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Sunday
Jul082012

Reader Question: CPM or CNM

With permission from the author:

I read your blog often, and would like to pick your brain on a question if you have a moment. I'm a mom and a big believer in women's right to choose where, how, and with whom to birth. I am also an aspiring midwife, and I feel stuck between a rock and a hard place, so to speak, in choosing the right path for me. So I'm writing for some advice. Are there any direct-entry programs in the US that you feel provide adequate and appropriate training for midwives? I have considered doing the CNM route, but I do have doubts about my ability to work in a hospital as a nurse, and about that kind of training as well. Will it be as holistic as I hope? The CNMs I've met tend to be more obstetrically-minded than I'd hoped (though maybe this limited experience has biased me unfairly).

Anyway- I want to be as well prepared as possible. I realize there is real risk inherent in birth and I know I won't be comfortable with myself as a care provider unless I feel I've sought the best training possible. I'm sure a lot of this is in the apprenticeship/clinical portion, but I know the formal ‘schooling’ is really important too. Any advice you might give would be much appreciated. Like I said, I read your stuff often, and appreciate your skepticism.

I share this email because I’m being asked this more and more. And while I’ve addressed it a couple of times, it seems the cycle has come around again to talk about it.

First, the only complete education and skills training program I think is more than adequate is Florida’s process to becoming a midwife. The Florida School of Traditional Midwifery (which happens to be MEAC-accredited as well) is the school I’m most familiar with. If there had to be a litmus test of other schools, it would be that they are MEAC-accredited and cost a buttload of money. $20,000+ gets you a pretty decent education. Beware the discounted and we’ll-get-you-through-fast programs. The road to becoming a midwife should be long and arduous. And expensive. There’s a reason for that. It is only through time does a woman witness a great variety of births and birth scenarios. Hypothetically, a midwifery student could attend 40 homebirths and never see anything more dramatic that sticky shoulders or a woman needing pit to stem a mild hemorrhage. It isn’t until the real difficulties occur –and many of those are so subtle as to be easily missed by the novice- that a midwife learns her skills.

Women wanting to be midwives (and I know there’ve been a few men interested, but in general it’s women) seem to want to zippity-doo-dah through the process. I know I sure did. I thought I’d seen enough already, that I knew so much, it was a mere technicality towards my having a license. How wrong I was. So much more responsibility is necessary than even I thought (and I’d already been to about 700 births by the time I got my CPM). There’s a world of difference watching/assisting and being responsible for the two lives. Only experience can develop that reality. And not being the Primary midwife, but a Primary Under Supervision of a very experienced midwife. It disturbs me, midwives who’ve had less than ten years of experience teaching apprentices. How can they teach when it isn’t even ingrained in them yet? (And I had an apprentice when I first got licensed. One of the stupidest things I ever did was believe I could teach someone the gamut of midwifery skills when my own weren’t even honed.)

So the reader’s questions aren’t black & white answers.

If you are more holistically-minded and think you will be brainwashed in Nursing School, perhaps you aren’t so strong in your beliefs or Nursing School has a lot of reality to teach.

If you find a great school to attend… MEAC-accredited, expensive and extensive… you will still need to find an experienced midwife to apprentice with. And your apprenticeship needs to be years long in order to get the proper and adequate education.

If this sounds daunting, good! It should be.

Now, looking at becoming a CNM, all schools to become a nurse and then midwife share the same quality education. You can pick a school anywhere in the country and know you’ve chosen well. Then, when you are doing your skills training, you know that almost all teachers have a certain level of knowledge and training themselves. If you happen to get a crappy mentor, wait a few weeks and you’ll get a different one. You learn from many different mentors, not just the one or two you apprentice with as a home birth student midwife.

Each non-CNM midwife has what I call “black holes” in their education and skills training. When they teach, they also teach the black hole… or rather, they leave out the knowledge of the black hole, thereby passing on the black hole from generation to generation of apprentices/midwives. Unless a student/apprentice has another midwife that accidently fills in the black hole, she can go her entire life not knowing about something. For example, I just reported on a study that showed “Heat Wave May Make Womb a Dangerous Place,” that heat was positively associated with congenital cataracts. When I reported on it, I noted that I’d not known babies could have congenital cataracts. Another midwife was surprised (understatement) that I didn’t test for them, looking in the newborn’s eyes with a flashlight to look for the “red reflex” (you can bet I know about it now!). I’ve had at least ten midwives teaching me how to do newborn exams and I can’t remember even one of them telling me about the red reflex. Clearly, this was a black hole in my education… and one I passed on to my apprentice as well. Hopefully, she’s learned about it since then. As an aside, I’m reading the new edition of “Heart & Hands: A Midwife’s Guide to Pregnancy and Birth” to review it here on the blog. H&Hs was a staple in my midwifery education, we nearly memorizing it for our NARM exam. I’m assuming Anne Frye’s replaced H&Hs, but know this is still an extremely important text for student midwives. In here it says:

Check the eyes for red spots, hemorrhages of the sclera due to pressure in the birth canal. Also look for evidence of jaundice: (sic) the whites of the eyes should be white, not yellow. Check to see if the pupils are equal in size and reactivity when exposed to light. Check for tracking by moving your finger back and forth close to the baby’s face. Check the shape and spacing of the eyes, noting any irregularities.

Then it goes on to erythromycin in the eyes, but nothing about red reflexes. It bothers me that it isn’t in there and disturbs me that I never checked a baby’s eyes for cataracts. I can only pray none of them had one or the Pediatrician found it if there was. That was a roundabout way to explain a black hole, but there you have it. It is unlikely this would happen in nursing and midwifery school.

I believe CNMs tend to be more medically-minded because they see far more than a home birth midwife does and understand the necessity of being on your toes in birth. One of my favorite midwives, who was also one of the most laid back, had an amazing education at Grady Memorial in the heart of Atlanta, attending to HIV patients and a wide variety of not-really low-risk clients, but learning what was normal and what, most definitely, was not normal. She was one of the best midwives I’ve ever worked with, gentle with clients while making sure they were safe and healthy. And then there’s the “hands-off” midwife I once was who didn’t listen to fetal heart tones because a mom didn’t want me to. You tell me who was acting correctly in birth. Just because I was filled with woo didn’t mean I was doing the right thing. There is balance and balance can only be found with education and training.

You have to know it all (or as much as possible) in order to make informed choices. That goes for midwives as much as it does our clients. If we aren’t aware of all our choices, how do we offer our clients the best care out there? We can’t.

It’s true. I am all gung-ho for CNMs now. Actually, it’s for their education. It’s just the more I know and the more I hear, the less I like the CPM education. It scares me in many ways. Most of what scares me is the arrogance of the groups behind the education process. Instead of seeing the gaping holes and trying to fill them, they pretend to fill the hole with a teaspoon of dirt. Why can’t NARM see that Biology, Anatomy & Physiology and other science classes should be required for the CPM license? Why, when they had the chance to add classes, they chose a class in cultural sensitivity? (Not that that isn’t important, but so are basic classes like the ones mentioned above.)

Dear reader, if you’re looking for the most comprehensive education process, there is no question. You will learn more, see more and do more in any CNM track than you would if you were going through the CPM path. While the argument is often said that CPMs learn normal birth whereas CNMs learn more complicated, medicalized birth, I’ll say that when the shit hits the fan in birth… and it does… knowing normal birth doesn’t save the lives; knowing complicated means does.

I look forward to your thoughts about what I’ve said. As well as others, too.

Saturday
Jul072012

The SOB

Home birth: Increasingly Popular, But Dangerous” in the Daily Beast by Michelle Goldberg started the hoopla.

For many parents, home birth is a transcendent experience, and they’re profoundly grateful to have been able to have their babies on their own terms. Yet as the number of such births grows, so does the number of tragedies—and those stories tend to be left out of soft-focus lifestyle features. Now a small but growing number of people whose home deliveries have gone horribly awry have started speaking out, some of them on a blog, Hurt by Homebirth, set up by former Harvard Medical School instructor Amy Tuteur. “These people are beating themselves up over this,” says Tuteur, perhaps the country’s fiercest critic of the home-birth subculture. “They did it because they thought it was safe, and it wasn’t safe.”

Out of 39 paragraphs, Dr. Amy Tuteur (the Skeptical OB) is quoted in four and mentioned in a fifth, yet the afterquakes have, almost exclusively, have centered around including Tuteur as a source for Goldberg’s article.

In fact, in The Slate, Jennifer Block’s piece entitled, “How to Scare Women: Did a Daily Beast story on the dangers of home birth rely too heavily on the views of one activist?” contains 16 paragraphs and Tuteur is highlighted in ten of those, not including the obvious reference to her in the title.

Goldberg's reliance on Tuteur is an interesting choice. Also known as “Dr. Amy,” Tuteur let her medical license lapse in 2003 and created the blog Home Birth Debate in 2006, which she used to advocate for her position, which is basically: Home birth kills babies. “Even the studies that claim to show that home birth is as safe as hospital birth actually show the opposite,” she'd frequently post in response to a challenge, smearing the researchers of those studies in dedicated blog posts and igniting flame wars in the comments section. On other sites, including Nature and RH Reality Check, her comments have been flagged and removed for being defamatory or basically spam.

The back and forth continues with Goldberg defending her original piece with “Michelle Goldberg Answers a Critic’s Distortions of Her Home-Birth Argument”, naming Tuteur in nine of the 21 paragraphs.

