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Sunday
Feb172013

Becoming a Monitrice

I’ve been asked more and more how one becomes a Monitrice, so I thought it good to write a post instead of continuing to answer in private. For those who don’t know, a monitrice is a doula with additional midwifery skills. I am a monitrice and doula, but as a monitrice, I go to mom’s home while she’s in early labor and monitor her and baby until the woman is ready to go to the hospital or I think birth is becoming more imminent. Or if I detect a problem with either mom or baby.

Here, a doula wanting to be a monitrice asks me questions:

Does a monitrice have to be a midwife?

Being a monitrice is more than a doula with a doppler. There are several skills needed and also the need for midwifery/obstetric training in order to be a skilled monitrice.

When the monitrice goes to the laboring mom’s home, she’ll not only monitor vitals and listen to fetal heart tones, she will also be on the lookout for signs of labor not progressing normally or even more dramatic, watching if something is wrong with either the mother or baby. And if there is, she needs to know what to do… change mom’s position or call 911… or something inbetween.

This knowledge comes with time and experience with laboring women. I believe that would include midwives, midwifery assistants or experienced apprentices who do hands-on co-care and L&D nurses. It’s not that the skills can’t be taught, but it takes a lot of on-the-job learning to be able to catch the nuances that can occur while mom labors at home.

Or can a monitrice truly be a separate professional goal?

I believe it can be a separate goal, but still apprenticing with a home birth midwife for a year or two would be necessary. I just don’t think a doula can jump in and be responsible for the lives of two people without having the experience doing it. Even experienced doulas, I think, would need at least some home birth experience.

If that’s all it takes, finding a midwife to apprentice with would be all that’s needed, right?

What’s hard about that is midwives might be wary of hiring an apprentice that isn’t eventually going to be a midwife. Apprenticeship is pretty much a linear generational experience; one teaches another teaches another teaches another. To teach the skills and nuances of midwifery to someone who’s leaving, possibly even becoming competition (monitrice jobs are not nearly as common as doula jobs), isn’t so appealing. I’d love to hear from midwives about whether they would be willing to teach a woman midwifery skills so she could branch off to be a monitrice. Would she ask that the monitrice apprentice pay her to learn?

What training and/or amount of experience would make this a safe option?

I believe it would take at least a year or even two of home birth midwifery training before a woman was ready to be a monitrice. She really would need to be familiar with the pace of home birth (it’s much slower than hospital birth) and understand how women labor out of the bed, which most doulas don’t often see, at least for extended amounts of time with untethered women.

With the apprenticeship comes learning the nuances of deciphering fetal heart tones. It can take years to learn what to do with them completely, but here I believe experienced doulas might have the edge over completely green women, that is if they have paid attention to the fetal heart monitor in the hospital. If the doula hears the heart tones going down, does she know to turn the mom on her side before the nurse even comes into the room to do just that? Has she listened to the machine and watched how the nurses responded over the years?

How experienced is experienced for a doula? I think that can best be served in numbers versus months or years. I’d say at least 100-150 births would give a decent idea of the rhythms of fetal heart tones. I still believe the monitrice-to-be needs home birth experience because hearing a deep deceleration in the home setting is treated much differently than a decel in the hospital.

What is the legality of working as a monitrice-doula without a midwifery license?

This is certainly going to depend on where you live and the midwifery laws. My own personal belief is I think monitrices need to be Licensed &/or Certified Professional Midwives, Certified Nurse Midwives or Registered Nurses, but I also acknowledge that many licensed women have no desire to do anything but midwifery or nursing work. It takes a specific type of person who is okay with abdicating responsibility mid-stream… as a matter of course, not only if there’s an emergency. In fact, some of the midwives in my area that do do monitrice work will only be with the women while they labor at home, abandoning the woman to labor alone or with another person as doula in the hospital. Can you tell how foul I think that is? Where’s the continuity of care?

