Dr. Amy’s Comeuppance

I swore I would never write about that woman again. She is the most hateful, angry and irrational woman to ever argue against homebirth/natural birth/un-CNM midwifery. 

However, in researching my Denialism post, I stumbled upon a blog entitled Science-Based Medicine, whose subtitle is “Exploring issues and controversies in the relationship between science and medicine.” Curious, I started reading and lo and behold, who else but Dr. Amy was regurgitating her homebirthdebate posts. I rolled my eyes, skimming the first post and then moved down to the comments. 

I sat upright. The science-minded blogsters began tearing her theories/posts/comments apart. As someone said, it was like Christmas. Over and over, her writings were demonstrated to be much more opinion than science-based fact and, the most recent post from her has (at last count) 194 comments that spank her for her hatred of natural birth (which they force her to define scientifically over and over again) and her extremely interventive beliefs, a few of the members having had Hypnobirthing births or empowering births, pushing her against the wall in a way none of us have ever been able to do. (I find almost everyone frustratingly gives up trying to explain things to her.)

 I cannot exclaim my glee in seeing her opinions questioned so deeply by people she thought were going to embrace her. If scientists can see her craziness, there is hope that she will eventually exhaust herself and vanish from sight. 

One can only hope.

Denialism

Denialism is a new word to me. I didn’t have to Google it to figure out what it meant; that was easy. I deduced the word was defined as the act of denial, probably in the face of facts. When I did Google it, sure enough, many options to explore denialism popped up, including a Wiki entry. (You know you’ve made it when you have a Wikipedia entry.) 

Mark Hoofnagle is one of three authors who write the “Denialism Blog.” (Chris Hoofnagle and PalMD are the other two.) Hoofnagle’s bio says, “Mark Hoofnagle has a(n) MD and PhD in physiology from the University of Virginia, and is now a general surgery resident. His interest in denialism concerns the use of denialist tactics to confuse public understanding of scientific knowledge.” I like the subtitle of the blog: “Don’t mistake denialism for debate.”

Hoofnagle has outlined six tactics that might be used to maintain the appearance of legitimate controversy;

1. Conspiracy - Suggesting opponents have some ulterior motive for their position or they are part of some conspiracy.
2. Cherry picking – Picking apart a critical paper supporting their idea, or famously discredited or flawed papers meant to make the opponents look like they are based on weak research.
3. Contextomy - Using a statement out of context to further their position.
4. False Experts - Paying an expert in the field, or another field, to lend supporting evidence or credibility.
5. Moving the goalpost - The use of the absence of complete and absolute knowledge to prevent implementation of sound policies, or acceptance of an idea or a theory.
6. Other logical fallacies - Usually one or more of false analogy, appeal to consequences, straw man or red herring.

Denialism is spreading in our country. From the “birthers” who don’t believe Obama is an American citizen to the continued denial of the Holocaust, standing on the moon and that HIV doesn’t cause AIDS. Depending on where you stand, the other side looks foolish, if not downright stupid, to believe in such absurd ideas. Denialism isn’t just not believing something, but not believing in the face of scientific, hands-on, well-studied and multi-checked facts.

This begs the question, whose facts are to be believed?

In the birth world, denialism meets evidenced-based medicine.

Evidence-based practice is a common request from those in the natural birth arena. We want an end to continuous fetal heart monitoring and keeping women from eating or drinking in labor because numerous studies show they do not improve outcomes. What if the research counters what the natural birth community believes and wants to continue doing? Many different studies have proven that the Active Management of Third Stage is safer for women, yet midwives and their clients insist on the Physiological approach. Natural birth advocates get all up-in-arms about allopathy continuing routines that have been disproven over and over, yet we do the exact same thing. Who’s in the wrong then?

There is no scientific evidence that homeopathy works. Yet midwives embrace it wholeheartedly. There is no scientific evidence that says keeping a woman in bed improves outcomes, yet hospitals continue with this practice… even when there is contrary evidence saying it might be detrimental. Why do we expect them to accept our quirks if we aren’t able to accept theirs?

Shifting sideways some, denialism takes a different form when discussed in the natural birth context. To me, one of the greatest forms of denialism comes from the Unassisted Childbirth (UC) faction. While no studies show the dangers of a UC (reporting would be self-disclosing and therefore difficult to measure), anecdotally, one simply needs to look at the UC boards at MotheringDotCom (MDC) to see the extremely high rate of affected babies to come to the logical conclusion that perhaps UCing isn’t such a good idea after all. In my own life, I have known of two babies that died during a UC. I have never known of a baby that died from the lack of a medical team’s care (meaning from a baby being left to perish without a team working to keep the baby alive). When babies die in the hospital, it is almost always because of congenital or prematurity issues. Rarely, full-term, pregnancy-healthy babies die. There are stillborns in each category, but monitoring absolutely can alert a care provider to act to help a baby birth alive. (And not just continuous monitoring.) When tragic things happen on MDC, the women  soothe each other, finding ethereal reasons for the tragedy; she didn’t think positively enough, it would have happened in the hospital anyway or it was the baby’s time. It’s heretical to say, “Maybe you should have gone to the hospital sooner” or even, “I wonder what would have happened if you’d had a midwife there.” Women go out of their way to help a mother not feel guilty for her choice, believing she already feels guilty enough, but in their comforting, they are leading the acolytes to believe it would have happened no matter where the woman was.

Of course the medical folks use these same arguments with homebirthers, saying that it’s a risk to deliver at home without continuous monitoring and the capability of an operating room to facilitate a cesarean in the case of the rare emergency. They surely believe Natural Birth Advocates (NBAs) are denialists, too. They point to studies that demonstrate that homebirth is absolutely more dangerous for babies. The major study, sometimes referred to as The Pang Study, has been de-bunked by several professional NBAs, yet is still quoted by med folks. When studies support homebirth as a viable option, factions of researchers and physicians attack methodology. NBAs do the exact same thing; it’s a war of the statistics. What’s amusing to me is when the study benefits either side and is hailed as the latest proof that they are right. No consideration is made regarding methodology then; it’s obvious the study is perfect when the beneficiary needs it to.

Denialism takes many forms… depending on your viewpoint. Pick any hot button issue and you find divisiveness that accuses its counterpoint of denialism: Homebirth/Hospital birth (including UC), ultrasounds, vaccinations, circumcision, naturopathic remedies/medications, television, cell phones, microwave ovens, shampoo, global warming… and on and on. (Interestingly, I hardly hear about a computer’s possible negative effects.) As mentioned above, a plethora of studies demonstrate the scientists’ point of view regarding controversial topics; a few studies do the same for the natural community. Each believes they are right and the other is wrong. Who is right? How do we separate the wheat from the chaff? Do we tend to be on one side or the other depending on how we were raised (similar to choosing religion or political parties)? Did homes that fostered individual thinking produce open minds that can embrace alternatives even when they have no scientific proof? Are there personalities that lean one way or the other? Are left-brained thinkers more apt to live a scientific life? (Of course there is a range from far left-brained to far right-brained folks.) I would love to see a study about this.

Does denialism equal lying to oneself? Or might it be simply looking at a topic, squinting and turning your head sideways to justify your thoughts.

I tend to be somewhat balanced between the two poles. (At least I like to think I am.) Looking at me from the natural vantage point, I am sometimes considered a medwife. I do not struggle with “interventions” when they are called for. I don’t hesitate to send a woman in for medications if she can heal quickly from them. Yet, I also advise natural methods of healing –from supplements to acupuncture- things that are often poo poo’d by the medical community. To them, since I am a homebirth midwife, I am seen as a kook. It’s definitely a balance walking between the two. I often joke about being the tie-dye and Birkenstock-wearing midwife who wears make-up tested on animals and who’s been known to eat too much McDonald’s. I love that I have a wide range of friends… from Christy Funk who owns the natural mom and baby store Belly Sprout to the most medicalized CNMs and family members. I believe walking on both sides of the line helps keep me balanced, looking at both sides of most issues and forcing me to keep an open mind.

Yes, as we all know, it’s the open mind that can pull our pendulum hard towards one direction or the other. A conundrum we all struggle with… and rarely perfect.

Hospital Birth In Progress on the Web

Lynsee is streaming her birth. I am not sure, but at 6:45pm PT, it looks like she's about 5cm. I'm sure they will say soon again.

It's obviously a progressive hospital (as hospitals go).

I wonder how long I'll watch. (I'm acting like I've never seen a birth before!)

Avoid H1N1 with Vitamin D Supplementation

I know, I know. You're tired of hearing about the H1N1 (swine) flu. The more I hear, the more confused I become, but I keep reading and learning and trying to decide whether to vaccinate myself; I am in a high risk category because of my past Disseminated Coccidiomycosis. My lungs have scar tissue that looks like lace on them. Sarah, too, is high risk; she had lung cancer when she was three-years old, having a third of her lung removed.

I've heard whispers of the Vitamin D Theory, but this is the first organized article that explains why and even dosages. The advised dose by our government is 400 IU every day. However, we continue being deficient, sometimes extremely so, in Vitamin D. Our indoor culture and sunscreen use when outside contributes to the cause of the deficiency. I take 8000 IU every day.

The article Swine flu deaths: What You Need to Know will share a good deal of information regarding our children, but this is the very important part I want to make sure people read:

Can we use vitamin D to prevent H1N1 flu or H1N1 flu death?

"...Cannell has reported on Sept 16 in his newsletter that two physicians, one in Wisconsin and the other in Georgia, suggested that vitamin D supplementation can be the key to H1N1 flu prevention.

"Norris Glick, M.D. of Central Wisconsin Center in Madison told Cannell in his email that 274 residents at his health care facility took vitamin D supplements and were monitored regularly for their plasma vitamin D levels; as a result, only two residents developed influenza-like illness and had positive tests for H1N1 during a period of observation. This compares to 103 of 800 staff members during the same period who were not required for the supplementation. This huge difference may be due likely to use of vitamin D supplements.

"Dr. Ellie Campbell, who also responded to Cannell's vitamin D theory, told Dr. Cannell in an email of a similar observation.   She said she told her patients to take 2,000 to 5,000 IU of vitamin D regularly and monitored their serum levels to make sure her patients had sufficient Vitamin D in their blood.  Campbell shared office with another physician. Her office mate did not do the same thing to his patients.  When H1N1 hit George, none of her patients came to see her for H1N1 virus infection while the other physician was seeing one to 10 cases per week of influenza-like illness."

Please, please supplement yourself and your children. Even if you choose to vaccinate, Vitamin D supplementation could very well save your life.

I write this because one of my on-line doula friends lost her sister-in-law... sick one day and dead two days later. I don't want to know any more.

MedFake: Hospital Birth Gone Awry: Is This Typical?

(This is in response to Medscape's article, "Homebirth Gone Awry: Is This Typical?" [the post before this one]. Writing was the only way I could answer the absurd accusations in that ridiculous article.)

Barbara E. Herrera, LM, CPM

Case History 

Being a homebirth midwife who sees women throughout their pregnancies, births and on into postpartum, I am familiar with the way these experiences and how they affect women and their families. 

So, when I was asked to assist a woman choosing obstetric care with a doctor and, once labor began, to deliver in the hospital, I never knew what lay ahead. 

Starting at the beginning of her care, Myrtle’s (not her real name and the details are slightly altered to protect her privacy) vitals were taken by a nurse and she only saw her doctor for five to seven minutes at each visit, although for her initial appointment, she saw him for ten. And, at that first appointment, she met the doctor naked! Myrtle was covered by a paper drape, but, not having met this man before, she felt vulnerable and very uncomfortable. After that visit, she was sent to the lab for blood work and was called two weeks later telling her she was extremely anemic and needed to take prescription iron supplements. She learned through reading on the Internet that her constipation was from the supplements and waited for five days for the nurse to call her back to tell her what she could do to help with the problem. 

At visit number one, Myrtle was told she had to have chorionic villi sampling and was scheduled for the next day. She was not told the risks of miscarriage after CVS, but was excited to know if the baby had any birth defects. When she presented the next day, she first had an extensive ultrasound (unexpectedly!) and then had the procedure which caused her discomfort and, again, she had to disrobe for a stranger. When the results came back normal, she breathed a sigh of relief. 

But when she was sixteen weeks, Myrtle had her blood drawn again (by another stranger; this time, a lab technician) for the Quad Screen, a screen to determine a woman’s risk of delivering a baby with either Down Syndrome or neural tube defects. When she told the nurse at her prenatal appointment she’d had CVS, the nurse couldn’t find that information in her chart and told her to go to the lab appointment anyway. The Quad Screen came back showing her risk of having a baby with neural tube defects was 1:25 and she was scheduled for the diagnostic testing, both a Level 3 ultrasound and an amniocentesis. At the prenatal appointment when she learned she would need further testing, she told both the nurse and the doctor she just met that  she’d had CVS and it came back normal, they both said it was important to have the test, so she followed the orders and had both the ultrasound and amniocentesis.

The ultrasound showed problems with the kidney and heart, but did show there was no problem with the baby’s spine – so far, they said. Myrtle worried every day that her baby was severely deformed and she and her husband debated keeping the baby or terminating the pregnancy. Waiting for the amniocentesis results was excruciating, both physically and emotionally. The procedure caused internal bleeding and she was put on bed rest for the two weeks she had to wait for the results. She lost time at work and, therefore, income for her already strapped family. The results were normal for Down Syndrome and neural tube defects, but she still had the heart and kidney problems to contend with. 

At 28 weeks, Myrtle was sent to the lab after her appointment (where she met another doctor in the practice) to do the Glucose Screen, checking for Gestational Diabetes. When she drank the 50 grams of glucose, she became extremely dizzy, fainting in the bathroom where she was found 45 minutes after she drank the glucola. Taken to the emergency room in an ambulance, she was given a lengthy ultrasound and an MRI to check the baby and her brain, had an IV put in and remained overnight to make sure she did not have a concussion. While she was in the hospital, she had to drink the glucola yet again, felt extremely dizzy and nauseated, but was told if she threw up she would have to drink it again, so she forced the liquid to stay down. She felt horrible for two days afterwards. No one had asked her how her diet was before sending her to the screen, did not talk about any alternatives to the glucose drink, but did tell her if the screen was positive, she would have to drink twice that amount and have her blood drawn four times. Terrified while she waited, she did not hear that her results were normal until her next prenatal appointment two weeks later. 

At Myrtle’s 34-week appointment, she saw yet another doctor and he measured her fundal height two centimeters larger than her dates, so was sent for an ultrasound. The amniotic fluid volume was slightly elevated, so was scheduled to have an ultrasound each week to watch the problem. At this sono appointment, the baby still had the heart and kidney problems; she was told the baby might need surgery after the birth and to be prepared to have a scheduled cesarean if the baby was still showing dangerous signs near birth. The OB explained that sometimes when the baby has defects, there is more amniotic fluid; she was sick to her stomach with worry every waking moment, having to leave work on early disability because she could not focus and do her job. 

Myrtle saw the doctor she’d chosen originally at her 36-week prenatal visit and even though he measured her fundal height as size equal to dates, he said it wouldn’t be a bad idea to keep going to the sono appointments, becoming Biophysical Profiles after 38 weeks. The technician who strapped her in never shared information about the testing she was doing, causing her to wait in agony for someone to call. Often, she called the office herself to see how the baby was doing. 

When Myrtle was 39 weeks, the OB she saw told her she had to be induced in one week if she didn’t go into labor before then. The female OB said, “We’ll just put a little pill inside and you’ll have your baby that day!” Myrtle was excited and scared all at once. She was going to have her baby! But what if he needed surgery. 

A week later, she entered the hospital at 5:30am but had to wait until 11:00am to be checked in and get a bed. She changed into a hospital gown, naked underneath, was strapped to the fetal heart monitor, had an IV inserted, and then the nurse (who she had just met 25 minutes earlier) did a vaginal exam. Myrtle was told she was “long, closed and posterior.” What did that mean? she asked. The nurse told her it didn’t matter and left the room. 

The nurse came back an hour later with the little pill (Cytotec), did another vaginal exam and pushed the pill onto Myrtle’s cervix. Within the hour, she was writhing in pain and the nurse asked her if she was “ready for her epidural”; she said she was, but the anesthesiologist had two cesareans to do first. He arrived two and a half hours later. Myrtle was in excruciating pain, but the nurse kept telling her, “This isn’t anything yet! Wait until you are really in labor.” 

The external monitor showed the contractions were barely peaking above early labor contractions, but because Myrtle was screaming so much (still waiting for the anesthesiologist), the decision was to begin pitocin instead of inserting another pill. She kept saying the contractions were one on top of the other, but because the monitor said they were erratic and mild, the nurse ignored the request to hurry and get the anesthesiologist. Repeatedly, she was told he was busy and she would have to wait. 

When the doctor finally arrived, he tried to get the catheter into Myrtle’s spine five times before hitting the right spot. He told her she would feel relief in 15 minutes or so and complete relief in 30. She waited and waited, but the pain never abated, the anesthesiologist having to come back and try again. When he was successful with the placement, the epidural only took on half her body; hardly any relief at all. 