Let’s start with her primary criticism—my use of Dr. Amy Tuteur, a figure anathema to the home-birth community, as a source. Now, I think Block overstates my reliance on Tuteur; there’s a difference between agreeing with her after doing my own research and repeating a “Tuteur talking point,” as Block accuses me of doing. But leave that aside, and let me explain why I’m not convinced by Block’s attempts to impeach Tuteur’s expertise.

So, why am I up at 2am counting paragraphs in tit-for-tat articles? First, because I cannot believe the energy spent on Dr. Amy… so many people arguing for or against her as a source. It’d be amusing if it weren’t such a serious topic. It’s really important for people to know that Dr. Amy isn’t going anywhere and that she will continue to be used as a source protesting Certified Professional Midwives and much of home birth. I know women who begin reading an article or post and if Tuteur is mentioned, abruptly end their reading session. Dr. Amy has been a source in over a dozen articles, from the Los Angeles Times, the New York Times and Time.com; it’s unlikely she’s going anywhere.

Something else you’re unlikely to see again is the debate about using Tuteur as a credible source. I just don’t see Newsweek debating the Times of London about whether she should be believed or not. I have the distinct feeling this back and forth of the last few days will be a rarity and limited to smallish, women-oriented ezines. Large magazines don’t have time for such nit-picking and have editors to determine whether a source is adequate or not before they ever make it to print. Apparently, Tuteur has passed muster more than once.

I wonder if the detractors think if they make enough noise, Dr. Amy won’t be used as a source anymore. I believe the louder they become, the more often she will be quoted, clearly annoying the home birth contingent; the press loves conflict.

As much as Dr. Amy Tuteur makes some people crazy, she has proven she is not a force to ignore. While I have issues with her delivery and am unsure about all she professes as fact, the woman has things to say that need to be heard and she’s going to be heard, whether we like it or not. Instead of trying to make her go away, how about we find people who can argue with/speak out against what she says in the same articles. And for crying in a bucket, debating statistics is not the way to do it! If you haven’t figured it out yet, the stats’ results are in the eye of the beholder, so finding alternative discussions is crucial. One of my favorite topics is why women want an out-of-hospital birth in the first place. And then it needs to move quickly to choosing safe home birth midwives. I believe until we have clear, fantastic midwifery education and a way for them/us to learn the advanced skills necessary for out-of-hospital births, we’re fighting a losing battle. Dr. Amy has the information about CPMs down to a sound bite; we better have an answer about them/us when asked.

I see people trying to shut Amy Tuteur up like trying to put out brushfires when the wildfire is just down the street. She isn’t going away. Deal with it.

NOW what are we going to do?

Thursday
Jul052012

Spanking & Mental Illness

The other day, a study came out about childhood spanking and its connection to adult mental illness; “Spanking Kids Might Lead to Adult Mental Illness” outlines what the information said.

“Childhood punishments such as spanking, slapping, and hitting – even in the absence of full-scale maltreatment – are associated with an increased risk of mental disorders in adulthood, researchers reported. 

“Adults who reported such punishments in their childhood had a greater risk of mood disorders, anxiety disorders, alcohol and drug abuse dependence, and several personality disorders, according to Tracie Afifi, PhD, of the University of Manitoba in Winnipeg, and colleagues.”

I fit this study to a tee.

I wouldn’t say I was abused, but I was smacked, hit and slapped throughout my childhood and early teen years. Dad’s military belt, hairbrushes, wooden spoons and fly swatters were all too familiar on my butt and legs.

So, 40 years later, as I climb my way out of the worst depression of my life, I can’t help but wonder just how much of this bipolar disorder was inherently going to show up in my life and how much came from being hurt and humiliated as a kid.

When I had Tristan (who’s 30 this year), I began parenting the way I learned (I was going to say taught, but it certainly wasn’t a conscious teaching or learning), smacking the poor child on his bottom and hands. Then, when I had Meghann 19 months later, I’d begun learning a new way to parent… a gentler way. Through the books at the La Leche League meetings, I learned I didn’t have to hit to get a child that would “behave.” It took a lot of unlearning and a lot of conscious not hitting, but I did a damn good job of not hurting my kids. Now, I’m sure if you asked them, they’d have great examples of mom’s misbehavior as a Good Mommy… I certainly yelled a lot more than I ever should have. (If I had it to do over, I would have meditated, taught the kids to meditate and I would have chilled out about the small stuff. I freaked out about far too many things and do apologize to the kids for my missteps.)

One of the major ways I realized my need to change was in remembering what it felt like to be hit as a kid. It was humiliating. In my new thinking, I couldn’t come up with a reason to make the children I loved more than anything in the world feel that horrible feeling of humiliation. That was the driving force of my transformation as a parent.

So, when I see studies like these, I am going to be vocal in their information. I’m almost as bad as Intactivists when it comes to hitting children.

Now, I’ve heard the arguments about discipline, not hitting a child in anger (which is absurd to me) and Look-How-Fine-I-Turned-Out, but they ring hollow for me. I beg people who were hit and who hit to tap into that child inside and see… no, feel… what it felt like to be hit. Not try and justify it with, “It was the only way I would listen,” or “That’s the way we do it in our family,” but to feel the feeling a child feels when he or she is hit. Why would you inflict that horrible feeling on a child you supposedly love more than life itself? It makes zero sense.

I’m glad this study came out. I’m glad when pieces of the puzzle are unwrapped every once in awhile so we can talk about this issue. “Discipline” isn’t a topic discussed as often as some others, so I’m glad to see this being aired right now.

If you hit, spank, slap, give the silent treatment or have discovered the various ways to manipulate children’s behavior, I pray you’ll stop and think today about how you 1) want to care for your children in the most loving way possible 2) want your children to be as adults. If there is a propensity for mental illness in your family, perhaps it’s the hitting that shoves the depression over the edge, dooming them for a life of difficulties through mental illness. Also, how do you want to be remembered when your kids tell stories about you? Do you want them telling a therapist how you mistreated them? Telling your grandkids how you shoved them in a cold shower with their clothes on? Is this the legacy you want to impart? I sincerely hope not.

I wasn’t a perfect parent and have written about when I’ve terribly failed… the one time I was hitting Meghann and Zack came and pulled me off of her… I had totally lost control and still remember it to this day. The time I went crazy because Meghann cut her own hair; poor Meghann… I’m sure she’s still traumatized by that incident. Even with my missteps, I’m so thankful I unlearned the horrible behaviors I was taught. My kids got a lot less abuse than they would have had I not stumbled on La Leche League and Bradley classes.

One more note. While I’ve had a ton of therapy, much of it discussing the hurt and humiliation as a child, I have come to a place of peace with my mom and dad, knowing they did the best they could with the information they had at the time. I was hit far less than my mom was and her parents were hit less than their parents, so at least the abuse was lessening over the generations. Perhaps Gabriella won’t ever have to endure a smack; one can only hope! Mental illness is rampant in my family, as rampant as the hitting, so it’s impossible to say if one would have been illuminated without the other. I can say that, so far, my own kids have bypassed the trips to the psychiatrists and therapists, so anecdotally, we’re spot on for staving off the mental illness. And that alone is cause for celebration.

Sunday
Jul012012

Cesarean Scar: adrienne's cesarean scar story

my cesarean scar is a reminder to be grateful.

i lost my first daughter during labor at an out of hospital birth center. heart tones were lost on her mere minutes before she made her entrance to the outside world. she was unable to be resuscitated. her absence in my life is felt each and every day.

when i became pregnant again, i wondered if i could go through another vaginal delivery. my body took a beating during my first labor...severe laceration, bladder damage resulting in a month's worth of self-catheterizing at home, post partum hemorrhage resulting in multiple blood transfusions, and a surgery to remove my retained placenta. all on top of losing my first born child.

in the end i opted for a cesarean delivery, and it was the best choice i could have made. my cesarean was awesome! it was over in 28 minutes (compared to my first 48 hour labor) and my daughter was alive!! my daughter was placed immediately on my chest and she was able to stay with me while i was sewn up. after getting checked out by the nurses, my daughter was placed back in my arms and we ere wheeled back to our room together. we nursed together right away, and snuggled all night. it was beyond perfect. and the cherry on top was that my recovery was a breeze compared to my first delivery.
just the other day i complained to myself about my cesarean scar itching. then i reminded myself to be grateful. a baby--my beautiful daughter--was born through that incision. a big thing happened there!
its ok to be upset over the appearance or the itch of my scar. as long as my next thought is to be grateful. grateful for life. for my body. for cesareans. and the people who perform them. and for my living, breathing baby girl.

love,
adrienne



Wednesday
Jun272012

Placentas in the Igloo

My son Tristan turns 30 this October. (I can’t believe he’s already that old. That makes me… older!) He’s finally ready to have kids (still needs the female part of the equation, however, so it’ll be awhile), so we’ve been talking about different aspects of his childhood and what he’s hoping for when it comes to being a father. It’s a delightful time with my baby boy.

He called the other night to tell me he went to an art show where many women attended and the topic of birth came up, so he mentioned his mom was a midwife, the women circling around and they began asking questions.

“What happens to the umbilical cord? Does it just suck back up into the baby?”

“How does a woman have a home birth without an epidural?”

And then there was the “What does your mom do with the placenta?”

Tristan laughed and told them we always had placentas in our freezer. “Watch out for the placenta! Make sure it goes back in the back when you get the popsicle out.” He told them he remembered women bringing me their placentas; I used them in childbirth classes to show the miraculousness of the organ and also demonstrate the uniqueness of each one. (We didn’t encapsulate them back then.) He said it was years before he realized an Igloo (a cooler) was used for something other than transporting placentas. The funniest part of that conversation was when he told them he was in his mid-twenties before he knew most people didn’t have a placenta in their freezer. I told him I could certainly get him one for his if he wanted one. He declined.

