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Sunday
Jan062008

The Myth of the Vertex

There is a belief that if the baby is head down, the baby will come out the vagina. The thought continues that, if the baby didn’t come out the vagina, something was overlooked, someone did something wrong or the woman didn’t try hard enough.

The reality is – none of these beliefs is true.

Sometimes, babies that are head down simply (or complicated-ly) just don’t come out the vagina. It isn’t often, but it happens enough that natural birth advocates really should take a moment to listen.

On Empowering Birth blog, in her post "Why are moms so threatened?", Kat asks why some women are so threatened by hearing her say that their complications might have been caused by their care providers that they attack her. While I agree that folks just might not want to read her blog (or mine!) if they don’t want to hear alternatives or learning that their experience might not have had to happen, I also know that some women DID all that (the alternatives) and still had a cesarean/forceps/vacuum and don’t want to be told they made the wrong choice.

Example One:

My recent births that were mal-presenting vertexes. One was a face presentation that didn’t show itself until mom had been pushing for two hours. Some of that was because I didn’t do a vaginal exam early in pushing (my usual style, plus mom’s request), but even when I did do an exam, the baby gradually moved his face towards the outside. With each push, he wedged his face deeper and deeper in the pelvis. The pictures here show the wiggle wiggle, back and forth movement his face made over time until I was able to feel the softness of his cheek and it hit me that he was a face presentation. We quickly moved to the hospital and the wonderful doctor gave mom a couple of more hours to see if he would change from a Mentum Posterior (impossible to birth vaginally) to a Mentum Anterior. His heart rate had been great at home, but he began showing signs of distress as time passed in the hospital. By the time the decision was made to do the cesarean, he was having late decelerations (an ominous sign) and going downhill fast. The cesarean surely saved his life as he came out completely gone, needing full-on resuscitation, including CPR. The amount of meconium that came with his birth was described as sludge.

The second, a military presentation – not quite forehead, but looking straight on – could also not be born vaginally. When it was apparent there wasn’t forward progress, mom did everything from lunges, nipple stimulation to increase the power of contractions, move side to side, walking, changing positions in the water, on the toilet, on the bed, wiggling her hips and a whole lot of visualizing. No, I didn’t go in and try to move the head. She didn’t climb on the couch butt up/head down to pull the baby out of the pelvis so she could start all over again. When her membranes ruptured about 40 minutes before leaving the house, there was very thin meconium and it wouldn’t have been appropriate to purposefully stress the baby out any more.

After so much pushing, mom was really tired and I worried about the baby petering out even though the heart rate clicked right along rhythmically. After all the attempts at forward progression, including val salva pushing, we decided to head into the hospital. She’d been pushing on and off for 4 hours at that point.

When we got to the hospital, the baby was still in good shape and mom was given an epidural after trying to push for another 40 minutes or so. After the epidural, the doc tried the vacuum because the baby had a great caput to hook onto. All we saw was thin meconium up to this point. No forward movement even with the vacuum and massive pushing, so the decision to have a cesarean was made. Mom was extremely relieved. Once the uterus was opened, a pile of meconium was suctioned out and the baby’s placenta and cord were stained, showing that the baby had had something happen at least twelve hours earlier – many hours before any midwife ever arrived. Serendipitously, I hadn’t encouraged mom to tump upside down! Had I, the baby’s head and face would have been bathed in the meconium. As it was, with her face in the position she was in, most of her face was kept out of the mass of poop. Suctioning, they didn’t pull out any meconium at all.

This baby, too, would have eventually gone downhill and, if mom were still pushing hours into fetal distress, the baby would have died. I’m really thankful for cesareans.

Kat says:
“My post was prompted by the sad reality that more and more women have been reaching out to me in my neighborhood informing me that their doctors bring up induction and the big baby worry. In my mind, that is a threat. When an "expert" declares you need to induce because you are going to have a big baby he/she is making a threat, not a suggestion. The threat is, if you don't induce, your baby will "be too big" and you may "tear", "baby may get stuck," etc. (this is what the doctors say to their clients, in reality there is nothing wrong with having a big baby). Moms are going to believe the doctor/expert. You may have nagging doubts but in the end most moms seem to choose induction because "if the doctor is telling me I should be induced, I probably need to be induced." My goal is to provide more information so that moms are encouraged to question their care rather than blindly accept the opinion of an expert.”

Kat is studying to be a midwife. I’ve flatly asked her what she would do if a woman was pushing and pushing and there was no forward movement. Would she just let her keep pushing until baby and mom died? She acknowledged that there were going to be times she would have to make a decision that might make a woman angry. Blinking, I wondered why she couldn’t develop a relationship with her client that fostered a belief in each other… one where if the midwife said, “There isn’t forward progress. We need to go in,” the client would say, “Let’s go.” One where no one is angry with anyone else. One where both client and midwife know each did everything in her power to create homebirth success. One where both know the true goal is for mother and baby to be healthily alive, not just to be born at home or vaginally or without an epidural.