The nurse told her she was really complaining a lot about the contractions so she felt her fundus and left to go get the doctor. When he came in (a doctor in the practice she had yet to meet), he inserted an internal monitor so the contractions could be read more closely. The monitor showed Myrtle’s contractions as tetanic – extremely hard and extremely long – exactly what she had been saying for two and a half hours. The pitocin was turned off immediately and the doctor told her she was now three centimeters dilated and she had to have her baby by 10:00pm or she would have a cesarean… that women cannot be on pitocin that long. 

It didn’t take that long to have the baby because the fetus could not tolerate the tetanic contractions, his heart rate going down into the 90’s. She had an oxygen mask put on and moved to her left side, where she remained until the birth. We watched as the baby’s heart rate went from 70 to 90 before, during and after contractions. No one seemed alarmed. The OB had just stepped into a cesarean, but said he would check back when he was done in 45 minutes or so. All she could do was wait. 

The nurse started bringing more paperwork for Myrtle to sign, telling her it was “just in case” she had a cesarean. Worried, she asked if that was what was happening and the nurse told her, “Not yet.” 

The baby’s heart rate never got above 100 and when the doctor came back an hour later, he said it was time to “get the baby out of there.” I was told to leave, but Myrtle told me what happened next. She was wheeled down a hallway and told it was an emergency to get the baby out. Because her epidural only worked halfway, she was going to have general anesthesia and wouldn’t be awake to see her baby. Her husband also wouldn’t be allowed in the operating room. She said she cried and the nurse told her to stop it, she had to get control of herself or the anesthesia could go the wrong way and cause problems. 

Once Myrtle was in the operating room, she had another mask put over her face and went to sleep. When she awoke, she was very groggy and didn’t know where she was. A nurse injected something in the IV she had in her hand and she went to sleep again. By the time someone told her she had had her baby, he was already eight hours old. One of the medications she was given during the surgery caused an allergic reaction – a medication she’d repeatedly told the nurses and doctors she was allergic to – so she was sedated and intubated until the reaction wore off. 

Her son was 15 hours old before she saw him. He was in the NICU being tested, checking his heart and kidneys because of the prenatal testing’s findings. He was hooked up to several monitors, had an IV in his head and Myrtle wasn’t permitted to hold him until the testing was complete. She was told she might upset him and that would make testing harder for them to do. 30 hours after the birth, all the test results showed there was nothing wrong with his organs and Myrtle was finally permitted to breastfeed her baby. He’d already gotten bottles for more than a day, so her attempts failed and she cried because she’d wanted to nurse so badly. The nurse in the Nursery told her it was easier to bottle feed anyway, that her baby would sleep more and “not bug her at night.” 

Case Outcome 

Myrtle left the hospital six days after her cesarean, taking with her a staph infection that required cleaning and packing for three months and a colicky baby who, she later learned, was allergic to most formulas. She was in pain for a year and didn’t have sex for 14 months because of her fear of getting pregnant again. She seriously considered tying her tubes. 

This story haunted me for years. How could the doctor miss a normal pregnancy, labor, birth and postpartum period? How could he pathologize such a normal part of a woman’s life? How could so many things be missed, incorrectly diagnosed, over-diagnosed and, dare I say, negligent? Is there anything we can do to help women see the path where medical care leads?  How do those of us who work with natural birth every day tolerate such things? Is there an avenue of discussion where we can process our experiences together? 

Do we even want to?

Medscape Article - 9/29/09 - Slamming Homebirth -again-

Home Birth Gone Awry: Is This Typical?

Maria I. Rodriguez, MD

Case History

Often, it is an especially busy night in Labor and Delivery when a patient with a disastrous clinical circumstance presents to the service. One call night, during my internship year, proved to be no exception. Although the events that follow happened many years ago, the encounter is indelibly etched into my memory. Hazel and her partner were brought in by their midwife "for pain medication." (Identifying details of the patient and midwife have been changed to preserve confidentiality.) Hazel had broken her bag of water 7 days earlier but had not started to feel any contractions until 5 days ago. She had been evaluated by the midwife when her water broke. Once labor began, someone from the birth center remained with her. Three days later, 2 days prior to presentation to the hospital, she developed a fever, and the contractions became stronger.

The midwife was a direct-entry midwife who had apprenticed and then practiced at a popular birth center in town. [Note to reader: Discussion section that follows explains the different types of midwifery trainings.] She indicated to us that she was one of their most experienced midwives. The midwife and I had actually met the month before when another patient from her practice was brought in hemorrhaging. That patient had attempted a home birth after a prior cesarean section but instead wound up having a cesarean hysterectomy, 12 units of blood products, and a prolonged stay in the intensive care unit.)

The moment I heard we were expecting another transfer from this center, my adrenaline surged and we started preparing for the worst. The expected patient (namely, Hazel) had been seen at our hospital early in her pregnancy; while waiting for the transfer, I reviewed the available hospital records. She was of advanced maternal age and had undergone in vitro fertilization (IVF) to achieve this pregnancy. She had an early ultrasound that put her at 2 weeks overdue the night of the awaited transfer.

When Hazel arrived, the nurse took her vital signs while I listened to Hazel and the midwife relate the rest of the history, placed the fetal monitoring belts, and prepared to do a cervical exam. Hazel was incoherent from exhaustion and pain; most of the history came from the midwife, who explained that the patient's cervix had last been examined yesterday, it was a "dynamic 8," and the baby was in occiput posterior position. My pulse climbed even higher; this was sounding worse by the moment.

The patient had been asked to start pushing 9 hours ago because the midwife was concerned about fetal heart rate decelerations that she was auscultating intermittently with a fetoscope. I interrupted her elaborations on the various positions the patient had been pushing in to ask about the monitoring. I was nervous as I watched our nurses having a hard time getting the baby's heart rate on the monitor. The midwife explained they had been listening to heart tones using a fetoscope every hour for a minute and that the fetal heart rate had been around 100 to 120 beats per minute for the last 3 days. By report, the fetal heart rate had been 140 when labor had started. Hazel was herself tachycardic to the 120s with her fever of 39 degrees Celsius, and the nurse had quietly called my attention to purulent amniotic fluid she noted on the pad.

More people were called into the room and an intravenous line was placed, type and cross sent, antibiotics ordered, cervical examination performed, anesthesia and obstetrical attendings paged, and the ultrasound set up. The operating room was on stand-by. Hazel was working hard not to push with contractions, and her partner was engrossed in supporting her. I had barely been able to talk directly to her, other than to introduce myself. Her pain and fatigue made it difficult to establish any kind of rapport, and the midwife was standing between the 2 of us, repeating what I said to the patient. I tried to change positions so I could at least make eye contact with Hazel, and the midwife changed, as well. I knew she wanted to maintain a role in the process, but her desire to do so was obstructing my ability to connect with our patient, and I needed to do so immediately.

I finally just pushed past the midwife to sit down on the bed next to Hazel and told her what we had learned. She was only dilated to 4 cm. Her cervix was swollen, and she was bleeding briskly from a tear in her cervix. Her baby was in frank breech position, edematous, and molded in her pelvis. The umbilical cord had prolapsed past the breech and was palpable; there was no pulse. No cardiac activity could be seen on the monitor or the ultrasound. They had likely been listening to Hazel's heart rate for the last 3 days. "Hazel," I said as gently as possible, "I am so sorry, but your baby did not survive this labor." This was Hazel's first pregnancy.

(PAGE 2)

Discussion: Controversy of Home Births

Home birth is common throughout the developing world, where resources are scarce, and maternal and neonatal death rates are high. In certain developed countries, such as Great Britain, The Netherlands, and Switzerland, home births are a fairly well integrated option in their healthcare systems.[1] In the United States, however, home births are controversial, both medically and socially. For many women, choosing to give birth at home is an important personal and philosophical decision that reflects their unique values.[2,3] In addition, given that the United States is actively evaluating healthcare expenses and how best to curb them, the question of the legitimacy of home births may be raised from an economic perspective, as well. According to some sources, an uncomplicated vaginal birth in a US hospital costs, on average, 68% more than an uncomplicated vaginal home birth by a midwife.[1,4]

National census data show that approximately 1% of all births are home births, with rates highest in Oregon and Washington.[2] Research in this area is inherently challenging. A randomized controlled trial would not be ethical or feasible. Women who elect to have home births self select, and they tend to be white and better educated than average.[2,5,6] This introduces significant confounding and bias into the observational studies conducted to date. In addition, most states do not record place of birth on death certificates for neonates, which further limits the ability to compare home birth with hospital birth outcomes. California is an exception.[1]
Midwifery Training and Certification

The wide variation in midwifery training and local regulatory practices also makes rigorous evaluation of home birth in the United States difficult. Midwives may be trained as part of a certified nursing program (ie, nurse midwives) or as a direct-entry midwife through apprenticeship. Direct-entry midwives may come from any type of educational background and may or may not be certified through an organization such as the North American Registry of Midwives. The term "direct entry" refers to midwives who enter the profession of midwifery directly without earning a nursing degree. The North American Registry of Midwives was developed in 1987 as a way to certify and credential midwives involved in home births who are not nurse midwives.[1] Not all nonprofessional, direct-entry midwives in North America choose to participate in the Registry by becoming certified; those who do represent a subset of direct-entry midwives in North America. The certification process for nonnurse, direct-entry midwives is quite variable as well; there are 2 main processes -- certified professional midwives (CPMs) and certified midwives (CMs). CPMs are trained primarily through apprenticeship; CM training is much more extensive, involving 3 years of university-affiliated training, completing the same science requirements and certification exam as a nurse-midwife.[7]

As the American College of Obstetricians and Gynecologists (ACOG) explains, CPMs are the least qualified midwives because of their lack of training and lack of collaborative work with hospital-based providers.[7] There are options for use of midwives in a hospital setting, hospital-based birthing center, or properly accredited freestanding birthing center. ACOG warns against using midwives not certified by the American College of Nurse-Midwives or the American Midwifery Certification Board.
Evidence For and Against Home Births

Multiple observational studies conducted to date do not show an increased risk for adverse outcomes for home births compared with a low-risk hospital-based cohort.[1,2,8] Conversely, other studies, such as a retrospective analysis of all home births in Washington state, showed a statistically significant increased relative risk for [6]:

* Neonatal death;
* Depressed Apgar scores;
* Prolonged labor in nulliparous women; and
* Postpartum hemorrhage in nulliparous women.

Data for this trial came from the Washington State birth registry between 1989 and 1996. Uncomplicated singleton pregnancies of at least 35 weeks gestation delivered at home (N = 5854) or transferred to medical facilities after attempted home delivery (N = 279) were compared with hospital-born singletons (N = 10,593) during that time period. The same relationship of increased neonatal demise and depressed Apgar scores remained when the analysis was restricted to pregnancies of at least 37 weeks gestation. This study suggested that planned home births in Washington State during 1989-1996 had greater infant and maternal risks than did hospital births.

A large, well-designed North American prospective cohort study examined 5418 women who had planned home births in Canada and the United States.[1] Outcomes studied included:

* Medical intervention rates;
* Patient satisfaction; and
* Maternal and infant mortality rates.

The study population was women who sought the services of a midwife certified via the North American Registry in Canada or the United States for a birth with an expected delivery date in 2000. In the fall of 1999, the Registry provided the research team with an electronic database of 534 certified midwives whose credentials were current; and the North American Registry of Midwives made study participation a mandatory criterion for recertification.

Compared with low-risk women delivering in hospitals, the cohort had a markedly low rate of medical interventions (such as epidural, cesarean, or assisted delivery), no maternal deaths, and a comparable neonatal death rate -- namely, 2.0 deaths per 1000 intended home births and 1.7 deaths per 1000 low-risk intended home births after planned breeches and twins were excluded. Of note, 80 breech deliveries occurred at home with 2 intrapartum deaths. Cesarean section for breech presentation is the standard of care in the United States. No separate analysis of outcomes for breech infants was done. A comparison of neonatal death for this subcohort with hospital-delivered breech would be of interest.
Where Do Professional Organizations in America Stand on Home Births?

Regardless of the paucity of data, as well as their conflicts and limitations, and despite ACOG's stated opposition to the practice of home births,[9] a few women will continue to choose this mode of delivery. Of note, not all professional organizations in the United States agree; the American Public Health Association passed a resolution in 2001 to increase access to out-of-hospital maternity care services.[1,10] The American Medical Association (AMA), however, supports ACOG in its resolution that "the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers."[11] ACOG and AMA share this position because "an apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia, or other obstetric emergencies, necessitating the need for rigorous standards, appropriate oversight of obstetric providers, and the availability of emergency care, for the health of both the mother and the baby during a delivery."[11] ACOG explains that "while childbirth is a normal physiologic process that most women experience without problems, monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies."[9] They go on to explain that the fact that home births in other developed countries, particularly in Europe, seem relatively safe does not pertain to the United States.[7] The Netherlands, for example, is geographically small and densely populated; therefore, everyone lives within 20 minutes of a hospital.
Guiding Our Patients: Why Do Women Choose Home Births?

Our responsibility as clinicians is to ensure that our patients are well informed and to advocate for the best possible outcome for both mother and child. Understanding the reasons why women choose to give birth at home is one opportunity we have to address their concerns, reassure them about the hospital birth experience, and help them make a well-informed decision.

In a qualitative study of US women exploring reasons they chose to deliver at home, common themes included[2]:

* Safety -- patients expressed the belief that home was the safest place for birth and would result in the best health outcomes;
* Fear of medical interventions;
* Previous negative hospital experience; and
* Desire for more control and comfort that they anticipated at home.

Narrative surrounding these fears is available from a descriptive study of women having home births in Sweden.[8] Women cited a desire to know the people caring for them and their newborn and feared a loss of control in the birth process if labor and delivery were to take place in the hospital. Understanding the reasons why some women choose home birth can also help facilitate change in hospital settings to better address patient concerns. ACOG cites women's desire for vaginal birth after cesarean or VBAC as another potential reason for seeking home birth delivery.[7,9] But attempted VBAC is all the more reason to deliver one's baby in the hospital; if the uterus ruptures during labor, this is an emergent and potentially fatal situation for both mother and baby.

The vast majority of physician encounters with home birth patients comes during a transfer for a problem or complications being experienced at home. In the prospective study by Johnson and colleagues[1] discussed earlier, 12.1% of intended home births were transferred for hospital delivery. The 3 most common reasons for intrapartum transfer were failure to progress in the first stage of pregnancy, pain relief, and maternal exhaustion. The time of transfer is a stressful and difficult situation for all parties involved. The woman does not want to be there and may be in medical distress. The midwife may be anxious or defensive. The accepting practitioner has the responsibility, both medically and legally, of caring for a patient whom they have never met before and who has now developed a potential complication.

Both common sense and research in this area suggest that facilitation of the transfer process is a critical way providers can improve outcomes for women.[3,12] Protocols mandating hospital transfer have been used with success in areas where midwifery is regulated. In The Netherlands, which has a high rate of home birth, midwives undergo 3 years of professional training and screen patients for high-risk conditions that merit referral to the hospital.[13] Central to their system's success in providing the best care for each individual's needs is close collaboration and communication between midwives and physicians.[13]

Clear communication is essential but is challenging due to the urgency, tension, and differing perspectives of the home birth proponents from the hospital team, particularly at the time of the transfer. Developing strategies to respectfully, efficiently, and safely care for the woman who desired to deliver her baby at home, in the hospital is critical. Dialogue is essential to developing relationships that will enable this. Improving relationships between the hospital and midwives that attend home births by inviting midwives to attend group debriefings following stressful deliveries or hospital educational conferences might facilitate future transfers.

(page 3)

Case Outcome

Hazel received an epidural for pain management and, with oxytocin administration, went on to have a vaginal delivery of a beautiful, lifeless boy. Her midwife had left shortly after the ultrasound, but the doula, her nurse, and I stayed with her through the night. The tragedy was heartbreaking.

Hazel haunted the halls of the hospital that summer. I saw her regularly, crying outside of the nursery, and when I stopped to talk with her, all she could say between sobs was, "Owen didn't make it." Our social worker and counselor worked with her, and I saw her in clinic, as well.

We all make choices in life, some of which have consequences we never anticipated. A minority of women in the United States will continue to choose home birth as a reflection of their personal values. Our responsibility as medical clinicians is to educate communities and to strive to provide care that balances respect for an individual's autonomy with the need for safe, efficient quality healthcare. Maintaining open, respectful dialogue with women and midwives that attend home births is essential in facilitating timely and safe hospital transfers. This includes providing balanced information for women interested in home birth and encouraging midwives to consult for help sooner rather than later.

How Homebirth Helps Avoid the H1N1 Virus

You cannot miss the headlines: 

Hospitals May Face Severe Disruption From Swine Flu – “Swine flu may hospitalize 1.8 million patients in the U.S. this year, filling intensive care units to capacity and causing “severe disruptions” during a fall resurgence, scientific advisors  to the White House warned.” 

Hospitals May Ban Visits to Newborns Due to Swine Flu – “With a potential outbreak of swine flu on the horizon, many hospitals are becoming more cautious when it comes to protecting newborn babies and their mothers -- fears that have prompted a complete ban of children from areas of one hospital where newborns and their mothers are cared for -- and that have caused more intense deliberations about the issue in other facilities.

