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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.

Friday
May112012

The Miracle of Peanut Balls

So my dear friend Coza, an L&D RN as well as a previous client of mine, has become a fan of the peanut ball. When she initially told me about them, I was baffled, not having a clue what she was talking about. Boy, did I get an education!

A peanut ball (PB) is like a birth ball, but shaped like a peanut. It comes in a variety of sizes, just like birth balls and can be used like one… in fact, several doulas use it instead of birth balls since they are more stable with a woman sitting on them.

But sitting on the ball isn’t what Coza was raving about. It was that, in the hospital she works in, they have lowered the cesarean rate considerably. Apparently, the news is leaking out about PBs and I’m learning creative doulas have manufactured their own “peanut” for women to utilize during their labors, using pillows and even the bedside table!

So what do you do with this fantastic peanut and how does it lower cesarean rates?

When women have an epidural, they are confined to bed and are pretty immobile. As we know, the baby’s head likes to be jiggled around in order to get into the pelvis in the correct position to be born. When a woman is mobile, she and the baby “dance” to facilitate the optimal fetal positioning. In bed, not possible. The peanut, while not wiggling mom around or anything, can be placed between her legs in a way to open the pelvis so dramatically as to allow the baby to get into his or her best position to be born.

Coza said this yesterday:

“So a bit ago I posted a thingy about peanut balls for the epidural crowd. Let me just say that we at Holy Family (in WA State) are firm believers in the power if the peanut! We are seeing labors shortened right and left. Women who stall flying to complete when that ball is shoved between their legs! Babies not coming down that are suddenly 'oh please don't sneeze or your nurse is catching your baby.' We peanut balls!”

Last year, Jill, of Unnecesarean, wrote about PBs in “Peanut Balls and VBAC Bans,” highlighting Banner Health’s new commitment to the peanut in all of their Arizona hospitals. The article Jill quoted from the Arizona Republic (“’Peanut Ball’ reducing C-section rate” said:

“The results were compelling. Those who used the ball decreased the first stage of labor by nearly 90 minutes and the second stage by 23 minutes compared with a control group that did not use the ball.

“The real payoff came through lower C-section rates. The C-section rate for the group of women who used the ball was 13 percentage points less than for the group that did not use the peanut ball.”

I was sent to a study that was done on PBs – “Use of a Labor Ball to Decrease the Length of Labor in Patients Who Receive an Epidural” and the Conclusion was:

“The use of the PB during labor for patients with an epidural significantly reduced the length of labor without adverse neonatal outcomes.”

What birth junkie wouldn’t be thrilled with such a low-tech way to help women have shorter labors and avoid a cesarean?

But how do you work with this thing? Where is it placed? And how can someone without a peanut mimic the position?

I was sent to this video on YouTube, but still don’t find as much about positioning as I’d like. My nurse-friend Coza gave me a graphic example of how to utilize the PB. Let me summarize here:

If the woman is on her side (and of course the bed will be somewhat elevated since you don’t want her flat), you bend both knees and push the PB as deep into her crotch as possible. Each woman will be able to have it at different depths depending on her thighs, but as far as you can is where the PB goes. Then, so the PB does tilt or fall out, roll up a towel and prop the end that pokes out of the back side of the woman; you want the ball parallel to the floor.

If mom is sitting more upright on her back (semi-Fowler’s position), alternate each leg and put the PB under one knee, the middle part right under the knee. Coza says this mimics lunges. She doesn’t say how often to change legs, but I can see every 20-30 minutes being a good time frame to have each leg open. (It’s what we do when we flip a mom side to side with her leg lunging on the bed, so makes sense it would be similar.)

Coza also says if she has a mom that can move to the position, she has them on all fours, leaning over the ball and rocking back and forth. She said this is so much easier for moms than doing it with a ball.

As you all use them, please let me know how they work for you.

Peanut Balls for everyone!

Saturday
May052012

Midwives I Have Loved

On this International Day of the Midwife, I thought I’d spend a few minutes reflecting on the midwives who’ve made an impact on my life, both as a woman and as a birth worker.

