions on her wrists. For years afterwards, she would wake in the night terrified and feeling as though she were dying.  She still deals with pain "down there" all these decades later. She asks me; "Do you know what happened to me?"
Do I tell her? Do I tell her about 'Twilight Sleep', women being strapped down to tables, episiotomies and forceps and the assembly line that was a labor and delivery unit? I ask her; "Do you want to hear my answers?" She responds that she does. So, I tell her, I tell her everything that likely happened to her. She is calm and quiet for a time, occasionally nodding to herself. Eventually she says, "Now at least I finally know that I am not crazy."  We two women looked at each other with silent tears on our cheeks and finished our coffee.

This is the truth behind the history of obstetrics in this country. This is the reality of what the knowledge is based upon. This is where "they are coming from" and we can never forget. Have we struggled, fought and toiled to make great strides to improve the care given to women during birth? Yes! Are we done? Hell No! This is why we must continue. Just because things are much better now does not mean that the work is done. I share this story so that we don't forget, so that the new advocates and activists remember the history, know the past and never forget where they came from.

Tuesday, May 12, 2015

#LifeOfAMidwife: Birth Happens

Birth Happens! Sometimes it happens so quickly that you barely have time to catch the sweet baby, let alone make it all the way inside the birth center! This handsome babe kept his parents in suspense, with a couple trips to the center with "false" alarms but then when he decided to make his move for real we didn't even get through the front door and only made it to the top of the stairwell. Both baby and Mama were fantastic and healthy, the baby was even born en caul. We quickly moved inside after the birth and they had a lovely postpartum recovery. This is a picture that I took later of the "aftermath" of the quick, beautiful birth. Then I had A LOT of scrubbing to do.

Saturday, May 2, 2015

What is The Worth of a Midwife?


This is a question that I often find myself contemplating. What is my worth as a midwife?  I wish to be able to give my knowledge and support to every person who would want it.  The reality is that that is not really possible. This is a fine line we walk as midwives. We wish to serve all but realistically we simply cannot. Here are some of my thoughts on the issue of why it is important to be “paid” in some way. I spend hours, days, weeks, months, years serving at the feet of my clients. I do so, willingly and with respect, but that does not make it easy. I do not expect to live a life of luxury, in fact, my life is pretty minimalist but I do expect and dare I say deserve to be able to provide the necessities for myself and my family.

·         Balance: work-life balance is a serious issue. In order for me to be the best midwife possible, both clinically and emotionally, I need a balance. Quality time off to spend with my own family, to practice self-care and to simply relax and have fun. I am no good to anyone if I run myself into the ground by working too much.

·         Energy exchange: providing quality midwifery care is energy intensive. Being open, available and supportive while at the same time monitoring the health of each client requires focus, time and strict attention to many details. This energy output deserves to be reciprocated in some way; this does not have to be monetary however, in our current society this is how the exchange of energy is most often handled.  Believe me, I see the value in a barter/trade system for goods and services but in the current culture I can’t make my car payment (and I need a car to be able to get to my clients) within that framework.

·         Time spent studying: I spent years of my life dedicated to learning my craft and I continue to spend a good amount of time staying current and continuing to learn. To go to midwifery school, I had to take out student loans and those need to be paid. Now, is there a big problem with our current educational system that saddles people like me with huge debt? Absolutely! Do I still have these payments to make? Yes.

·         Time away from my own family: to me, this one of the biggest ironies of midwifery. Midwives strive to support families in all that we do, we fight for people to be able to have the best choices and care available. We are focused on helping to foster strong, healthy families and yet we’re often doing so at the expense of time away from our own children and family. If I am going to be away from my own family and children, I need to be bringing something back with me, like; food for the table, helping to provide the roof over our heads, clothes for my family, the ability to have some fun as a family every so often, etc.

·         Marginalization of women: this is a big one for me. Historically speaking, women have been marginalized in our culture. While we are in a much better place now than we were, say 100 years ago, we are still marginalized. Our work is often undervalued and under paid. Midwifery is a classic example of traditional “women’s work” that is undervalued and overlooked. As a midwife, I am also a woman and I need to be able to provide for my own family. Again, in our current system, that is done through the exchange of money. Are my clients also in this marginalized group? Yes. And is there a huge problem in our current health care system in regards to access? Absolutely! We as women need to stand up and demand better. We as women need to stop “taking it” and subvert the dominant paradigm. Through my work, I hope to be working towards this goal by empowering and fostering strength in my clients and their families. The other side of the coin is the reality that I must also function in our current currency driven society.

