Thoughts on “When a Homebirth Doesn’t Happen”

Maryn Leister wrote a beautiful article in Indie Birth, “When a Homebirth Doesn’t Happen.” 

“There is a Higher consciousness that serves us all, and to act like we KNOW how things need to turn out is just plain arrogant and egotistical. Who’s to say that a woman needs or should have a certain kind of birth? How is that respecting the path that she walks? It is not my job or my goal to affect change on anybody’s path. We each have our own to walk, and our own lessons and trials and triumphs.” 

It’s a lovely self-reflection about a midwife’s desire for her clients to have their babies at home and the subsequent feelings in both midwife and mom if the birth moves into the hospital. At the beginning of the piece, Maryn says: 

“I’d like to approach the delicate subject of transports to the hospital from home; mainly for my own reflection and processing. I say ‘delicate’ because for many (midwives and mamas alike), a transport conveys the ‘failure’ of someone or something. In the past, I’ve been the midwife that, I’ll admit, has heard other midwives’ transport stories and thought indignantly, ‘You transported for THAT?’” 

I’ve found that, with time, all midwives eventually come up against this reality check. It really is pretty easy to second-guess another midwife’s actions, especially when not a midwife yourself. But when the woman and baby are in your charge, the scenario can look entirely different. I believe it would be a fairly immature midwife to not look at this issue with a brilliantly bright light and a daringly sober attitude several times over a career. 

Through the years, I’ve revised my Statement of Purpose as a midwife when the situations led me to do so. At the moment, my Statement of Purpose is: 

My main role as your midwife is to keep you and your baby alive. However that unfolds, I am here to serve you.

As Maryn and others have also experienced, the feelings of failure, of being a not-good-enough midwife have splashed about my ankles and calves. I’ve even had times when the guilty waters have, tsunami-like, threatened to take me under the waves. But, I force myself to remain in a place that does not include self-pity. There’s a difference between wishing things were different and beating one’s self up; the former can be productive if processed correctly –the latter is wasted energy. 

I’ve had my share of transfers (going to the hospital in a non-emergent fashion) and transports (going to the hospital in an ambulance) and I think with all but the clearest of reasons (i.e. placental abruption and posterior face presentation are two that come immediately to mind) I have wondered “Could I have done anything more?” There have even been a couple of births that haunt me, wishing I would have done things differently. While it might be a woman’s path to be in the hospital, perhaps if I had <fill-in-the-blank>, it might not have been in her cards in quite the same way. Blessedly, no mothers or babies were lost in the process, but I do believe at least a couple of women have been (cesarean)-scarred by my decision to move to the hospital. My heart aches with that belief. 

When I became licensed as a midwife in 2005, I’d had many years of experience as a doula and a few as a midwife in a birth center and even fewer as an assistant and then primary in the homebirth setting. During my homebirth apprenticeship, experienced homebirth midwives would say, over and over, homebirth was a different animal than hospital and birth center births. Really, all I could tell was it was a lot slower and gave the woman a ton of one-on-one care, especially compared to the high-volume Casa de Nacimiento birth center. I mean, wasn’t birth birth? Didn’t all women labor the same, birth from the same body part and have the same needs? It was even easier in the more relaxed settings because women didn’t have to struggle with The Establishment over her autonomy. I grew tired of their repetition… “Homebirth is different.” For goodness sake, most of them didn’t have nearly the number of births under their belts that I had. 

But they were right. Homebirth is a different animal than birth center and hospital birth. (I thought it would be a bitter taste in my mouth to say that, but it actually came out easily.) 

Now that I’m five years into being a Licensed Midwife, I feel I am just now coming into my own as a homebirth practitioner. I know that probably sounds ghastly, especially to past clients. I don’t mean I was a bad midwife before, but feel I am now a more mature midwife… less skittish than I’ve been in the past. All those years of erring on the side of extreme conservatism; was that really necessary? I’ve not heard other midwives speak about this learning curve, so I’m left wondering if this is a solitary experience… these feelings of previous inadequacy. (If you have written about this topic or know someone who has, please point me in the direction; I’d love to hear from others.) 

I don’t believe this was a technical lacking in my education or training. It is more of an intuitional process that can’t be taught… that place of balance between trusting all of my capabilities implicitly and knowing the exact moment to hand over the reigns to a medical professional. I’m not sure if this perfection is ever achieved, but I know I could have come a lot closer to the mark. 