These talks with my kids are so awesome. They were always delightful as kids, but as adults, they are amazing. I love my babies. Can you tell?

Tuesday
Jun262012

Cesarean Scar: Kathryn

I was young, newly married and ecstatic when I found out we were expecting our first. I never dreamed I'd have any problems, I always pictured this perfect vaginal birth where the baby would be placed on my chest and would nurse right away. My mother had had 10 uncomplicated vaginal births, 1 UC birth at home; I didn't think I would have any problems. At my 36 week checkup the doctor told me I had pre-eclampsia and that he wanted me to stay on bed rest for the week. I had to have a nurse come to my home every day and check my blood pressure and swelling. Four days later I went back to the office for a checkup and he told me that he was sending me to the hospital; I would stay overnight and then would be induced in the morning. So off to the hospital I went. Heartbroken that I wouldn't be starting labor on my own when the time was right.

That night they gave me cervidil. In the morning things drug on and on. They finally hooked up my IV at about 10:00. I don't remember much of what happened after that, I do remember that the contractions were hard and strong and that they hurt, horribly. A little before 2:00 the doctor came in and sat by my bed for a few minutes, I remember him leaving the room and then all this commotion as the nurses rushed into my room. Apparently his heartbeat was dropping. I was rushed off to the operating room. I remember laying there on the table totally naked, alone and scared. First they told my husband he could suit up and come in and then they told him he couldn't come in.

I remember feeling the sting as they put in a few shots of local anesthesia on my lower tummy. And then the burn as they started cutting. I was going to do a drug free birth so I didn't have an epidural. When the call went out the anesthesiologist was five minutes from the hospital. I was later told that he got there just as they were cutting into my uterus. I remember a nurse standing at my head telling me to breathe in, and then I was gone.

When I woke up my baby was in the nursery. He wasn't doing too well and had to have some oxygen. I honestly don't remember much of what they told me was going on with him. I just remember I hurt like nothing I had ever felt before. I'm not sure how long I was out but it was awhile. They finally brought my beautiful baby boy to me. He was so tiny, 5 lbs. 9 oz. and 18 inches long. I know now after having more children and having them vaginally that I didn't have the same bonding with him as I did them.

Even though it was medically necessary to have him by c-section, the cord was in front of his head being smashed every time I had a contraction, I still feel like I failed in my birthing experience. My scar says I failed. I also feel like I failed at nursing him. At three weeks old he was admitted to the hospital because of failure to thrive. I have never felt like more of a failure then that day when I found out I was starving my child because my body wasn't doing what it was supposed to.

I have since had 6 vaginal births and have had a lot better experience.

Tuesday
Jun262012

Guest Post: From an Ex-(CPM)Apprentice

I got the piece below as a comment in the Dead Breech Babies post and felt it was too powerful to leave hidden amongst the other (equally great) comments. In this Guest Post, an ex-apprentice outlines her thoughts about the quality of midwives the license is producing and some random thoughts about where midwifery is headed if it stays on the same course. I believe what she says is right on for many, many Certified Professional Midwives (CPMs), my voice echoing hers in many respects. (Although she is echoing me since I said some of these things first, but who’s quibbling.) 

On the same day I got her comment, The Daily Beast printed “Home Birth: Increasingly Popular, But Dangerous,” a scathing assault on home birth in general, but CPMs in particular. Reading as a normal, rational person, CPMs seem worse than fringe, telling women to put garlic in their vaginas instead of antibiotics for an infection (GBS) and ignoring red flag after red flag during complicated and even high-risk pregnancies, labors, births and postpartum periods. Sadly, as most of us reading this know, these are the typical truths, not the exception. No wonder more and more people are speaking out against the lack of education and skills training of CPMs and how they, in way too many cases, ignore the adage that midwives only attend to low-risk women. Low-risk, it seems, is subjective when, in fact, it is quite objective. 

But, let’s listen to what one ex-midwifery apprentice has to say about her training and why she left the midwives she was working with. 

I’ve been reading your blog for a few years I’ve really become interested in the topic of education and licensure of CPMs. I don’t believe CPMs should be vilified as they are by certain blogs on the internet but a critical look at their licensing and educational standards is in order. THANK YOU for being unafraid to voice your opinion about this. I, at this point, am too timid to publicly voice my deep concerns for the training of CPMs, the “standards” by which they practice, and the lack of accountability by the regulating body/bodies.

The breech post really struck a chord with me. I read the Ina May article in the New York Times and was surprised that she’d revealed a story about the delivery a breech baby under her care who became stuck and then suffered brain damage. Yes, most of the breech babies just “fall out” and so yes, most of the time anyone could attend the birth of a breech baby. And having witnessed dozens of breech babies falling out during delivery might give a midwife the false belief that “breech is just a variation of normal” - and because they went to a workshop given by a midwife who attended the Canadian breech summit that they are competent and skilled at attending breech birth.

 As an apprentice midwife, I’d often asked myself “Just WHAT does it take for a woman to get risked out of a midwifery practice?” Because although midwives tout that they attend low-risk healthy mothers, the risk factors would pile up but never seem to push the clients into the realm of “high risk” or even “not low risk” and therefore not necessitate a transfer of care.

 As a conscientious human being, I was acutely aware of my limited and outright lack of skills in high risk deliveries. As labors would progressively get more and more complicated over hours and sometimes days, I would run resuscitation drills in my head, recheck the postpartum anti-hemorrhagic meds, and mentally try to prepare myself for a true emergency situation where someone’s life was on the line. I knew I was labeled as “primary assistant” to the midwife, I’d be expected to attempt to perform life-saving measures in an out-of-hospital setting and I knew I was under-qualified for that job. Other apprentices were not so self-aware, and that was even scarier. They would be more attentive to the birthing music CD and keeping candles lit than understanding the complexity of the situation that was unfolding.

Then birth would unfold and with some gentle stimulation or a shot of Pitocin everyone turned out “Just Fine” and the midwife could then assert that that whole roller coaster ride of labor and birth was just a “variation of normal” and that the objective is not to transport when a midwife “gets scared” but to “trust birth” and would often belittle other midwives who were quicker to transfer care to a hospital when things weren’t going perfectly smoothly.

 Back to the breech thing when I’d started midwifery training, I’d assumed that midwives risked out breech birth, no question. But it was slowly revealed that many midwives felt that breech was a “variation of normal” and they felt fully equipped and skilled to attend breech births of all variations - simply because they were midwives, they trusted the inherent birthing process, they’d read up on it, and seen some Ina May videos about breech birth. IS THIS NOT INSANE?

 And there was a certain level of delight on the part of the midwife when a mother would want to have a home birth with a breech baby. Or when a woman would consent to home delivery DURING ACTIVE LABOR when a surprise breech was discovered. Tell me, can a woman truly understand the risks of breech birth at home when she first hears of it when she’s 7 centimeters dilated and has had not even considered the possibility this “variation of normal” for the entirety of her pregnancy? I don’t think midwives even consider that the baby could die when they agree to practice their substandard skills in attending childbirth with a breech presentation. Most breech babies just “fall out.” And the breech birth I witnessed as an apprentice was a case of the baby just “falling out.” But I am not lulled into believing that all breech babies come flying out this way. But I’m afraid that many apprentices will be lulled into this belief. As well as many midwives.

 I do believe that women have the right to birth their babies, even their breech babies, vaginally. They are entitled to full informed disclosure of the risks of breech delivery and the experience of the provider. They should have access to skilled, capable providers for vaginal breech births and I think it’s a crying shame that women do not have these options in hospital settings. They are also entitled to compassionate and respectful care.

 My interaction with midwives has shown that they are incredibly compassionate, caring and attentive providers. But these skills, though vitally important to the midwifery model of care, cannot replace critical life-saving clinical skills. And midwives who attend hundreds of births where babies, vertex and breech, just “fall out” will never gain these skills.

 I feel like I need to add my voice. These stories about midwives attending breech and high-risk deliveries ring too true to what I’ve experienced in my years as an apprentice midwife. I’m glad these issues are being brought to light. It’s time.
 

And a second comment from the same woman goes on: 

CPMs need to understand statistics. They need to grasp the statistical (un)importance of an anecdote. The professional organizations representing CPMs need to educate the membership about real statistical risk to the profession when individuals take on high-risk cases. The professional organizations have to stop bullying members and engage in true critical and thoughtful discourse regarding the profession of midwifery and let  go of the emotional ties to former styles of midwifery that are no longer valid or acceptable in today’s world.

 I’ve noticed a lot of burying heads in the sand when it comes to looking at practice standards and education of CPMs. No one wants to examine where the CPM credential falls short. They just want to get louder and blindly proclaim its inherent worth, fight for licensure, and assert that the end (CPM) justifies the means (apprenticeship, correspondence course, what-have-you) in training midwives.

What is unfortunate about this burying heads in the sand is that CPMs are not participating in this raging discussion regarding their own professionalism and competency. This discussion is largely being defined by Dr. What’s-Her-Name and other sensationalist voices. It’s creating a false black and white dichotomy and painting ALL midwives as incompetent, ALL midwives as bad, ALL midwives as heartless self-centered egomaniacally superstitious pseudo healthcare providers. And this is not true. Mothers who have been misled by midwives are bravely coming forward and it is incredibly disheartening that CPMs and CPM professional organizations - are not the FIRST in line to hear these stories and to address the issues brought forward by them.