‘For pregnant women, there is a much higher risk associated with H1N1, and they wanted to err on the side of safety for pregnant women,’ said Mike Green, the chief executive officer of Concord Hospital in New Hampshire, which imposed the outright ban.”

81 U.S. healthcare workers found to have H1N1 virus - “At least 81 U.S. healthcare workers have contracted laboratory-confirmed cases of the novel H1N1 influenza virus and about half caught the bug on the job, the Centers for Disease Control and Prevention said today.

The finding is worrisome because it suggests that hospitals and workers are not taking sufficient preventive measures to limit spread of the virus. If a large-scale outbreak of the virus recurs this fall, a similar infection rate could cause significant problems -- not only because it would limit the number of workers available to care for the sick, but also because the infected nurses, doctors and others could transmit the virus to debilitated patients before their own symptoms become apparent. Already-ill patients would be more likely to develop life-threatening side effects from the flu.” 

Does this scare you? It should.

While balancing the information you get from medical and holistic sources is crucial and each family needs to make their own decisions regarding vaccinations or nutritional support, the one clear truth is: those that are the sickest with H1N1 (“swine flu”) will be in hospitals. Considering and choosing a homebirth takes on an urgency not previously needed.

Women who have thought homebirths were for hippies and counter-culture crunchies now find themselves thinking hard about having one of their own. If you are one of the women who have thought a homebirth might be a good idea, but you were not sure of the safety aspects, it is time to fill in the information gaps. Wouldn’t it be wonderful to not have to worry that the person holding your newborn might be carrying a virus that can seriously harm you and your newborn? 

Having a baby at home is for healthy women having uncomplicated pregnancies. If you fit that description, you are already on your way to taking healthy control of your upcoming birth. But, where do you begin learning about the safety of homebirths, finding a midwife and how to prepare? 

The Internet abounds with information regarding birthing in one’s own home. Search “homebirth,” “home birth,” “waterbirth,” “midwife,” add your city to those terms, too, and you will find local resources. If you add “safety” to the terms, you will find yourself reading study after study that speaks highly of the safety of birthing at home with an experienced/educated midwife. A great place to start is the McMaster Study which, in part says, “Almost 6,700 planned home births in Ontario were assessed in the study. Results indicated that newborns and mothers were no more likely to suffer complications than their counterparts in a clinical setting.” 

It is important to have a midwife that is experienced with homebirth and most midwives in the United States are licensed or certified; be sure to ask when you interview a midwife. Midwives are well-prepared for emergencies, carrying medications for hemorrhage, being certified in neonatal resuscitation and being able to repair any tearing. 

While pain medications are not offered in the home setting, women are mobile and use a variety of pain coping techniques including massage, positioning and even immersion in water (which is often called the midwife’s epidural). Women birthing at home who have also had hospital births will say their homebirth was much more comfortable than the hospital birth, even without an epidural or narcotics. 

If a situation arises that moves out of the scope of practice for a midwife, whether it is a non-emergent (such as malposition of the baby’s head that does not resolve) or emergent (such as a hemorrhage that does not stop with basic medications), the midwife does not hesitate to move into the hospital. Even when we are trying to stay out of the hospital because of the H1N1 virus, weighing the pros and cons of going in are crucial and, when absolutely necessary, the pros outweigh the cons. 

For those women who cannot avoid the hospital during the birthing process, perhaps staying home as absolutely long as possible and then going home as soon as is safe can also help lower the risk of obtaining the virus. The less time you are in the hospital, the less chance of getting ill. 

But, when everything unfolds in the natural way birth is designed to do, staying home will definitely lower your risk of acquiring the H1N1 virus. You have control over who comes in your house and if they are sick, they do not come in. You can make sure everyone, including your own family, washes their hands regularly and remind people how to cover their mouths and noses with their sleeves should a sneeze overtake them. You can have your family take nutritional supplements that support the immune system; you will also do this for you and the baby. By taking control over the environment and keeping healthy family and friends close, you are minimizing the places you could get sick. 

So, if you have ever thought about a homebirth or if it never even crossed your mind, this might be the time to do so. Over and over, we hear in the news, “Stay out of the hospital unless you are extremely ill because there will be so many infected people there.” While we do not always believe what we hear, this might be one thing we really need to listen to. 

For more information about homebirth and homebirth midwifery, Search “Midwife,” “your state (or city),” “homebirth” and you will find several options. Whoever licenses midwives in your state will also have a list of those that carry certification or a license. In the states that do not have midwifery regulation, perhaps now is the time to get involved to make it possible in your state. Even in un-regulated states, Certified Professional Midwives might be in your area and worth talking to. 

Choosing a homebirth is a deeply personal decision and one that needs to be considered seriously and completely. For those that decide staying home and out of the line of the H1N1 fire, their births can be a way to remain well with a large dose of incredible.

What Doesn't Feel Right, Isn't

Zipping around Facebook a couple of weeks ago was the My OB Said What?!? site.  It reminded me of an old post I wrote in 2004 right after I learned what birthrape was. I’d been quite angered by the women who used the term because, as a woman who has been raped, it was offensive. How could anything in birth be equated with the horrific experience women around the world experience? I could have closed my mind and left myself in anger, but I probed and really pressed the women to explain it so I could understand what they meant.

Reading around the Net, women have written about birth traumas and abuses, including birthrape.  Kathy shares information from Rixa Freeze’s doctoral dissertation about how some women choose to deliver unassisted because of their past experiences with medical or midwifery care. Interestingly, Rixa and Kathy used my own description of the abuses I participated in as I was learning to be a midwife. I’ve written about my sadness and sincere apologies to the women I have hurt (emotionally and physically) and that, in speaking about exactly this, I could find a place of peace inside myself. (Reference the post I wrote in 2004 above.) 

Back in 2004, I listened to the words women used to describe their pain and was told about actions that did, indeed, sound extremely coercive, manipulative and even pushing women to do things completely against their will. I went to Sarah who at the time was a Deputy Sheriff and I read through her official code book that defined things like “assault,” “battery” and “rape.”

Legalese regarding the definition of assault includes (emphasis mine and my comments in parenthesis):

“… the essential elements of assault consist of an act intended to cause an apprehension of harmful or offensive contact that causes apprehension of such contact in the victim. (“You need to have a cesarean or I will get a court order to make you have one.”)

The act required for an assault must be overt. Although words alone are insufficient, they might create an assault when coupled with some action that indicates the ability to carry out the threat. (“Open your legs. I’m going to do a vaginal exam.” And the woman tells the practitioner that she doesn’t want an exam or tries to close her legs before the exam begins.)

Intent is an essential element of assault. … the intent element is satisfied if it is substantially certain, to a reasonable person, that the act will cause the result. In all cases, intent to kill or harm is irrelevant. (I’m going to give you an episiotomy.” “No!”)

There can be no assault if the act does not produce a true apprehension of harm in the victim. There must be a reasonable fear of injury. The usual test applied is whether the act would induce such apprehension in the mind of a reasonable person. The status of the victim is taken into account. A threat made to a child might be sufficient to constitute an assault, while an identical threat made to an adult might not.”

Battery definitions include: “The act must result in one of two forms of contact. Causing any physical harm or injury to the victim—such as a cut, a burn, or a bullet wound (episiotomy, cesarean, IV, internal monitors, IV antibiotics, etc.) —could constitute battery, but actual injury is not required. Even though there is no apparent bruise following harmful contact, the defendant can still be guilty of battery; occurrence of a physical illness subsequent to the contact may also be actionable (a post-cesarean infection, systemic yeast after IV antibiotics, etc.). The second type of contact that may constitute battery causes no actual physical harm but is, instead, offensive or insulting to the victim. Examples include spitting in someone's face or offensively touching someone against his or her will.

Intent: Although the contact must be intended, there is no requirement that the defendant intend to harm or injure the victim. (This allows for the belief of doctors and nurses that the procedure/intervention is helpful, but the woman sees it in a completely different light.)

Intent is not negated if the aim of the contact was a joke. As with all torts, however, consent is a defense. Under certain circumstances consent to a battery is assumed. A person who walks in a crowded area impliedly consents to a degree of contact that is inevitable and reasonable. Consent may also be assumed if the parties had a prior relationship unless the victim gave the defendant a previous warning.”

Still, my biggest quibble is with the term “birthrape” because most definitions connote rape with sexual intercourse or genital to genital contact.

Among the common definitions of “Rape,” we find this: “Forced sexual intercourse; sexual assault; sexual intercourse between an adult and a minor. Rape may be heterosexual (involving members of opposite sexes) or homosexual (involving members of the same sex). Rape involves insertion of an erect penis or an inanimate object into the female vagina (gloved hand, speculum, internal monitors, amniohook, etc.) or the male anus. Legal definitions of rape may also include forced oral sex and other sexual acts.

Victims of rape suffer physical and mental trauma. Physical trauma may include cuts, bruises and abrasions in the pelvic area as well as elsewhere on the body. Mental trauma may include overwhelming feelings of humiliation, embarrassment and defilement (classic signs of PTSD). Rape victims should seek treatment at a hospital. There, doctors and nurses can treat the injuries (eek! Not for birth traumatized women), administer antibiotics to prevent sexually- transmitted diseases, and provide counseling or any other additional therapy (mental or physical) that the patient requires. The hospital team's evaluation and report will help document the condition of the patient for legal purposes.”

These legal descriptions of rape do not take into account birth trauma/abuse and trying to use these definitions to prove it would be very challenging (I suspect). I know that the majority of people reading the definition of rape and attempting to apply it to birth trauma will feel it is a stretch to do so. It took decades to believe that rape occurred in marriage or that women could be rapists, too, so expanding the definition to include birth might take a very long time and, I am sure, many, many years and a slew of failed lawsuits before anyone in the legal system recognizes birth traumas/abuses, much less birthrape. In fact, I have known of women to talk to lawyers as they consider suing their care provider and the lawyers won’t even discuss it. The typical proof of “lasting physical harm” is even abandoned as some women have had to have reconstructive surgery to repair the damage caused by their doctor or midwife. What is a traumatized woman supposed to do? I think we all know it takes an extremely powerful woman to even think about bringing a lawsuit against a perpetrator and the aftermath of trauma is not the most conducive time to do this.

I believe this is where a support system can take a major role. Women who have been traditionally raped or assaulted, including domestic abuse, have dozens of places to turn to for help and support. The hurt woman may not realize this or know how to find those resources, but they are there. I know the Internet has changed the face of helping hands, although women in domestic abuse situations still have to be careful lest their Net records be looked at. For those who are not in fear for their lives, but for their mental stabilities, the Net can be a haven for the women who need it. One former birth traumatized mom started Solace for Mothers. An organization in the United Kingdom, the Birth Trauma Association, began at the same time I learned about birthrape/birth trauma in 2004. I’ve corresponded with several of the women who keep that organization going and they are just as committed to helping women as the newer groups here in the US.

Look at that. 2004. Only 5 years of the realization of birth trauma. But, how many decades (centuries?) before were women living with the painful and scary memories of their births?

Above, I alluded to the challenge of trying to get anyone to understand the reality of birth trauma… that people will roll their eyes and think, “Why is she being so dramatic? Women have been having babies for eons.”

When I began talking to my mom about this a couple of years ago, she told me about my own birth in 1961. She said that when she went for prenatals, all the women went into the bathroom, peed in a cup and put their underwear in their purses. They would then have to sit for hours together in a hot room waiting for their few minute appointments with the doctor. When they went into the exam room, they were put in stirrups and left there until the doctor walked in, did a vaginal exam, listened to the baby and sent mom on her way. When she was in labor with me, there were four women to a labor room and when she started pushing, they moved her to the Delivery Room, put her in the lithotomy position, legs buckled into stirrups, arms put in constraints and left until someone came in to catch the baby. She remembers how horrified she was that a very young man (black, something that was an important factor in that time) kept looking at her perineum to see if I was coming out. My mom is so shy I have never seen her naked. She can’t even pee in a public place, so being stared at was, for her, humiliating.

As I asked her how she felt about the birth, she matter of factly told me that that was just the way it was. No one questioned it. She said it was always good to hear other women’s stories at baby showers, that it was affirming of her own experience, but she was too busy to consider the experience as much more than having her first child.

Women birthing in the United States have it really easy compared to some women around the world. We don’t have 1 in 8 women die at births. We don’t lose our babies like too many other countries. We don’t labor on the floor with rats and roaches, sitting in the blood of a hundred other women who birthed before us. We don’t give birth as mortar shells explode outside the window. We don’t really have to worry that our children probably won’t make it to their first year’s birthday. Women in other countries can labor for a week before someone gathers the few dollars it takes to get her to a hospital hundreds of miles away, only to know the baby has already died and the mom now at serious risk of dying from hemorrhage or infection.

Do these women have PTSD? Or do they live in some sort of Traumatic Stress every moment of their lives? Do stressors have ratings? The stress of trying to staying alive much higher on the scale than having a mother-in-law that won’t allow you to go to the hospital? What would these women think of us who are saying they have PTSD for being touched where we said we didn’t want to be touched? Would they think we are absurd? Would they think we are so privileged and take for granted aspects of life they cannot even fathom a woman would be granted.

Is Postpartum Post-Traumatic Stress Disorder (PPPTSD) an illness of luxury? If we were huddled in a migrant camp, would we really be concerned that the doctor pushed our legs apart to do a vaginal exam? Or would the multi-rape experiences overshadow the minimal intrusion the roaming doctor or midwife does.

Is PPPTSD judged by societal norms?

When I was in sexual assault self-help groups (almost always led by therapists), there was a tendency among the women to rate the abuse, almost always minimizing their own. “Well, I was just sexually abused at twelve from the guy next door. She was six and it was her brother. She had it much worse than I did.” Over and over, we had to remind each other (and be reminded) that rating the abuse discounted our own. We had to really work to learn that the measuring stick with which we measured was created by our own hearts. Continuing on that path, it is important for women to take their own experiences and not judge them, comparing them to others. “I just had my membranes stripped without permission… she had an episiotomy!” Your own trauma is just as valid as the next woman’s. I like what Jennifer Zimmerman says: “But, rape is rape. One woman may label it that way, one woman may not, but it is what it is. …if a women has her membranes stripped without her knowledge or consent, that act is a violation no matter what the woman feels about it. If she was not offered informed consent, it doesn't matter whether she is thrilled that she went into labor a day later, she was still not offered informed consent and that makes it wrong for the provider to have done it.” 

So do we start telling women who loved their births that their births really sucked? Do we burst the bubbles of those great stories we hear all around us? Were we elected to Name the Abuse of every woman we meet? 

When I had Tristan (and you can read his story here), I thought the birth experience was so great I wrote a letter to the doctor, nurses and hospital administrator thanking them for the great birth I had in their hospital. When I was pregnant with Meghann, I was talking to a group of Bradley mamas, most of whom had had homebirths. I proudly showed Tristan’s birth pictures, all green draped, lithotomy, oxygen masked, baby across the room… all the things we know now are awful! The women never said a word to me about how horrified they were looking at the pictures. It wasn’t until the whole experience was re-framed by Bradley standards that I began to see the experience as sucky and blech. Even today, the feeling of joy far outweighs the supposed-to-be horrible, angry emotions I should have had back then. It was others that used their knowledge, given to me, pulled into my own psyche, that gave the first experience the shadow it now carries. I asked the Bradley moms how come they didn’t wince and cringe when I so proudly showed Tristan’s pictures off and the Bradley teacher said, “We knew you would figure it out yourself when you were ready.”

The dilemma, of course, is what do we do? 

I say we write and speak our realities. I want women to write in blogs, write articles and get them published, write the hospital, write the doctor, write the nurses. I vacillate between asking women to write filled with their anger and sadness or if they should wait until the anger has subsided and they can write in a voice that will be heard more than a shrill postpartum patient. Angry letters are often dismissed. I think they are fabulous to write and hang onto for awhile before sending them, re-vamping them as time passes, but I’m not sure how helpful the highly charged letters are. If it is a serious part of your healing, then I say go for it. But, know that you may not get any response. If you do write, speak as unemotionally as you can. Speak of specific actions, not a blanket “She sucked” kind of way. Ask someone else to read it to see if it makes sense, flows well and isn’t defamatory. Please don’t threaten the doctor with, “And I’m going to tell everyone I know how awful you are” because you can find yourself in court for defamation of character.thrilled that she went into labor a day later, she was still not offered informed consent and that makes it wrong for the provider to have done it. 

For the women too traumatized to write, draw. If you can read (I could not in my depressions), get Birthing From Within and work through the art suggestions. They can be very telling and very healing. Showing your pain on paper can help those around you “see” what you are talking about. 

Clay is another outlet. I used to do collages. I went to used bookstores and got dozens of magazines and pieced together a collage that spoke my pain in words and pictures. I still have a couple of them. You can also do a collage of what you hope to be/look like after you pass through the storm. Painting… deep, dark colors… the canvas holding the pain through brushstrokes and pallet clumps. 