First would have to be Mary Carol Akers, a Certified Nurse Midwife I’ve written about before. Over the years, I’ve heard from Mary Carol a couple of times and recently had a NetFriend attend a birth with her. I’ve heard she’s actively working on opening a birth center. How wonderful she’s still making an impact all these years later.

Mary Carol with Aimee, 2 days after her car birth. 

Mary Carol was my midwife as well as my partner Zack’s (when he was Sarah) back in 1985-1986. She was so loving towards us, non-judgmental and treated us as intelligent women when so many did not. Mary Carol was a midwife I could bring my natural birth questions to and she never rolled her eyes or was condescending towards me, but would answer honestly and truthfully, giving me more information instead of creating a wall of disdain.

I remember specifically telling her I didn’t want to be a CNM because I didn’t want to waste my time with nursing school, that I didn’t want to sit with geriatric patients, taking their vitals and listening to a hundred hearts that had nothing to do with listening to newborn hearts. She, in her calm and gentle style, said to me that in listening to a hundred geriatric hearts, I would learn what normal sounded like, that I would learn the variety of normal and that was extremely relevant to listening to newborns. She said when you’ve listened to a thousand hearts, when you hear The One that is out of synch, you know it immediately. Over the years, I’ve applied that piece of wisdom, acknowledging that if I’d have felt thousands of clavicles, it would have, indeed, helped me as a midwife to know what a normal clavicle felt like. While I didn’t miss any broken collar bones, I still understand that feeling more could only have added to my knowledge base. The skills learned in nursing school are not for naught; they augment a midwife’s education, both with book learning and skills training. Until Mary Carol, I thought nursing school was a waste for any midwife.

Another midwife whom I adore is Suzanne Paszkowski, CNM. Suzanne and I worked together at the now-closed Special Beginnings Birth Center in Orlando, Florida. She’s still there, no longer doing births, but is a women’s nurse practitioner for an OB/GYN office. When I knew her, she was active in midwifery and I loved when I was on-call with her.

Suzanne was one of the calmest midwives I ever met. Her gentle style was amazing, even in the face of dire emergencies. She’d gone to the University of Florida for her degree (and was a die-hard Gators fan!) and then to Grady Memorial in Atlanta for her hands-on training. She told amazing tales of her time at Grady, the women the midwives attended to that no CNM would ever be expected to take care of: women with HIV/AIDS, women with multiples, women beaten by their partners… the list went on and on. I remember sitting with rapt attention as she described midwifery in the trenches, a lesson I would never get as a Licensed Midwife (which wasn’t legal then anyway in Florida). I remember thinking that if she was able to do all that, she most certainly was fine with easy-going pregnancies and births. Wasn’t she ever bored after all that excitement? Not at all, she said. Watching Suzanne at births, her quiet demeanor settling everyone’s nerves and concerns, was a joy and a privilege. I could never than her enough for teaching me how to BE STILL at births. She was/is a wonderful teacher.

The third midwife who’s made a distinct impact on me is Jennie Joseph, also in Orlando. Jennie is the most famous of the midwives who’ve touched my life and rightly so. Jennie is the creator of the JJ Way® Model of Maternity Care and owns The Birth Place. In Jennie’s words, “The goal of The JJ Way® is to eliminate racial and class disparities in perinatal health and improve birth outcomes for all. Key objectives of The JJ Way® are for pregnancies to reach a gestation of 37 weeks or greater and for newborns to have a birth weight of 5 lbs. 8 oz or greater, for women (and their families) to bond well to their babies and to start and succeed at breastfeeding.” She works and speaks tirelessly to eliminate pre-term and low birth weight babies. Amazing work.

Jennie came from England with her midwifery knowledge learned there. When she arrived in Florida, licensing had been abolished decades earlier. But, Jennie joined the others in fighting to reinstate Licensed Midwifery in Florida and she became the first modern Licensed Midwife in the state. It was a thrilling day when she finally received that piece of paper!