In ignorance, for there is no other way to say it but this, Kat says that whenever a doctor or midwife speaks about induction because the baby is getting large, that that is a threat. Only someone who hasn’t struggled with a shoulder dystocia – either in her own vagina OR with one in her hands as a midwife – would say something so amazingly dangerous. As a homebirth midwife, I am hyper-aware that threats are used in obstetrics and midwifery, but to blanketly say that “in reality there is nothing wrong with having a big baby” when a provider is speaking about how large the baby is setting a team of folks up for a fight in a possibly dangerous situation.

Kat says, “Moms are going to believe the doctor/expert. You may have nagging doubts but in the end most moms seem to choose induction because "if the doctor is telling me I should be induced, I probably need to be induced." My goal is to provide more information so that moms are encouraged to question their care rather than blindly accept the opinion of an expert.”

I ask: Shouldn’t the woman believe the doctor or midwife? If she doesn’t have the type of relationship where she doesn’t believe anything the doctor/midwife says, shouldn’t she find another provider? This is not to say I don’t want to be questioned, but when it comes down to an urgent/emergent situation, sometimes there isn’t time to delve into the psychological aspects of changing lanes. The care provider is hired to utilize his or her expertise! Why else have a care provider?

I used to try and please everyone… every client that came to my door. I submitted to interrogations about my style, my beliefs and my past choices in births. Once, I was asked what my favorite book was and what party I voted for. I knew enough to send her away, but when women came to me and said, “I don’t want you to do anything but sit in another room,” I used to obsequiously tell them I would. It is the woman’s birth, after all, right?

Then, with more experience, I woke up and figured out I couldn’t help if I didn’t monitor the mom and baby. It’s not like I’ll do vaginal exams that aren’t warranted or intrude in women’s space, but there are minimums that I feel are necessary for competent care and I no longer will compromise on that belief. Since I have gotten stronger in my skin as a midwife and not gone on to be the midwife for a woman who automatically considers me The Enemy, my births have been glorious, even when they were very complicated. When a woman pokes at me with a stick over and over, trying to make me do her bidding, thinking everything that comes out of my mouth is suspect, I release her from my care and send her on to someone else who will better be able to tolerate her paranoid thoughts.

What’s so funny is I used to be one of these women! I think I know where they’re coming from, but whenever I’ve assisted these women, I am fucked beyond repair. I worry I will have my license yanked from me long after the baby turns one year old. I worry about my reputation in the birthing community. One angry woman can make it difficult for awhile. When it was me, I was so pissed at The System, I took it out on everyone. I really didn’t think I could trust anyone at all, so I didn’t. Everyone was suspect. No one wanted me to have the birth I strove to have.

Well, I was wrong and I wonder why so many women see every care provider as a threat. If you haven’t read me long, you don’t know that I “get” birthrape and understand the amount of birth trauma out there. I do acknowledge the challenges and difficulties in finding a care provider to trust, but I wholeheartedly beg women to try and find someone they don’t have to keep at arm’s length. If it isn’t me, that’s fine! There’s a midwife for every woman. And plenty of women for each midwife. (Unless, of course, the woman is UCing… no midwife is good enough in that situation.)

Is there a way to resolve this mutual suspicion of each other? For me, I accept clients that believe me when I say, “the baby’s getting big… let’s get an ultrasound to check things out.” (For those that will tell me how inaccurate ultrasounds are late in pregnancy, the ultrasound tech I send women to has been spot on with the weight over half a dozen times, so with this tech, I know I will get an accurate weight.) The flip side is I believe them when they tell me something’s wrong or what their communication is with their baby. Trust is mutual. Should be mutual.

When I am hired to be someone’s midwife, I am being hired as a consultant. I am being asked to share my experience and knowledge, to utilize my skills – the ones that can save a life. As a consultant, one that differs from an interior designing consultant, I am being asked to take the lives of two people in my hands and to accept the consequences of the outcome whether that is a spritz of champagne or a cell in a prison. I’ve had a long time to adjust my considerations with my practice – and they might change again (I’d be shocked if they didn’t!). I see women as individuals, listen to their needs and concerns and if we both feel we could work together, I’m game to give it a go. If I find a woman lied to me about her medical or obstetric history, if she hides behaviors she doesn’t want me to know about or if she continually jabs at me questioning my concerns with her pregnancy (and all of these have happened in the last 2 years), I’m going to send her on her way. She is a liability I don’t need to take on… a risk to my profession and life.

Example Two:

A 150-pound (at term) first time mama who meticulously ate organically throughout her pregnancy had the most severe shoulder dystocia I’d ever experienced. The 10 pound 2 ounce boy took 2 minutes for the head to be born, 2 minutes for the body to be born and 2 more minutes for him to begin breathing. It was a horribly traumatic birth for mother, dad, baby, the other midwives and myself. Postpartum discussions included how to make sure that experience doesn’t happen again – how should she change her diet? Should she have exercised more? Really truly, I believe her body grew a really large child because of her and her partner’s (he’s quite tall) heredity. I can’t see a way for her to avoid that next time and told her I highly encourage her to schedule a cesarean for the next baby. Incredulous that those words came out of my mouth, all of us sitting around the table when I said that knew that that really was the best solution. In order to take care of any other questions, I am sending her to Dr. Wonderful for a second opinion. Another person any woman should believe – Dr. Wonderful – sometimes we really do have to take what someone says as gospel. Sometimes emergencies happen and someone has to be trusted to take care of them. Sometimes births need help and someone has to be there to give it. And take the liability for it, too.