Find your own outlet. Therapy, of course. Find a therapist who gets it, though. It really is hard to have to teach a therapist about birth trauma before you can get to the meat of the healing. You shouldn’t be the teacher, you are the client. There are many different types of therapy for PTSD. These include talk therapy, medications (temporary or long-term), holistic treatments, dietary changes, acupuncture, hypnosis (although that can be felt as a loss of control to some women – unacceptable), EMDR (Eye movement desensitization and reprocessing), and more. I wish there were Group Therapy groups, but I haven’t heard of any. There certainly are enough women to get dozens going. It really is important in self-help groups to not just be in a place of “poor, poor pitiful me,” but to actively work towards healing and a whole life with the trauma assimilated into the grand scheme of a woman’s life. With the acknowledgement of PPTSD, I believe women are more apt to begin their healing. 

Oftentimes, the therapy includes telling the perpetrator how the woman feels. I’ve seen letters, heard of throwing clay/dough around the room (at his/her hands or face), speaking to the abuser as s/he sits invisibly in a chair and, for many, eventually finding the power to be able to speak to the person face to face or through a letter or email that goes beyond the write & burn stage. It can be freeing to tell the perpetrator your feelings, but really, only if the person acknowledges their culpability in the experience. I remind women that most care providers will act defensively and even put some (all?) of the blame back on her. A woman has to be incredibly sure she can withstand a firestorm before she confronts her provider in person. I believe it is much easier to accuse and confront in writing, at least in the early stages of healing. 

As a healthcare provider, it is imperative for me to listen to women, believe them when they tell me about their abuse/trauma/rape whether it was someone else who did it or even if it was me. And after my 2004 disclosure of the past abuses I participated in, I have been involved in other women’s traumas, albeit accidently. It pains me knowing my actions have hurt another. I am definitely more aware of what I do and say, but there are times when situations create a ripe atmosphere for hurt and anger.  

My wish is that all providers find a place where they can listen –and hear- those that have been hurt, whether it was us or someone else. Until we all can hear, women must keep talking, writing, photographing and screaming about birth trauma. Providers can do the same.

Maybe then, someday soon, we will all be heard.

   

Re-Writing Progress (odd)

The revision of two posts earlier has transformed into a loooonnnnggggg piece about birth abuse/trauma/rape. I don't know where it came from or is coming from, but I am being driven to write about this. I haven't in a long time, haven't had anyone come along talking about it necessarily, but it's just coming out of my fingers.

So, I am working on it, but it's taking time. I write a little, stop to think/process, then write some more. I keep sighing and Sarah asks what is wrong. I tell her it's just a heavy piece I'm writing. As I research, I am reading all sorts of yucky things about assault, battery, rape and then birth Post-Traumatic Stress Disorder (aka Post-Traumatic Birth Disorder). Not zippy, happy topics, no matter from which angle you look at it. It's hard, sometimes, to remember that birth isn't always so happy.

I'm not on another writing strike; just taking time to write this piece (unnamed at the moment). Thanks for your patience!

Re-writing...

...the last post. Hope to have it finished today or tomorrow. It is similar, but different... discusses assault and battery in the LDR room. I will be using aspects/lists from the last post, but wanted to remove a lot of the anger, replacing it with reasoned thought and new information I've gathered over the last three years.

Hope it's done today.

Just because it's the standard of care...

... doesn't mean it's ethical.

(This is part of a post I wrote in May 2006 and it seems appropriate even today. This was right after I learned the term "birthrape.")

I worked in hospitals for 15 years before moving to birth centers (there was crossover) and finally now in home and hospital birth. I know what hospital birth looks like. I know what doctors are thinking because I have spent HOURS with them at the nurses station talking to them. Nurses have confided in me, telling me the vile things that come from physician's mouths the moment the door is closed. I have heard vile things with my own ears from doctors and nurses - and midwives.

Birth trauma is not a doctor-only proposition. Birth trauma happens with nurses, direct-entry midwives, licensed midwives, certified professional midwives, certified midwives, etc. Some of the most horrid things I've seen have come from a midwife's hand or mouth.

Here, from an old post and my birth stories blog - and while midwives are specifically addressed (because of the original discussion) it obviously encompasses physicians and nurses as well:

Birthrape: The experience of having fingers, scissors, and/or tools put/pushed/shoved inside a woman's vagina or rectum without her direct (or indirect) permission.

Being coerced, manipulated, or lied to regarding the health and safety of the baby or themselves so the midwife is able to do something to the mother's vagina, rectum, cervix, or perineum, usually with excuses; rarely with apologies.

Some find the definition expanded to:

The midwife taking the woman's Power by using disparaging comments, unsupportive expressions, speaking around her as if she is unable to hear or process requests or information.

and

Even though consent forms are signed in the hospital, birth center, and at home, consent for care does not include the manipulations or coercive words to get women to obey the caregiver.

I thought it was time I shared some of the thousands of comments I have personally heard that have facilitated birthrape over the years.

I share them and am writing about them and speaking about them and nearly screaming about them in the hopes that midwives will hear what they are saying that is sending their clients into therapy, pushing them to depressions that require medication and alternative therapies, keeping them from coming back to the midwife at all because of her Power Hunger and covert misogyny. Too many women (in my opinion) find Unattended Birth their only acceptable option after their experiences with professional caregivers in birth.

You see, most midwives talk a good game. They will say any number of things in pregnancy to lead the woman to believe she (the mom) is in control. I have sat through hundreds and thousands of prenatals with midwives and listened to the party line about how they believe in a woman to know, how they will "let" them labor how they want, how they will limit vaginal exams, etc. And then, when labor is in full swing, I sit by (or participate) in the amazing disregard for the woman's prenatal wishes and dreams of an unhurried, unfettered, un-directed birth. I am not a part of the delusion or lies anymore.

Common Beliefs

* Women in labor don't really want to use their birth plan.
* Women in labor aren't able to verbalize their needs.
* Women in labor don't know when they need to pee or drink or eat.
* Women in labor don't know when to change positions.
* Women in labor can't make decisions.
* Women in labor want an epidural.
* Once labor kicks in, they all want epidurals.

Directives That Disembody Her Being

* Lift her leg.
* Move her to the bed.
* Grab her knees.
* Put her feet in the stirrups.
* Put her hands on the grips.
* Push her head to her chest.
* Push her chin to her chest.
* Put pillows under her head.
* Put pillows under her butt.
* Pull her down to the edge of the bed.
* Push with her so she knows how to do it right.
* Count for her so she knows how to do it right.

(while these next phrases end in periods and question marks... almost exclusively, the following words have been shouted at women... an exclamation mark is more appropriate, but there aren't enough in the computer to add them all)

Comments That Negate Her Intelligence (spiritual, physical, emotional, and intellectual)

* You aren't pushing right.
* Push like this.
* Get mad at the baby.
* Quit making noise.
* No, push longer.
* Push like you are having a bowel movement.
* Push the watermelon out.
* Push the bowling ball out.
* Don't push in your chest, push in your butt.
* Push like you mean it.
* What are you doing?
* Can't you push harder?
* Have you ever been raped? (asked in labor)
* Are you an abuse survivor? (asked in labor)
* Have you been abused? (asked in labor)

Coercive and Manipulative Remarks

* I need to get in there.
* (pressing knees apart) I need to do a vaginal exam.
* C'mon, just let me see what is going on.
* I'll do it quick and fast, I promise.
* I promise to be gentle.
* I just want to feel the baby's position.
* I just want to see how dilated you are.
* You asked me to be your midwife, now let me do my job, okay?
* I'm a woman, too, I know how it feels... I promise to be gentle.
* I remember how vaginal exams felt in labor, I promise to be gentle.
* Do you want the baby to come out or not? Just open your legs.
* Are you sure you are ready to be a mom?
* You had no problem opening your legs 9 months ago.
* Just let me break your water, it will speed things up.
* If I break your water, the head will be applied better on the cervix.
* If I break your water, prostaglandins will stimulate things nicely.
* Here, drink this. (as Gatorade with cytotec is given to the mom)
* You might feel a pinch. (as pitocin is injected into the vaginal vault)
* I am just wiping up some stuff. (as pitocin on a gauze is pushed inside the vagina or rectum)
* Here, drink this. (as blue and black cohosh are given without consent)
* Here, put these under your tongue. (as homeopathics are given without information or consent)
* I'm just feeling your cervix... it might hurt a little. (as manipulations to the cervix are done... from stripping the membranes to manual dilation)
* I'm just feeling your cervix. (as cytotec is put onto the cervix)
* Do you want your baby to die?
* You don't know the seriousness of the situation.
* You have been a martyr long enough.
* Just take the medication.
* Just get "your" epidural.
* Would you like something for the pain? (in the middle of a contraction)
* This will take the edge off.
* It doesn't do anything to the baby.
* If you were my daughter/sister/mother....
* I have had three scheduled cesareans myself! I don't know what you are complaining about. (being wheeled into the OR)
* Stop whining.
* Why are you crying?
* What is wrong with you? Are you trying to hurt your baby?
* In this day and age, no one needs to suffer in childbirth anymore.
* Mothers and babies died without hospitals 100 years ago.
* Let me call the anesthesiologist... just talk to him about your options.
* No, you can't eat... just in case you need a cesarean... and your labor is rather slow moving.
* No, nothing by mouth after 7 centimeters. (or any number the caregiver randomly pulled out of her ass)
* Only ice chips.
* Oh, Bradley... they always have cesareans.
* You wanted a homebirth? That's child abuse!
* Are you one of those La Leche League people who nurse until the kid dates?
* Do you vaccinate? (after discussion of no erythromycin in the baby's eyes)
* You want your baby to go blind? (after refusal of erythromycin in baby's eyes)
* Your baby might bleed to death. (after refusal of Vitamin K injection for the baby)
* It's just antibiotics.
* God, you have terrible veins!
* Where are your veins?
* (to the Licensed Midwife during a transport, a nurse asks) Do you know how to take a blood pressure? Did you do any?
* Why did you wait so long?
* Why did you get here so early?
* You aren't in labor.
* How would you not know if your water broke or not?
* Can't you stop moaning?
* Be quiet!
* Oops, your water broke! (while using fingernails or fingers to break it on purpose)

Whispering to Other Birth Attendants

* My god, I wish she would hurry up.
* I am so bored!
* She is going so slow.
* I wish she would let me break her water.
* My baby needs to nurse, I need to go home.
* My boobs are going to burst if I don't go home and nurse. She needs to hurry up.
* I am so tired.
* I want to go home.
* I am going to talk her into letting me break her water so she will hurry up.
* I am going to talk her into letting me manually dilate her so she will hurry up.
* I need her to hurry up.
* She's holding back. There must be some emotional barrier we haven't found yet.
* I bet she was abused. Look how she: keeps her legs together/cries with exams/doesn't want us to touch her/doesn't take her clothes off/won't take her shirt off/won't relax enough to let the baby out/is afraid to be a parent/hasn't worked through her issues/has body image issues/has eating issues/is fat/is thin/lives in her head/isn't in touch with reality
* She is so noisy.
* She is too quiet.
* She needs to let go.

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I am exhausted writing this much pain. I know there are hundreds of thousands of remarks that have been said that I haven't been witness to and I encourage women who have had them said to them to email me privately so I might start a list that lets caregivers know what not to say to women during pregnancy, labor, birth, and postpartum.

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This came as an addendum to that blogspot:

* There's not much happening here (as the midwife does a vaginal exam)
* One woman wanted to stand on her own during her births, but, both times, was forced to do a deep squat or be supported by others, causing vaginal tears and "mad" that she wasn't honored at her own births (her words).

* I had a midwife write me thanking me for disclosing what she, too, has seen in her training.
Blessed Be! I am not alone!

This next series from a nurse friend of mine:

* "Stupid Bitch" (said by a Doc before he even left the room)
* The same doc (we hated this prick, he still practices) elbowed a woman (hard) in the thigh because she wouldn't open wide enough for him
* "Well, the Anesthesiologist is here now for another pt and he wants to go home, this is your last chance for an epidural"
* "If you would just stop moving we could get a good tracing on the baby" (and other variations of the same)
* "Quit being such a baby"
* "Oh come on, it doesn't hurt that bad, you are only ____cms dialated."
* "These stupid wetback women just scream and scream, I wish they would shut up" (same prick as above)
* "If you don't hurry up we will have to do a c-section"
* "No way is that one going to deliver vag, did you see the size of her?" (I personally have never seen a vag delivery of anyone over like 200, that is after preg weight)
* "No you can't walk because you are on pit" (everyone I have ever seen in labor was on pit)
* "Walking doesn't do anything for labor" (said by a doc, different one than above)
* "Oh no, she has a birth plan"
* "If you wanted to walk you should have stayed home" (after her IV is in and she is on pit now)
* "Give her a sleeper already so she will be quiet and stop bugging us"

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How can people NOT believe women would consider their experiences traumatic and abusive.

It would be wonderful to demonstrate a completely natural birth in the hospital (NOT a homebirth in the hospital as many would want to call it) and watch all the care providers squirm with discomfort as their jobs became almost useless "just" sitting and observing. It would take an incredibly strong woman to be able to withstand the intense tension brewing, but it would be a great lesson for hospital personnel to witness. I believe it could never be done - and that's just so sad. It's sad that not only could we not even demonstrate a normal birth, but that nothing like it would ever occur in the hospital setting. The closest I have seen is in in-hospital birth centers, but even that is difficult to compare to a homebirth.

When I first heard the term "birthrape," I was really offended as a woman who has been raped before. However, talking to police and deputy sheriffs as well as lawyers, the above descriptions of what happens in hospitals absolutely fits the LEGAL definition of rape and assault. It is simply so foreign to our legal system and our mental health system, the designation hasn't yet been given its rightful place. There were times when terms and syndromes or disorders didn't exist even when people carried them in their brains and bodies. This simply is a new one - BECAUSE of our medical system seeing women as THINGS and not people - the pain is catching up to us all.

Medical care sees women as a number - as a collection of symptoms to be treated. It is in this disembodiment that abuse can occur without thought or concern.

Many, many, many of us are saying NO MORE.

No more.

Hibiclens Discussion (for GBS+ women)

This is a letter I share with moms considering the Hibiclens vaginal douche in lieu of antibiotics in labor when they are positive for Group B type of  beta-hemolytic streptococci (not Group Beta Strep as it is often mis-named):

This is the research information I have found regarding using chlorhexidine wash (Hibiclens) in lieu of antibiotics. I'll share some quotes along with where they came from (more from me at the end):

http://www.medscape.com/viewarticle/542430_4

Vaginal Cleansing

GBS Colonization and Infection. GBS is the major cause of early- and late-onset neonatal sepsis in full-term infants in developed countries. Intrapartum chemoprophylaxis and multivalent conjugate vaccines reduce neonatal colonization and the risk of early-onset sepsis. Costs, shifting serotypes, and lack of skilled personnel, however, have impeded widespread implementation of these strategies, particularly in low-resource settings.

Vaginal cleansing with chlorhexidine before or during delivery prevents vertical transfer of GBS to the neonate. The Swedish Chlorhexidine Study Group explored the minimum inhibitory and bactericidal concentrations of chlorhexidine, described postcleansing vaginal concentrations of chlorhexidine and its residual effect on GBS carriage, and demonstrated that trace levels of chlorhexidine could be absorbed through the vaginal mucosa. Pilot studies showed that vaginal washing with chlorhexidine reduced newborn colonization with GBS compared with those born to nonwashed controls. These studies prompted a series of large randomized controlled trials with varying vaginal cleansing protocols for further exploration of the potential of this intervention to reduce GBS-related neonatal morbidity ( Table 2 ).

Two trials demonstrated reductions in vertical transfer of GBS, admissions to the neonatal intensive care unit, and neonatal infections. A third study confirmed that vaginal disinfection reduced GBS colonization of the newborn, but hospital admissions, cases of probable infection, and mortality were equal between the groups. Conducting vaginal examinations during labor using surgical gloves lubricated with 1.0% chlorhexidine digluconate cream did not provide protection against vertical transfer of GBS compared with the use of nonlubricated gloves.

Although these data indicate that vaginal disinfection may reduce neonatal colonization with GBS, the low overall rates of early-onset GBS sepsis has precluded estimation of the impact on newborn infection. None of these studies was conducted in developing countries, and the validity of extrapolating the potential benefit to such settings is problematic. GBS generally has not been identified as a major neonatal pathogen in developing countries, especially in South Asia. In some settings, however, vaginal colonization rates among women are similar to those in industrialized countries. Because the majority of births occur outside of health facilities, the impact of maternal GBS colonization and vertical transfer may be underappreciated, yet further research is required.

Vaginal cleansing with chlorhexidine reduces vertical transmission of GBS to the same degree as intrapartum antibiotics and may be significantly cheaper and easier to implement in settings where skilled providers are lacking. Additionally, the antibacterial action of chlorhexidine extends beyond GBS to a broad spectrum of potentially invasive pathogens. In developing countries where sepsis rates in general are significantly higher, vaginal cleansing interventions have the potential to affect a wider range of neonatal infections.