 Anyone read MANA (Midwifery Association of North America)  news lately? Is there even the faintest whiff of the negative publicity that homebirth and CPM care has been receiving in the past months? Year? Is there any inkling that MANA (oh, MANA represents
all midwives, not just CPMs, right. How do I keep forgetting?) is responding to the lack of educational standards, lack of professional standards and the stories of poor outcomes? Are they even acknowledging the theory-practice gap that is rampant in midwifery practices? Low-risk is the theory. High-risk is the practice.

 No just the endless hollow sing-song of “I am a midwife….” “We need more midwives!” “License CPMs!”

 If CPMs want to thrive as a profession, their professional organizations need to step up and start addressing these difficult issues on a professional level. They need to participate in this discussion. They need to let go of their emotional gut reactions, stop attacking each other, stop being afraid of asking the hard questions (For instance: is the current CPM educational pathway sufficient?) and react accordingly not only to benefit the profession of midwifery, but to the families they serve.

 I would love to see this happen. I don’t want midwives go away. I don’t want home birth to become illegal. I don’t want to see the CPM credential disappear. But I would like to see it improve. I believe it is possible. But CPMs need to be on board. And that hasn’t happened yet.

Brava!

Saturday
Jun232012

What Influence?

Tristan, my oldest, healed from a devastating break-up last year, met a girl! I asked if she knew about his crazy family. He said: 

"Mom, before the bread's on the table, I tell her about my lesbian mother, my transman step-mother, let her know she has to attempt a natural birth with a midwife and breastfeed for years. If she's cool with all of that, we have dinner." 

I laughed my butt off. 

And so started the thread on my Navelgazing Midwife Facebook Page. Initially, people laughed and thought it was great, but it deteriorated into an Us vs. Them commentary that disturbed me on several levels. 

First came the whose business is it of mine how my future daughter-in-law birth… the most obnoxious comment seen here: 

“Sad that how a women feeds her own children or birth her own children matters to ANYONE....I honestly hope you future Daughter in law formula feeds and has hospital birth...maybe then you would be more open minded...and realize what is really important in being a mother!!!” 

Then came the thoughts that Tristan having any beliefs about how his wife delivers being any business of his were completely ridiculous. 

 “If any dude I had just met had made such a joke to me, I probably would have shot back – ‘Just so long as you get that vasectomy without pain relief after that last kid, because that's how you get in good with MY mom.’" 

It bothers me enough that so many people are humorless, but can only assume the majority don’t have a clue who I am and wouldn’t know that I, of all people, am not going to command how another woman has her babies or feeds them. While I might have preferences, they are mine. I do have extra education and skill in natural birth and nursing, but that doesn’t mean I’m a birth nazi. 

And then, after thinking about this thread all evening, I got more and more disturbed by how hospital birth and formula feeding were being held as a punishment for a natural birth and breastfeeding comment. I find that incredibly offensive… to hospital birthing and formula feeding mothers! To wish a hospital birth on a midwife is no different than telling a woman who knows she wants an epidural you hope she has a precipitous labor and can’t get anything for pain. How freakin’ rude! 

(And I haven’t even mentioned in the thread my daughter did have a planned hospital birth and I supported it 100%.) 

I find myself going ‘round and ‘round here, knowing there’s something more to what I’m hearing but unable to put all the words to it yet. 

Turning my head a little, I wonder… is it a bad thing to have wishes for your children when it comes to birth? Is it wrong to want my future daughter-in-law to have a (what I consider to be a pretty) great birth? Is it wrong to hope she nurses her babies? Is it wrong to hope they don’t circumcise? Are there aspects I can wish for that aren’t intrusive on her choices? Can’t I be a resource for my children without seeming to try to brainwash them? Wasn’t watching moms labor at home “brainwashing” enough? Wasn’t seeing happy nursing toddlers a lesson on its own? 

Meghann had a hospital birth-turned-cesarean. She struggled with nursing for a few weeks… a nasty case of thrush and then oversupply that mangled her nipples. And while she took some of what I knew, she needed help from outsiders because I didn’t have all the information she needed. On her own, she has found Babywearing and clean eating and La Leche League… and now, it seems, cloth diapers (something I did briefly and hated). She is following in her mother’s footsteps without my saying a word. Is that bad?  

So, how much influence would I have on a daughter-in-law? Probably not a lot beyond what my son already knows is important to him. 

When Tristan was telling me the above quip, he said to me that he really wants kids sooner than later. “I love kids, mom. You made me that way.” 

That’s when my heart melted and everything all those cranky pants are saying just vanishes. 

My kids have taken some of my beliefs on as their own. There is no prouder moment.

Wednesday
Jun202012

Dead Breech Babies

Recently, I read an article about Ina May Gaskin entitled “Mommy Wars: The Prequel - Ina May Gaskin’s and the Battle for Home Births.” In the very long piece, Ina May speaks about breech babies, saying in part:

 “’Footling breeches, which are thought to be the most difficult, in our experience, they often just slid right out.’

Now, I have a huge issue with her saying this in print at all because footling breech babies are the highest of high risk breech babies and out of the hands of someone as skilled as Ina May, the birth can also be a death. Granted, she wasn’t saying it to the reporter, but to a breech class at The Farm, but it’s out there, nevertheless. And she’s teaching this to women in a weekend seminar? C’mon.

Ina May continues:

“‘The main danger with breech babies is that the head, the largest part of baby, is last to come out, so it may get stuck,’ she told the students. ‘If the baby has been delivered to the umbilicus, you have five or six minutes before hypoxia sets in, but you don’t want to pull on the head if you can’t see the neck for fear of injuring the baby,’ Gaskin said.

 Sounds a little more than the baby “sliding right out,” doesn’t it? sigh

There is the belief (true, from what I’ve seen) that midwifery care creates a level of connection so intimate that if things go wrong in birth, the midwife is rarely blamed by the parents. In fact, even when the District Attorney or Medical Examiner takes up prosecuting the midwife, it’s extremely rare to have the parents speak out against her. Instead, parents often become the most vocal of supporters. To this end, the article says:

“Farm midwives give intimate intensive prenatal care and have a high degree of trust with their patients. That’s why, Gaskin said, in 2006 when a breech baby she delivered became temporarily stuck and suffered permanent neurological problems, the parents did not sue. ‘We thoroughly discussed the issues, and they didn’t see a reason to be punishing,’ Gaskin told me.

That’s one damaged breech baby born.

The newspaper piece continues:

“When I visited the Farm, Gaskin was planning to travel to testify at the trial of a C.P.M., Karen Carr, who delivered a breech baby in a home in Virginia who died.”

That’s one dead breech baby.

Karen Carr, a midwife “pleaded guilty to two felony charges in an infant death that she attended during a home delivery in Virginia last September. The state of Virginia argued that Carr was negligent during the home birth after the baby's head became entrapped for more than 20 minutes during the delivery. The baby died two days later.”

Lisa Barrett is another midwife who has lost a breech baby. (I’m struggling to use the word “lost” because I feel she was more actively responsible, not a passive bystander.) Jahli Jean Hobbs died in April 2009.

Two dead breech babies

In April 2004, the first twin of Elizabeth Hammill (in the UK) delivered breech and got stuck, the parents refusing to allow the three midwives required to attend to do anything, believing only an unassisted birth was a true natural birth. (“Home birth baby died after mother told midwives not to interfere”) Even when the mother was counseled two weeks before the birth about the risks of delivering a vaginal breech birth, the family said they wanted the unassisted (but observed) birth anyway. Then, after the death, the mother had the gall to say no one told her of the “gravity” of the situation. Makes me cringe, her backpedaling on her initial beliefs. (I do believe some women aren’t told the risks clearly enough, but it sounds like this mom was so freakin’ married to natural birth that nothing less than unassisted was going to do for them. Who knows if the baby might have lived if the midwives were able to assist at the birth. Possibly, that’s for sure.) The woman’s twin was delivered via (emergency) cesarean at the hospital. Alive.

Three dead breech babies.

Two babies died at home after the mother tried to be birth them breech. (“The tragic dangers of home birth – ‘A senior coroner has urged a change in the guidelines for midwives on home births after two breech babies died.’”)

Phoebe was born at home in January 2002, her midwife “suspecting” the baby was breech; the mother saying she accepted the risk of delivering at home. While the birth had a challenge with the head, the baby delivered and was resuscitated. She seemed fine, but two days later, died from an adrenal hemorrhage caused by lack of oxygen at birth.

Four and five dead breech babies.

Christopher was born in July 2002 and seems to have been a surprise breech whose head got stuck and the baby died an hour after the birth.

Six dead breech babies.

In March 2012, Sara Snyder’s baby Magnus died 13 days after birth, attempted breech birth at Greenhouse Birth Center in Okemos, Michigan.

Seven dead breech babies.

And this is just searching “dead breech babies” on Google. How many more stories are out there we don’t even know about.

I’m writing about this because it isn’t a subject spoken about very often. Instead, breeches are considered “a variation on the norm” of pregnancies and labors. On the contrary, 3 to 5 percent of babies present breech at birth. That is hardly a variation of normal. That would almost be considered “not very common.” I think that until the very real risks of breech births are talked about, women who choose to birth one out of the hospital isn’t receiving true informed consent. Romanticizing and simplifying these types of births… as Ina May seems to do in her breech workshops (just reading what was in that original article at the beginning)… does an enormous disservice to women needing the most information before making their decisions.

