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Entries in trust in birth (2)

Friday
May162008

Respectful Trust

The discussion goes like this:

I trust birth.

That means I inherently believe birth is normal and without flaw. As a midwife, I am able to sit quietly, witnessing the beauty of birth as it unfolds the way nature intended. While variations on the norm might occur, they are rare and usually resolve by leaving well enough alone. Birth is as safe as life gets.

When I question the “trust birth” philosophy (dogma?), I am generally considered a heretic… on the “other” side that believes birth is to be dis-trusted. It seems that either one trusts birth or one doesn’t – no middle ground, no grey area.

Needless to say, I disagree.

Various definitions of trust abound and include:

- Assured reliance on the character, ability, strength, or truth of someone or something

- Dependence on something future or contingent

- A charge or duty imposed in faith or confidence or as a condition of some relationship

- Reliance on something in the future; hope

- Implies depth and assurance of feeling that is often based on inconclusive evidence

- To feel that (something) is safe and reliable

- To believe that (someone) is likely to do something safely and reliably

- To expect with assurance; assume

SYNONYMS: Trust, faith, confidence, reliance, dependence

These nouns denote a feeling of certainty that a person or thing will not fail. Trust implies depth and assurance of feeling that is often based on inconclusive evidence

I find that, for me, using the words, “I respect birth” fits better.

Definitions of the word respect include:

- A feeling of appreciative, often deferential regard; esteem.

- The state of being regarded with honor or esteem.

- Willingness to show consideration or appreciation.

- The act of noticing with attention; the giving particular consideration to; hence, care; caution.

- An expression of respect of deference

- The act of noticing with attention; the giving particular consideration to; hence, care; caution.

- To feel or show honor or esteem for; hold in high regard

- To consider or treat with deference or dutiful regard

- To show consideration for; avoid intruding upon or interfering with

SYNONYMS: Esteem; regard; consideration; honor

- Esteem: a feeling or attitude of admiration and deference toward somebody or something

- State of being admired deferentially

- Consideration or thoughtfulness

Using these words, it is hard to imagine anyone would have issue with the word “respect,” but I know it exists.

We “respect” authority. We respect our elders. We respect those that impress us with their integrity and honesty.

How can birth be respected and not trusted at the same time?

To me, the definitions speak for themselves. I believe the nuances of the meanings we put behind the words are incredibly important, too.

Trust is to be earned, not just given. Respect, too, has to be earned.

Looking at birth, which mindset repeats as labor and delivery unfolds?

In order to build trust, it takes time, experience, the ups and downs of a relationship and the ultimate belief that, with that one person or experience, for now, the person can be trusted.

As we know, trust can be rescinded because of a circumstance, an experience or because new information has surfaced.

It is thus so in birth. While entire conferences and belief systems revolve around the “Trust Birth” concept, I believe that, in knowing birth, in developing a relationship with each individual woman, only then can a trusting situation occur. It’s important to me to develop a trusting relationship with my clients. I want the relationship to be so ingrained, so deep that if an emergency should arise during the birth and I ask something of my client, she says, “Okay” and does it, not expending time asking if there are alternatives. I want her to know, during the pregnancy, that I will have used all the alternatives by the time I ask the seemingly impossible of her.

As the table is turned, I implicitly trust my client as well and if she tells me something – she feels poorly or she needs to go into the hospital – I hear her and believe her.

But, what if she tells me something like she doesn’t want to eat, but she’s nauseous after not eating for 8 hours? What then? Do I push through and insist she eat? What if I feel she needs a vaginal exam and she says, “No?” Do I coerce her to accept one?

This is part of the trust aspect. I trust that she has asked me to be her care provider and in that, I am being asked to do what I do best – oversee her labor and birth, working to keep homeostasis so she can deliver her baby in the most wonderful – and safest – way.

What ends up happening when I suggest something like a vaginal exam, the women already know I wouldn’t want to do one unless there was a real issue to examine… something going on that needs more information and the exam is the method in which to find it.

But, the trust I really mean is when I ask a comfortable woman to turn over/get up/move because the heart rate is down. To put oxygen on now for the baby. That we are going to the hospital via an ambulance because she is bleeding too much and we need more help. That pushing just isn’t working and we need to transfer in order to facilitate the delivery. These are the circumstances that all the trust-building during pregnancy leads up to.

I am particular about who I take as a client. I want to have clients that also want to build a trusting relationship with me. I’ve had my share of tentative clients, ones that question every move/decision/thought and never are comfortable with my answers. It’s a precarious place, serving women who don’t believe in the basics of prenatal care and monitoring the labor, birth and postpartum in the way I am trained and believe in. I choose not to do it anymore.

I am not a tyrant in birth. I don’t ask my clients to remain mute and obsequiously accept my tenets regarding their care. I welcome questions – and ask plenty myself! It really is the only way to move forward, into and through relationship-building. It’s wonderful to verbalize, over and over, how I feel about AFP Screens, Glucose Tolerance Testing, ultrasounds and controlled cord traction. I want to be pressed against the wall. I want to be challenged to think, consider and re-consider beliefs I have. I am not rigid in my care with women, but do utilize my experiences and share that with my clients. They, in turn, share their experiences, what they’ve read and what they believe.