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http://209.85.173.132/search?q=cache:_oI3xt55LPcJ:www.collegeofmidwives.org/GBS_2006/GBSprophylactic-VaginalFlush_07.pdf+chlorhexidine+in+labor+for+GBS+newborn&cd=8&hl=en&ct=clnk&gl=us

Chlorhexidine instead of Antibiotics in Treating Group B Strep at Birth
Submitted by Gretchen Humphries, who notes that this alternative treatment in GBS+ labor is easily
done at home.

J Matern Fetal Med 2002 Feb;l l(2):84-8 Chlorhexidine vaginal flushings versus systemic
ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.
Facchinetti F, Piccinini F, Mordini B, Volpe A. Department of Gynecology, Obstetrics and
Pediatric Sciences, University of Modena and Reggio Emilia, Modena, Italy.

OBJECTIVE: To investigate the efficacy of intrapartum vaginal flushings with Chlorhexidine
compared with ampicillin in preventing group B streptococcus transmission to neonates.

METHODS: This was a randomized controlled study, including singleton pregnancies delivering
vaginally. Rupture of membranes, when present, must not have occurred more than 6 h previously..
Women with any gestational complication, with a newborn previously affected by group B
streptococcus sepsis or whose cervical dilatation was greater than 5 cm were excluded. A total of
244 group B streptococcus-colonized mothers at term (screened at 36-38 weeks) were randomized
to receive either 140 ml Chlorhexidine 0.2% by vaginal flushings every 6 h or ampicillin 2 g
intravenously every 6 h until delivery. Neonatal swabs were taken at birth, at three different sites
(nose, ear and gastric juice).

RESULTS: A total of 108 women were treated with ampicillin and 109 with Chlorhexidine. Their
ages and gestational weeks at delivery were similar in the two groups. Nulliparous women were
equally distributed between the two groups (ampicillin, 87%; Chlorhexidine, 89%). Clinical data
such as birth weight (ampicillin, 3,365 +/- 390 g; Chlorhexidine, 3,440 +/- 452 g), Apgar scores at 1
min (ampicillin, 8.4 +/- 0.9; Chlorhexidine, 8.2 +/- 1.4) and at 5 min (ampicillin, 9.7 +/- 0.6;
Chlorhexidine, 9.6 +/- 1.1) were similar for the two groups, as was the rate of neonatal group B
streptococcus colonization (Chlorhexidine, 15.6%; ampicillin, 12%). Escherichia coli, on the other
hand, was significantly more prevalent in the ampicillin (7.4%) than in the Chlorhexidine group
(1.8%, p < 0.05). Six neonates were transferred to the neonatal intensive care unit, including two
cases of early-onset sepsis (one in each group).

CONCLUSIONS: In this carefully screened target population, intrapartum vaginal flushings with
Chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical
transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was
reduced by Chlorhexidine.

PMID: 11995801 [PubMed - in process]
1: Int J Antimicrob Agents 1999 Aug;12(3):245-51 Vaginal disinfection with Chlorhexidine during
childbirth.

Stray-Pedersen B, Bergan T, Hafstad A, Normarm E, Grogaard J, Vangdal M. Department of
Gynecology and Obstetrics, Aker Hospital, University of Oslo, Norway.

The purpose of this study was to determine whether Chlorhexidine vaginal douching, applied by a
squeeze bottle intra partum, reduced mother-to-child transmission of vaginal microorganisms
including Streptococcus agalactiae (streptococcus serogroup B = GBS) and hence infectious
morbidity in both mother and child. A prospective controlled study was conducted on pairs of
mothers and their offspring.

---

Page 2
During the first 4 months (reference phase), the vaginal flora of women in labour was recorded and
the newborns monitored. During the next 5 months (intervention phase), a trial of randomized,
blinded placebo controlled douching with either 0.2% Chlorhexidine or sterile saline was performed
on 1130 women in vaginal labour.

During childbirth, bacteria were isolated from 78% of the women. Vertical transmission of
microbes occurred in 43% of the reference deliveries. In the double blind study, vaginal douching
with Chlorhexidine significantly reduced the vertical transmission rate from 35% (saline) to 18%
(Chlorhexidine), (P < 0.000 1, 95% confidence interval 0.12-0.22). The lower rate of bacteria
isolated from the latter group was accompanied by a significantly reduced early infectious
morbidity in the neonates (P < 0.05, 95% confidence interval 0.00-0.06). This finding was
particularly pronounced in Str. agalactiae infections (P < 0.0 1).

In the early postpartum period, fever in the mothers was significantly lower in the patients offered
vaginal disinfection, a reduction from 7.2% in those douched using saline compared with 3.3% in
those disinfected using Chlorhexidine (P < 0.05, 95% confidence interval 0.01-0.06). A parallel
lower occurrence of urinary tract infections was also observed, 6.2% in the saline group as
compared with 3.4% in the Chlorhexidine group (P < 0.01, 95% confidence p interval 0.00-0.05).
This prospective controlled trial demonstrated that vaginal douching with 0.2% Chlorhexidine
during labour can significantly reduce both maternal and early neonatal infectious morbidity. The
squeeze bottle procedure was simple, quick, and well tolerated. The beneficial effect may be
ascribed both to mechanical cleansing by liquid flow and to the disinfective action of Chlorhexidine.

Lancet. 1992 Sep 26;340(8822):791; discussion 791-2. Prevention of excess neonatal morbidity
associated with group B streptococci by vaginal Chlorhexidine disinfection during labour.

The Swedish Chlorhexidine Study Group.Burman LG, Christensen P, Christensen K, Fryklund B,
Helgesson AM, Svenningsen NW, Tullus K. National Bacteriological Laboratory, Stockholm,
Sweden.

Streptococcus agalactiae transmitted to infants from the vagina during birth is an important cause of
invasive neonatal infection. We have done a prospective, randomised, double-blind, placebo-
controlled, multi-centre study of Chlorhexidine prophylaxis to prevent neonatal disease due to
vaginal transmission of S agalactiae.

On arrival in the delivery room, swabs were taken for culture from the vaginas of 4483 women who
were expecting a full-term single birth. Vaginal flushing was then done with either 60 ml
Chlorhexidine diacetate (2 g/1) (2238 women) or saline placebo (2245) and this procedure was
repeated every 6 h until delivery.

The rate of admission of babies to special-care neonatal units within 48 h of delivery was the
primary end point. For babies born to placebo-treated women, maternal carriage of S agalactiae was
associated with a significant increase in the rate of admission compared with non-colonised mothers
(5.4 vs 2.4%; RR 2.31, 95% CI 1.39-3.86; p = 0.002). Chlorhexidine reduced the admission rate for
infants born of carrier mothers to 2.8% (RR 1.95, 95% CI 0.94-4.03), and for infants born to all
mothers to 2.0% (RR 1.48, 95% CI 1.01-2.16; p = 0.04). Maternal S agalactiae colonisation is
associated with excess early neonatal morbidity, apparently related to aspiration of the organism,
that can be reduced with Chlorhexidine disinfection of the vagina during labour.

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Page 3
1: Eur J Obstet Gynecol Reprod Biol 1989 Apr;31(l):47-51 Prevention of group B streptococci
transmission during delivery by vaginal application of Chlorhexidine gel.
Kollee LA, Speyer I, van Kuijck MA, Koopman R, Dony JM, Bakker JH, Wintermans RG.
Department of Paediatrics, University Hospital, Nijmegen, The Netherlands.

In a prospective study in 227 parturients, carriership of group B streptococci was established to be 25%. In carriers, transmission of streptococci to the newborn occurred in 50%. 10 ml of a Chlorhexidine gel
containing hydroxypropylmethylcellulose was introduced into the vagina during labor in 17
parturients, who were known to be carriers of group B streptococci from the first trimester of
pregnancy. In none of the newborns from these mothers colonization by group B streptococci did
occur. Vaginal application of Chlorhexidine may prevent transmission of group B streptococci, and
serve as an alternative to intrapartum prophylaxis using antibiotics. A large multicenter randomized
controlled study should be performed to confirm this hypothesis.

Eur J Obstet Gynecol Reprod Biol 1985 Apr;19(4):231-6

Chlorhexidine for prevention of neonatal colonization with group B streptococci. III. Effect of vaginal washing with Chlorhexidine before rupture of the membranes.
Christensen KK, Christensen P, Dykes AK, Kahlmeter G.

A single vaginal washing with 2 g/1 of Chlorhexidine was performed before rupture of the
membranes in 19 parturients who were urogenital carriers of group B streptococci (GBS). Two
(11%) of the infants became colonized immediately after birth, in contrast to 16 of 41 (39%) infants
to controls (P = 0.02). A significant reduction of GBS colonization of the ear (P = 0.02) and
umbilicus (P = 0.01) was noted. Taken together, 2 of 57 (4%) cultures obtained at birth were
positive in the Chlorhexidine group, in contrast to 30 of 123 (24%) among the controls (P less than
0.01). These findings raise hope for the design of a simple washing procedure which might prevent
serious infections in the early neonatal period with GBS but also with other chlorhexidine-sensitive
organisms.

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http://www.medscape.com/viewarticle/542430_6

A review of topical applications of antiseptics to the umbilical cord noted the strong evidence for reductions in bacterial colonization after chlorhexidine treatment of the cord and highlighted the need for further investigations with 4.0% chlorhexidine in developing-country settings.

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http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2386993

We conclude that maternal vaginal cleansing combined with newborn skin cleansing could reduce neonatal infections and mortality in hospitals of sub-Saharan Africa, but the individual impact of these interventions must be determined, particularly in community settings. There is evidence for a protective benefit of newborn skin and umbilical cord cleansing with chlorhexidine in the community in south Asia.

(Me again)

So, when we move to the Informed Consent aspects of GBS treatment during labor, it is important to know that the recommended protocol is IV antibiotics given every 4-6 hours (depending on the medication given), with at least two doses needing to have been given before delivery. The protocol can be found here:

http://www.cdc.gov/groupbstrep/guidelines/recommendations.htm

So, I am offering you the option of IV antibiotics, either with my giving them or your going into the hospital to receive them (and birthing there) OR the chlorhexidine wash (which includes a shallow douche as well as a wash).

Either way, there will be extremely minimal vaginal exams since that seems to assist in the transmission of GBS to the baby; with or without rupture of membranes.

I encourage you to look over the information I am sending here as well as exploring more on your own. You will also find information saying the wash doesn't work (or rather, more research is needed), but it is also important to know that having the IV antibiotics does not preclude the possibility of infection in the newborn either.

The majority of early-onset newborn GBS occurs in the first 24 hours, so no matter what protocol we decide to do (together), I will educate you and your partner on the signs and symptoms of GBS infection for after we leave your home after the birth. I will also return about 24 hours after the birth (or sooner) and will assess the baby as well. It will be vital to take the baby's temperature every 4 hours without fail. A baby cannot regulate his/her temperature very well with GBS infection; not just a fever, but also low temperatures. Please make sure you have a good working thermometer in the baby bag. The forehead ones cannot be used, nor can the ear ones. It has to be taken under the baby's armpit.
The other sign is respiratory distress. We will talk about that as well.

We will continue this discussion because I want you to be as informed about your decision as possible. I am here to offer what I know and my experience, but I also need your input before your decision is made during your labor.

Please ask any questions at all. I am here to answer what I can and what I cannot, we will explore together.

This is the consent I have them sign:

Barbara E. Herrera, LM, CPM has informed me of an herbal treatment that is done during pregnancy that has been shown to be effective in eliminating GBS. The protocol is a standard of care in the midwifery community, but I understand it is not in the medical community. After completing the herbal treatment, re-testing can confirm or deny if there is a continued GBS status. If I am negative, I have the option of continuing the treatment through until birth or I can stop the herbal treatments, accepting that I am GBS Negative. I understand that the medical community considers me GBS Positive after a positive result whether or not I subsequently test negative. 

Barbara E. Herrera, LM, CPM has informed me of the standard MEDICAL protocol for a GBS Positive woman. The CDC protocol requires a woman to receive IV antibiotics in labor, one dose every four hours after the initial loading dose. I understand that at least two doses must be given in order for it to be effective. I also understand that accepting the antibiotics does not guarantee my baby will not get GBS and that additional antibiotics would need to be given to the baby if s/he is GBS Positive. 

Barbara E. Herrera, LM, CPM has also informed me of an alternative to the routine antibiotics in labor: a Hibiclens wash… 4% Hibiclens to 10% water, put in a PeriBottle to gently wash the lower vagina and vaginal area. She has sent me information showing the effectiveness of the wash and I have also researched the research myself. I understand this protocol is an (alternative) standard of care in the midwifery community.

(in the present again)

So there you have it. I really do prefer this to IV antibiotics; it is easier for the mother and better on the mother's and baby's system.

I hope this helps those curious about this option in midwifery care.

Birth Guilt

A long discussion on Facebook unwittingly delved into why women feel they failed after their births. It began with reading this letter from a woman who felt forced into a repeat cesarean.

She exposes her heart by saying, “Under your care, I failed in the most basic way a woman can fail – I failed to birth my children.” 

This sad and angry woman doesn’t outline the many things she probably did to prepare for her birth, but she does mention her birth plan that was totally ignored. It really is important for women to know that just because they spend the time researching and writing out a birth plan doesn’t mean anyone is going to read it, and if they do read it, they might not care a whit what is in there. Body memories shuffle nurses along from placing external fetal monitors to injecting narcotics to preparing the woman (physically) for a cesarean. Attending to a patient’s individuality is a jarring experience that requires thinking and, perish the thought, caring for the woman as an individual. Many nurses do care about their patient’s worries and concerns, but I have rarely found a nurse who cares about her experience. “The experience” is tossed aside for all the nuts and bolts of birth – the tangible – because, to them, that is the only requirement, a live baby and mother. Mothers, of course, want that same thing, but also meekly ask for some civility and tenderness along the way. Efficient care is rarely kind. 

Objections often include, “I don’t have time to be touchy feely with patients; I have another patient next door.” Even those nurses that would like to be more intimately involved with their patients are pulled in a dozen directions, certainly needing to push the urge to help aside in the name of quick resolutions and compliant patients. I have heard more than one nurse say they breathe a sigh of relief when the patient accepts an epidural; suddenly, they are wonderful, quiet patients who sit still. Those pesky wandering, out-of-bed mothers are too hard to keep track of. I mean, they have to watch the time to make sure the patients get their 20 minutes on the monitor out of every hour, sometimes having to hold it on because the woman just doesn’t want to get back in bed. Sitting there, the nurse must be tallying the tasks she should be doing and fretting about how far she’s going to be behind now. *tap tap tap* Hurry up already. (And, of course, this is with a NICE nurse! The mean nurse wouldn’t hold a monitor on for anything. “Get in bed,” she’d bark, “The baby needs to be monitored now.” This is the nurse who never watches the time and the woman finds herself in bed for hours at a time when she didn’t want that at all.) 

It is in this attitude surrounding birth that women try to get a different experience, a “homebirth in the hospital.” When I wrote “When You Buy the Hospital Ticket… (You Go for the Hospital Ride)” three years ago, I didn’t expect the amazing response and the continual referral to the piece. I wrote, “Why… why oh why… if you want a ‘home-like birth inside the hospital’ aren’t you considering a home or birth center birth? If you want control, why go where egotistical birth is the norm? If you want autonomy, why go where lawsuits and defensive medicine are the rule? Ohhhhhh, because it’s safer? Is that what you think? Oh! I see. Well if you believe hospital birth is safer and that’s why you want to be there, then BE THERE – with all it has to offer… in all its guises… in all its paranoid glory.” I didn’t address women who have no choice about where they birth. Honestly, I still don’t have solid answers about what to do when you have to have your baby in the hospital beyond saying, “That sucks.” I mean, you could certainly do your best to find a supportive doctor or midwife, you could try to work with them regarding a birth plan (make it very, very short!), but the likelihood of “success” is, according to history, not that great. 

So, in this climate of Laboring-Woman-Has-Very-Little-Control-Over-the-Outcome, it’s almost astonishing the number of women who feel guilty after their birth plan falls apart. These women/You women are the norm! As the author of the letter to her OB says, “I hired you for an intervention-free VBAC.  Instead I had EVERY intervention I told you I did not want.” 

A birthing woman myself, I am well aware of the coulda-shoulda-woulda’s of postpartum reflection. I had a UC that could have been disastrous (I had a shoulder dystocia), but miraculously ended in a live baby. I replayed that birth a million times, eventually realizing if I’d have had a midwife, things might not have been so dramatic. I also knew if I birthed in the hospital, she would have been a cesarean. While I was healing, another couple in our Bradley class had had their baby, so I went to hear their story (I’d just become a birth junkie). I listened wistfully as the mom re-told her birth story, of how peaceful her labor was, how she pushed her baby out slowly on a bear-skin rug in front of the fireplace. I remember having tears in my eyes, so wishing that had been me. Then I heard it… the first time of hundreds of subsequent times… this woman who’d had such a glorious birth said, “I just wish....” I don’t even remember what she wished for… a sip of water? Different music on the stereo? For her other child to be in the room? The impact was deep and lasting; even women with fantastic births have regrets. I suspect we all carry pieces (or chunks) of guilt around, too. Until Meghann was tapped as gifted, I worried continually that my UC choked her oxygen supply and damaged her brain. Even now, 25 years later, I can feel the sting of guilt at my choices with all three births. 