For the women who trust in who I am as a human being and a midwife, I give everything in my Be-ing. I work my ass off to never betray their hearts. To me, that is what being a midwife is all about… serving women who hire me to tell my truth, to share my experience and knowledge and to sit next to them as they birth their children.

There is no greater honor.

Reader Comments (37)

I love this post for many more reasons than I can type one handed--snoozing babe in my other arm! Thank you for articulating your perspective so well...

January 6, 2008 | Unregistered CommenterHeatherK

Thank you, again, for your comments. I can speak from the "other" side. I had a difficult position with my son's birth that just wasn't going to resolve on its own -- not after three day at home and not after another day in the hospital with helpful, respectful on-call physicians.

If the mom (and dad) and the care provider have developed trust and respect throughout the pregnancy, when it comes time for the birth they can rely on each other. We were a team, through all the hard times and all the difficulties, the four of us (including my son, because he was part of this too!) worked together. When it was time to trasport, it was time. There was no recrimation or anger on anyone's part. It was time. When it was time for the c-section it was time.

One thing the experience of my son's birth has taught me is to be very careful to never tell another person "if you only had." All we can do is work together as a community of women and mothers (and fathers) to support each other. We need to develop trust and understanding so that if a hard decision has to be made, it can be made without all that other crap muddling it up.

January 6, 2008 | Unregistered CommenterJess

well, once again, I am applauding your words as being the articulation of my own thoughts. I have had two births this week where the woman's trust in e as a midwife allowed her to accept interventions that really were needed and mad a huge difference to the final outcomes: One an episiotomy, and one syntocinon augmentation. Both women did not want those interventions, both trusted me when I said that it was now a necessary cosideration, and that I strongly advised the action. Both women in debrief afterwards, said "I knew you wouldn't have suggested it if I didnt need it". That is trust. trusting the process is one thing, but sometimes, the process doesn;t work! And then we have to get creative.

January 6, 2008 | Unregistered CommenterTrin RM

thank you thank you thank you. as a young doula and aspiring midwife, you give voice and credance to many of the 'heretical' inklings i have had regarding care provision. i have no doubt that i serve women better for reading your words. i return to your blog again and again for the opportunities it offers for real learning and deep thinking!

January 6, 2008 | Unregistered CommenterAnna

(And I thought I'd be totally blasted for what I said!!! So, far, I am shockingly surprised. Thank you all so very much for your kind words. They'll help when those that disagree with me jump into the fray.)

January 6, 2008 | Unregistered CommenterNavelgazing Midwife

I wish I lived near you. When I get pregnant, I'd love to have a midwife who shares your philosphy.

January 6, 2008 | Unregistered CommenterRebecca

I was going to say what Rebecca did. I might have to move to the San Diego area for birth.

January 7, 2008 | Unregistered Commentersara

Amen sister.....Sometimes you do all the right things and still the baby does not come out the vagina.

Sincerely, Chris

January 7, 2008 | Unregistered CommenterAnonymous

Very interesting post although I think that you might have misunderstood where I stand on some of these issues. That is the nature of blogging and will be the topic of a blog post in the very near future. A few if my thoughts on this post can be found here: http://empoweredbirth.typepad.com/empowering_birth_blog/2007/12/why-are-moms-so.html.
I would add that my comments about big babies had to do with theoretical big babies, doctors that guess the baby will be big just because you are past your due date, or they say that you need to be induced just because you are past your due date. I always encourage moms to ask for a biophysical profile, ask for a second opinion etc. (often the big baby scare comes not from their doctor but from another doctor in the practice, we have many VERY large practices in the area and communication between the doctors is frequently not so good).
To me there is a big difference between doctors mentioning the big baby problem merely because a mom is past her due date, which I see as potentially a threat, and a true big baby, which, as you noted, can increase the risks of shoulder dystocia (I have much to learn on the subject but did take a workshop with Anne Frye).
And one last stream of thoughts, trust of your care provider is extremely important, but this trust must be earned and (to play the midwife's devil's advocate) can this trust always be earned in 10 minute prenatal visits? The reason I mentioned that I knew one day a mom might be angry with me if I suggested a transfer is because that is what has been on my mind lately. My midwife has two clients who are extremely angry with her at the moment (yes you can argue that she should not have taken them on) I have been attacked by angry moms on my neighborhood listserv, and I recently returned from The Farm where we studied in depth the case of a mom who sued her midwife because she was angry at the decision to transfer (in my opinion the transfer was definitely warranted and the lawsuit was thankfully dropped). This is the background information that is often missing when blogging and often not added when you have a mom who is usually blogging with little kids and so keeps her posts to the bare minimum. It is my sick little Fenimore who is allowing me to blog today. I am sad that he is sick but thankful that your comments have stimulated so much thinking and that I have had the chance to respond. That said, as I said in my response to the Homebirth Debate's comments on a recent post, I will try to remember when blogging that I would like to reach the broader birth community, not just the birth junkies and that in order to do so, more background info/facts is often warranted.
Oh, one more thought, I certainly don't think you should be blasted for what you have written, that is what makes me so sad about virtual communities, everyone is so quick to blast away and say things we would never say to people's faces. Discourse is much better then blasting and I am enjoying our discourse. Thanks!!