OK, there are some of my current thoughts on the topic of “giving it away”. What are your thoughts?....


This post was recently republished on Birth Wisdom, a resource for maternal health advocates by Birth Institute. Want to become a midwife? Check out the Birth Institute Holistic Midwifery program. 

Thursday, February 5, 2015

Choices

I have some soap boxes to get on today. There is a lot of "doctor or hospital blaming" that can happen in the natural childbirth community. Some of it is deserved and some of it is not. What is becoming clear to me is that for any real change to happen, the women must stand up and demand it! Money talks and if women start taking their money to where they will get the care they want and deserve, change will eventually happen. One of my pet peeves is that many people seem to spend more time researching which TV to buy than on where and with who they will give birth. To this end, here are some of my thoughts.

In order for a person to have the optimal birth experience for themselves, it is CRITICAL to choose your care provider and birth setting accordingly. If you desire a natural, physiologic birth you need to hire a provider who aligns with that desire and then works in a setting that supports the process. If you would like an epidural, choose a hospital that has 24/7 anesthesia available. Research these issues; be sure that your provider and birth setting truly have and offer what you are looking for. Ask around in your community; what is the cesarean section rate at the local hospital, what is the epidural rate? Ask your provider how they feel about your wishes; are they supportive or dismissive? It is not unusual in the current culture to experience the "bait and switch" of having a provider say one thing early on and then start to change their tune as the pregnancy progresses. If you want a physiologic birth then the first step is to be in an environment, surrounded by people, that will facilitate natural birth. When a birthing person is well supported, they will feel comfortable and can more easily relax. This will in turn increase the release of endorphins and decrease the release of stress hormones; it will hurt less and progress more effectively.  Planning a natural, un-medicated birth in a hospital that has a very high epidural rate may be like fighting an uphill battle as they may not be equipped to support the process. Birth should not be a battle, you should not have to go in ready for a fight. You should be welcomed with compassion and support.

Another point to be made: you have hired your provider, if the relationship is not going well do not be afraid to change providers! Prenatal appointments should make you feel supported and comfortable. You should have time to ask questions and those questions should be treated thoughtfully and fully answered. Going to care should not be a battle that you have to gear up for...if it is, leave and find a new provider.

Don't forget about the postpartum period. Many first time families have a tendency to only focus on the birth itself. Really, that is only the beginning. Think about how you want those first few precious hours to go. Uninterrupted skin to skin time is crucial for long term breastfeeding success, does the birth setting you choose support skin to skin care? Will the baby be left in the room with you or will they be removed to a nursery for an exam and observation? What types of routine procedures are done? Research these issues, ask questions and be persistent. These are reasonable questions and should be easy to answer. This is your baby and you have every right to know these things.

Essentially, here is my truth: Be Honest about what you want, Research your options and Choose a provider and setting that will truly support you.

Saturday, January 17, 2015

Nitrous. Yes, No or Don't Know?

****I do not want this to become a discussion on the safety of nitrous. The evidence is strong and overwhelming on the safety; it has been used for decades with no documented concerns for women or babies. I am wanting to have a discussion about the philosophy of using something like nitrous.****

Several months ago my birth center started offering Nitrous Oxide (N2O) for the use of pain management in labor. This is something that I had been wanting to do for several years. I have been reading about it and researching it for quite some time. The first time I proposed this to the other midwives, it was not popular and was basically 'voted' down. A year or so passed, we had some changes in midwives and I presented the idea again. This time the response was very positive and we decided to go for it. I then did all the necessary things; staff training and education, ordering the equipment, letting our families know complete with educational handouts and consent forms, and all the other technical requirements. And in September of 2014 we rolled it out.

