It is highly unlikely that anyone has ever actually died from happiness. I have taken anatomy and physiology four times over the course of this wandering life of mine, and it is completely uncommon for the limbic system to simply explode, leaving a patina of oxytocin dripping down one’s face. Uncommon , but not absolutely theoretically impossible, so I am leaving it open.
Before I left, Always Longsuffering Pat (hereafter to be known as ALP) Asked me if I were excited. No, not excited, with its adrenaline tinged barely concealed hysteria. Not excited, simply happy. Happy to see my friends, happy to go back to a place where, against any odds one can measure, I fell utterly and completely at home.
And now I am here, at whatever 8:30am means after crossing so many time and space barriers. And now at 8:30, I notice my happiness is tinged with joy. Joy and I are not well acquainted. We nodded at each other as we passed in the corridor in school, and she moved in for a bit when holding a newborn was a possibility, but we are not usually on a first name basis.
Except here, in a country most people cannot find on a map, now would they care to. We took the long/short way here. Long in frustration in that our first flight was cancelled, and we lost two pieces of luggage filled with medical supplies. But short in the way that bonding and laughter makes the time fly, and anticipation makes the breath be short.
Arriving in Entebbe airport and dealing with the lost luggage took the better part of two hours as we are passed from clerk to clerk. Finally it became obvious nothing else could be done that night and we went outside to meet out pick up.
Midnight in Uganda is the most midnight place ever, dark as dark, the Milky Way clearly visible, leading us somewhere just over the horizon. And waiting just outside was Ben, our driver and my friend. Hugs and greetings were exchanged and I may or may not have flipped a surreptitious tear to the red dirt below my feet.
Ben looked great, as did the new Project Coordinator, Salam, and one of the volunteers, Cara, an Australian who shares my hatred of birds. Clearly a woman of discriminating and refined taste.
After the usual journey of hours over pot hole invested roads, we arrived at out guest house in Kasana. It is a new one from last year, very conveniently located. The proprietor also owns the volunteer house we use at Shanti, so this is keeping it in the family. It is very comfortable and even has solar power, so we may end up with more power than I am used to there. May. Anything can happen. The linens here are so clean, and all monogrammed. Adrine has done a wonderful job. She is a business women with whom to be reckoned. If you remember our adventures with the electric showers last year…let’s just say we seem safe so far. And even hot water mostly. I am so happy. Adrine has done a beautiful job.
Like most women everywhere, Adrine was in constant motion. Women always move, right? When laboring, our hips sway, our bodies shake. Even if confined to bed, our feet will jiggle, our fists will clench. Unseen’ our cervixes will slowly open (and sometimes quickly close; remember to read beyond textbooks.) our hearts beat faster, we blink, our mouths open and close.
Just as artists swish paint brushes over canvases,women move through life in a state of creation. Creation is movement. As much as we would like, babies do not just fall out even the fastest twenty minute labor , while over quickly, brings a lot of physics and a lot of feelings to the table. And even the slowest 4 day, ctx q 10 until pushing, which then takes another three hours as that baby inchworms her way down…it too brings it’s own dance, it’s own perfect movement.
When babies become children, a woman’s movement increases. Running late, stopping by the store on the way to school, running in to drop off the lunch that was truly meant to be handmade, but is now covered in plastic wrap and branded with etching we hide under our coats, rushing to work or the doctor, or to the gym where before we move we have to pick our feet out of a quagmire of guilt and others’ ideas about our bodies, moving home or to the coffee shop, or to supportive meetings where, if we are lucky, we can move into projects of the family, of the heart, of the spirit.
Always moving. None can be still for long unless we schedule a meditation session, or time for prayer. But still, these are a conscious slowing, done on purpose, a respite, never completely still. We are after all women. We move.
I see this movement at Shanti, and not just In its laboring and birthing women, but in the project coordinators, in the volunteers, (almost exclusively women) who move across continents and philosophies, who move against cross cultural norms who seek to oppress, who say that our movement means nothing and we should be frozen.
I see it in the Ugandan staff, these most excellent midwives and support workers who are always always learning, stretching across the divide of what they have been taught and what they know is possible. Over the past four years, I have seen them come to a new place, one guided by intuition and love, a desire to move each birthing woman forward rather than backward.
So much movement. And while it is highly unlikely that I will die of happiness, literally, my heart is swelling like the Grinch at the end of that Christmas special with Boris Karloff. I am ready to move.