These three women have forever changed me as a midwife and on this auspicious day, I publicly thank them all.

Thursday
May032012

The Ethics of Facebooking a Birth

I was directed to a CPM’s Midwifery Facebook Page where she was sharing an enormous amount of information about clients… that one was miscarrying, then she found the baby’s heartbeat… that one woman was having a long labor, how far she was dilated and then when she delivered, including the sex and weight of the baby. I discreetly (believe it or not) mentioned that she might not want to share that information without a Media Release and I offered the Release I use with my clients. 

A tiny bit of my own back story. I revealed some unflattering information in this blog about a client that I thought I’d hidden enough details about several years ago. She recognized herself and I hurt her and her family very much. I apologized profusely and still feel horrible about hurting her. After that, I created a Release and use it with clients. I was given verbal permission with some of the women you see and read about here in my blog and that is written in their charts. I know now that isn’t enough and have clients sign the Release instead. So, you see this is a major hot button issue for me. 

The midwife in question on Facebook first told me she didn’t say anything other midwives shared and I encouraged her to lead, not follow… and that they were also wrong. I then got this (verbatim): 

“Hmm. Maybe someone needs to clarify for us poor ignorant midwives what is and isn't acceptable to post. Because we are under the impression that as long as we are not posting identifying information, such as they're names, addresses, phone numbers, social security numbers that it is ok to tell some information. Like mentioning that someone with insulin resistant PCOS actually got pregnant and carried to full term without complications. No one has any clue who I am talking about other than my apprentice. This also serves as encouragement to other women with the condition that they do can do it." 

For the record, I did not call her ignorant, nor even imply it. 

When this topic comes up, as it does from time to time, always when a midwife or doula shares information about a client on Facebook or in her blog, the subject of a HIPAA violation invariably follows. So, here I discuss what my understanding of what HIPAA says and how it relates to midwives and their Internet disclosures of clients’ pregnancies, labors, births and postpartum periods. 

HIPAA stands for the Health Insurance Portability and Accountability Act (HIPAA) and it: 

“It establishes appropriate safeguards that health care providers and others must achieve to protect the privacy of health information.” 

“It holds violators accountable, with civil and criminal penalties that can be imposed if they violate patients’ privacy rights.” 

It empowers individuals to control certain uses and disclosures of their health information.” 

Below, I discuss the relevant definitions for care providers, including midwives. Doulas, not being Healthcare Providers, are exempt; more on this later. I know this can be boring as crap, but bear with me. This is important for all of us to know and understand as the Internet consumes more and more of our lives. Note that the emphasis is mine. 

There is one definition that causes pause and that’s for what a Healthcare Provider is: 

“Every health care provider, regardless of size, who electronically transmits health information in connection with certain transactions, is a covered entity. These transactions include claims, benefit eligibility inquiries, referral authorization requests, or other transactions for which HHS has established standards under the HIPAA Transactions Rule. Using electronic technology, such as email, does not mean a health care provider is a covered entity; the transmission must be in connection with a standard transaction. The Privacy Rule covers a health care provider whether it electronically transmits these transactions directly or uses a billing service or other third party to do so on its behalf. Health care providers include all “providers of services” (e.g., institutional providers such as hospitals) and “providers of medical or health services” (e.g., non-institutional providers such as physicians, dentists and other practitioners) as defined by Medicare, and any other person or organization that furnishes, bills, or is paid for health care.” 

I’ve read this as Internet discussions of clients do not qualify as HIPAA non-compliance. I wish I could find something that specifically addresses Internet conversations, but haven’t found that yet. 

However, I am not a HIPAA expert so perhaps we should assume HIPAA rules our transmissions and use them as our ethical responsibility. 

That’s a huge ASSUME, though, isn’t it. 

Let me continue for a second, with the assumption that we are, indeed, covered by HIPAA regulations. 

Protected Health Information. The Privacy Rule protects all ‘individually identifiable health information’ held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information ‘protected health information (PHI).’ 