I know this sounds crazy, but it is now that I wish I could apprentice with an experienced homebirth midwife. It is now that I know what I’m watching for in a domiciliary experience. I’m finally (I think) more balanced in my knowledge of all births, homebirth included. That doesn’t mean I still don’t have slews of things to learn, by any stretch of the imagination. It doesn’t mean I won’t still waver on the cusp of uncertainty. What an apprenticeship would do is validate my decision-making skills, allow me to say, “I did know everything to do after all,” or show me my blind spots, forcing me to acknowledge “I hadn’t thought of that; I will remember next time.” 

I would be more patient in an apprenticeship now. In the early 2000’s, I couldn’t wait to be on my own, really believing I didn’t have all that much to learn… perhaps how to do longer prenatals or organizing a birth kit… but not so much about birth itself. I wonder if I wasn’t arrogant even. I might have been at times, but think I was simply naïve more than anything else. 

Maryn says that even as she brings up the topic of transports…: 

“… I am trying to prove something, or maybe it’s to disprove something. That my transports (or lack of) somehow indicates my worth as a midwife. As if I am in control of the outcome, as if these births I attend are all about ME and how skilled, intuitive (substitute your favorite midwife attribute here) I am. These 2 transports, the most recent in particular, have shown me how ridiculous this mindset is. And how if I (or any midwife) operates under that notion, birth becomes ego-centric and also totally disempowering to the woman.”  

To me, midwives are in control of at least some of the transports. If they (I) don’t have certain skills, then some situations can be out of the scope of practice for the midwife… and a transport becomes (almost) inevitable (unless she sallies forth, trusting the knowledge is there and will pour out of her brain into her hands). While the outcome itself might not be in my hands, by making certain decisions, the selection of outcomes narrows. By making the decision to transport, I have removed the option of having a homebirth and, in all likelihood, thrust the woman into the pool of an uncontrollable cesarean rate. 

I have said, more times than I can count, “Who knows why your baby needed to be born in the hospital/by cesarean.” I’ve toddled along, counseling women after their complicated births, helping them to reframe their experiences into some (possibly) pre-destined ordeal. With Maryn’s unwitting help, it is this attitude I am questioning. Perhaps by believing birth is already written even before labor begins… by believing in fate… might not that absolve the midwife from any culpability? Isn’t that the selfish and egotistical notion? Might the midwife not accepting her role in the outcome be the disempowering factor in the mother’s attempts to make sense of it all? Might this attitude not be a subtle way to blame the victim for her own circumstances? 

I agree; it isn’t All About Me when it comes to a woman’s birth or her transport to the hospital because of a complication, but I feel there must be room for the client to ask, “What could you have done differently?” I mean, the woman hired me as a consultant in her birth, didn’t she? Even women who want autonomy, if they’ve chosen to have a midwife at their births, they (often) look to the midwife to make the ultimate decision to transfer/transport. If we/I can accept that our/my actions might have pulled the laboring mom down the path towards Intervention World, perhaps that creates the space for women to find their power surrounding their births. Perhaps this acknowledgement is the tipping point between a woman’s self-flagellation and the ability to retain/regain her sense of self-confidence… an attitude that, most assuredly, spills over into her mothering. 

None of this is meant as a recommendation for making the midwife the scapegoat in a transfer/transport… something I have seen happen before. But, as with all things, a balance of responsibility allows room for learning, explaining and even asking for forgiveness if that is appropriate. 

Just writing this, I have uncovered places where I now want/am ready to accept responsibility for my actions and apologize for them. I know it can’t fix the outcome, but it can, at least, acknowledge their own niggling questions about their births, letting them know their births were an integral part of my continued education as a homebirth midwife. Not many pregnant/birthing women would purposefully want a midwife learning on her, but, in a way, aren’t we always learning by caring for women? If I could do some of those births differently, I would. The fatalistic part of me says we chose each other; me to learn… they to teach.

But I can’t help but wonder, is that my justifying all over again?

(photo by Nova Bella DeLovely)

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?”

The Myth of the Vertex

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

The reality is – none of these beliefs is true.

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

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

Example One:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Example Two:

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

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

There is no greater honor.