January 7, 2008 | Unregistered CommenterKat

This post is such a breath of fresh air! Bravo!

I've read some things out there that are truly scary. What makes me almost sick to my stomach is the consequences that these beliefs, fears, etc are going to hold for Mom and baby.

One of my boys "had a cord" and thank God for monitoring. Certain positions would result in variables that led to lates. With the help of monitoring and my midwife we found a position that my son liked, and I labored on. With my other son, I had intermittent monitoring and it was fine. Each baby is different, and each labor can have unique needs for mom and baby.

Are there too many interventions in birth? Yes. I agree 100%. However, I also believe that these interventions can be used for good, and in some cases, lead to better outcomes,save the life of mother and child, etc.

January 7, 2008 | Unregistered CommenterAmy

Great post Barb. It is so good to hear these words spoken honestly and clearly from a midwife (and a midwife I have admired for a while now, online that is).

Thanks.

January 7, 2008 | Unregistered CommenterAnonymous

I hope more aspiring midwives, doulas and birth activists read your post and take it to heart.
Birth works.....most of the time. Sometimes things go wrong even with the 'perfect' diet, 'perfect' exercise program, 'perfect' attitude etc.... I see little difference between the mental manipulation laid on pregnant women by playing the 'dead baby' card and the guilt and blame laid on women by practitioners who blame the woman for her birth 'not working' whether it's pre-e, or malposition, or shoulder dystocia or any of the other dozens of situations that require a hospital or C-section. If only you had done x,y,z..... your baby would have born vaginally/had your homebirth etc.... It really infuriates me. I've had more women than I care to count cry on my shoulder because they 'failed' and that feeling of failure was not assuaged by their midwife or birth support or childbirth educator but made worse or even instigated.

I have hyperemesis gravidarum. I need some serious intervention to keep me and my baby unharmed and alive.oral meds, Zofran pumps, PICC lines, at home hydration..for me everything short of TPN. We're a group of women that have a REALLY hard time find supportive practitioners of ANY philosophy. We're often tagged as mentally ill, weak, attention seeking, bulimic and more.
It's one more example of having to accept that not everything is normal and mainstream and sometimes drastic measures need to be taken to ensure a healthy baby and momma instead of focusing on 'the pure pregnancy and birth'. And it helps so much when we HG'rs end up with pre-e and are told it is our fault because we didn't follow the Brewer Diet. More blame, more guilt.

Also, one can accept the interventions when necessary and leave the rest. Look at your Dr Wonderful VBAC mom. There are so many that would poo-poo her amazing experience because it took place in a hospital with an OB, a male OB to boot-the horror. WHO DO THEY THINK THEY ARE to belittle this woman's victory?!

I could go on and on but I will stop here before this becomes even more of a senseless rant.

January 7, 2008 | Unregistered Commentermomomany

This is difficult for me, in that I am still struggling with my son's c/sec--it's a slim possibility it was needed, but I was manipulated so much and lied to, so I cannot ever be sure what could have been. I did not get the chance to try much of anything in the way of healthy birthing first, and so lost the chance to make any sort of peaceful acceptance or arrangements beforehand. It was very bad. And yet I am daily surrounded by people who think I overreact by grieving about what happened.

I don't really know what a good c/sec could be for me, should I be so unfortunate as to need another one; I am not in the place of having that kind of trust in a midwife or dr. Because I read your blog a lot I can accept what you're saying--but a midwife handling a client like me would have to work really hard to overcome past mis-treatment and get to a place where trust like that was even possible.

January 8, 2008 | Unregistered Commenteremjaybee

Thank you so much for writing such profound truth! I started my blog, Close to the Root, for these very reasons...because I am finding, especially over the last 5 years; that women are not able to accept our limits and that aspiring midwives and doula's ( God love them ) are "educating" women to mistrust any "expert" including Midwives and are leading women to believe that there are never good, clinical, life saving reasons to provide everything from routine prenatal care to a vaginal exam during labor to a transport from home to hospital. I have struggled, mightily, trying to acclimate to a new generation of "home birth" mommas' who honestly believe that all birth is "normal" and that nothing ever really goes wrong.

It doesn't take long for a new midwife to realize that Midwifery is not a game; the first time someone is bleeding down your arms to a pool at your feet or you deal with a shoulder dystocia that is just not resolving quickly; you learn....you learn that you are, indeed, responsible and that your skills and education matter and life is not always fair or kind.