Listening to fetal heart tones isn’t the part that’s practicing midwifery… it’s interpreting them that is. When I was a doula and occasionally had a mom laboring at home for an extended period of time, I would sometimes listen to fetal heart tones to see how the baby was faring. I didn’t interpret the heart tones; I would tell the mom that between 120-160 was normal and then tell her what the heart tones were when I took them. She interpreted them, not me. But this shows you how ignorant I was at the time. Fetal heart tones are not read on a one time reading every couple of hours, but more frequently and before, during and after a few contractions. (Even as a midwife, I was remiss in doing this too much.) So much can happen during labor to the baby, just listening for the heart tones, inbetween contractions, once an hour just isn’t enough. Once labor kicks into higher gear, every 15 minutes really is necessary and listening before, through and after the contraction simply should be done. And of course, there is the interpreting part. We are back to that experience thing.

I want to help my clients keep safe and wonder if there aren’t skills I could learn that would help them. Perhaps palpating the uterus or checking cervical dilation could help them more than if I didn’t do the skills?

Palpating the uterus takes longer to learn than interpreting fetal heart tones. Your hands, literally, have to “see” what is beneath the flesh, muscle, fascia, etc. And only in touching dozens of bellies hundreds of times can your hands begin to see what is where. Of all midwifery skills, I think palpating is one of the most difficult to learn well.

Learning to do vaginal exams isn’t as challenging, but still takes time to learn. Once you’re able to find the cervix and use your two fingers inside it, there is still the subjective aspect of the skill. Only with time do you learn what is six is six for the others also checking dilation.

Or, perhaps the answer is that, because I don't have these skills, I shouldn't be assisting women in their homes? That by virtue of being there, I am taking responsibility for something that I don't have the skills to be responsible for? And that I should only be meeting women at the hospital?

This is what I do. As a monitrice, I go to their homes. As a doula. I meet them in the hospital. I cannot, in good conscious, be at their home with mom in labor and not monitor her and the baby. I know too much. I know many doulas don’t have any problem going to the home in labor and staying with them for an extended period of time, especially with VBACs, but I just don’t feel it’s safe without monitoring. Do I think doulas should never go to a mom’s home? I think that’s up to each individual doula, but I tend to find the more a doula knows, they less likely she is to hang out at home for a long time because she knows monitoring is so important. The laboring woman’s blood pressure could climb precipitously. The baby could be stressed or the mom could develop a fever, which affects the baby, too. There are infinite hidden variables that monitoring can uncover. As I said, I know too much.

I would love to take a monitrice apprentice, but the women who have approached me rethought the idea when they realized the legalities of taking care of a woman in labor. Would it be practicing midwifery without a license? Probably. I try to think of how it could be a gray area, but it wouldn’t be, at least here in California. A monitrice without a license would be at risk for prosecution if anything untoward occurred.  In other states, the issue might be different.

There is only one online place to study the monitrice occupation. That’s through Birth Arts International and it’s a $1250, year-long program. I’d love to see the program to better be able to comment on it, but the outline for it looks comprehensive. Even so, I still believe an apprenticeship has to happen.

I wish there were more monitrices out there. I’d love to see the profession grow. Maybe I should start a monitrice organization to gather together the monitrices out there. Not sure if I have the energy for that, but would love it if someone did, me or someone else.

To the woman asking these questions, I think you have your answer now, yes? Do let me decide what you choose to do and I will add an addendum to the post.

Does the prospect of being a monitrice intrigue you? Do you want to try this profession? What do you think of the legalities? What about doulas who go to mom’s homes, good or bad idea? I’d love to hear your opinions.

 

Photo by Nova Bella Conte

Saturday
Jan072012

What a Doula Said

On my Facebook Page, I dropped a link to this piece, “Journal Article Review – Bipedalism and Parturition: An Evolutionary Imperative for Cesarean Delivery?”, an article about (just what it says) walking around on two legs and does that fact make it more likely that we’d eventually need to deliver our babies (at least more of them) by cesarean section. It’s an awesome piece and the comments have, for the most part, been great… Creationists aside. Well, their comments are interesting. Hard to believe people still think like this, but who am I to poo poo another person’s religion. 

Anyway. 

Along the thread comes this doula who says, and I quote verbatim: 

This is the most insidious article I have ever read and it figures that it was written by a man with a penis who will never experience childbirth. Fact: only 3% of women in the US actually need a Ceasarean due to try complications. In most cases they are performed out of laziness and impatience on the hospitals and docs part. And insurance companies, lest we not forget those bureaucratic jackasses.” 