There and There Again: A Midwife’s Tale- Jane October 12, 2013
Viola October 22, 2012
There has been a woman in labor here at Shanti for the past two days. Viola looks about my daughter Anna’s age, but she is actually 25, and this will be her third living child. She is petite, commited to this labor, and really really working hard. She is laboring out of site of the training, although we catch glimpes of her walking around the beautiful grounds, working with through her contractions with the help of an older woman. I assume this is her mother-in-law, as they seem to be the most common labor attendants here. She has captured all of our hearts; her labor is difficult, and she is so so tired.
We always say that third babies are the wild card. While they are housed in an experienced uterus, it is one who has been stretched out. Third babies can get into all sorts of wonky positions, causing a longer (and depending on the position of the baby) more intense. labor. Early this afternoon, one of the midwives asks if I would check her, as they would like to know if I can ascertain the position of the baby, and maybe give some suggestions to help.
When I enter the birth room, Viola is lying on a plastic sheet, moaning slightly, even when she is not actively contracting. She is having a very difficult time relaxing between contractions, and she is holding her lower back. I note where she is lying (her left side), and that she taps out a quick staccato rhythm with her right hand when she contracts. She is sweating, shaking, and she is deep deep into that place we call Labor Land. She does not glance up at me as I sit silently on the bed next to her, just letting her get used to my presence. Her belly is flat in front, from just above the umbilicus to a few inches below. Her contractions are irregular, between 3 and 6 minutes apart, although when they do come, they are very strong. I ask her softly if I can feel her belly, and she nods quickly, just once.
Now, so far, my “examination” of her has been pure observation, and observation is the heart of doula work. If she’s clutching her back, there’s a good chance it probably hurts even in between contractions. Lying instinctively on her left side is not only good for getting the maximum amount of oxygen to the baby, but can also help a baby rotate and come down into the birth canal. And a flat front belly can indicate a baby who is hanging out in the occiput posterior position, also known as “sunnyside up.” The baby’s spine is resting against the mother’s and this bone on bone action can cause the dreaded “back labor.” And, from the shape of her belly, I can tell that the baby has not yet dropped down into the pelvis. This is not uncommon in women who have had prior babies, so it doesn’t really concern me. From the length of her labor, I can theorize that this baby is probably not only sunnyside up, most likely acynclitic as well, a situation where the baby’s head gets cocked off to one side or the other. This makes it harder for the baby to descend, as the surface area of the head is increased.
All of these things can be helped along (sometimes) by positioning exercises, which, coincidently, is exactly what we are teaching today! So convenient. The midwives have already used some of the exercises we showed them, but here is a great chance to illustrate how to read a labor, how to put all these little clues together and make a plan to get this baby shifted. I knew that as soon at the baby worked out how to drop into the pelvis, Viola would not have to push long. I could tell from the size of her belly and some gentle palpation that this was not a giant baby, and if she had birthed two full term babies previously, there should be plenty of room.
At this point, I pretty much knew all there was to know, and an internal exam was just going to be a formality. She was most likely almost through dilating, but the baby was still high in the pelvis, trying to turn its head this way and that, searching for the way that fit him or her best. The trick was going to be to give her enough time, and keep her energy up enough to let her body and her baby do their work. She was very very tired, although she was eating pineapple and peeing frequently. (This last is important, as a full bladder can impede a baby’s descent. Think about how close the bladder is to the uterus, and you can see why. For those readers without a uterus, I’m sure you can imagine.
I grab a glove from the box, and ask her permission to examine her. She nods once and rolls over. Sure enough, she is 9 cm dilated, but the baby is still floating. As hard as she has been working, she’s going to have to do a bit more. I explain how to position her on her left side, with her leg raised high on pillows, almost lying on her baby. In the western obstetrical world, we call this position Modified Sims. In Viola’s world, we call it resting comfortably. I give the midwives a few more suggestions for when Viola is able to participate more actively, including the Captain Morgan (one leg on a chair, the other on the ground, swaying gently through contractions) and hands and knees, leaning over one of the new donated birth balls. (Thank you, Simkin Center in Seattle!!). I smile at her, check the heart tones of the baby to ensure that he or she is liking this position, (heart tones are perfect!) and leave her with the Ugandan midwives.
This goes on all afternoon. Periodically I would be asked to check on her, and periodically I would go in and hang out with her, offering suggestions as we went. Eventually the midwives start an IV, just to keep her hydrated in the Ugandan heat. We also used the rebozo with her, and put her through a million different other positions. She was a trooper though all of it. Eventually it was time to leave, though, and Viola was still laboring. I was certain she would either deliver that night, or be transported for an obstructed labor.