A doula and childbirth educator, Heather, who writes Oatmeal Intellect said, way back in 2007, “'Birth guilt' is an unnecessary and heavy burden to pull around. To carry it is (to) assume that you had the power to change the birth experience, when in reality, there is so much you cannot control in childbirth. It is a force of nature that you can only set the stage for, and then stand back and let it unfold as it sees fit. To think you can change how it unfolds is like trying to hold back the sea as it starts to roll in. When you are able to let go of the things you really never had control over in the first place, and to allow yourself to just ride the experience nature has provided you, it can be a liberating experience. Instead of trying to make things be 'right', you end up empowering yourself to experience what is pure and simply, yours.”   

Sounds so easy, doesn’t it? Why aren’t we able to say, “I did my best” and leave it at that? How come we aren’t permitted to set the stage as much as we have control over and then sit back and watch, detached and observant? What is it inside us that makes us pick over each detail, playing, re-playing it over and over until we’ve played out the zillion ways the moment could have gone –had we only done this or that. 

As if our inner guilt isn’t enough, it doesn’t just come from inside. Sometimes, it’s others that stab guilt into the cracks and crevices we developed during our births. While we study each nuance with a magnifying glass, others also point out our "deficiencies". 

Playing the “If Only” game is a favorite pastime of those of us in the birth community. As a midwife, I am often asked to play, whether as a participant in someone else’s game or by the woman herself as she explores the birth she felt went so wrong. It’s easy for us who sit on the sidelines, to see exactly where the birth started to go “wrong.” “Ahhhh, she should have asked for more time instead of letting them break her water. That’s why the baby’s head was cock-eyed and she had the cesarean.” “Her husband didn’t tell that nurse to get lost or to shut up about the epidural. If someone had been there to remind her she didn’t want the epidural, she wouldn’t have caved.” “There you have it. If she hadn’t eaten so many carbs her baby wouldn’t be so big and she wouldn’t have had the ultrasound. And if she’d have told them ‘no’ to the ultrasound, well, she wouldn’t have been induced.” (And of course, we can all detail the cascade of each of these women’s experiences, can’t we?) 

How does playing the If Only game affect the postpartum woman? Even if you whisper these thoughts amongst friends, doesn’t the energy travel to her? Your judgmental attitude touching her tender heart? Sadly, though, the If Only game isn’t just relegated to Sunday brunches and trips to Starbuck’s. Some people are so crude as to drag the new mom into her If Only game, not seeing her fear and the piles of guilt sitting on her lap. “Why did you…?” “How come you…?” “Did you try…?” as if the mother hasn’t asked herself these questions a thousand times already. As one birth traumatized mother said to me, “I also have had to hear for four years the questioning of my choices, the searching for blame that other women do. And then the ‘Well, there you go, bingo! That is the one thing you didn’t do that I did and that is why your birth sucked and mine was awesome. It’s not even subtle. I say something like, ‘Well I wanted a natural birth, but it didn’t go so well…” and they say, ‘Oh, well, did you have a doula?’ ‘Yes, I had a doula.’ ‘Did you have a midwife?’ ‘Yes, I had a midwife.’ ‘Well, did you do Bradley?’ ‘Um, no, that wasn’t really my philosophy.’ ‘Oh, yeah, well, you see, we did Bradley and it went just great. I highly recommend it.’ I truly think women want to believe that what they did had an effect, and I mean, it does have an effect, but there is also just luck, too.” 

I think the dialogue this mom experiences is echoed so many times each day with multitudes of postpartum women. The crunchier the community, the deeper the scrutiny. 

Perhaps it is time for us to put the brakes on all this judgment and find compassion for birth traumatized women. Maybe we have been unwittingly piling more guilt on an already birth-guilty mother. If we can open our eyes to her pain and choose our words more wisely, perhaps she would be able to heal more quickly.

“It must be hard for you. I’m sure you’ve looked at your birth 1000 ways from sideways and wonder what you could have done differently. I am here if you ever want to talk things out.” 

“I hope people aren’t telling you how you could have avoided a cesarean. I know you were really educated, but it does suck that sometimes crappy things do happen in birth. I’m sorry you had to experience some of those.” 

“I know it’s early, but whenever you’re ready to talk about what you would have changed and what you might change for the next time, I am here to listen.” 

“Do you need to talk? I’m here, without judgment, to listen.” 

“How are you doing?” 

“I can’t imagine what you must be feeling, but I am here to listen if you need me.” 

“I totally understand. My own birth had so many unexpected things happen, I was so angry for a long time. It helped me to talk about it, so if you ever want to talk, I am here for you.” 

There are many ways we can support a mom who had an experience they didn’t want. The mom above said it’s the (birth) “educated” women who have the hardest time because they know what they missed and, usually, why. Women who haven’t spent their entire pregnancy trying to make everything perfect don’t know any better. (They may still have birth trauma, but not know where it came from or where to direct it. They, too, deserve our compassion as they explore their own births.) 

I wrote about (what I feel is) a woman’s process of healing from birth trauma in The Gray, Grey Messenger: Recovery, seeing the pattern weave this path: 

- Adoration (of the care provider)
- Disbelief  (in what happened)
- Sadness for Naiveté (playing the If Only game)
- Anger & Blame (at the provider, but the anger sometimes oozes throughout the woman’s life, to her partner, the baby, all care providers, childbirth educators and, of course, herself)
- Sadness for Experience
- Re-framing (Taking new information and looking at the birth from different viewpoints, including the medical personnel’s.)
- Acceptance (of one’s experience and who she was as a person then and who she is now)
- Assimilation & Preparation (Pulling the whole process into one New Self as she prepares for another birth or for her life with the children she has.) 

As with Elisabeth Kubler-Ross’ stages of grieving, women can go from one stage to another and even experience two or more of the stages at the same time. Some women will be in the Adoration phase for a few minutes and others for a year. You see the Anger & Blame stage? That is the place where Birth Guilt resides; a part of the healing process. It needs to remain a part and not become the overwhelming part of the woman’s inability to find peace with her birth.

I believe it is with our compassion and kindness that women can work through their difficulties. It is important for those of us who are near the devastated women to remember this is their walk and we are merely there for them to lean on.

ACOG’s Homebirth Blame-Game

ACOG has created a survey, now members only, asking OBs to tell them if they have had homebirth transfers and what their outcomes were. I wish I’d copied the exact wording, but it was something to the effect of, “We know that we have to take homebirth transfers, but it puts us in an unfortunate place of cleaning up the midwife’s mess and is including our being sued when the midwife should be the one being sued, not us. Please fill out this short survey so we can demonstrate how pervasive this problem is.” 

The questions included gravidity, parity, how long the woman was in labor before the transfer, what she was transferred for (prolonged rupture of membranes, meconium staining, fetal heart tone problems, uterine rupture, etc.), how it was resolved by the OB and who the care provider was in the home (CNM, CPM, unlicensed midwife or no one but the family [UC]). 

When us crazy natural birth folks got wind of this, we dashed to the website during its brief public moment and filled it out for our own births. As a midwife, I also filled it out for my July baby, a wonderful home-waterbirth. I know the HBAC women flocked there, too. While I wish we’d had longer to make an impact, I love that we did make one so graphically that they felt they had to block us out. We are some noisy women! Hurrah for us! 

Some women in Facebook were summarizing the request as trying to show the negative outcomes of homebirths, but I believe the goal was slightly different. 

Doctors and nurses have long felt midwives bring in “train wrecks” that they are then responsible for cleaning up. Using me as an example, when I transported the surprise breech baby and they had to do an emergency cesarean, in the woman’s records, it said it was a failed attempt at a breech delivery. They never let me give report, never asked me what happened; they didn’t care. They saw it as a completely negligent action of a Licensed Midwife. Of course, I saw it as asking for help with a situation that was out of my scope of practice and skill level. When I had the 11-pound HBAC that hemorrhaged and I transported her, I could see the doctor tsk tsking off to the side, feeling, “Here I go again with the mop soaking up the blood that midwife caused.” 

I can see the doctors’ point of view on several levels. What has happened is some of the women who have transferred to the OB’s care have had negative outcomes and sued the doctor. That has to be incredibly frustrating for them. Where does the line between midwife negligence and doctor negligence lie? If a midwife transfers for thick meconium and the OB monitors the baby, doing a cesarean after a few hours, only when the baby showed signs he was having some distress… and the baby has Meconium Aspiration Syndrome (which we know now happens in utero more times than out)… and the parent decides to sue, who gets sued? Whose responsibility was the MAS? If you believe as I do that no one was responsible, that isn’t the point. A mother with a sick baby tends to want to blame someone; who gets it? 

What I think happens is that doctors are sued much more because of the relationship aspects a midwife develops with her clients. It has long been known that women rarely sue their midwives. If anyone sues midwives, it is the State. But, for a homebirth family, the doctor is an unwilling scapegoat. 

Is there anything a midwife can do to keep these types of lawsuits from happening? They really tarnish the homebirth community. Of course, if the doctor was negligent, that is one thing, but is a midwife big enough to say, “I don’t think anyone could have seen this happening,” or even “I’m sorry this happened; I did exactly what I knew to do and transported you as soon as I saw things were outside the realm of normal.” Is it a midwife’s responsibility to help her client-family see the truth of the situation? 

I wish they would have put some of their examples up. I haven’t yet seen one of these lawsuits, one that straddles the responsibility of midwife and OB. I’d love to hear any so we can take it apart and see the dilemma the OBs speak of. 

While we all are thrilled with our wonderful homebirths and so many of us got our voices heard on their site yesterday, it is important to remember they have a reason, a valid reason, for wanting to hear from their constituency. Perhaps a midwifery organization could do something similar, asking, “When you transfer a client to the hospital, what do you transfer for? How were you treated by the nurses? OBs? How was your client treated? What was the outcome? Did the nurse or OB say anything directly to you or your client regarding this being a complication of homebirth? How does your client feel about her complete transfer experience?” 

I’m sure there are more questions that need to be asked. Let’s ask them. It isn’t only ACOG that can do surveys.

Old Time Obstetrics

So, I have this book... The Nurse's Handbook of Obstetrics... originally written in 1929, but the copy I have sitting here is from 1952. I used to have an original copy that got lost in a move, so know that not much changed from the original printing and this one I have here. In fact, homebirth wasn't terribly common in 1952, especially with a doctor, yet this book has fold-out pages that show how a nurse should set up for a doctor for a home delivery... the room as well as the kitchen (they carried as much stuff as I do!).

So, of course, things were a lot different back then. The cesarean rate, from what I know, was less than 5%. The book never talks about doing cesareans for breeches (I will outline what they *do* say to do a cesarean for), but does make a point of saying the mortality rate for babies was horrid for primip breeches - 1 in 15 births. Eek!

The book utilizes the complete range of casts that Maternity Center Association did early in the 1900's, and that remain exquisitely accurate and beautiful even today, including the casts that show how to deliver the different breeches and doing internal versions (which is never done today).

So, without reading the whole book here, I will share a few examples of the differences between then and now. The examples are random and not in any particular order. I will quote the entire snippet, so's to keep it in context.

- Smoking: While most obstetricians disapprove of excessive smoking in pregnancy, there is no reason for believing that a woman who smokes moderately, ten cigarettes or less a day, need change her custom at this time, except as preparation for hospitalization in a ward where smoking is prohibited.

- Marital Relations: The husband is to realize that his wife is under nervous and emotional tensions whcih call for constant patience and sympathy on his part. If at this time a wife should feel a sudden and unexplained aversion to her mate, let both of them realize that it is an accompaniment of her condition rather than a real change in her attitude.

- Criminal Abortion: Criminal abortion means the instrumental induction of abortion without medical and legal justification. Since these operations always are performed secretly, accurate figures concerning their frequency are difficult to secure, but the very minimum estimate is 100,000 annually in the United States, while some authorities put the figure at over half a million. This means that each year in this country between 100,000 and 500,000 potential lives are destroyed simply for "convenience," a frightful wastage of human life and a sorry reflection on our civilization. Quite apart from the destruction of fetal life, criminal abortion is one of the most common causes of maternal death. Unless the mother's health is at stake, no reputable physician will induce abortion, for it constitutes murder. Consequently, these clandestine operations usually are performed by hands which are not only unskilled but unclean. As a result, fatal infections are common. Of those that survive many are left invalids, others permanently sterile.

- Methods of Anesthesia: The most commonly employed methods of obstetric anesthesia are: inhalation of ether, nitrous oxide, chloroform, cyclopropane, or ethylene; spinal anesthesia, produced by introducing a solution of procaine (Novacain) or similar drug into the lower spinal canal, thereby aboloshing sensation below the level of the umbilicus; caudal anesthesia, produced by introducing a solution of procaine into the caudal space (in the sacrum), thereby producing an effect similar to that of spinal anesthesia; intravenous anesthesia, in which an anesthetic, such as Pentothal Sodium, is introduced directly into the bloodstream by needle; and local infiltration anesthesia, in which the tissues concerned are injected with a solution of procaine, thereby deadening sensation in that particular area. Inhalation and intravenous anesthesia, of course, produce unconsciousness; in spinal, caudal and local infiltration the patient is awake, but sensation has been abolished in the areas concerned.

- Rectal: In modern obstetrics, the majority of the examinations during labor are abdominal and rectal only - not vaginal. Rectal examinations are much safer than vaginal examinations, since they avoid the risk of carrying pathodgenic bateria from the introitus and the lower vagina to the region of the cervix and the lower uterine segment.

- Delivery in the Home: From the beginning of true labor, the patient should use a commode or bed pan, as it may not be wise for her to go to the toilet. After each bowel movement or urination, the external genitals should be sponged with the antiseptic solution ordered by the doctor.

- Cesarean Section: The main indications for cesarean section fall into five groups: 1) Disproportion between the size of the fetus and that of the bony birth canal, that is, contracted pelvis, tumor blocking birth canal, etc. 2) Certain cases in which the patienc has had a previous cesarean section, the operation being done because of fear that the uterine scar will rupture in labor. 3) Certain cases of very severe toxemia of pregnancy, but rarely in eclampsia. 4) Certain cases of placenta previa and premature separation of the normally implanted placenta. 5) Miscellaneous complications.

- Early Ambulation: The hospitals accepting early ambulation set up their individual routines and practices, such as the following: 1. The patient is "up and out" almost immediately. 2. Twelve hours, or the first day after delivery, the nurse assists the patient out of bed to stand and then circle the bed for 5 minutes, allowed to walk but not to sit. The following day the "time up" is increased to 20 minutes. Perineal care is given through the third morning and then the patient is taught "self-perineal care." The patient is discharged after the fifth day. 3. After 48 hours the patient is allowed to stand for 1 minute but not permitted to dangle her feet from the side of the bed. Activity is increased each day, and the patient is discharged the seventh or the eighth dat. Patients who have undergone cesarean sections usually are allowed up on the third or the fourth day and are discharged from the hospital about the tenth day. 4. About 19 hours after delivert the patient is assisted to stand and walk to a near-by chair to sit for 3 minutes. She is encouraged to be active in bed. Out-of-bed periods are increased gradually, and the patient is permitted to be up longer and do more walking. By the third day the patient is up at least 2 hours and is allowed bathroom privileges.

- Nursery Care: In today's modern nurseries some of the protections offered new babies are: the beds or units with individual equipment and greater space separation; air conditioning and humidifying apparatus; sterilization of all articles used for the baby; heated bath tables and regulation of thermostatic control of any water used for the babies; limiting the number of individuals who enter the nurseries; culturing the throats of nurses and doctors before assigning them to this service; and provision for isolation for any suspicious or questionable infections of eyes, mouth, skin, and intestinal conditions. Some hospitals have an observation nursery where babies are kept until any question of infection is eliminated.

- Rooming-In: "Rooming-in" is the name given to the present plan of having the new baby share his mother's hospital unit. It is the present custom for any so-called new idea in medicine to be written up immediately in the popular magazines and newspapers, with and without factual basis. This leads the public to make demands of the profession often before hospitals are equipped to meet these requests.

- Baby Care: One of the first fruits to be given the baby is orange juice. Others such as tomato, prune, apricot, pineapple, and other cooked fruits, may be prescribed for variety and to relieve constipation. When the baby is about two weeks old, the doctor probably will order one teaspoonful of freshly extracted strained orange juice to which an equal amount of boiled water may be added to prevent the baby from "choking."

- Diet During Illness: When the baby appears ill, it is always advisable to suspend regular feedings and substitute barley water until the advice of the physician can be obtained. (recipe for barley water follows)

So, these things explain a LOT about my ancestors. There was so much, I didn't know quite what to include. I left out cleaning the cracked nipple with alcohol, putting the baby on the chamber pot as soon as the cord heals (the sooner they learn what the toilet feels like, the faster they will potty train), how every picture of a woman in here has her completely shaved and draped so all you see is the vulva, she always in lithotomy, I didn't talk about the constant comments to help the doctor be more comfortable, even moving the mother into positions so he could reach her without difficulty.

Just amazing! What will OUR future midwives think reading Heart & Hands or Spiritual Midwifery? What will future OBs think about Williams Obstetrics? It would be very interesting to know.