“’Individually identifiable health information’ is information, including demographic data, that relates to: 

the individual’s past, present or future physical or mental health or condition,

the provision of health care to the individual, or

•the past, present, or future payment for the provision of health care to the individual,

and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.  Individually identifiable health information includes (my addition: but NOT limited to) many common identifiers (e.g., name, address, birth date, Social Security Number). 

I say “NOT limited to” because the midwifery community, especially the homebirth community, is so small that almost any information given out will be easily known by others, doulas and midwives. Probably even other mothers. 

“De-Identified Health Information. There are no restrictions on the use or disclosure of de-identified health information. De-identified health information neither identifies nor provides a reasonable basis to identify an individual. There are two ways to de-identify information; either: (1) a formal determination by a qualified statistician; or (2) the removal of specified identifiers of the individual and of the individual’s relatives, household members, and employers is required, and is adequate only if the covered entity has no actual knowledge that the remaining information could be used to identify the individual.” 

The homebirth midwifery community is too small to be able to share even the most basic information about clients online. If the mom has shared even one part of her unique story with someone else, that someone else can identify the woman in question. 

Example: 

Pregnant woman’s membranes ruptured with no contractions and was given Pitocin at 20 hours post-rupture.

Even that small amount of information might identify more than one woman, but in a homebirth community, it’s unlikely to lead to more than one person. And, the person that matters the most about who recognizes the woman is the woman herself. If she reads the midwife’s Facebook Page or blog, she will, undoubtedly, recognize herself. How fair is that? 

For those that have followed births on my Facebook Page who are now wondering if I broke these rules myself, the answer is not at all. Some women love the updates of their labors and births, being able to see the timeline when they have a minute to read postpartum. Even following my daughter’s labor and birth on Facebook was done with permission. Blessedly, my kids are comfortable with their mother’s outgoing writing. 

So what if HIPAA doesn’t cover the privacy of clients on the Internet, should there be an ethical responsibility to them? Absolutely. And this is where the doulas come in, too. I believe there should be peer pressure to keep our clients’ private lives private. If we can’t have legal rules about the issue, there should at least be moral rules. I hope others will join me in helping to protect women’s pregnancies, labors, births and postpartum times. I really hope midwives and doulas can get permission to tell the great birth stories! I love watching birth unfold as much as the next gal. Below is my Media Release for anyone to use if you want. Try and get both parents to sign. I believe more communication with clients is always a good thing.

Media Release 

I hereby give my permission for Barbara E. Herrera, LM, CPM to:

(please circle acceptable choices) 

______ Take photos of my pregnancy, birth and postpartum period. 

______ Photos may/may not show nudity – breasts – the actual birth with vulva pictures. 

______ May/May not use my name when using my photos or speaking/writing about my pregnancy, birth, postpartum, breastfeeding or family experience. (She has explained she typically does not use names.) 

______ May/May not use the photos on the following social networking sites: www.NavelgazingMidwife.com (Midwifery website), www.NavelgazingMidwife.squarespace.com (Blog), Facebook, www.YouTube.com, etc. If new technology is created, she will ask specific requests regarding using the photos there. 

______ May/May not submit photos of me, my baby or my family to magazines and media. No photo of the baby will include genitals (inclusive of entire Media Release). I will receive no compensation if the photos are published, but Barb will give our family a copy of the periodical in which the photo appears. Magazines might be hard copy or on the Internet. 

______ May/May not use photos of me, my birth, my baby or my family during conference presentations, midwifery texts and books. 

______ If any opportunity to use the photos arise that are not covered here, Barb will ask specific permission and add it to this Release. 

______ To speak about/Not speak about my pregnancy, labor, birth, postpartum, breastfeeding, parenting on any social networking site, periodical, public speaking engagements, book or midwifery text. If future technology is created, she agrees to ask additional permission to include it. She agrees to use professional discretion and we understand her primary reason for sharing is educational and not voyeuristic. She agrees, if I ask, to disclose where she has discussed me, my pregnancy, labor, birth, postpartum, breastfeeding, parenting and marital situations. 