I couldn’t help laughing outloud, but what I wrote was: 

Where did you come up with only 3% of women need a cesarean? I have NEVER seen that number in 30 years of birth work. Source, please.” 

And this was her answer, again quoted verbatim: 

I got the stat in an article I just read, I will find it and repost. In my experience with my clients he need for C/S deliveries is 0 with home births and about 2% for hospital deliveries. The procedure has skyrocketed unneccisarliy.” 

My short answer to that was: 

So, <Doula’s Name>, how many births have you been to? 4? Talk to me when you've been to the 900 or so I have, then we'll see what "your" cesarean rate is. 

You have a LOT to learn, young lady. Your arrogance is going to bite you in the ass and I hope you will then learn some humility. 

And quoting ONE FREAKIN' ARTICLE that said the c/s rate shouldn't be above 3% is the height of gullibility. Do you not know discernment? It scares me there are doulas like you out there.” 

What is this doula teaching her clients? What is she saying to women all around her? Spouting off her amazing statistics without so much as any qualification of how she got to that number. 

I started thinking, “How could I get a 0% c/s rate at home and a 2% for hospital births?” 

  • I could have only attended 5 births.
  • I could take only clients that have had babies born vaginally before and are truly low-risk in this pregnancy.
  • I could lie about my statistics. 

There are so many parts to her comments that annoy me, it’s hard to just pick out a couple. But, I’ll try. 

  • If we are to believe she’s been to at least 100-200 births to even get a somewhat valid number, “her” 2% hospital birth cesarean rate is incredible considering the cesarean rate in hospitals. Is she so magical that when she is there her clients miraculously avoid the operating room? If she is that magical, she should be teaching courses all over the world so the rest of us can know her secrets. 
  • If you throw out the word “Fact,” you better have a buttload more than one article to point to and, at the very least, one you can put your finger on at a second’s notice. That she even had to look for it stuns me. 

Note to doulas and other birth workers: Just because you want it so badly you can taste it, doesn’t make it so. If you repeat crap others say, even others who proclaim they are (or who are heralded as) experts in birth, you best be able to back up your beliefs. Sure, statistics can be skewed, but looking deeply into anything touted as real and true will probably give you a much clearer picture of what you’re talking about. 

No one… NO ONE… in this community has The Answer. If she did, it would be headline news.

Thursday
Aug112011

Ignorant Bliss

I had a doula-friend ask me a question about one of the babies she saw born a few weeks ago, a baby that she can’t stop thinking about, so she finally decided to ask me what she should have done and if there’s anything she should do now. 

The baby was born, had some stress during the birth (meconium, needing a little bit of resuscitation), but did okay afterwards. The baby looked sort of odd to the doula and one of the nurses confided in her she thought so, too. There were a couple of reasons the baby could stay in the NICU for a couple of days, so he did and some tests were run. Infection? Nope. Omething physical? Nothing they could find. He’s home now with his parents, nursing is going so-so, but how unusual is that, right? 

The doula wanted to know if she should tell the mom that something is bothering her, that she still thinks something’s going on with the kid. This is my answer. 

Sometimes it can be hard to decide what to say and not say. And saying it as a doula is totally different than as a midwife who was hired to care for the mom and baby. Since the hospital’s seen the kid and he’s doing well so far, this is the place of watchful waiting. Or, a better attitude perhaps, one of release. 

Because I know you’re considering midwifery, I’ll speak to that, too. It’s great you’re worrying about the baby, wondering if you should tell the mom your thoughts and concerns. But, I encourage you to stay in the “What would I do if I were the care provider?” place instead of becoming the care provider. I know it can be frustrating as all get out when the hospital and pediatrician sends a baby home without answering the initial (and subsequent) question/s, but we have to believe they’ve looked at the most obvious causes and ruled them out. Could they have missed something? Of course. Might something come up they should have found earlier? Of course. But, NICUs are pretty thorough. Too thorough for many of the babies we’ve seen in there, right? 