I truly appreciate what you've done here and you've inspired me to get my blog back on track towards it's orignal purpose; you given me courage! Thank you. Kneelingwoman

January 8, 2008 | Unregistered CommenterKneelingwoman

I am very happy that you have said all this, it makes alot of sense and I am also haooy and surprised that you didnt get "slammed" yet :)

For too many of us, we do not have doctors we can trust even the tinyiest bit, and to have a midwife that we love and have mutual respect for is also a rare rare gift.

I think this post helps midwives more than anyone else. As a pregnant woman who has a midwife whom I love AND as an aspiring midwife, this was just a great perspective. I dont know what it can do for all of us (myself included) who have had C-Sections that we just have so much mistrust and doubts about, regrets, wonderings, mommy-guilt compounded through time, perhaps--but it does help my attitudes about the future. Long time reader and fan

January 8, 2008 | Unregistered CommenterHousefairy

Barb, you said: I ask: Shouldn’t the woman believe the doctor or midwife? If she doesn’t have the type of relationship where she doesn’t believe anything the doctor/midwife says, shouldn’t she find another provider?

I find it interesting that you pose this argument, because this is exactly what landed me in the OR on my daughter's "birth" day. I believed in and fully trusted my midwife up until about six weeks after my daughter's birth. Then I realized...she completely abandoned me at 2am while I was in labor because, as weeks passed it became more and more apparent that she didn't want to be there all night with my "ineffective" 45 second contractions.

So, when you say "trust your care provider", I say "no, I trust ME".

Because in the end, my CP is NOT the one who has to live with my birth...but I DO. And finding a new CP at 2am in Orlando, FL is not an easy feat, unless you do what I did and walk myself into the hospital for an unnecessary augmentation, epidural and cesarean all in the name of "trust".

January 8, 2008 | Unregistered CommenterI am a Monkey's Momma

Thank you for a great post. I read your blog all the time as I see you as a real balance in the birthing community. I uc because there just have not been midwives available where I am and I won't birth in the infection-filled hospital unless there is an emergency. I am quite tired of all the uc'ers thinking that they know everything and that you have to be a "pure" ucer. It is irritating and condescending. I believe in birth and womens' bodies (I have birthed eight times, four times in a hospital, once with a mw and three uc's) but I also believe that accidents happen. I just hope and pray that I will be able to birth another time without an accident. I still wish, every pregnancy, that I could have midwife I could trust to "take care of me". Keep up the good work! :-)

L.

January 8, 2008 | Unregistered CommenterAnonymous

It's refreshing to see such a wise midwife as yourself state that yes, sometimes bad things do happen during birth. That's a much-appreciated honesty, and I'm certain that the two women you gave as examples are the type who truly benefit from C-sections, definitely falling into the 10% that the WHO deems necessary.

BUT, it can be so, so, sooo hard to see this honesty as what it is and not just more trickery. Because really, it's everywhere. You speak of trust and believing in your care provider...some of us did exactly that, trusted that they had our best interests at heart and would never let anything bad happen to us (and yes, bad things happen, but you get my drift here). This charade keeps up all during pregnancy, and then when it comes time to birth, the sheepskin comes off and the wolf is exposed.

I know that you were being 100% sincere and loving when you told your client that she should schedule a c-section next time, and that she and her baby could have died. But these words are hard to swallow when someone who turns vicious and uncaring during your birth is sitting at your bed telling them to you. ESPECIALLY when you KNOW in your heart of hearts that it just isn't true.

Wow, I really poured my heart out in this note. Didn't mean to. :) I guess you can see why I'm bitter about CNMs now. I'm fairly sure that homebirth midwives will be a whole new ballgame for me and hopefully I won't have to deal with the same trust issues and backstabbing that I did with my former CPs. When all the experience you've got to go on teaches you that all CPs are a threat, it can be hard to break that mentality.

January 9, 2008 | Unregistered CommenterJill

There's a delicate balance between promoting trust in a woman's ability to give birth, and acknowledging that sometimes, despite doing everything "right," things will not always work out well. Frankly I've never met anyone who really believed that you could ensure a vaginal birth, a good outcome, or a good whatever if you did everything right. Or even that if the baby's head-down it would ensure a vaginal birth.

Yes, we probably all know Gloria Lemay's article "Pelvises I Have Known and Loved", and perhaps it's her assertion you're responding to: "Any baby can slide through any pelvis with a powerful uterus pistoning down on him/her," she writes.

Thing is--that is true for *most* mothers. And if a woman reads that and feels inspired and finds the confidence within herself to push herself to her utmost limits and give birth to a baby that her midwife or doctor had told her could never come out vaginally, then that is fantastic. And if a woman does her best and the baby just will not come out, then she will know she did everything she could and, hopefully, will not feel any guilt or regret about accepting a surgical outcome. Maybe she will mourn the loss of her dream birth, but hopefully there won't be any blame/guilt/second-guessing going on.

So I guess my question is: is it better to promote optimism and trust in women, knowing that a very small number might encounter disappointment? Or is it better to set them up for failure in the first place, and to tell them that their midwife or doctor knows best? I'm not saying you're doing this at all, Barb, but that does happen with many women who hear from their CP's: you might not be able to birth this baby vaginally, your pelvis is very small, you're taking too long, etc...