It really is only in the emergent situation that questioning can waste precious time and where I want to move through during the pregnancy so we don’t waste a moment in discussion. The discussion should have already occurred, long before that crucial fulcrum.

But, how does one build trust in birth? Is birth able to rationalize its way through, maintaining its sameness time and time again? Does birth always go the way we hope it does? Is there so much of a rhythm in birth that expectations are met more times than not? Whose expectations? Does trusting birth simply mean we expect/know/believe that birth – THE BIRTH – will happen? That the end result is a baby will come out of the uterus one way or another?

What does “Trust Birth” really mean?

Because trust can be altered with a variety of circumstances… differing opinions that cannot be resolved, actions that are inappropriate or harmful, variations that threaten the health and safety of the individual… I can only trust birth so far.

To me, Respecting Birth is timeless.

I can respect someone when they change their mind after careful consideration, even if it doesn’t agree with my wishes. I can respect those that demonstrate behaviors that fulfill my expectations of integrity.

I can respect, in a different way, the power behind the actions – as in labor. I am deferential to the flow of pregnancy, labor, birth and postpartum. I am a witness, yet a watchful witness that has been blessed with skills and the knowledge to nudge Nature back into normalcy should she slip once in awhile. Even as I respect birth, I know that she can falter once in awhile. She certainly rarely unfolds as textbook as any of us would like.

Looking at birth from a hot air balloon versus next to a woman’s AquaDoula are two very different viewpoints of what is happening. From far away, lumping all women together in a great conglomeration of birthing women, I can see how someone would believe in trusting birth. But, when taken individually, when seen close-up and right there, nothing is as mundane as “normally.”

I don’t sit wringing my hands expecting birth to fuck up so I can step in and rescue the woman or the birth. I merely hold the information sometimes needed to recognize when she begins to swirl outside the realm of typical/normal and I quietly, gently nudge her so she can find her center once again. I want to hold the worries and concerns of a mother so she is able to labor, unencumbered by the thoughts that can hinder her labor and birth. Through experience, I am able to hold them quietly and back in the recesses of my mind, yet easily accessible should they begin to present themselves.

Birth moves out of the realm of “typical” so often that implicitly trusting her seems absurd. Even experiences as small as a quicker birth, a baby that needs stimulation to breathe, a mom who needs encouragement to change positions and a uterus that needs massage postpartum can tip the scale out of the “trust birth” category. How can we trust that we won’t have to do something sometimes? Even UCers sometimes have to go to the hospital, be sutured or bury a baby. If we trusted birth because she could be trusted, wouldn’t these things never happen?

It makes so much more sense to me to accept birth where she stands, to acknowledge the swishes and sways she manifests – seeing the subtle nuances only something so ethereal/illusory/ tenuous could create.

To me, respecting birth is very, very different than blanketly unconditionally trusting birth.

It always annoyed me when I, as a doula or childbirth educator, would be told, “You just haven’t seen enough” when I believed complications were more created than something random. And yet, here I am, many years and many birth experiences later, saying that very thing to women-midwives and natural birth advocates alike who insist it is the provider that creates the difficulties and if left alone, birth would be perfect.

It’s not true.

You know how sometimes you hear your mother’s voice coming out of your mouth? Saying those phrases you swore you’d never say? It is like that.

“You just haven’t seen enough.” “The odds aren’t great, but when you are that 1% it is 100% to you.” “The important thing is a healthy mother, a healthy baby.” I don’t always say such phrases, at least that callously and angrily, but I sure do believe them.

Hang around birth long enough and you begin to see she doesn’t do anything by rote. Trends, yes. Meticulousness, no.

Birth has shown us that she deserves respect. It is much more infrequent that she implicitly earns trust. Even the most straightforward birth has twists and turns that must be worked around.

The mother in the water gets too warm and she needs to get out because the baby’s heart rate is climbing from the heat.

In a trusting circumstance, one might not have even bothered with listening to fetal heart tones because the baby is assumed to be just fine… and wouldn’t the mom know different if something was wrong?

In a respecting mindset, listening to fetal heart tones demonstrates the vulnerability of the mom and baby and then adjusting accordingly to keep them both safe.

When speaking about respecting birth to clients, I rarely (nowadays) come up against resistance. Unlike some un-natural birth advocates, I understand how important the birth “experience” is. Yet, I believe that most women would sacrifice the experience for the life of themselves or their babies.

I believe first-time moms are more idealistic than second or subsequently delivering moms, yet, in discussions it’s fairly easy to explain the incremental nuances birth can demonstrate. Eventually, most women I work with comprehend that their dream birth really isn’t 100% possible, that “going with the flow” of birth is much more enjoyable than clinging to a hope that probably will never happen. Whether the mom has to have a waterbirth or that she will catch the baby herself, the baby’s dance inside, and on the way out, has much to do with what each birth, exactly, will look like.