I’ve had a couple of babies I’ve referred to Children’s with distinct problems who left with exactly the same problems, but no cause for it being found. I still remember gasping when they told me the newborn with the heart rate of 70 was going home fine and dandy. What do I say to those parents who got so scared when I was responsible for their child’s hospitalization? Those bills? When the hospital insinuates, “You really didn’t need to come in for that.”? My pat answer is: I’d much rather they say, “You didn’t need to come in” than “Why the hell didn’t you come in?” (“Hell” wasn’t what I wanted to say.) And it is that belief that certainly made my transport rate higher than some/many other midwives, but erring on the side of caution was important to me. 

For now, however, as the doula, you don’t have to worry about those things. Embrace this time! Taking that responsibility can be very tough. Right now, as a doula, you can be there as a doula, loving and supporting the mom where she is and how she needs you to help her right now. Even if that means nothing more than supporting her desire or need to do nothing. 

If you’re in the child’s life for any length of time, you will learn if there is something wrong or, better yet, see that nothing is wrong at all. If there is something wrong with the baby, the mom will eventually see it and take the kid in. But, perhaps there’s nothing more wrong than the baby not being fully “in his body” yet and he just needs to climb in and things will be better. Know, though, that some kids are just FLKs – Funny-Looking Kids. (Yes, this is a term many midwives use.) Nothing at all wrong with them that we can see or test for, just a quirk of biology. 

But, what do we do with those feelings that something isn’t quite right? Why do we have them in the first place. I’ve written before about premonitions versus fear (Premonitions, from June 8, 2006.) and how we can only say it was premonition in retrospect. Intuition is much the same; we can only have the intuition validated after the fact. What do we do with it? As I said above, as the doula, you get to sit on it and let mom and baby unfold their own story. 

Knowing nothing about this baby other than what you’ve shared with me, and I have zero premonition about what’s going to happen, but I wanted to mention something that was taught to me early in my midwifery training. 

At the birth center where I was, a baby was born that was obviously very deformed and probably not long for the world if the outer body was any indication of the inner workings. We all saw the problems immediately, but the mom was in total bliss about her new baby! She was all over her, kissing her, cooing, touching her all over… loving on her, obviously oblivious to the baby’s probable incompatibilities with life. I was in a position to pull someone out of the room and ask why the heck no one was telling mom they needed to take the baby to the hospital? Why were they letting her be in ignorance instead of telling her there was something seriously wrong with her baby? 

I was told that sometimes, the best thing a midwife can do is leave moms in their place of ignorant bliss so they can bond with their babies deeply and without prejudice (i.e. seeing their kid very sick or even gone already). That this “pure” bonding time will only last until someone bursts the bubble with “Your baby is quite ill,” and that time is so very precious and should be preserved and protected as long as possible. I’ve never forgotten that lesson. 

But what of those feelings you have that something isn't quite right? Maybe they are about something on a deeper, more spiritual level. Perhaps he's going to be schizophrenic, but that won't appear until he's 22 years old. Perhaps he's going to be profoundly autistic. Perhaps he has a cancer cell already that's going to take him when he's 6. And maybe there's nothing you will ever know about this child, but that, on some level, you are aware of. I really have learned to just let some things lie and let them unfold in their own time. Patience is the hallmark of a midwife, now isn’t it. We never know all the answers. And that can be very frustrating, but can also be extremely freeing if we let it be. 

One last thing. As you play the What Would I Do game, be careful not to get too wrapped up in someone else not doing what you would do. That’s another part of the letting go of the situation. Everyone, ourselves included, are allowed to make our own choices… and mistakes. As a parent, you know this lesson very well. It is the same with clients; letting go and watching them make different choices teaches us our own lessons… on many, many levels. 

Take care of your Self through all of this.

Barb

Wednesday
May182011

What If?