I initially began this post after reading the article about Ina May because in that piece, she mentioned one damaged breech baby and one dead breech baby all while touting their ease of delivery. I can’t recall an article that talked about birth while including a mention of a stillbirth because they are so incredibly rare. It seems, from reading the press alone, that breech deaths are not that uncommon at all.

Think, oh women with a breech baby, before coming to the conclusion that it’s fine to deliver your baby at home or in the birth center. I’m aware the options aren’t fabulous for a vaginal birth in the hospital, but is the life of your baby worth the risk just not to have a cesarean? Please be sure of your decisions. I once thought I would want to deliver my breech baby at home. Now that I know better, I would have a cesarean without hesitation. You have to make your own choice, but you also have to live with it. And I don’t think anyone can say “I didn’t know any better!” anymore. Now you know.

Tuesday
Jun192012

Cesarean Scar: Sarah

What does your scar say when you look at it?

My scar says, "I am unnecessary. I am a result of lack of knowledge, fear, betrayal, and lack of support. I made you feel disconnected from your babies and lonely in pain. I am embarrassing and ugly. Don't show your husband or anyone for that matter. Hello mom jeans and goodbye bathing suits. Have sex in the dark, always."

What does your scar say when you touch it?

"Don't touch me."

My story... the quick version.

#1 - I was a first time mom with a big baby and an OB who recommended a cesarean. I trusted her.

#2 - VBAC attempt at a "VBAC friendly" hospital. I carried my baby for 41w5d. I was packing my bag when I get a phone call from the hospital telling me to go elsewhere for care - they would not support my VBAC, if I walked in there I would have a cesarean. I went elsewhere...it was a dead end.

#3 - Planned HBA2C. I went into labor at 41w3d and my 3rd son was born in the water at 1:14am on Mother's Day with his daddy catching. The birth was beautiful and healing in many ways. I was supported and I found out that I am stronger than I ever imagined.

I am scarred, but not broken.

Monday
Jun112012

HBACs

After some long and deep thinking about this topic over the last couple of years, I’ve come to the conclusion that Vaginal Birth After Cesareans (VBACs) should be permitted to birth at home (a Home Birth After Cesarean – HBAC). I’ve been vocal about my belief that homebirth midwives need more education and skills training and have intimated that breeches and twins should not be born at home, but this is the first time I’ve spoken clearly about my feelings about HBACs.

As I considered this, I re-read the entire National Institutes of Health VBAC Summit’s recommendations a couple of times, read statistics in a variety of journals and then read both pro and anti sites regarding both VBAC (at all) and HBACs. I also tapped into my own cesarean and VBAC experiences as a doula and homebirth midwife, but tried to take the hard data at least as valuable, if not more so, than mine. In my ponderings, I’ve also put myself in the place of a birthing woman; what would I do if I were considering a VBAC/HBAC? Also, I’ve taken my own daughter’s situation… a primary cesarean, wanting a VBAC… and wondered how I would counsel her. I honestly feel I am infinitely more conservative with her life than I ever was with my own.

While I acknowledge there is risk in VBAC and surely more risk in HBAC, I feel that weighing the risks between a possible rupture versus the risks that can and do occur during and after a cesarean can lead a woman to, with true Informed Consent, to choose to VBAC/HBAC. And in some ways, having an HBAC can be even safer (safer being relative) than a VBAC in the hospital because women are able to be mobile and not be induced or augmented. Of course, women having an HBAC do not have continuous fetal monitoring so there is the argument that early signs of rupture can be missed in a homebirth. I’ll accept that and women choosing HBAC will have to, too. Women at home, however, are able to feel the rupture when an epidural’d woman would not. Not that all ruptures can be felt.

The great majority of ruptures are slow, not the catastrophic ones usually thought of when discussing this topic. While time is of the essence, there can be enough time to transfer to the hospital if a non-catastrophic rupture begins. (Catastrophic meaning sudden and imminently life-threatening… not that a uterine rupture isn’t a horrible event all on its own.)

In my opinion, the ideal HBAC client looks like this:

  • has had a previous vaginal birth
  • has had only one previous cesarean
  • has had at least two years between pregnancies (not births)
  • does not have insulin resistance issues or gestational diabetes mellitus
  • has not had a previous baby over 9 pounds
  • is not expected to deliver a baby over 9 pounds
  • does not go over 41 weeks 3 days (Seems arbitrary, I know, but will explain below.)
  • has a midwife who is highly educated and amply skilled
  • is within 15 minutes of a hospital, 15 minutes car driving, not ambulance driving (ambulances coming to the home and then getting to the hospital can take 15 minutes or more)

But, ideal is probably pretty rare.

I’ve written that the safest place for birth is in the hospital. Ample staff, access to technology, an operating room and blood products are in hospitals, not at home. So, if one is wanting the safest (with regards to the mother’s and baby’s lives) place for any birth, the hospital wins, hands down. But, there are trade-offs and they do not always have anything to do with “the experience.” At home, technology isn’t foisted on women and babies, technology that can hinder labors and cause more problems than they solve (induction and augmentation as one huge example). Women are also treated as human beings and while this might seem “experience-y,” civility can help women relax and allow their labors unfold as well as trust the provider more and, therefore, be more inclined to share worries or concerns about what is happening in the labor.

Regarding delivering before 41 weeks 3 days as the ideal time frame, if a woman is wanting a VBAC, this timeline allows hospital interactions if the birth doesn't happen before then. That labor might begin after that and an HBAC happening, that's certainly true, but I am inclined to want to offer the mom every opportunity for a VBAC and, to me, that includes the hospital "interventions." Again, it does seem awful arbitrary, but just how I feel.

This is, in no way, meant as The End of the VBAC/HBAC discussion, but a beginning. Women must play out every scenario, discuss every concern with their partners and providers (ideally, a medical and midwifery provider in order to get a balanced perspective) and ultimately decide, for themselves, if the (extremely) minimal risk of a catastrophic rupture is worth staying at home. Remembering that uterine ruptures also happen before labor even begins can help them consider the risks.

In this discussion on my Navelgazing Midwife Facebook Page, women have shared their stories of uterine rupture and fetal death, so acknowledging that possible reality is crucial. Weighing each location’s pluses and minuses is vital. The only two uterine ruptures I've had with clients have been with women having their first babies and the women were induced/augmented with pitocin. I've known of other ruptures, but have no experience with any catastrophic ruptures. But, even so, I absolutely understand the risks. (I have seen a maternal death, so totally get risks in birth.)

For me, I would, with the above ideal situations, attempt an HBAC. Even though my daughter hasn’t had a previous vaginal birth or a baby under 9 pounds, I believe that, with care, she could attempt an HBAC next time. That, above everything else I’ve said, speaks volumes. (Not that she would want or try to HBAC; she isn’t pregnant, so moot at the moment.)

I look forward to thoughts and concerns, though I did try to address most of them.  

Monday
Jun042012

"Stretch"

I asked folks to “Toss Me a Birth-Related Word” on my Navelgazing Midwife Facebook Page and “Stretch” was the one of the words. Here, I’ll use it as a springboard from which to jump.

When I was pregnant, I really needed to stretch a lot. I have a short waist and grow big babies (uh, with the diet I had, I grew big babies), so had kids packed in a small area. I was thrilled when I learned to put one arm over my shoulder with my hand on my back and the other arm around my waist with that hand on my back, too, and how that opened my chest up considerably.

I loved doing that move several times a day and try to show it to clients.

I also loved doing pelvic tilts. They were a total Bradley thing; we were taught to do 80 three times a day. Seems like a lot, but really did strengthen my lower back when I was carrying 10-pound Meghann. Pelvic tilts are often done incorrectly, so I learned a way that helped me and others know the correct way to do them. Doing them the right way saves your back, including the lower back because if you sway your back, especially pregnant, it can pull a lot of muscles. So, instead of arching like a cat and swaying down (the “Cow” yoga move), go on hands and knees, back like a table top… parallel to the ground. Now, pretend you have a tail on your tailbone and then pull the tail between your legs. That’s the pelvic tilt movement that will help your lower back get some tone and stretch. After pulling the tail in, the let the tail relax, back going parallel to the ground again. No sway back! Do the tail-pulling as many times as you can… slowly and with purpose… this isn’t to be done quickly. Nice. And. Slow. Pullllll… stretch inward. Releeeaaassseee and relax. Over and over. 80 times is as long as a 3-minute song. Impossibly long if you have kidlets, I know. But, even 10 a few times a day would be a great start.

When thinking of the word “stretch” with birth, we can’t help thinking about the vagina stretching, right? While there’s a belief in perineal massage in order to help the stretching birthing vagina not tear, I am not a fan of that at all. I believe women stretch just fine and have found the less they (women) are messed with, the better they do. When hands are all over the vagina, stretching it, “massaging” it… “ironing” it… the tissues swell and tend to tear more. I’ve found women rarely tear when they birth in tubs, too, and gee, no one can manipulate the vagina from that position. I believe the vagina knows what to do and, without futzing with it, is going to tear or not, depending on the baby’s head’s position.

Now, I have helped women with the speed of the head’s delivery and that can be good for saving some tearing, but that’s different than perineal massage; that’s perineal support.

And what else stretches in birth… ah, yes… the cervix.

I’ve recently discussed my feelings about stripping membranes (which involves the cervix directly), but what about the cervix stretching on its own?