______ To write about/Not write about my pregnancy, labor, birth, postpartum, breastfeeding, parenting on any social networking site, periodical, public speaking engagements, book or midwifery text. If future technology is created, she agrees to ask additional permission to include it. She agrees to use professional discretion and we understand her primary reason for sharing is educational and not voyeuristic. She agrees, if I ask, to disclose where she has discussed me, my pregnancy, labor, birth, postpartum, breastfeeding, parenting and marital situations. 

While I may make changes in the future to this Media Release, the changes will not be retroactive, but will be from the date of changes forward. 

Barb will keep a copy of this Release in my midwifery chart or, if I am not a midwifery client, in a separate chart specifically for Releases. She will scan the Release and email me the copy. 

I have considered these options and have discussed them with my partner/another important person in my life and understand the importance of full informed consent – and give it here.

Thursday
May032012

Labor Taking Longer Today

It’s been all over the news, “Babies Take Longer to Come Out Than They Did in Grandma’s Day,” the National Institute of Health’s study (“NIH study finds women spend longer in labor now than 50 years ago”) that looked at birth practices in the early 1960’s and compared it to those in the early 2000’s… a 50 year spread. Among the findings are that labor in the (1960’s) historical group was 2.6 hours shorter in first-time moms than the (2000’s) contemporary group. Subsequent labors were 2 hours shorter in the 1960’s group.

The quick run-down is women are older when they’re having their babies, episiotomies are done far less frequently, forceps are also done less frequently and that cesareans are utilized 4 times as often as the historical group… from 3% to 12%.

Wait a minute. A 12% cesarean rate in the early 2000’s? Where in the world would that have been? I cannot fathom that is here in the United States. Jill from Unnecesarean will know for sure, but wasn’t it about 30% back then? What does that make it… 10 times the number of cesareans as in the 1960’s? And today… we’re at 40% - 50% in plenty of places, making the percentage between the two cohorts even larger.

The study minimally looked at why the labors would be longer, including epidurals, but oxytocin was used much more in the contemporary group, one would think making up for the lost time with the epidural, but that didn’t happen.

So why have labors slowed down? I have my own theories.

Women go to the hospital a lot sooner than they used to. If women presented under 4cm in the olden days, they were sent back home and told to come back later. Now, if a woman’s having even prodromal (not changing the cervix) contractions, it’s more likely she will be kept than sent home. I’m sure liability is the major reason why this happens. If something happened to the baby in the interim between presenting at L&D and then finally being admitted many hours later, the hospital would be in serious trouble for sending the mom home. In fact, that happened in the UK with a mom (looking for the link).

When I first started attending births in 1983, women who went to the hospital and were found to be 3-4 centimeters, were sent out walking for two to three hours before they were checked again. If there were changes, then they were admitted. If there weren’t changes, they were sent home. That pattern was followed until the early 90’s (in my experience). That was when women started being admitted sooner and sooner, even if it was obvious their labors had barely begun. Now, if a woman is sent out walking, she wants to know why she isn’t admitted, somehow thinking if she’s in the hospital, things will move faster.

Is that why Pitocin is used so often, too? Maternal expectations? I wouldn’t doubt if it had a hand in the escalating use of the artificial hormone.

It can be frustrating for doulas who know their clients aren’t in active labor, yet the client wants them by their sides. That can make for an enormously long time with a woman, tiring her (the doula) out long before she would really be needed in labor. I’ve seen this time and time again. I’ve taken to saying, “Once you’re in active labor I will remain with you continually” and that has virtually eliminated the marathon labor sitting and giving the mom room to be self-soothing. Of course, I am always available to chat/text/talk and even visit, but being with a mom from prodromal labor on is ridiculous.