Prior to this, I had never seen N2O used. I was simply passionate about it as a safe option for women. As a midwife, I am committed to ensuring that women have options and are presented those options with true informed consent. I spoke with several people; other midwives, experts in the field and women and felt that it should be an option. At the time there was no other facility in our entire state offering N2O. Since then, one of our local hospitals has started offering it as well. I am very happy about that as it only increases access and choice to the women of my community.

Now that we have been using it, I have several observations from experience. There are things that I really like about it and others that I don't. Overall though I really like this option and am very glad that we have it available. I know for a fact that it has helped to prevent several transfers from our center to the hospital and that is a huge success to me. We have also used it to prevent a transfer postpartum for a laceration repair in a woman with severe anxiety about the process. Here is a little break down of my thoughts so far;

Things That I Like
  • The woman is in complete control.
  • It can be used in the birth pool, sitting on the birth ball, in the bathroom on the toilet, standing at the bedside...you get the point.
  • It can become a sort of focal point that helps her to focus on her breathing.
  • It really seems to decrease anxiety
  • It can be used at anytime during labor
  • It can be used for other indications; laceration repair, third stage, IUD insertions
  • If she does not like it for any reason, she simply stops using it and the effects wear off within minutes
Things That I Don't Like
  • The machine is cumbersome and takes up a good amount of space
  • The scavenging vacuum is loud, it becomes a 'white' noise but is still there
  • The mask can seem claustrophobic
  • It can be distracting for some women to figure out the timing, making it harder to focus on her breathing
Clearly, N2O is not for everyone and sometimes it just does not offer any benefit for an individual woman. It does not take the pain away and so the expectations have to be appropriate. What I have noticed in the social media forums is that there is a definite bias in some of the "natural childbirth" communities against N2O. Bias that using N2O is not "natural birth". That it is a type of cop out or that only women who don't have good enough midwives, support persons or who are not properly prepared would need it. To me, this smacks of judgment, which is something I think that we all as humans need to be very careful of. Judgment runs rampant in our current birth culture and this is just another example of that. So, what do you think? Have you used N2O yourself or have you had clients use it? I would love a positive, open discussion about all thoughts.

Thursday, January 1, 2015

Elemental My Dear

This work, the work of being With Woman, is elemental.

Conception is a spark, bright and warm, in the watery depths of the Mother. A spark fed by the eternal breath of the Creator.

The baby grows and develops in the dark, rich soil of the womb fed by the running waters of the Mother's blood.

Labor is a force of nature! It requires the passion of fire, the gentleness of water, the calm of air and the strength of earth. And let's not forget the Spirit, ever present and supporting.

As a midwife, the element that I most often channel is that of water. I am never exactly the same midwife for every woman. I am always myself (guided by Spirit) and bring with me my fundamental knowledge (supported by the Earth), have passion and compassion for my families and the work (fueled by Fire) and my critical thinking skills (through the lens of Air). However, it is as water that I enter each birth space. Each woman has her own song, her own path and will need me to adjust to her. Water takes the shape of the space it fills and that is how I enter; filling the space as needed. Water is soft, gently supporting and caressing, warm or cool depending on the need. Water is strong, clearing away obstacles and creating new paths. Water is quiet, whispering in your ear. Water is
booming, commanding attention when necessary. Water is my midwife elemental energy.

Midwives and Doulas out there...what is your birth element and why?....

Sunday, December 28, 2014

Stats....300 Babies!

300 Babies! Once again, I am honored and humbled to be in this position serving women and their families. I am eternally grateful for my own family who make it possible for me to do what I love; particularly my amazing husband who is my rock and my own Mother who is my biggest cheerleader and the best Grandma ever! I am also thankful for the birth center, it is a labor love and passion to work at and keep a birth center open, and I am thankful for each and every person who has worked with us in the past and present.

I have kept a detailed birth log since starting as a student midwife. I am committed to maintaining this personal tradition for a few reasons. I love periodically reading back through the birth stories, especially during trying times to remind me why I struggle and fight. I am a writer of sorts and it has now become a part of my process after each birth. And the reason I started keeping the logs in the first place, to have a record of my own outcome statistics. I cannot speak highly enough of this point, as midwives it is our duty to keep these records. Through these records we can objectively look at our outcomes to ensure that our practice is indeed providing the best care. Transparency is critical. I openly share my outcomes, some of which are difficult to share, in the hopes to inspire others and to keep myself honest. I will gladly discuss my outcomes, if the discussion is respectful and from a place of true constructive criticism.