January 9, 2008 | Unregistered CommenterRixa

o thank you thank you sooo much! my 2ed was military presentation. i we both nearly died, i bled out compleatly! thanks g-d for blood banks... the c-sec saved our lives..
it makes me so sad, i dont feel supported by mag like mothering, that some how i am less than for having a c-sec. and worse for planning my last one.
what matters is that BOTH baby and mother come out alive and well.
thanks again.
erika

January 9, 2008 | Unregistered Commenteruumomma

I have always had this idea about y needs balancing out at any given moment. I think that opinions and practices tend to do that from scheduled cesareans to UC.

We seem to live in this time and country of extremes. I always wonder about the bigger picture, places where women don't have the choice to be either way but their choices are made for them, for good or bad.

Do you think that those extremes result from this imbalance? We as a country are generally imbalanced one way or the other.

January 9, 2008 | Unregistered CommenterSunshine

What is really hard in an OB office is that you get who is on call in some practices. I have not had my personal OB for delivery since 1996. Also, if you go with an CNM or an OB and go to the hospital, you are at the mercy of strangers. I honestly didn't know much about midwives around here before I had my first baby. I went with an OB, and it went well. I trusted the nurses generally, and you know, I think I was right most of the time and they are nice. However, the rate of medicated women has risen in the hospital I go to and the nurses don't know comfort measures anymore, and expect me to want meds at some point. They marvel at me, a woman with six kids who has never had an epidural...and doesn't want my water broken or anything like that. My OB was shocked I didn't tear after my 5th was born as she was born so fast. My 5th, I shouldn't tear I think. Maybe I'm just strange though. Anyway, I think women are afraid because medical people have proven they cannot be trusted. It's a big thing to "break up" with your provider. It's hard for women to do this, and many don't realize they CAN do this. I never have left a provider mid-pregnancy. I've never asked for a new nurse during labor. I tell you what though, I am going to a midwife in the future if I get to have a baby again. I am doing this because I know if I have to be tranfered to the hospital, then baby really does need help. You cannot trust hospital staff from the get go, but in my case last time and with a history of meconium upon delivery (and the t-18 screen result) I felt the hospital was the best and safest for my baby with a level 3 nicu. I didn't trust my nurse or the on call OB who wasn't listening to me and it was too late to make changes. If only women would choose a midwife or a provider they could trust for ALL their gyn care, then you'd have the long term relationship. Specialists for problems in gyn and pregnancy/delivery midwife for gyn care and tests. This seems like a better system all around. When my girls are the age they need their first paps, I'm going to see if a midwife can help them. I may even go to the midwife for a consultation on sex education type stuff...and then the midwife will be seen by my daughters as an expert they can trust. I will explain to them how doctors are great for real medical problems, midwives are for non-medical issues and birth, and after care etc.

Blessings!
Dawn

January 9, 2008 | Unregistered CommenterAnonymous

I think this is very true. I think that it is ok to trust your care provider if THEY trust birth. If THEY approach all births from a fear base of belief, then I think it can lead them to suggesting unnecessary interventions just because something might happen, with no true indications that it might happen in their particular situation.

Hence the need for parents to CAREFULLY choose their care providers. Sadly most do not and they move forward and do whatever they are told without thinking for themselves, or trusting their instincts.

I was so proud of my SIL who was being pressured to induce... for not good reason, but the holidays were coming. She said no. Then the holidays were over. She was a little over 40 weeks. OB checks her, she is 4 cm. He says, go to the hospital, let's get this baby out. She says, NO. (She is a VBAC mom, doesn't want added risk of inducing) He says, fine but you must go get NST. Basically admits it is to cover his butt. She says, "No, I feel fine and baby is moving well. I trust that all is well." Anyway, she goes on to birth her baby girl the next morning at 2AM. Her OB was coming from fear of covering his BUTT, from maybe seeing a still born a few weeks before, whatever. But from fear. He was trying to impose that on her and not listening to her intuition. Not wanting to letting her trust her body and her baby. Not all women are strong enough to say no to an induction in situations like that.

Anyway, I wanted to say I agree with most of what you said, but when you pick a care provider who is filled with fear and distrust of birth, then you come into situations where it is better for the moms to not trust them and to listen to their own instincts!

You trust that most births are normal and safe, so I would trust you.

January 9, 2008 | Unregistered CommenterSheridan

I loved this post too.

I love this attitude and the reality of it. I had a fatal shoulder dystocia ( I am also average sized) and have gone on to have cesareans. I am thrilled that I can keep having children, even if it is by c/s. I am very thankful for that.

It can be a tricky all or nothing environment right now for a lot of birthing women, but this post articulated a lot of the grey areas and how to be open about them.

January 9, 2008 | Unregistered Commenterclara

Barb, I respect you too much to "slam" you and I do bow to your superior experience, however, as others have said, it's a fine line between trusting our bodies and trusting our providers. And it's sometimes a fine line between our bodies working...and not! Three recent examples in our community. A VBAC mom who pushed at home for NINE HOURS rather than have a another C section. A mom whose babies (home born) who got progressively bigger until her (now nine month old) was born....eleven pounds two ounces. And me! Creeping pressures with BOTH pregnancies which apparently is my body's way of saying that it's done being pregnant. Fortunately both times I had Midwives who trusted my body and the process, otherwise I might have been transferred and been induced for pre-eclampsia!