So, what isn’t explained in all the articles is the definition of what “labor” includes… what’s the dilation at admittance? Has there been spontaneous rupture of membranes? Was there artificial rupture of membranes on admission? And probably the largest question: What is the dilation that’s considered active? 3? 4? 6 (which is the newest definition… one that I adore!)? For many years, 1-3cm was early labor, 4-6, active and 7-10 transition. If that was standardized between the comparison groups, it would make the gathered information more relevant.

I’d love to hear from long-time L&D nurses, why they felt labors are longer now. Just like the study, I don’t know the exact reasons, but I think those of us in birth have a pretty good idea why. Women haven’t changed, but maternity care sure has.

Thursday
May032012

Cesarean Scar: Mandy's Story

Reading these stories has helped me. And so I share mine, in hopes that good will come from something that has hurt me deeply.
 
I always wanted to be a mother. I pictured myself loving every minute of pregnancy, and the joy and memories that bringing my children into the world would create. I didn't expect infertility. But I am glad God allowed it, because it taught me patience, and it taught me the priceless blessing of a life. I didn't expect pregnancy to be so hard on me. My body is not the same as it was 4 babies ago. But I am glad God allowed it, because I have learned to appreciate the value of working hard to take care of myself and eat right, and to do what's right for my body whether it responds or not.
 
I didn't expect for each one of my birth experiences to be so troublesome and uncertain. Preeclampsia with my two girls, two boys that were bigger than my body seems to tolerate, a uterus that somehow ensured each one of them would be posterior and cock-eyed, and a body that can't seem to get itself in labor for anything. I managed to push the first three out after an entire day of laboring. My third and fourth epidurals worked only for a short time, then they gave out. I am still glad God allowed it, because I learned that even when the worst happens to me, He is there to get me through.
 
I didn't expect to have to have my fourth baby cut from me. But he was over 10 pounds, and his head was turned wrong, and without the epidural my strength eventually gave out and his heartrate became erratic. I cried all the way to the operating room. I had a doctor I didn't trust who was abrasive and pushy, and now his mark is on my abdomen for life.
 
From such a big baby, I have a huge fold of skin that drapes over my scar. Some here have said that they are glad it hides the scar. To me, it draws attention to it. And it peeks out from every piece of clothing I have tried. My scar taunts me. It says I failed to bring my son into the world correctly. It says that he is healthy and beautiful and precious. The trade off was this horrible, ugly, sagging skin covered in stretch marks. This off centered, numb scar that hurts or itches from time to time even now when it has been almost a year. The knowledge that inside I have a cervical tear that I'm told means I can never even try to give birth naturally again.
 
This is the hardest one to be thankful for. But I'm glad God allowed it. If for no other reason than for the reminder that His love is sure even when I become less than I was.
 
When I look at my scar it says "I will always be with you, so you might as well accept me and learn from me, and comfort others who have me too."
 
When I touch my scar it says "Don't touch, I'm too unnatural and sensitive. Don't bother to shave here, it's going to be ugly either way. And don't let anyone see me. Not even your loving husband. Be ashamed of me."
 
But it can never make me be ashamed of the four beautiful children that have become my world. No regrets.
 

front view of c section scar, over 11 months postpartum

 side view of the large flap of skin covering the scar 
 

other side of the flap

the actual scar itself when the skin is lifted
Thursday
May032012

Cesarean Scar: Ashley E.

I had a Caesarean birth in May of 2009. . . since that day all I do is hope and pray that one day I will get give birth the way I always want to. Intervention free. (HOMEBIRTH!)

Every time I look in the mirror at myself and can see the scar I am reminded of that day I "gave birth" to my son. I love him no less, but I will never feel the closure needed to get over it. I recognize that it is a nice scar. It isn't all evil and scary looking. It healed nicely and is fairly straight. It does not completely disrupt my flow, but the mental notes attached to it are overwhelming. I remember the feeling of not having any control while in labor and now I have a scar to prove it. It makes me angry. I wish it weren't there. It's my battle wound.

I barely stand the thought of being touched on or around the scar. It is terribly uncomfortable. Some parts around the scar are completely numb. Severed nerves. Makes me sick.