Putting My Things in Boxes

I’m looking around my house and see the litter of a lifetime of collecting strewn about the tables, chairs and any other level surface. I have KEEP boxes, STORE boxes, SWAP MEET boxes, OFFICE SUPPLIES boxes and am now starting a box for each of the kids. I was crying yesterday about all these keepsake books I have, what could I do with them? We have a new midwifery school here, Nizhoni, and they said they would take whatever I could donate to them, so most of those keepsake books will go there. A signed copy of Spiritual Midwifery, several issues of Our Bodies, Ourselves, an extremely rare (and impossible to find) copy of You Can Breastfeed Your Baby –even under special circumstances, classic Dr. Spock’s from the late 1950’s and an original Thank You, Dr. Lamaze (the book that transformed birth towards natural birth); Books that deserve to be used, not hoarded.

One book in particular, (Having a Baby) I was telling Sarah about and tears just streamed down my face. I didn’t know that was going to happen! I’d read that book until the pages were tattered when I was pregnant with Tristan. I have books like that for each of the kids. Giving those up was so painful. Blessedly, my love told me to write notes in the books and give them to the kids. Wonderful!

You see, in order to let go of most of our things, I got into the mindset that the next people to see our stored boxes would be the kids after we’re gone. I can’t see Sarah and me ever having a house again. While it is going to be sad to leave our home that we’ve been in for ten years, we are looking at living in an RV as a giant adventure! We’ll be able to travel when and where we want, with our bed and our dogs. (Yes, we’re officially old women who treat their dogs like kids.) With this storage mindset, it is much easier to let go of some things... the starfish I got to remind myself that change happens one person at a time, my hourglass I bought to remind me to stay in the moment and many of my little chatchkes that brought me a smile, but would make my kids say, “Huh? Why did she have this?” and toss it aside. It’s better if I put things where they should go... even if where they should go is the Swap Meet.

I have hundreds of cd’s. I do not have an iPod anymore, so when I want to listen to something, I go back into the 90’s and pop it into the cd player. Amusingly, we even have loads of cassette tapes. Sarah says these things are perfect Swap Meet material so to put whatever music I want to keep on my computer, back it up and then we can sell them all. I also am keeping the videotapes of the kids when they were little, including the KidPrint ones that we paranoidingly made in case our kids were ever kidnapped. (Remember those?) Someday, I need to get them put on dvd’s or whatever you store things like that on nowadays.

I had Sarah get out more tape today, tape to close boxes with. I wince seeing all the rolls, knowing they will all be used to close up the things in my midst, vanishing, albeit lovingly, but my familiar surroundings are slowly being put away for someone else to unwrap.

I have a giant plastic box (3 feet by 2 feet) filled with photos, most of them of the kids and Disney World. I can’t even get to it yet, but ALL of those need to be scanned and stored on my computer (thank goodness for the huge HD!). I am almost immobilized by all that needs to be done.

I have the medicine closet to go through. What do I do with the things I don’t need now, but need if I get sick, get cut, get an infection? Do I throw out half-used bottles of shampoo? Alcohol? Nail polish remover? Where do these things go? It seems so wasteful to just toss all of this, but who wants the ¾ gone bottle of Benadryl?

And then my clothes. I know the rule... toss what you haven’t worn in a year. But I have clothes I didn’t fit in this last year that I will fit in this coming year. (Everyone says that, I know, but I am going to have a revision of my gastric bypass, so I know it is true for me.) Where do I put those clothes? In storage in the front so I can get to them? Keep them in the RV down below so it’s easy to get to them when I need them? I have to save room on the RV for my midwifery supplies.

That back room... where all the midwifery and medical supplies are kept, have been kept since Ama Mama closed. My goodness, I am just baffled about what to do with so much of that stuff. Donate it to Nizhoni so they can divvy it out to students who can’t afford some of these supplies? (Probably what I am going to end up doing.)

Questions, questions. I need to stop writing and get working on these boxes that are sitting, staring at me with gaping flaps that beg to be bound with tape, their mouths full of yummy memories and delicious mementos.

Considering a VBAC?

I gave out an assignment to my Facebook friends asking what they would say to a woman considering a Vaginal Birth After Cesarean, but who was unsure of which way to go. Below are the responses, but first is mine.

- Where did you hear about VBACs? Did someone bring it up or were you discontent with your cesarean experience. What have you read so far? What do you know about CBACs (Cesarean Birth After Cesarean)? Especially scheduled CBACs.

The discussion of rupture surely has taken center stage and if you aren’t worried about it, your partner most likely is. It really is vital to weigh the risks and benefits of VBAC vs. CBAC. Where do you begin?

I encourage you to start a list, even from the very beginning of research. A column for Risk of CBAC and then another for Benefit of CBAC. Then do the same for VBAC. As you learn, put your thoughts into those columns. I promise, as you read more and hear about more, your risks and benefits might flip flop several times. But, having the columns allows you to keep a somewhat logical head about the impending decision. Of course, the earlier you are in your pregnancy, the more time you have. Plenty of women change their minds from CBAC to VBAC at 36 weeks or later (I’ve had two change at 39 weeks!), so until you are in the operating room, you do have a choice.

This decision does have many emotional components to it and writing or talking about those is vital. I encourage finding someone who isn’t strongly opinionated one way or another, but one who will read the research and books with you and be there as a sounding board as you figure all of this out. It might be your partner, your mother or a therapist. People usually do have an opinion one way or another, though, so sometimes finding someone on each end of the spectrum is what needs to be done. It can be challenging to find someone pro-VBAC and that’s where ICAN comes in. The International Cesarean Awareness Network supports women from around the world as they work to have the birth of their dreams and hopes. And it can be work.

Not all doctors or hospitals support VBACs. This can be an important part of your decision. Do you "love" your OB? Or is s/he not listening to or dismissing your questions about natural birth. Are you in a location where VBACs are even an option in the hospital? Far too many hospitals around the US no longer offer VBAC as an option because insurance companies (who lose money with lawsuits regarding not doing cesareans/repeat cesareans fast enough) don’t allow it. Even if your doctor is VBAC-positive, the hospital s/he works in might not be. It is up to you to learn your options ALL of them.

For some women who have no in-hospital options, they decide to birth at home. Birth centers with CNMs are not an option for VBAC women; the nurse-midwives depend on physician back-up and they and their insurance companies do not allow it. If the idea of homebirth is horrifying to you, you are not alone. Most of us thought homebirth was for the radical hippie, not the middle class soccer mom. That has changed as natural birth has become extinct in hospitals; women still have the urge/need/desire to birth their way, just like in the 70s. Perhaps someday hospitals will have enough consumer pressure to change their highly medicalised way, but we can’t wait that long. Women have taken birth into their own hands.

So, if homebirth seems absurd or completely foreign, keep an open mind for a few minutes and then, with introspection and very real knowledge, you will be better equipped to make a decision. For some, it is the only VBAC option. For others, it becomes the most likely path to VBAC.

All over the Internet, you can find the pros of delivering at home. Read about them and picture yourself in the birthing woman's position. Look at homebirth videos on YouTube and the many sites around the Net on private websites. Google words and phrases such as "homebirth," "homebirth midwife (your city here)," "waterbirth," "natural birth," and "what is a midwife?" The answers to those search words will add to your knowledge base and allow you to get a feel for if this is something you might be able to wrap your head around or whether this is way far-fetched and impossible for you to do.

What if you do decide to have a homebirth, but there aren't midwives in your area? Most women do the best they can by finding the least invasive care provider possible. Ask around at La Leche League (breastfeeding support group) or find a Bradley or Birthing From Within teacher... someone should be able to point you in the right direction. (When you are considering your childbirth classes, another must-explore is Hypnobirthing. I've seen wonderful births that were too similar to be coincidental with Hypnobirthing. But, as a midwife, I highly encourage you to ignore the perineal massage information and homework.

There is the rare woman who chooses to birth completely unassisted instead of facing the known repeat cesarean awaiting them in the hospital. I have very real safety issues surrounding UC (Unassisted Childbirth), but for women with no choice, this can be an option.

I’m not going to outline all the studies that are out there either for or against VBAC because they are easy enough to find (the ICAN site and then medical journals) and I don’t need to even speak about the pros and cons because those lists are out there in spades. I will talk from a homebirth midwifes opinion and experience. For those that don’t know me, I also assist women as they have hospital VBACs, something I enjoy for those women who don’t feel an HBAC (Home Birth After Cesarean) is for them. I try to be balanced in my opinion, but definitely have a bias towards the more natural route.

Women in labor are meant to move around. The baby and mother do a dance with each other, each having their own role in getting the baby into proper position for the birth. While most see the baby’s head and the mother’s pelvis as a solid, they really are more liquid. The head has soft spots (openings in the bones) that allow the head to mold, smoosh together, the bones crossing over each other, making the head smaller going through the pelvis. The mom’s pelvis is not solid, either. It is two pieces joined by cartilage that softens during pregnancy. During labor, as the baby’s head begins its descent into the pelvis, the bones pull apart, ever so slightly, accommodating the head readily. When women are left alone in labor, they stand, rock, sway, do shallow squats and lean over. In all these years, I have rarely seen a woman not do this dance and it tends to be women who feel that the bed will make the pain go away, similar to when we are sick and hunker down inbetween the sheets. But birth is not an illness and lying in the bed does not make the pain less; it actually amplifies it greatly.

Women who have had two types of labor one lying in bed and the other out of the bed- will tell you the mobile labor was infinitely more comfortable. Knowing how the bones (both mothers' and babies') work together to bring the baby down the pelvis to be born, you can visualize why movement would be crucial. When women are in a bed and then let’s add an epidural to that for increased immobilization the pelvis stagnates into one position that doesn’t change unless the mom turns from side to side. Even then, the pelvis ability to shift is quite minimal. When mom doesn’t move around, the head isn’t rocked into position very well, either, and Failure to Progress as a cesarean diagnosis can happen all too often.

As you probably know, having a baby in the hospital requires you to remain in bed. In fact, The Bed takes on an almost exalted status, its being in the center of the room, surrounded by a mass of technology. Trying to have a birth plan that includes staying out of bed is close to impossible to achieve.

Even if you do decide to birth in the hospital, considering staying home for as long as possible in labor might be a good option. While some are comfortable on their own, you might consider hiring a monitrice, a doula with additional skills in monitoring the baby and you as you labor out of the hospital. I have a distinct prejudice for hiring a monitrice over a doula; I feel monitoring is pretty important in labor for a VBAC. Many people are perfectly fine with having a doula that comes to the house for moral/emotional support before going to the hospital. Some doulas will only meet laboring clients once she is in the hospital, so be sure to ask this question of your support person (if having her come to your house is important to you). Because I know how to monitor the mom and baby, I know my viewpoint is different, but when I was a doula who used no clinical skills, I was still pretty comfortable supporting women in their homes. Nowadays, many pregnant women choose to rent dopplers and know how to listen to the baby themselves. A doula cannot diagnose what is happening, but if you all know the normal fetal heart rate (120-160 beats per minute), you can count and make a decision with the information you gather. This is NOT to say you need to have a doppler; it is merely something some women choose to do.

Below, a mom offers some ideas of books to read to help you come to your own best choice for where and how to birth. I cannot recommend Ricki Lake's and Abby Epstein's Your Best Birth enough. The book is the most balanced and informative book on the market. Please, please do yourself a huge favor and throw What to Expect When You're Expecting away and get yourself Your Best Birth. You won't be sorry. Read Birthing From Within helps women work through the fears of the upcoming birth. Even if you aren't pregnant yet or don't know if you are ever going to birth again, Birthing From Within can transform your emotional and spiritual healing from the last birth. Anything by Ina May Gaskin or Sheila Kitzenger are great, too. Search "natural birth books," read the reviews and see if they resonate with you. Check your library first before spending the money if that is an issue (as it is for so many of us), although some libraries are very conservative in the childbirth sections.

If you are definitely leaning towards a CBAC, please listen to this story. I recently heard a surgeon speak and she talked about repeat abdominal surgeries and how dangerous they are for the patient and how challenging they are for the surgeon. She explained that as incisions heal, whether inside or outside the body, they create scar tissue -adhesions- and subsequent surgeries are more difficult, even the second surgery, each one getting more and more complicated. She described scar tissue as "Super Glue" in consistency, the surgeon having to carefully cut through each band lest some vital artery be mistaken for an adhesion, causing quite the complication in the patient. After her talk, I asked about cesareans in particular and she said that each layer that was incised creates its own scar tissue, making the surgery more delicate than standard abdominal surgeries. Of course, there is the baby under all of that Super Glue to think about, too. OBs are loathe to do several repeat cesareans, urging women to not have more than a couple of cesareans. Plenty of doctors highly encourage women to have a tubal ligation with their third or fourth cesarean. Yes, women can (and do) have several cesareans, but it really is important to know what the consequences are if they do. Research CBACs as much as you research VBACs. The information is certainly black & white, but listening to both polar sides of the equation, I firmly believe you can find your own center.

So, here are the pieces of wisdom from my Facebook friends:

- Anna says: Visualize your birth every day.”

- Christie says: “Stay open to all options as well as the way things may unfold.”

- Cristina offers: “VBAC can be an option for many women. It must not be considered lightly. Who is you care provider, & do they really support VBAC? How long ago was your c-sec? WHY did you have your c-sec? How was your c-sec performed & closed? Is your support team (partner) behind your choice to VBAC? What is your emergency back up plan?

- Another friend offers: My short piece of advice is that she might like to sit quietly and connect with her baby.... what occurs to her? Birth choice is highly personal and should, imo, be directed by the whole self not policy, not statistics, not popular opinion. Blessings....”

-And another: I’m not a birth professional but my friends do know me as someone who is passionate about birth, has done a lot of reading etc so I have friends I hope will ask my advice on this topic one day.

(She continues...) My 1st advice would be to look at their medical records from the last birth. Find out why the section was done, have some proof of a double sutured low transverse incision, etc.

Also I’d have them find out what their current Health Care Providers typical protocol is and what her preferred places of delivery usual protocols are for VBAC.

Best case scenario, the section was for something not likely to show up again w/ the next pregnancy, was a double sutured low transverse incision and she’s already with a provider who is open to VBAC and delivers at a location with good VBAC protocols in place.

Even then, I would recommend she do some reading from both sides of the argument. Look up some recent studies, read some of the classics... Silent Knife, etc. and some of the newer ones like Henci Goer; read a few recent books about the birth culture in general Pushed for instance.

Definitely contact ICAN (International Cesarean Awareness Network) and read their white papers and read their forums.

If she wasn’t the reading type, I’d print some summaries out for her and get some magazine articles together.

If she wanted to know what I would do, I'd tell her that for me, a VBAC would be the optimal choice based on everything I’ve read.

I’d go over the stats regarding uterine rupture (seems to be the big thing w/ providers who are against VBAC) and compare those stats to some other commonplace interventions like amniocentesis.

I would give her the name of the OB in town w/ the best/ lowest repeat section rate.

I would pretty much just give her all the info I have and let her make her own decision but I’d offer to doula for her and just support her anyway I could. (Regardless of her decision, I’d be supportive.)

Would I try to talk her into a VBAC over a repeat? Yeah, to a point. The evidence supports VBAC as a safe and probably safer option. I’d absolutely be sure she had evidence-based info. But if she was dead set on a repeat then that would be her decision and once she had made it, I wouldn’t continue to argue with her about it.

- Jen says: The number one thing I would say to a woman seeking VBAC is:

If you have the knowledge, tools, and support, the likelihood that you will successfully VBAC is high. Hire an OB or midwife that is truly supportive, because they will set the tone of your birth. Aim for an unmedicated birth because drugs, most of the time, increase the risk of complications as well as repeat cesarean. Select a birth location that will be encouraging rather than be a source of fear, doubt, and, ultimately, failure. Find women who are planning VBACs or have VBACed and use them as your cheerleaders and sounding board.

(Me again) So, I hope this information offers at least a jumping off point for your VBAC consideration. Feel free to ask questions here or on forums, of doctors, midwives and read, read, read. Make your decision as informed as possible. And may your upcoming birth be everything you wish it to be.

Blog and a Movie

Last night, Sarah and I went to see “Julie & Julia.” We loved the movie, but one aspect of it moved me to... well, forward movement.

I haven’t blogged since June 11, 2009 (as I have been reminded by several people); I have been unable to write. Not physically, of course, but emotionally. I seem to go through (emotionally/spiritually) constipated moments which translate into no-writing periods... until I am able to work through it all and begin writing again. About mid-July, I realized I was in that place, depression descending on me like an old familiar, very heavy, cloak. I simply must write. I’ve written before about this inability to write leading to depression; how could I have not started writing again when I began slipping into the chasm?

As these words tumble out, you will see the mosaic of challenges in my life. I am absolutely not writing as a poor, poor, pitiful me; I am writing to show my underbelly and to do what I am compelled to do... navelgaze. Some people think Navelgazing Midwife means I stare at the belly buttons of pregnant women. No, it is an expression of introspection, sometimes to a level that sends me in circles, but usually lifts me to a more elevated place so I can see things I never would have seen from any other vantage point.