The cervix is amazing. It can be tough and thick, like a soft piece of plastic, and it can be thin and stretchy, like a rubber band. While the majority of cervices (plural for cervix) get thin and stretchier as labor progresses, not all do. But, in my more hands-on days, have lifted a stretchy cervix over a baby’s head, helping the mom get to second stage quicker. It’s as if you took dough and used a glass to cut a hole in the dough (like for biscuits) and then put your finger inside the cut-out hole and pulled on the dough. That’s what a stretchy cervix feels like and depending on how thick you make the dough, depends on how effaced she is; the “shorter” the dough (the thinner), the more effaced mom is and it’s usually easier to stretch the cervix back and over the baby’s head.

Now should we be stretching the cervix over the baby’s head? Usually not. In fact, usually you can’t. But, there are times when it can be a kind and loving thing for mom to minimize the urge to push, if it’s been going on for a long time. What’s typically happened for me is that I didn’t do vaginal exams, but would listen to mom’s urges to push, letting them lead the way. Then, when there was no progress after some time… usually a long time… I would do an exam and find the “cervical/anterior lip” (the small part of the cervix left over from the rest of the dilated cervix), stubbornly keeping the baby from coming down and into the mom’s pelvis. I’ve never figured out why some cervices do this… positioning, timing, size of the baby… it all seemed so random. But, when it happened, I thanked the Universe when the lip was stretchy and not thick and tense. Then, hooking a finger under the lip (like lifting that swatch of dough) and lifting it up, usually during a contraction, would bring the baby right down through the rest of the cervix. True, sometimes it would take a couple/few contractions and manipulating the cervix isn’t comfortable at all, but it is better than transferring to the hospital and either having the hospital folks do the same thing or having a cesarean for failure to progress. As with anything, moderation is the key.

Can you think of other stretchy things in birth? Thoughts on what I’ve written? Have you had your cervix lifted over the baby’s head?

Monday
May282012

"Crowning"

I asked folks to “Toss Me a Birth-Related Word” on my Navelgazing Midwife Facebook Page and “Crowning” was the one of the words. Here, I’ll use it as a springboard from which to jump.

When I attended my first birth, when the baby crowned, I thought there was no skull and was horrified. No one else seemed worried, though, so I tried to keep my panic controlled. Then, when the baby came out, the skull magically appeared! I watched closer the next few times, trying to see what the heck that was, the brainy-looking head coming out with crowning. It was the skin of the head smooshed together as well as the molding that happens with the sutures as the baby goes through the pelvis. While molding can hang on for a couple of days, that skull-less image was gone immediately after the head was born.

That feeling was so scary, I can remember it even now. I try to warn new doulas about that so they don’t get weird about it themselves.

Hmmm… maybe in the age of YouTube that doesn’t happen anymore?

Monday
May282012

"Mucous"

I asked folks to “Toss Me a Birth-Related Word” on my Navelgazing Midwife Facebook Page and “Mucous” was the first word. Here, I’ll use the word as a springboard from which to jump.

 

I’ve written about “gloppies” (my nickname for mucous in birth) before, but thought I’d write about how gloppies clearly demonstrate how far a woman is in labor. I’m sure there are exceptions, but they would be extremely rare. I’ve talked to nurses and other midwives about this so have more info than just mine.

When a woman advances in labor, her mucous gets more and more copious. Personally, I have never seen a woman over 6 centimeters who didn’t have gloppies. When I meet up with a mom who looks like she’s in kick-ass labor… even if she smells in labor (another topic)… if she doesn’t have gloppies, she invariably turns out to be under 4 centimeters. I came to be able to tell if a woman was in progressing labor (as opposed to prodromal labor) by her gloppiness.

Of course, you have to be near the vagina in order to see how much there is.

And the closer to birth, the bloodier the mucous. I don’t mean bright red blood, but more period-blood looking, mixed with the mucous. I’ve asked women if they have to wipe two or three times when they call with “really hard” contractions. Not that I don’t go if they don’t, but lets me know if I need to run or not.

There is a seemingly endless supply of mucous because, well, this is an endless supply. Just like when we have a cold, mucous is made until the cold is over, the same with birth mucous. It’s just made until birth is over. I always wondered about the two kinds… are they similar in make-up? What’s different? What makes one when we’re sick and then other when we’re birthing?

Things I think about.

Monday
May282012

"Placenta"

I asked folks to “Toss Me: A Birth-Related Word” on my Navelgazing Midwife Facebook Page and “Placenta” was the one of the words. Here, I’ll use the word as a springboard from which to jump.

Placenta

Placentas are miraculous organs! The only completely regenerative and disposable organ, specifically made for each new baby grown inside a uterus. I could stop there and we’d all just sit, mouth agape, with wonder and amazement.

I’ve seen some amazing placentas over the last 29 years. Some that were humongous and others that were teeny tiny… and both types with full-term babies. I’ve rarely seen premature babies in my doula or midwifery clients, and haven’t ever even seen one born in front of me. (Isn’t that amazing?!) So, I haven’t seen premature placentas except in photos and yes, they are very small, too.

But seeing really tiny placentas with full-term babies is a whole different thing altogether. One of the smallest I saw was with a mom who weighed over 400 pounds and had a baby a couple of ounces under 5 pounds; her gestational diabetes was completely out of control. That was the first time I learned that gestational diabetes mellitus (GDM) can not only make large-for-gestational age (LGA) babies, but also small-for-gestational age (SGA) babies.

The placenta can give so much information about the health of the baby. It can say things about the mom, but years into my learning, I quit being so arrogant/ignorant as to think it only had to do with the mother and her behaviors. Sometimes placentas have their own problems, independent of the host.

Did you hear that?

Sometimes placentas have their own problems, independent of the host.

Even with ultrasounds, the placenta can be having issues and it not be known until the placenta is held in your hands. Midwives should consider placental issues if there are any growth issues with the baby. Hard to diagnose, easier to monitor over time… if done carefully.

Placentophagy (consuming the placenta) is a whole other topic I’m not going to get into except to say I doubt it hurts anyone to ingest, but unless it’s eaten raw right after birth, I have a hard time imagining it does much of anything.

I used to believe putting a piece of placenta under the tongue would help with hemorrhage, but don’t believe that anymore. I know that a shot of Pitocin stops (most cases of) hemorrhage and would go to that in lieu of a bite o’ placenta instead. While the hormones might help, why waste time when it takes 3-5 minutes for the shot of Pitocin to kick in in the first place. If the placenta didn’t work (how long do you wait, anyway?!), then you give the shot of Pit and have to wait that 3-5 minutes more. Do you know how much a woman can bleed in 5-7 minutes? A whole helluva lot. Maybe some would suggest a piece of placenta and a shot of Pit? I just know for me, I would not/could not eat a piece of placenta. Or drink it in a shake. I might be able to ingest it in capsules and did have postpartum depression bad enough that I might have decided to take placenta capsules prophylactically, but have a lot more belief in medication than Placentophagy.

All that said, I still think the placenta is a miracle organ. I love that it holds the baby afloat, that it filters some infectious agents and that the amniotic sac is made from two seran-wrap thin pieces (the amnion and chorion) stuck together, one half (the chorion) that makes the amniotic fluid the baby lives in during its growth. It’s just amazing!

I’ll end with an anecdote about the amniotic sac… some of you may know this story, but I hope you’ll enjoy it again.

My partner Zack had ocular lymphoma (eye cancer) and his surgeons were dry as toast. Z, always amusing, tried to lighten the subject so he didn’t get morosely depressed over the issue at hand. When they were talking about the actual surgery to remove the cancer (what we affectionately call “melon-balling”), they said they had to put a graft over the hole in the eyeball so the eye’s cells could use it like scaffolding, growing back together on each side. Amazing! When Z asked what they were going to use for the graft material, they said they used one of two things. The first was the foreskin of a newborn baby’s circumcised penis. Not kidding. Without skipping a beat, Zack said he couldn’t do that because he’d be cock-eyed. I busted out laughing. The surgeons did not. Boring sticks in the mud!

Z said he couldn’t do that on principal; what was the other choice.

One of the surgeons said, “A chorion.”

I perked up. “Chorion? Like amnion and chorion? From an amniotic sac?!”

They said yes.

I started laughing and said I had several placentas in my freezer, that I could bring swatches of amniotic sacs to see which one matched Zack’s eye color best! Dryly, they said we couldn’t do that, that the “specimen” needed to come from Pathology, blah blah blah. No kidding. I shook my head and said I was joking.

Z said that was what he wanted them to use.

The day of surgery, Zack and I had a little ceremony where we lit a candle and thanked the mother and baby, neither of whom knew the gift they were giving, for the part of the magical organ to help keep Zack’s eyeball safe as it healed. We still think of them today.

Who knew the amniotic sac was used for other things besides the trash? Amazing, isn’t it?

Oh, and Z's cancer is gone. Yay!

Monday
May282012

"Primal"

I asked folks to “Toss Me a Birth-Related Word” on my Navelgazing Midwife Facebook Page and “Primal” was one of those words. Here, I’ll use the words as springboards from which to jump. 

Is birth primal? 

Some definitions of the word primal include:

  • having existed from the beginning
  • in an earliest or original stage or state
  • serving as an essential component
  • first, original
  • of first importance
  • fundamental

I know when I hear the word primal when used with the topic of birth, it brings up images of a woman squatting in the sand on a beach or holding onto a tree as she standingly squats to push her baby out. I see not-white women birthing… the video “Birth in the Squatting Position.” How racist can I get? By the definitions, primal does not mean primitive, which brings up its own set of considerations.

So, I’ll stick to primal birth. What would that look like?

Primal birth could be anything from unassisted birth to hands-off birth to birth in a locale that doesn’t have midwives. Hmmm… or does it have to be birth without midwives? From what I know, most cultures around the world for eons of time have had midwives or, at the least, a knowledgeable female helper at birth. I don’t know enough birth anthropology or archeology to know if there are remnants of midwives in fossils or cave paintings, but do know that more recently, we have been written about and drawn about in Egyptian pyramids and the Bible.