It's unfortunate that I feel so badly about the way I "gave birth". . . it is what it is, I guess.

Thursday
May032012

Cesarean Scar: Jamie

My birth story is a story is not the way I had planned. I was asleep in bed when my water broke, Jan. 26, 2009. While cupping myself, I ran to the bathroom and sat on the toilet. I called my mom shaking like a leaf. I woke up my Don, my husband and he flew out of bed (just went to sleep like an hour before). I called the doc and they returned my call and told me to stay at home till the contractions got closer together. She asked me if I was feeling the baby move around and I was not. She said to eat something and try to get the baby moving. I didn't feel her move so I called back and they told me to go to the hospital.

I got to the hospital and they wanted to actually make sure my water broke because I had no pain. I had to wear a thick pad and walk the halls. My husband had me laughing and water was just gushing out. About an hour later, I had to show the pad, which was drenched and bloody. Then a resident wanted to check me. She took a sample of the fluid and came back and told me that my water didn't break. I told her yeah cause of the gushes I was having. She wanted to check me again, she was between my legs and told me to push. I pushed so hard and sprayed all over her! HA. THEN, she comes back and tells me that my water STILL hasn't broken!! WTCrap! They admitted me anyway. I didn't even have all my stuff cause I figured they would send me home. 

I walked the halls…..walk….walk….walk & walk and NOTHING!! I sat on a ball, nothing! Was having very mild contractions but no biggie. I even said "if this is what contractions are, I can do this NO PROBLEM", then I said "I know I will eat my words later"!

They gave me a Cervidil. Contractions were coming more frequently still, the pain wasn't that bad. I was told the next morning that I would be induced. The rest of the night, I had little to no sleep. The contractions kept me awake. 

Jan. 27th, they gave me the evil drug pitocin and was on my way! Boy, did I eat my words! I was dilating SOOOOO SLOOOW and was in SO MUCH PAIN!! I was given Stadol. Just took the edge off, still felt the contractions. They kept checking me and wasn't really dilating!! GRRRR!!! I was doing good with the contractions, THANKS to my mom!! She and I had eye contact and she was breathing with me. She was my focal point and what we were doing was definately working!! My midwife told me when I get to 4 cm, I can get a epidural (YEY) hours passed and I was checked, I was 4!! YEY well, so I thought, she wouldn't let me have one. WHAT?????

I begged for a c-section! She was like "no, you can do this". I begged for anything! I got NOTHING! One nurse was horribly rude to say the least. I looked at her and said "it just hurts so bad", her reply "what did you think was going to happen???", WHAT???? GRRRRR!!!

Hours and hours passed, I was checked, I was 5 (YES, only 5) FINALLY, they gave me my epidural! The BEST invention EVER!! Hours and hours passed again, they checked, I was FINALLY ready to push. I pushed, pushed, pushed for 2 and 1/2 hours, no baby. They told me I was going for a c-section, BUT they never turned off the pitocin. My mom freaked out, my sister called the hospital and screamed at the nurses. It was shut off then I was off to the OR for a c-section. 

While laying there, I was cold and SOOOOOO scared! I was shaking uncontrollably. They were ready to start. My arms were not belted down like I'd seen on TV and they kept shaking off the table. I kept asking for my husband and finally he was there by me. I felt them cut me. I told them, they said "we didn't tell you that you wouldn't feel anything", WHAT?????

So, Leah was born Jan. 28th. First word out of the doc's mouth was, "WOW, she is a big girl!". They showed her face over the drape and went to clean her up. I told Don to go take pics. On the way back he said he saw all my innards! (ha-ha) They weighed her right in front of us as I was being sewed and stapled shut. 9lbs, 13.5ozs, WOW she was way bigger than I thought! Was bigger than what all the docs thought also. I just couldn't get her out! TOO BIG!! BUT I had a BEAUTIFUL baby girl. 