Also, I work in a group practice, please know that these statistics are my own personal outcomes for the births that I have attended and are NOT from my birth center as a while. As a practice, we also diligently maintain and review our outcomes and participate in the national birth center data collection database, Perinatal Data Set or PDR.

Without further delay, here we go;
148 girls and 152 boys; 6 of these sweet ones were born en caul

Postpartum Hemorrhage: my overall rate is 16%, this is high and I have spent a lot of energy into looking at these numbers. (Please see the discussion from "Stats...200 Babies" and the follow up "The Great Chux Weighing Experiment") For births 201-300 I have been weighing each and every Chux pad and recording the actual EBL down to the ml. What I discovered is that for the first 200 births, I was over estimating EBL. Also, I have been more thoughtful about what actually constitutes a PPH. One woman may lose 700ml but not require any anti-hemorrhagic medications and not develop any symptoms of high blood loss. On paper, she technically has a PPH, but did she really? I would love to discuss this question....

Shoulder Dystocia: overall rate of 6%. This is another outcome that seems very high! However, in looking back, the vast majority were mild and under 60 seconds from birth of head to birth of the body. Some practitioners may not even consider those as dystocias. In looking at each birth, if I only
included times greater that 60 seconds and births that required more than one maneuver to relieve,
then my overall rate would be 2.3% which is much more appropriate. I think that I have been too quick to "label" these births. Again, would love a discussion on this topic.....

I preformed AROM in 13% of labors and it was always done as augmentation and with informed consent after discussion with the woman and her family.

I have had 6 retained placentas. In my birth center, per state regulations we have a time limit of 30 minutes for the birth of the placenta.

I have done a manual removal of the placenta twice, both times were for active heavy bleeding related to partial separation. I have had 4 cord avulsions, only one was severe and required newborn
transport. I have found one true knot in an umbilical cord. I have had one labial hematoma, which
resolved on its own and did not require transport.


My episiotomy rate is 3%. All of the episiotomies were done due to significant fetal heart decelerations with crowning. Approximately, one third of them extended to third or fourth degree lacerations.

Lacerations; intact = 102, first degree = 87, second degree = 95, third degree = 12, fourth degree = 4. For the vast majority of the third and fourth degree lacerations, they were either as a result of episiotomy or the birth happened on the birth stool. I have recently been actively working against birth stool birth for this reason, and that I have noticed higher blood loss. I still use the birth stool in second stage, but as birth approaches I encourage the woman to change positions.

My water birth rate is 37%.
Birth positions (I have rounded these rates up or down to the nearest whole number); hands and knees = 30%, semi-reclining = 17%, birth stool = 17%, McRoberts =14%, squatting = 11%, side lying = 9%, standing = 1.5% and supine = 0.3%.

I have transported 12 newborns; 7 for Transient Tachypnea, 2 for anomalies, 1 for congenital pneumonia and 1 for pneumothorax.

I have transported 27 women after the birth; 16 for laceration repairs, 5 related to PPH and 6 for retained placenta.

So there it all is. In the next couple days, I will post an update with my outcomes for transfers in labor, those births are not included in these numbers. I am ready and open for discussion...

**Update on 12/31/14**
I have just finished compiling my outcomes for the Ladies that I have transferred. At my birth center, when transfers are necessary, we work with some amazing OB's and are very lucky to have them. One of them actually does vaginal breech births! Also, once a client has transferred, we are no longer involved in the clinical management of their care.
Here goes: 39 women have been transferred by me to the hospital in labor. The primary reason was failure to progress or arrest of dilation. We do not have time limits on progress and our ladies are not on any type of clock. The decision to transfer for this reason is one based on how she and baby are handling the labor and is one made in conjunction with the entire family. They are not typically quick decisions and have a lot of thought behind them. The other major reason for these transfers was the presence of meconium in the waters. Per our state regulations, we are required to transfer for this reason unless "birth is imminent". Of those women who transferred, 18 had cesarean sections and one gave birth via Forceps assisted delivery. This gives me a c/section rate of 5.3%.