Women who’ve had previous traumatic births can grip their upcoming birth dreams tightly – sometimes so tightly that they squish out the cracks of their white-knuckled fingers. Oftentimes, manifesting the vision is impossible – even under ideal circumstances. It’s hard overcoming the disappointment of not achieving the Ideal Birth. Isn’t it better to not have rigid expectations that birth will be “perfect” and instead visualize “wonderful?”

When birth is trusted, she can hardly be blamed when she disappoints. How often is birth exactly as we wish her to be? Rarely.

However, if we respect birth, we can dance with her as she winds her way through her labor and the delivery of the newborn she cradles.

When we respect birth, we can accept her wherever she is – in perfect normalcy or as she foists serious complications upon her lady. Offering her respect, perhaps she will be gentle on us. With us. Giving her respect, we can hardly be disappointed.

Sitting with a woman, watching quietly from across the room, I am awed by her power and strength. She commands respect. Even as I believe/trust that all will be well, I also acknowledge the reality that birth is never a carbon-copy of someone else’s birth. Newer doulas can often super-impose a previous birth onto the woman laboring in front of them. It is a skill to allow each woman’s birth to unfold and to create her own experience and history. It is in this understanding that respect is honored.

In delving deep inside, I see that I respect those that simply allow birth to be all that she can be. Whether they are midwives, nurses or obstetricians. Acknowledging the truth that birth is oftentimes unpredictable (always unpredictable?) is, to me, a sign of maturity in birth and life.

Now, that is someone in whom I can trust.

Monday
Feb112008

The Gray, Grey Messenger - Gloria LeMay

These next three posts wind around and around. It's taken weeks to write them and while each can stand alone, I believe they are all entertwined.

I hope they make some sense to you readers. Thanks for your patience in sloshing through.

I re-published the “Sanguineous Shock” piece after reading what Gloria Lemay had to say about unassisted birth. You can read the entire response on dear Rixa's site - Gloria Lemay Responds... - but there are parts I simply must take to task.

Gloria says:

“First of all, yes, it’s possible to hemorrhage and bleed to death quickly in birth IF YOU HAVE A SURGICAL WOUNDING. Women die from bleeding in cesareans and with episiotomies. The closest to death that I have ever seen a woman in childbirth was in a hospital birth where the ob/gyn cut an episiotomy, pulled the baby out quickly with forceps and then left the family doctor to repair the poor woman. We were skating in the blood on the floor and desperately trying to get enough IV fluids into her to save her life while the family doctor tried to suture the episiotomy wound as fast as he could. I have never seen anything like that in a home birth setting or a hospital birth that didn’t involve cutting."

"Think about it--would any midwife ever go to a homebirth if it was possible for the mother to die from bleeding in five minutes? I know I wouldn’t go if that could happen. We had a visit here in Vancouver BC from an ob/gyn from Holland back in the 1980’s. Dr. Kloosterman was the head of Dutch maternity services for many years and he was a real friend to homebirth and midwifery. He told us that you have AN HOUR after a natural birth before the woman will be in trouble from bleeding. Does this mean that you wait for an hour to take action with a bleeding woman? No, of course not. If there’s more blood than is normal, you need to call 911 and transport to the hospital within the hour, but you’re not going to have a maternal death before an hour is up.”

So, just because Gloria hasn’t seen a mother bleed to death in 5 minutes means it doesn’t happen? Does a midwife have to SEE something happen before she believes it can occur? Does a mother? Father? Nurse? Doctor? How could she not have learned about – heard about Amniotic Fluid Embolisms? Disseminated Intravascular Coagulation?

“AFE is considered an unpredictable and unpreventable event with an unknown cause. In the national registry, 41% of patients had a history of allergies. “Reported risk factors for development of AFE include multiparity, advanced maternal age, male fetus, and trauma. In a retrospective review of a 12-year period encompassing 180 cases of AFE, of which 24 were fatal, medical induction of labor increased the risk of AFE.8 In the same study, AFE was positively associated with multiparity, cesarean section or operative vaginal delivery, abruption, placenta previa, and cervical laceration or uterine rupture.”

While a homebirth midwife wouldn’t be participating in any medical induction, cesarean, traumatic birth, forceps or vacuum, we do have women who have had more than one baby, women that have sons, women who are over 35, could have a uterine rupture or placental abruption, a cervical laceration and, if the woman hasn’t had a sono, possibly a placenta previa (although there are usually signs beforehand that the placenta is overlying the cervix). And, as we all know, there are going to be some women who don’t fit into these categories at all.

So, why would a homebirth midwife continue attending births even though she knows there is a risk of losing a woman in under 5 minutes? Why do I attend births knowing what I know – having seen what I saw 20 years ago?

When I first went to learn midwifery and left school with a license to practice, it was the birth in the poem that continually danced in front of my eyes. I kept thinking, “What if that happens when I am the care provider? How will I handle the death of a woman… or baby?”