The rest of my visit was horrible. I didn't get to shower till the next day. Don actually washed my body while I stood there in horrible, awful pain! I ended up staying at the hospital for 4 days after giving birth. My aunt worked at he hospital as a lactation consultant, which was great. She tried to get Leah to latch, wasn't having it. I had to pump then bottle feed her. I told my aunt my birth story and told them that I had a horrible experience and that I will never give birth in the hospital (thanks to the nurses) and never have the same docs again! She brought in the head of the hospital to talk to me. She wanted the names of the nurses (I had other rude nurses, and I couldn't remember their names!) and to write a letter to the hospital. I never did. But I will never have a baby there again!! Horrible hospital! 

A week later (yes, a week later) they wanted to take my staples out. Few days later, was at the ER. I had an infection that luckily, I caught early. The staples were taken out to early, but I didn't know. Horrible doc!! 

So, even though I had a horrible hospital issue, what my scar says when I look at it is "even though you didn't have a vaginal birth, its amazing that your body carried a baby for 9 months and still gave birth to a healthy happy baby. It doesn't matter how she was brought into this world, she is here." 

What my scar says when I touch it is "we brought Leah into this world together. You didn't give up, I am here cause you needed other assistance bringing her into the world".

I have no bitter feelings toward the scar. I rarely touch it though. It is hard, bumped out and numb. Sometimes it burns or feels like it's being ripped open. I am ok with it. It's a part of me. I think it as a gift from my daughter that I will have forever. I would do everything all over again… well, almost everything.

 

21 months post-cesarean

Thursday
May032012

Cesarean Scar: 3 Babies; 3 Scars

My first cs is the lower of the scars. Pit induction at 37 weeks for one bp of 160/90 or so, labs were fine though. First baby, didn't know any better, just wanted to be a good patient. I'm sure she was catywhompus anyway.

Ah, scar number two, hbac attempt to icky not fun cs. Of my scars this is the one that makes me saddest. Always thinking if I had done this or that different maybe I wouldn't have said scar, I was thiiiiiiis close....

Because of my muscles being cut into twice before and ultra loose hip joints I was in constant pain with preg number three. I was told that I risked perm hip damage if I tried to pass a kid through there, so cs there was planned, I still have days where I think I should have tried though.

I have no feeling in my lower left quadrant from my cs, I have def probs with my hips in the winter and have pt I do to try to strengthen the damaged muscles to help hold them together.

Thursday
May032012

Cesarean Scar: My Scars Are Loved

My scars are loved. It's where my beautiful children entered this world.
Love.

I had a sketchy troublesome first pregnancy, almost lost my Baby at 24 weeks. Bed rest. Lost what little confidence I had in my body/birth. I had an elective c section. My Doctor did try to talk me out of it, he was against the idea. Ultimately it is my body, my choice.

With my Second I had another elective c section. I feel if I knew that I could have successful natural births, I would have. But I had no faith in my body or birthing, and I wanted control.

I was glad that my water broke the morning of my first C section. I knew Baby was ready. I do wonder how it would have gone if I birthed naturally that morning.
Thursday
May032012

Cesarean Scar: Joy

What do my scars say?

Scar 1

Heartbreak.  Disconnect.  Confusion.  Anger.  Pain.
Bumpy.  Red.  Sore.  Knotted.  Angry.
Out of place.
Unsupported.
Groggy.
Distanced from my baby.  Ignored.  Left out.

VBAC

Determined.  Focused.  Natural.  My terms.  Unafraid.
Intense.  Overwhelming.  An experience.
Attempted.
I carried to the operating room the benefits of the labor experience.
I carried to the operating room the peace that I had tried and that this time it was MY decision.
Old scar cut away from me, in so many ways.

Scar 2

Less bumpy.  Less raw.  Calmer.  Less Angry.
Disappointed.
More connected.
Joyful.
Supported.  United with my child.  Skin to skin, nursing.
My child never leaving my side.
Respected.

The difference?  Education.  Preparation.  Prayer.  Support.  Advocacy.  Bravery.
 

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