Much has been said in the press (and for goodness sake, the Washington Post most of all!) about Karen Carr and the case of the breech baby who died in Alexandria, Virginia last year. For the two of you who haven’t read about this, a 43-year old woman, in her first pregnancy, having a breech baby, wanted a homebirth. Her CNM care providers explained she was high-risk and they couldn’t keep her as a client for either a home or birth center birth, referring her instead to their back-up obstetricians. The mom chose to ignore their advice and searched for a midwife who would agree to do what she wanted… to help her have her primip breech baby at home. Carr, a CPM in Maryland, but not licensed in Virginia became the (unlucky) midwife. She didn’t have a license in Virginia because they have a regulation that says a midwife cannot carry medications, including pitocin, which can save lives if the woman hemorrhages after the baby is born. Instead, she chose to forego a license in order to carry the life-saving medications, to me, a valid choice.

Let me state here that, to me, the least of the issue is Carr not having a license. She’s a perfectly acceptable midwife on one side of the line, but becomes a danger to society if she takes one step over that (state) line? That’s stupid logic and while I am not one to flagrantly ignore the law, sometimes there are extenuating circumstances when the law hasn’t caught up to the reality of the situation. Carrying life-saving medications was a choice to care for women, not to slap the legislators.

So, on September 11, 2010, the worst-case scenario of a breech birth occurred; the baby’s body was born and the head was stuck inside, above the mother’s pubic bone, still inside the uterus because the cervix wasn’t completely dilated/dilated enough to allow the head to be born. Knowing how the press skews facts, I am taking what is said with a salt lick, but even if we gave a lot of grace for the reported information, the times before Carr called for help were, in my opinion, ghastly. Twenty minutes of head entrapment and then another thirteen of resuscitation before calling EMS. The tension in my body reading that is enough to give me stomach cramps.

On Thursday, May 5, 2011, Carr plead guilty to charges of child endangerment and performing an invasive procedure without a license. She apparently regretted the decision to plead guilty to the child endangerment charge, saying she tried to do everything she could to save the baby. I don’t doubt that for one second.

Googling “Carr” and “breech” gives loads of sites where the discussions/arguments about the case rage on.

Instead of adding to the debates, I thought looking at this from a different viewpoint might be of interest.

It isn’t uncommon for midwives, student midwives and doulas to say, “I wasn’t there,” when asked to comment on cases that end badly for either mom or baby. It’s a genuine way to show compassion to the midwife and situation at hand. But I feel there is a valid lesson to be learned in discussing, and even dissecting, the heard-about event. If no one present knows the absolute facts, discussing the case as if can be just as valuable. By playing out scenarios that have gone awry, midwives build on their knowledge base, deciding in a non-emergent, un-stressful moment what they would and would not do as a midwife in a similar situation. From transferring a woman to the hospital for exhaustion to a fetal death, every scenario holds endless lessons. Sure, a part of it might be that hindsight is 20/20, but leaping off another’s difficulties/tragedies is an excellent way to learn. I’ve come to call this the What-If Game. Here are some What-If’s that immediately come to mind with regards to the Carr case. Let the discussions begin.

  • What if you were asked to attend a birth that other midwives turned away?
  • What if you were asked to assist at a birth where the midwife didn’t have much experience in the variation of the norm? (GDM, rising blood pressure, GBS+, etc.)
  • What if you were asked to assist a midwife at the birth of twins or a breech and you knew the midwife had minimal experience with that type of delivery?
  • What if you were asked to midwife a women who says she’s fully informed and still wants to birth at home despite having serious reservations yourself, but have made a commitment to helping women achieve the births they desire?
  • What if you were asked to work in a state where you were illegal and had no solid back-up?
  • What if you’re the midwife in a homebirth and things turn dangerous and the mother refuses to transport to the hospital?
  • What if you saw things were turning dangerous and you were illegal; do you have your speech ready for EMS? Practice it with others!
  • What if you are practicing illegally as a midwife, are you willing to go to prison for a mom’s right to birth at home?
  • What if complications arose and you, an illegal midwife, knew you were going to get shit if you transported, would you delay calling for help? Hoping things would resolve before you had to take that shit?
  • What if you were an assistant or doula and saw things going to hell in a handbasket and the midwife wasn't saying "Call 911!" and you knew the mom or baby needed emergency care?
  • What if you weren’t permitted by law to carry medications, would you anyway?
  • What if you weren’t permitted to suture, would you anyway?
  • What if it was up to you to decide the line between following the law and supporting a woman’s right to choose?

Let the discussions begin.