I really feel if there was more back up support CPMs, DEMs etc would have less to fear, and could therefore make better calls.

I don't know, obviously there are times when birth doesn't work. OBVIOUSLY. But perhaps I'm hearing you wrong, it just sounds too much like the same song and dance we warn women away from so often.

January 10, 2008 | Unregistered CommenterRed Pomegranate

P.S. What do you think about the "Trust Birth" initiative? Wish I could go, I'm already planning a trip to San Francisco that month.

January 10, 2008 | Unregistered CommenterRed Pomegranate

I think you are very right on and remind us that we need to stay balanced. That being said, in defense of Kat, there are many scare tactics used in obstetrics. I say this as a labor nurse, and future nurse midwife. It doesn't happen all the time, but it does happen. I think that the reason so many voice the "anti-establishment" and "all doctors use scare tactics" is because those who have had bad experiences speak louder than those who were happy and content with their birth.

I also believe that any provider who has a trusting relationship with her client will not be "angry" as Kat believes. And then there will always be a few who will forever be distrustful no matter what, and be angry at any recommendation beyond their "plan".

January 11, 2008 | Unregistered CommenterLabor Nurse

I really like this post. As much as I believe my c-section would not have happened had they not done AROM and made melie in one spot, I do trust my Doctor. She was a great woman and I had much respect for her. Unfortunatly, she wasn't allowed to be my OB this time. Apparantly I am stuck with Dr. soandso because he does all the c-sections. My OB was/is an intern under him, so he is familiar to me, but the relationship just isn't there. It could have something to do with him scarring my son's head with his overzealous use of the vacuum... Or that he is convinced I am going to develop GD just b/c my son was 10'9 (no bad sugar results for me or him)...

I wish there were midwives like you in my area and that I could get my insurance to cover them!

January 11, 2008 | Unregistered CommenterJenn

Jenn,

I don't know if you've read enough of what I've written about GDM and/or babies over 9 or so pounds, but if you are wanting to do your best, diet-wise, to try to have a smaller baby, this is what I ask my own clients to do.

Try HARD to not eat any meat that isn't organic. There is a belief that the growth hormones in our beef can really affect our growing babies.

Eat/Drink only organic dairy products for the same reason.

Cut out ALL dairy products the last 6 weeks of pregnancy. Over and over, I have seen (as have other midwives) taking dairy out of the diet can create babies significantly smaller than their previous siblings. I know this can be really hard to do, but it is only for 6-8 weeks... and I ask my VBAC moms, "How badly do you want a VBAC?" and that seems to spur them on to make smaller babies. And it works!!!

NO juices at all during the pregnancy. Juice (along with milk) is pure sugar. Eat the fruit; not the juice.

While I understand that your glucose test/screen may have come back perfectly fine, over the last 25 years, it has become apparent that MANY women (myself included) "pass" their GTT while still have some serious insulin resistance issues. Insulin resistance cannot be seen with a GTT (and how accurate is that test anyway?). I concur with those that say that if a woman has a baby over about 9 pounds (9.4 or so), she is at a MUCH greater risk of developing diabetes by the time she is 40. I developed diabetes at 34 after having babies weighing 9.4, 10.6 and 8.13 in my early 20's. I passed every GTT I was given (and I was given a LOT because I was well over 250 during those pregnancies).

Anyway, I hope this helps some!

January 12, 2008 | Unregistered CommenterNavelgazing Midwife

Interesting post. I am always surpised by those who think that anyone can guarantee a good outcome for a birth in ANY situation. Even in the best circumstances there are no guarantees and I would hope that everyone realizes that. I will say that I must disagree that mothers should always trust their care providers. Even midwives should not be blindly trusted. While I feel it is important to have the trust there between mother and care provider, not everyone is worthy of that trust. I completely trusted my midwife and ended up with a cesarean. She recommended that I schedule cesareans for all future babies and that I should reconsider my plans for a large family. I chose not to trust her and instead trusted in myself, my body, my babies, and God. I had a wonderful HBAC and still don't understand why she would have pushed me toward unnecessary surgery.

Also, all of the talk about diet and big babies really interests me. What about a mother who follows your recommendations and still has a large baby? Do genetics play no role? I was 9.11 and my brother was 10.8 while all of my husband's family ranged from 10lbs up. I have had an 11.1 lb baby myself. I'm 5'10" and my husband is 6'3" so could it not just be normal for us to have large babies or is there really some underlying issue? Nobody in any of our families has diabetes. Also, I have read that most SDs occur in babies of "normal" weight and there really aren't any ways to predict when it might happen. In the absence of other risks factors, is suspected fetal macrosomia alone a cause for concern?

January 12, 2008 | Unregistered Commenterheather

I've read your blog forever, & this is possibly the best thing you've ever written.

You're so right.