While I knew I wasn’t writing and had an inkling of why (because there seemed to be nothing but crappy news), it wasn’t until I was in the middle of “Julie & Julia” that it all flooded through me, making me dizzy with realization and knowing I could no longer ignore my stunted feelings.

In the movie, Julie, a woman in 2002, blogs about her goal of going through Julia Child’s “Mastering the Art of French Cooking.” As expected, she learns a lot more than just how to cook. She finds her core, vowing to change her life as Julia Child did late in her life. Through writing, she shares fears, hopes, trials and difficulties, usually relating to food, but having a parallel in her 30-year old life. In one scene, she fights with her husband and he yells at her to not write about that fight in her blog – because she does write about everything else. When she sits down to write that evening, she types out a line about her husband leaving her... but after a sigh, deletes it. I know exactly how she feels.

Years ago, when I started writing my blog in earnest, I sat with Sarah at Disney’s Grand Californian, by the pool (we were dressed and alone that early evening) and I explained my compulsion to write... that I needed to write... that it didn’t seem like a choice anymore. She said something she has since repeated several times. “Write! I never want you not to write. Just don’t put it in your blog.” I can’t. I don’t know how anymore. I own dozens of hand-written journals and notebooks but once I discovered that people actually liked what I wrote, that I heard back from others about it and that it was much more tantalizing than writing on any piece of paper could be, blogging was like a drug. I also asked my children about any limitations they had about my writing about them. They all said there were none. I gave examples to everyone, including Sarah, that could embarrass them or make them angry and all said, “Write.” And so I did.

I’ve certainly had quite the experiences with this blog. Sometimes people get very, very angry with my thoughts or ideas. I’ve had to delete posts more than a couple of times because I said something so vile (according to others), it was nearly demanded. And I buckled under the peer pressure. One post in particular got so much anger hurled at it; I knew I really hit quite the nerve of the midwifery community. I dared to say I felt Certified Professional Midwives needed more education in order to practice effectively, that the education at that point in time lacked many important skills that keep women and babies safe. I demonstrated the training of a Certified Nurse Midwife alongside a CPM’s training, really just saying someone needed to correct the deficiencies so we would be more respected, even if those corrections included a formal education process. Boy, did I get the comments! From everywhere, including NARM and MEAC... the folks who do the education and testing process. Heresy! How dare a Licensed and Certified Professional Midwife not uphold everything a midwife needs to do to become licensed. After awhile, it got really nasty... personally mean... and enjoying my mental health, I deleted the post. Didn’t even save it anywhere.

Another experience was when I wrote about a client without her permission. She read it, didn’t like what I wrote and I had never been closer to a lawsuit for defamation than at that time. Besides removing every post about ANY client that hadn’t given me permission, I apologized deeply for hurting her –in public. The relationship remains severed. Ever since, though, I ask clients if I can write about them. If they have not given me permission (and I know, I know, I really should have it in writing... said that was what I was going to do, but just have not), I say nothing about them in writing. There are so many parts of my midwifery life that are interesting, wild and educational, parts that I cannot share, I really should write and not publish until I am gone. No one knows better than my former apprentice Donna. She and I would look at each other with disbelief that we were really in the midst of something so odd, so surreal, that I bet readers would think I am making it up. I wouldn’t have been. After that experience, I didn’t write for several months, fell into a deep depression that landed me in the hospital for half a second and I had to find the resolve to forgive myself and move on. It took quite awhile and Sarah’s gift of a long-haired dachshund puppy we named Cash that got me well, inch by inch. (She often thanks Cash for saving my life. I do, too.)

Backstory is important sometimes.

I’m shocked, standing beside myself, to see what my life has become. Over and over, “You reap what you sow” sing-songs through my mind and I wonder what in the world I have done so wrong as to have this plethora of sadness going on in my life. What is the lesson? (Writing this, I can hear those who despise me laughing and laughing at my difficulties, but I write in spite of their meanness. I’m trying hard to tune them out. Even writing about them gives them more power, but I can’t ignore the inner conflict pervading my self-esteem.)

Within a very short period of time, Donna left her apprenticeship, I found myself with a mere one client, I’d gained an ungodly amount of weight, Sarah and I are moving into an RV instead of a house, money vanished (it is now a year since my offices closed because of the economy), my family and I had serious communication issues (for the first time ever) and there seemed to be so many shitty things to say, I stopped writing – and found myself clinically depressed yet again. Somehow, Sarah and I remain closer than ever, each of us repeating, like a mantra, “We’ll just stick together with the dogs and we’ll be fine.” I would collapse if my relationship disintegrated; it is one of the only things holding me up at the moment.

Last night, on the way home from the movie, I tearfully told Sarah why I wasn’t writing (she gets nervous when I don’t blog), that there were so many limitations on what I could write... that I’d rather disappoint my readers than her. I didn’t want to embarrass her, either with our choices or our experiences. She, once again, said, “Write! Just don’t publish it.” And I shook my head, the words stuffed inside my mouth, unable to find their way out for the tears in their way. I was finally able to explain, once again, the bizarre compulsion to write in public, that writing in private just does not fulfill. Talking with Meghann this morning, she helped me articulate it by saying I get help, validation, friendship and companionship through sharing with my cyber and real friends. I reiterated that I don’t want to write about all these crappy things so people go, “Awww, poor Barb,” but I want to write so I can look, with an objective eye, at each situation and examine how exactly to get out of them. I know I can’t be the only one and I believe many people cannot talk about their own lives in the way I do... fear, shame, sadness in the way... so I write for them, not those that laugh at me, but for those that nod with understanding and compassion for all of us in these situations.

So, I’m going to toss this up on my blog and pick each topic independently and write about it. I just can’t keep it all in anymore. The depression has to go somewhere... it might as well find itself in my blog, the place where it transforms into light and hope... both of which I know exist just out of my reach. I’m determined to find them.

Apprentice Midwife Material?

It's really cool, being interviewed as a midwife. Lately, here and there, I have been talking to several women either in (a) midwifery school (of one brand or another) or in an apprenticeship. Talking yesterday to Kim Pekin brought up a bunch of thoughts. Yes, I've written on this topic before, but it's been awhile, so here's a revisit.

Sweet women come to me, starry-eyed and their heads tilted sideways, looking at me with respect and (sometimes) awe. It's an honor to help women on their paths towards birthwork, but it is also a responsibility. I've listened to midwives wax poetic about being a midwife, pulling the potential apprentice along, muchly because the midwife needs some free help with her work. I think this is unfair and, as happens too often, the women end up leaving the "apprenticeship" once the realities of birthwork tarnish the dream. While I might be seen as a wet blanket with these dreamy women who come asking questions, I know it does no one any good if they begin and quit, one "apprentice" after another; it's just easier to get the whole picture out in the open from the get go.

"I want to hold babies" is a common refrain from the women who sit across from me. I smile and say, "Listen, we only hold babies from here (the vagina/vulva) to here (the abdomen)." Taken aback, I'm assuming they just hadn't thought of that since their faces goes blank. I then begin listing the things a midwife does hold: sweaty hair, the barf bowl as the woman throws up in it, the laboring woman as she dangles and the mother's hand as she squeezes it white and bloodless. We hold placentas as we demonstrate their amazing beauty. We hold scrub brushes as we wash blood off our instruments. We hold needle holders as we suture vulvas. It's important to me to make sure the woman knows the unglamorous parts of the "calling"/"job", just as much as she knows about the good parts.

She needs to know - the most important thing we hold is two lives in our hands.

If, after telling her all those realities, she is still drooling and her eyes light up more with every description, then it is obvious the woman is pretty darned birth-obsessed and a good candidate for apprenticeship.

But there's more. I let Donna (my apprentice) tell these parts of the apprentice story. She speaks about missing birthdays, telling them how many she missed in the first year along. She tells them about missing her kids' school awards... how we've had births on Thanksgiving, Christmas Eve (which requires us to make a home visit on Christmas Day) and wedding anniversaries. How we are called at all stages of the pregnancy, sitting with a woman with a UTI in the hospital at 30 weeks, going to a woman having a miscarriage at 13 weeks or driving 60 miles for a look-see if the woman's membranes have ruptured (nope!). She tells the woman how she can be gone sometimes for 3 days at a time, pumping her breasts so she can keep nursing her one-year old.

We both share the reality of putting 60,000 miles on your car a year, not having an income, paying for gas and child care, food outside the house, buying birth clothes or shoes, all kinds of incedentals that are easy to forget about.

As I said, this might sound all dramatic and tragic, but really, really, women need to know the realities of being a midwife's apprentice. And none of this includes the prenatals, the office work, the making of charts, the answering of emails, calling women back with lab results and all the other nuances in the life of a woman wanting to be a student midwife.

I imagine women's spirits sagging by this point, those sitting in front of me and those reading this, but there are AMAZING parts of being a midwife, too. But if you don't want... no, CRAVE... all that I said above, then reconsideration of this career is called for.

Being at a birth is glorious, but it is a blip in the life of a client's pregnancy. We become part of the family's life, we become part of the birth story forever, even if they can't remember our names 30 years later. We are invited in to see the wondrous joy a new baby can bring, but we also become counselors as the pregnancy brings out the warts and hoptoads lurking beneath the marriage's fascade or their relationship with the in-laws. As midwives (and students), we are privy to things most regular folks never hear from their neighbors, co-workers - and even closest friends. We become connections for women and their families to find food, help them see parts of themselves they'd hidden for decades and stand by them as their world is forever changed by the new soul coming to them.

Some clients become friends, but most slowly disappear over time, coming around again when the midwife holds an anniversary picnic or when they are again pregnant. It's important to keep a boundary between friend and care provider because care providers sometimes have to make serious decisions a friend would never even think of. It doesn't mean you can't empathize with your client... heck, if I don't cry with a client at least once during the pregnancy it's because she's changed care providers! Women become their own type of midwives, creating their style as they walk through their apprenticeship. A good mentor/preceptor doesn't want a clone, but fosters her apprentice's individuality. While I am a motherly type of midwife, other clients want a more business-like provider; there is a midwife for every type of client (in some areas like here in San Diego). Midwives are responsible for being perceptive as to how close or far her clients want to be. It can be a fine line and is crossed sometimes, but realizing it and correcting it quickly brings the relationship back into balance.

It's pretty clear, without even saying it, that a midwife must have worked through a great deal of her own issues... fear, abuse history, pregnancy, family dynamics, child-rearing and more. It's crucial not to bring one's own issues into the prenatal, laboring, birthing and postpartum periods. We talk about that with new doulas, to see each birth as an individual experience, not thinking, "Oh! My last lady had pitocin and a cesarean, so this woman will, too." But allowing the birth the unfold in its own way. Sure, there are themes and generalizations, but when WITH a woman, BE with her, see her as herself and see her birth as her own. With midwifery, this admonition is even more important because there can be a tendency to think her clients' births will be/should be just like her own midwifery birth. Midwives, too, must allow the woman to have her own walk, even if that walk includes a cesarean. We have to BE with her, not drag her along, but to stand by her side (or even a tiny step behind) as she feels her way through her birth experience.

Birthing women are extremely vulnerable. They (often) take advice literally. They(often) are easily swayed. I am not saying that they don't have a mind of their own or that they can't feel very strongly about certain things, but I have seen women bend to the will of her midwife simply because the midwife is The Expert. Midwives canNOT exploit this. Can NOT. When offering options and giving informed consent, it is imperative to keep one's feelings about the coming choice out of the equation. It doesn't mean you can't share how you feel about a test or a procedure, but not being married to the outcome is vital. I really can't stress enough how important it is to not exploit a client's vulnerability. I believe it takes a great deal of self-discipline not to. Midwives, please don't. Please.

This has gone on longer than I expected, but I felt led this morning to write this out. These are thoughts that come out in small spurts when I speak about what being a midwife is about. Of course, midwifery is different for every woman; these are MY experiences and they seem pretty universal, but others certainly have their own story to tell. I am honored... that word seems so small... so honored to be called to be a midwife. I hold the honor close to my heart and work so hard to do the blessing justice. I always have room to grow (who doesn't?!) and I welcome the ways my midwifery practice will continue to change, evolve, as I learn more and more with every client (and inbetween).

I hope this resonates with some of you. I write this for those birth addicts who know in their very soul they are destined to be midwives. I'm waiting to bring you into the fold.

Newborn Spanish Mishaps

So, even though I am Cuban, I didn't grow up speaking Spanish. I learned in school, taking all the classes the community college offered. I took a Medical Spanish class, trying to fill in the spots regular classes couldn't touch. However, it took a LONG time before I spoke fluent OB Spanish.

Even though my Spanish wasn't perfect, I wanted to work with the migrant women in San Diego, so I started volunteering at Planned Parenthood in their prenatal program. I nudged my way into a doula position because I was willing to come to the clinic, meet the women and then go with them when they went into labor. Initially, I told the hospital I was a translator. I explained it that I was not only translating Spanish & English, but that I was translating Medicalese. Over and over, I helped women have their babies in the hospital. I racked up a great number of births this way, learning so much along the way.

With my very first Planned Parenthood client, I was very nervous, but I pretended I wasn't. I sure-footedly walked into the triage room, sitting with the mom who was in kickin' labor. The nurse came in and asked me to have the woman move her bottom towards the end of the table so she could be examined. Whew! I knew these words! "Por favor, muevate tu culo mas abajo." The woman, in the middle of a contraction, sat bolt upright and said, "COMO?!?" Baffled, I repeated what I'd said and she just rolled her eyes at me and went on through her labor. I couldn't figure out what was wrong. I *knew* these words... of all the words I knew, I learned these as a child. "Besa me culo!" my family would shout at each other. "Kiss my butt!" I labored with her, am guessing I didn't make any other disgusting comments because she held my hand as I breathed with her the rest of the time.

The next day, back at Planned Parenthood, I began telling the birth story, starting in triage. I told them I wasn't sure what happened, but when I said, "Por favor, muevate tu culo..." and the room ERUPTED in laughter. What had I said?! They couldn't stop laughing, tears streaming down their faces. Finally, while I sat there totally embarrassed waiting to hear what was so funny, someone wheezed, "You told her to move her fucking ass down to the end of the table." HUH?!? Apparently, "culo" is a vile vulgar word in Mexican Spanish. When I went to go see her postpartum, I apologized profusely, in my broken, embarrassed Spanish. She laughed and let me know it was fine.

In my quest to learn obstetric Spanish as well as get a foothold as a midwife, I went to Casa de Nacimiento in El Paso, Texas for 3 months in 1993. I learned quickly and learned a LOT. It was great! I began dreaming in Spanish and the words came to my tongue quickly from my brain. After Casa, I worked at the Farmworker Association of Florida (in Orlando) under a CDC Grant to teach Hispanic women HIV/STD prevention techniques. Allllll in Spanish. Feeling better about my language skills, I could feel there would be gaping holes still lurking. Whenever I began a class, I told them my "culo" story, bringing them to hysterical laughter, but it illustrated the point that if I said something stupid or rude, it is because my Spanish sucks, not because I am a jerk.

After several years in Orlando, I headed back to San Diego, where, once there, I spent a little over a year (total) at Casa to gather education, experience and numbers so I could eventually sit for the license in CA. I would come and go from El Paso, but it didn't take 48 hours there before I was once again dreaming in Spanish. I was more fluent than I ever imagined, being able to do complete prenatal and postpartum counseling as well as speaking to the family, no matter where they came from around Mexico.

So, it was amusing as crap when I was talking to a father who'd stepped out to let his wife deliver the placenta and be sutured. He asked if he could go back in yet and I said a phrase I had said at least 100 times before: La partera esta cocinando la vagina. The husband turned his head sideways and asked, "Cosiendo?" and I nodded happily. ("Wasn't that what I said?" I said in my head.) And I was off shift and went on my merry way.

2 hours later, I am in the kitchen where the interns all hung out and slept and I was making Rice-a-Roni... standing there... saying to myself, "Estoy cocin-an-do..." OH MY GOD!!!!!!!!!!!!!! All those years I was saying the midwife was COOKING the vagina, not SEWING the vagina! I fell on the floor laughing and could barely stop until I saw that family again 2 days later. I laughed and laughed, telling the husband how many DOZENS of times I had said that to a husband and NONE of them corrected me! I thanked him profusely for getting the vagina out of the kitchen.

Another smaller gaffe I have done is with the words "estrella" and "estrilla" - very similar in English, but words apart in Spanish. I would have a woman lying on the table during her prenatal and rub her stretch marks and tell her how BEAUTIFUL her estrellas were. Uh... estrellas are "stars" - estrillas are "stretch marks". I could always get a chuckle from women as I told them what a beautiful night it was, the moon and all those stretch marks in the sky.

Even now, many, many years later, I am always wary of the words that might spill out of my mouth. Are they colloquial? Did they come from my family? Is the woman Mexican? Puerto Rican? All of these different aspects come into play, just as if we were working with a woman from Canada, Great Britain or Georgia.

I love that I speak Spanish, but I also love that I can laugh at my second language skills. Always triving. Always striving.

 My Grandmother Almerinda "Mami" holding my dad... la Havana, Cuba... 1940.