So, what would birth look like in its original state? Do we really know?

Let’s take the definition fundamental. Don’t we fundamentally want a safe birth? (Using the word again…) Isn’t a fundamentally safe birth kind of subjective? What of the mom who had a horrific hospital birth and is choosing a homebirth for the subsequent birth, having complete informed consent and accepting the risks of not being in the hospital? Isn’t her desire for a fundamentally safe birth? But, would that be considered a Primal Birth? Probably not necessarily.

I think I don’t have a good answer for this question. Anybody else have any ideas? I’m not doing such a good job.

Sunday
May272012

"Baby"

I asked folks to “Toss Me: A Birth-Related Word” on my Navelgazing Midwife Facebook Page and “Baby” was the first word. Here, I’ll use the words as springboards from which to jump.

Baby:

Today I had a baby. 28 years ago today, I had my baby Meghann. At home. An unassisted birth. If I stayed in that moment, it was amazing, empowering, glorious and triumphant. I hadn’t yet looked back to the carelessness of my actions, how I’d come so close to losing my newborn girl. Then, I was high as a new mom could be with joy and love. She was huge! I’d pushed for two hours and had this ten-pound-plus child out my vagina, knowing she would have been a cesarean if I’d have been in the hospital. I’d done it! I had the homebirth I ached to have.

I held my new baby to my breast, feeling how fat she was, next to my own fatness and you could hardly tell where one of us ended and the other began. She smelled so good. So raw. We didn’t bathe her for days and days. We smooshed her vernix into her skin, finding stores of it in her (copious) creases.

Even almost three decades later, I can feel her in my arms. I know now that memory will never leave me… and I am so thankful for that. That I can feel the weight of her body in my arms, feel the way her hand wrapped around my forefinger and see her eyes as she looked into mine.

Baby. My baby. I had a baby. Baby, Mine. I love my baby. I loved kissing my baby. I love you, my baby girl.

Other words I’ll jump off of:

  • Cesarean
  • Primal
  • Placenta
  • Mucous
  • High
  • Open
  • Trust
  • Fecund

And surely many more.

Wednesday
May232012

How to Interview Your Midwife’s References

Over and over, we hear for potential homebirth clients to not only interview the midwife (which I’ve discussed at length here, here, here, here, here and here), but to also ask the midwife for references. But what do you do with those references? And since they’re coming from your midwife, how to you find dissenting opinions or learn about her less glorious beliefs and actions?

The first is to check with The Birth Survey (TBS). The Birth Survey, while not terribly comprehensive, can be a good springboard. (Note: I cannot get the thing to work for me for anything. It says I need a new “key,” but doesn’t lead me to it and when I copied the url it says to go to, it’s a giant technogeek site I can’t figure out. Does anyone have any ideas so we can access the site? Are others having the same problem? TBS people need to fix this glitch!) It’s important to know TBS has its limitations, too. For example, my own section includes negative reviews along with awesome ones. Who’s right? Obviously, it’s an individual decision based on what a woman wanted, expected and received.

When you get the names of past clients from the midwife, you’re surely going to get the women who gave those rave reviews. So, how do you filter their enthusiasm to learn the information you’re needing before making the final decision about who you hire to attend you at your homebirth?

I highly encourage you to consider visiting the referrals in person. While the same information can be imparted over the phone, actually seeing the person’s face can tell you more. Plus, if she has birth photos or a video she’s willing to share, that can give you information, too.

Was the birth straightforward? Did anything unusual happen the mom can tell you about? Did she have an extra long labor? GBS that was treated with Hibiclens? A breech baby at one point the midwife said she didn’t have a problem delivering at home? These give you information that the she tends to operate out of the low-risk standard of care and/or is inclined to use “alternative” methods for medical issues; definitely not evidence-based.

Did she talk to the mom about possibly risking out at any point? Was she post-dates? Did she have a persistent urinary tract infection? Did her water break before contractions began? If the midwife even brought up the topic of transferring care, kudos to her. Too many midwives ignore the issue and when it’s brought up, will merely say, “Don’t worry about it. That’s not going to happen.” Sadly, if/when it does, the mom isn’t at all prepared for it. A midwife who discusses transferring long before the possibility is offering kindness and respect for the woman’s intelligence and sensitivity.

Speaking of transfers, when asking the midwife for referrals, be sure to ask for at least two transports… preferably one transfer (non-emergent) and one transport (emergency). How a midwife performs her duties during times of stress can give you a lot of information. Ask the previous client how the midwife handled the complication, about her demeanor during the emergency. Did she know her stuff? Also, how did the midwife act with the transport team? Was she cocky? Or was she respectful. When in the hospital, how were the interactions between the midwife and the nurses and doctors? Did the midwife ask you to lie about any aspect of your labor or birth? Did she lie about anything? Was she forthcoming with sharing your records with the staff?

The answers you’re looking for, in my opinion, should focus on the health and safety of you and your baby. It’s easy enough to get a hands-off midwife; it doesn’t take added skill to do this. But, it does take extra skill to know how to do neonatal resuscitation and manage a hemorrhage. Did your potential midwife have to attend to any variation from the norm? Ask her for references that include these types of births.

I do know it’s hard to know what to ask when you’re a novice yourself, but the above questions can give you an idea about the midwife whose actions you’re exploring. I encourage you not to just accept referrals that chirp happily about the midwife. While she shouldn’t have been a part of a debacle, having her being human says a lot. Has she said, “I’m sorry” to the client? (Perhaps she had to change course mid-stream.) Does she exhibit humility or arrogance? Do women speak about her like she’s a goddess or a woman who works hard for women and their babies? Be careful of the “heroes” among us; they rarely hold up under scrutiny.

I’d love to hear from others about what they’ve asked referrals or what they wish those looking for a midwife would ask them. I want to add to these questions… feel free to let me know your thoughts.

Wednesday
May162012

Did You Have Your Membranes Stripped?

I started this post eons ago, so trying to find it on my Facebook page would be all but futile. I still felt it was relevant so am sharing it now.

I really do love some of the questions I think of on my Navelgazing Midwife Facebook page. While some are frivolous, others like this one can provide so much information for those who don’t know this could happen. And we all need to come up with strategies to make it stop… or at least have it done as part of a discussion that begins with informed consent. This is one of my biggest hot button issues; I really want to see women’s bodies respected and their wishes honored.

I was just in a conversation with Jennifer Zimmerman who runs Solace for Mothers, a group for women who’ve been victims of birth violence, and I’d made the comment, “If you don’t want your membranes stripped, don’t take your pants off!” Except I YELLED it. Whew, that brought a strong reaction from several women, but Jennifer seriously admonished me. She first said I didn’t need to yell AT women and I defended myself saying I wasn’t, but I wanted women to have a mechanism to protect themselves. During our discussion, I could see the other point of view, that I was almost blaming women who took their pants off, that they “asked for it” just by that action. Believe me, that is not what I meant at all.

Further exploration nudged Jennifer and I in the same direction, believing (knowing!) that it is the medical folks that need to be re-trained to respect women’s bodies instead of women needing a shield during prenatal visits. The dilemma of course, is how to do that. Wouldn’t it be great to have the doctor or midwife ask, “You want me to do a vaginal exam, right? Do you also want me to strip your membranes?” That way mom is able to say, “What is that?” and “Is it going to hurt?” or “Please don’t.” And then, in the new atmosphere of client respect, the provider would do exactly –and only- what the mother asks for.

So what is “stripping the membranes,” or as others call it, “sweeping the membranes” and why would it be done?

There is a belief in obstetrics/midwifery that messing with the cervix, either rubbing it with Evening Primrose Oil or putting fingers inside the os and stretching the cervix stimulates the cervix to sit up and fly right. To do something. To hurry up and ripen or open.

An on-going Cochrane Review, in Issue 1, 2010, found:

“Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women's discomfort and other adverse effects.”

Yet, a study last updated 8/10/10 said:

“The efficacy of membrane sweeping is well studied, and has been shown to increase the number of patients in labor within 72 hours, reduce the frequency of pregnancy continuing beyond 41 or 42 weeks, and reduce the frequency of formal induction of labor. Thus, it is a safe and practical option for women who wish to avoid inductions of labor or postterm pregnancies.”

I’ve stripped membranes for years, but stopped about two years ago when I read a pretty convincing study that said the action doesn’t do anything but hurt the hell out of the woman and make the provider feel like s/he’s doing something to hasten labor.

“If you do have your membranes stripped, expect to be uncomfortable and slightly crampy during the procedure. You might feel mild cramps or contractions for up to 24 hours after your membranes have been stripped. You may also have slight spotting (a small amount of bleeding) for up to 3 days after your membranes are stripped.”

Mild cramps? That’s quite the understatement as these glimpses into women’s experiences with stripping demonstrate.

- We did with my last pregnancy. OMG it hurt so bad! It also caused exactly one contraction and that's it.

- Not too uncomfortable, kinda that weird pressure-y feeling.. didn't exactly work, but my understanding is that for a first it takes more than once :) I forgot to mention mine was by a very gentle midwife :)

- I had mine swept with both my kids- and I was in labor with both within hours. However, I was also 4cm with both, so who knows whether it was the procedure or whether I would have gone into labor on my own regardless. It was uncomfortable, but my midwives went very slowly and made sure I understood what was going on, which really helped. I wouldn't call it painful, but just a lot of stretching and maybe a scraping sensation.