If women don't trust us, then where are we? Who are we?

Powerful stuff. l love it. xxx

January 12, 2008 | Unregistered CommenterAgatha

Interesting stuff. I am still working through it.

But I do have one issue--I *thought* I could trust my midwives. But because they were working with backup doctors and a hospital that were not trustworthy, and had to protect their liability and that of the backups, I ended up feeling betrayed. They were very, very sweet, and gentle about it, but I felt the pressure nonetheless. They were correct in predictions about a large baby, but I felt very betrayed that they let the consulting doctor threaten me and tell me that if I didn't induce early or schedule a section, there was a high probability of my baby dying and me being severely injured.

It was very frustrating to me to be told through my whole pregnancy "You're fine, we believe in you, you can birth a big baby!" but the minute I crossed a certain liability point (not sure what it was-could have been several factors) to feel like I either had to fight for a natural birth on my own or go under the knife. That is why I arrived at the hospital pushing. On purpose.

On diet-I freely admit mine could use some changes. But I don't believe that it's everything. My close friend has had progressively larger babies and they eat *all* organic, and *very* healthy. Her last baby was half a pound larger than my "impossibly large" baby.

January 12, 2008 | Unregistered CommenterCappuccinosmom

I am still trying to get over the birth I had a few months ago, when I tried to do everything 'right' (intermittent monitoring, no pain meds, staying upright in water etc) and everything still went 'wrong'. I veer from blaming the midwives for not realizing earlier that the baby needed to be turned, to blaming all the natural birth literature I gorged myself on prior to the birth for deceiving me, to blaming myself for not being able to push him out by myself. Every time I read about how everyone and anyone can give birth naturally ('Trust the Process! Trust your Body!'), I feel indicted somehow. I tried to push for hours, but I never really got the pushing urge I'd read about at all, and in the end, my contractions just died off. I still start crying when I think about it; I read the similar birth story posted recently on your blog, and wondered how she could feel so happy when I still feel such a failure.

January 18, 2008 | Unregistered CommenterAnonymous

How do those around you act? Have the midwives helped you process? Shared their experiences with you on the familiarity of what happened? Have they expressed their sadness that you couldn't have the birth you worked so hard for? Are your friends pitying you?

Those around you, I find, have a HUGE impact on a woman's healing positively or negatively from such an experience. There should be CLEARLY open lines of communication between your midwives and your family. Everyone should be able to express his or her feelings about what happened. If necessary (which is almost always), the groups need to cry together to get to a place of healing together. Not to minimize your pain at all, but we midwives also grieve for our clients... not because it "upsets our statistics," but because you are someone in our hearts now! And if the midwife is worth anything, she works hard to not disappoint or anger any of "her" women. I know I am devastated in my heart when someone's wish-for and long worked-for birth changes so dramatically.

But, the reality is, birth is unpredictable. (I am writing, writing the piece about Gray/Grey and will discuss many of your comments in depth.) Anyone who told you otherwise is deeply involved in wishful thinking.

(You bring up THE point of why I have no interest in the "Trust Birth" Conference; women are led to believe if they eat right, think right, heal old wounds, take the right childbirth class, read all the right books and are evolved to the point of perfection, they will have the birth of their dreams. As I am saying more and more... the BABY hasn't read "The Secret," yet. The BABY can have other ideas that are asolutely counter to the mother's. Who knows why? We can only be SO SO SO thankful we are here in the United States/Canada/where there are computers and decent health care that our babies LIVE whereas if we lived in another country and you continued in labor without contractions and without the baby birthing, you would have not had the baby in your arms now... and your family might very well, in many circumstances, not had you either.

I know none of what I say can take the pain of all the emotions you are feeling, but I need you to know that your experience... your feelings... are SO SO common. So much so that Gray/Grey has to be written to share the nuances of the emotional/spiritual/cerebral experience of the natural birth movement in these early 2000's.

I cannot thank you enough for being Exhibit A in an enormous list of other women too hidden with shame or sadness to speak out. If I could, I would hold you warmly and love on you while you cry.

I cry right with you.

May you find healing soon and completely.

Barb

January 18, 2008 | Unregistered CommenterNavelgazing Midwife

Thank you so much, Barb... I got an awful lot of 'But you have a healthy baby! That's all that matters!'

They are right. And yet... And yet.

January 18, 2008 | Unregistered CommenterAnonymous

As usual you nailed it. You are awesome. I asked myself why I've been present for some horrible near- miss tragedies, all but one not at all of my making. I think now that it's so there would be a near miss and not a tragedy and that i get a higher percentage of them because I cope with them well, God knows how to arrange things that the right people will be present. Nerve wracking though. I really get what you're saying about trust, so important. I must not come accrossed forcefully enough. Some women have viewed me as their talisman who's going to magically get them thru it safely not matter what damn fool thing they do!

January 19, 2008 | Unregistered CommenterAnonymous

As a fellow nurse-midwife I love this post! I want women to trust me (don't get me wrong, I can understand why they don't when listening to their stories re other care providers) but I am not them! Great post!

October 5, 2010 | Unregistered CommenterAlison

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