- I had it done with my fourth baby, when i was 40w6d pregnant, and I was 4-5cm/50% --not in labor. I didn’t want induction, but consented to this. That was Friday morning. Didn't go into labor until Sunday night, so, no, it didn't work even though I was super-ripe.

- I had mine swept due to avoid a pharma-induction due to gestational diabetes, at 40w3d. It was pretty uncomfortable for a minute, but I was in labor an hour later, and 30 hours later brought my little (okay, not so little) man into the world peacefully and ecstatically.

- Felt like an aggressive pap smear, and it kinda worked. Kick started my labor, but my baby was not ready, so it was still almost 2 days of labor before my baby arrived.

- I did not, but I told the OB before she checked my cervix at my 40 week appointment that I did NOT want my membranes stripped (I heard rumors there was stripping going on without consent). She looked at me like I had a third eye and said..."WHY??" Because it's MY body, that's why!

- Had them swept with my second at 41 weeks/2cm/50%. It mostly felt like a lot of pressure/pushing/pulling. I had heard it hurt terribly and was bracing for it to be really bad, but I didn't think it was that bad. Unfortunately, it didn't do a thing.

- Not until faced w/ possibly being induced - I was rapidly approaching 41 weeks, with no cervical progress at all. It hurt like hell, and I don't think it worked anyway.

- Yes. I wasn't expecting it and it hurt - worse than any pains I could remember - so much so that I stopped breathing and [husband's description:] had a horrified look on my face. I think the ob said I was 1 cm. [& I've had a lot of injuries... due to accident-proneness to compare it to.]

Thankfully, it didn't work & son came when he wanted to - a couple weeks later.

- I did with my first (who was late, but also malpositioned, the only thing that dilated me in the end was having my water broken), but I don't think he was able to get far with it as I was really quite closed still. It hurt a bit, like a really bad menstrual cramp, but it wasn't excruciating or anything. Nothing came of it.

- Yes, with all 4 pregnancies. It just feels crampy… (unless you're high and tight, thank you OP buddy, then it feels like a tiny yet somewhat transition-esque contraction/cramp in your cerxix) and while I never just jumped in to labor, I'm convinced that it absolutely sped up the process with the first three labors.

- Had it done with #2 and #3. With #2 it wasn't much more uncomfortable than a normal exam. With #3 it was more uncomfortable. Both times started labor.

- ‎7 times with baby #2 and 6 times with baby #3r. Could've cared less if it hurt as I was past EDD and couldn't walk due to SPD. Did any of those times work? NO.

- I had it done without my knowledge or consent for my first. It was horribly painful, like a menstrual cramp only with somebody's hand up there digging around. I was horrified that my midwife would do such a thing when I wasn't even 40 weeks... yet, and she didn't stop when I was obviously upset by it. I was achey and sore all night, but had no contractions. My inner thighs hurt, my lower back hurt, everything hurt. I went into labor three days later on my due date. I read that it works up to three days later, so it could have worked I guess, but not instantly.

- Did anyone else experience a water-balloon-in-your-vagina feeling afterward? I'm certain I did, but I've never heard anyone else describe that. And, no, labor didn't start for another week.

- Twice with #1. Was done very gently by a midwife - didn't hurt at all, just pressure. Some cramping/pressure waves after but unsuccessful.

- First time I ever had it done was my most recent (3rd) pregnancy. I was only 37 wks 3 days and my OB didn't ask, but she was playing the big baby card the whole last third of my pregnancy. I was only 1cm dilated that day and had contractions and lost my mucous plug for the whole next week. At my 38 wk 3 day appt, I was dilated to 3 cm, but I requested she not do it again. Two days later, I delivered my little guy and I could tell he was earlier than he would have been had it all been left alone. I don't think he was finished gestating.

- Just felt like a *very* thorough pelvic exam, not painful at all really. I had it done this time around after several days of prodromal labor. The midwife asked if I wanted it done and I said yes. She said no one had ever consented with such enthusiasm before!

- Had it done about a week past my edd. I'd also agree that it felt like an aggressive pap smear (I always find those to be uncomfy, blargh, and have friable cervix). Think it woke us up...labor started gently a few days later and DD was born ...almost exactly 24 hours after I woke up with mild crampy contractions. If I were in the same position (stalled dilation, no other indication that labor is imminent and past dates by more than a few days) I'd do it again. I trust my doc (a family practice who began her career in birth centers-she joined this larger practice for the opportunity to teach new docs) very much, and she would never do something without discussing it first.

- My OB stripped my membranes at 39 weeks. I had been 3+ cm dilated, 75%+ effaced since 37 weeks. It was just a more vigorous cervical exam, not really painful for me. I ended up waking up in the middle of the night with steady contractions, had my husband stay home from work, because we thought this was 'it'. And then the contractions stopped cold. Didn't get another one for a couple hours- and I'm a girl that gets Braxton-Hicks from about 10 weeks on, so I contract a lot. Anyway, my daughter was born one week after the stripping, right at 40 weeks. Walking did nothing for me either. The one thing that seems to work with both my babies was sex. Twice in less than 24 hours produced a baby the next day.

- I did and the midwife was horrible and rough. It was at 40 weeks and 4 days when I went into labor. Felt like she was rubbing my cervix hard. Not fun.

- I think a sub OB (mine was out that week) stripped mine without telling me with my 6th baby. I had blood after the exam and contractions. I lost a big chunk of plug. I didn't want to be in labor and was getting mad thinking she did that without asking. They went for the day and interrupted my night. But they stopped the next day. I had that baby 3 days after my EDD.

- hmm... Did with my last as we neared 43 weeks gestation. It felt like she was trying to tickle my tonsils through my vagina... rather agressively... ouch... oh, and NO it didn't work. He stayed put for another 3 days.

- Yep...it was REALLY painful....won't do it again unless I'm facing a section. I went into labor within 48 hours.

- Ditto on the aggressive pap smear. Then cramping. My midwife swept me three weeks in a row. It thinned and dilated me a bit the first time (lost my entire mucus plug in just a short couple of hours). Second time, nothing but a couple cramps. Third time it kick started my labor and I started real labor the next day and gave birth just before midnight.

- I am sure my ob swept my membrane although he denied it! But from everything I've read I am certain he did. I was about 40 weeks at the time. Felt like he was digging through my cervix with his whole hand... it caused 1 contraction and other than that I was just sore with spotting. (I had already had cervical checks done before so there is NO way he was just checking my cervix.)

Nothing beats hearing other women’s experiences. Thanks to everyone who shared their stories.

I also had my membranes stripped with the first two kidlets. With Tristan, I was totally ignorant and thought it was a part of a standard vaginal exam in pregnancy. Ow! He was LGA, so am sure the doc was trying to get him out. The stripping didn’t work; he ended up being born at 41.3 weeks, induced after spontaneous prolonged rupture of membranes.

With Meghann, I was very educated, having attended Bradley classes and hanging out with La Leche League women, so even though I planned (and had) an Unassisted Birth, I was still going to the military’s OB. They blah blah blah’d about my big baby at every visit and at 41.1 weeks, insisted on a vaginal exam. I knew to keep my pants on, but didn’t… and ended up kicking myself for years over it, too. The doc said he just wanted to see what was happening and I specifically told him not to strip my membranes. When he did, I about crawled off the table backwards and started crying immediately, knowing he violated what I had asked him not to do. Barely able to speak, I asked why he did that and he said he did not strip my membranes, that he was merely trying to find my cervix. Liar. I began losing my mucous plug immediately and having that awful crampy feeling like period cramps.

When I explain early contractions, I tell women they often feel like period cramps, but they come and go, whereas period cramps’ coming and going is random. It can be comforting to know, in the middle of the cramp, that it’s going to end in a minute or so, but period cramps just keep coming and coming. These post-stripping contractions didn’t have any rhythm to them at all. They just hit hard, then stayed throughout the day and night… and day again. I was exhausted by the damn things!

I finally started active labor about 18 hours after the stripping, but still don’t feel it did anything but tire me out all those hours before labor really began. I was clear with the midwives in my third pregnancy and never had a rough vaginal exam and most certainly wasn’t stripped.

I wonder how much longer this intervention will be a part of standard obstetric and midwifery care. I hope not forever.

Sunday
May132012

Neonatal Resuscitation: Crucial Skill for Your Midwife

A video of a homebirth neonatal resuscitation (NR) was brought to my attention, being asked what I thought of it. Sharing it here is irrelevant, but the ensuing discussion after my viewing is not. Just know the whole unfolding was horrible to watch as the baby received tactile stimulation instead of Positive Pressure Ventilation (PPV), had wet blankets (and sometimes no blankets) on him and the PPV was done incorrectly.

As the discussion unraveled, commenters noted the assistant didn’t look very skilled in NR, that maybe she was nervous or just forgot some things she should have been doing… namely getting the bag & mask into the midwife’s hand so she didn’t have to do mouth-to-mouth on the baby.

My response to the entire video was one of, not only distress, by intense frustration (and anger?) that such a crucial, life-saving skill wasn’t second nature to the midwifery team.

Your homebirth midwife and her assistant should have NR embedded in their entire being, it being a body memory, able to be tapped into almost in their sleep. I don’t care how nervous anyone is. I don’t care how green the assistant. No professional should be at a birth without exquisite skill at NR.

If you’re reading this and go to births, I hope you’ll schedule a NR practice this week. Encourage your Peer Review to do a NR practice session at every meeting. If you have prenatals during the week, practice there.

Your skill can… and will… save lives.

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