The next morning, I was delighted to find that she had birthed during the night. Hooray!! And sure enough, it had only taken two pushes . Baby just had to find the way. As Melinda and I sat admiring the baby, and telling Viola how wonderful she was, I asked his name. “Jane, I want you to name him,” she replied, smiling. I was shocked and honored. Together we decided on Patrick, after my beloved husband. It is a gift to get close enough to someone that they want you to name their baby. A true gift to connect on the most basic womanly level, though birth. I hope Patrick lives a long and happy life. I know he has a wonderful family, and I hope I can see him next time I return to Shanti.
“False Labor”: Misnomer of Grand Proportions–Jodilyn May 21, 2012
The language of pregnancy and birth showcase our society’s beliefs with perfect clarity. I can think of dozens of phrases that divide mother from baby, spirit from body, mind from health, and mother from inner knowledge. I want to look at just one phrase to showcase the way we approach these linguistic faux pas in midwifery care, and how we get to the bottom of events in pregnancy that can be difficult or seemingly in need of a cure.
We can attribute the language of divisiveness to many sinister roots and spend all day railing at The Machine and The Man–but why spin in circles when we can gain some insight instead? Something I’ve learned over the years and hundreds of births: the roots lie beneath layers of asphalt, cement, cobblestone, and packed dirt. The energy required to dig them up and cultivate new soil and plant new trees is the work of modern midwifery. Meanwhile, we like to say we “forgive” those who have attached themselves to the practices that stem from these roots because that is their only paradigm and how they were trained. While that’s fair to some extent, each of us is responsible for lifting our heads so that we can partake of a broader vision. I know it’s not politically correct—but shame on all of us who are entrenched in one way of thinking, talking, and acting. And a double shame if that tunnel vision limits the experience of something so fundamental as the birth of a baby and a mother: the building blocks of any society. (And yes, this cuts both ways–midwifery care and homebirth are not the right fit for every woman.) What makes one person or another apt to lift their eyes and stretch their perspective or practice? I would call it holistic curiosity, and it should be taught in every medical and midwifery school. Actually, scratch that. It should be taught in every elementary school.
It is unfathomable to me that any person could witness birth and think only of the moving parts and mechanics of it, but there is where the roots of modern birth and the language and rituals that surround it lie. The medicalized perspective of birthing must work very hard to connect the parts that authentic midwifery honors as inextricably bound together. There are wonderful OB’s and OB nurses who see the whole woman—this is really not a message about them, it is a message about the environment, language, and curiosity that we surround ourselves with.
Back to the misnomer we are looking into: “False Labor”. This term is typically applied to bouts of contractions a mother has between 37 weeks and the onset of rhythmical contractions that get stronger and longer and culminate in birth. A contraction is an activity of the muscle. A mother cannot make her uterus contract the way we can flex our biceps. The uterus contracts in response to internal stimulation—be it from any of several maternal or fetal hormones, movement from the baby, an orgasm, or changes in the lower neck of the uterus called the cervix.
The idea that the body would generate activity, heat, and motion for false purposes is nothing short of absurd. Every contraction has a purpose. Each one massages baby, helps baby adjust its position in the pelvis, and stimulates receptor systems for hormones we need to birth our babies. Emotionally, contractions pull us inward and force us to spend time with our bodies and babies. They pull our attention from the world, the clock, the to-do lists. They teach us lessons about control and surrender. Often times in our busy lives it is the norm to be in a state of disconnect with our bodies. Mothering needs us present in our bodies. It demands that we feel and sense and respond to these feelings and sensations in order to ensure the very survival of our species. Contractions that come and go, sometimes for nights on end, and in fits and spurts help us acquire and practice these skills.
“False Labor?” I don’t think so. The body is wise and begs the mind’s attendance in this wisdom. A provider who looks a mother in the eye and tell her that this wisdom is “false”, and demands that she separate her wise body from her knowing sense of her truths does not see a whole woman in front of her. Midwifery care, at its very best, does not get lost in the mechanics, but honors the wisdom of the whole mother and her baby. It sees them work together in harmony to bring about motherhood in its richest, fullest sense, and babyhood with the right I wish every baby on this planet had—the right to a mother who has integrated her body and mind and honors her senses, her knowledge, her gut, and her heart and can be present for her baby. “False Labor?” I don’t think so. The next time we meet a mother who is contracting in these patterns, we can stand in awe at the integration of mother and baby, spirit and body, mind and health, and mother with her inner knowledge—and know, with absolute certainty, that there is nothing false about it.
More Vbac Stuff-Jane April 18, 2012
I’ve been doing a lot of sitting on the couch lately, working with a set of premature twins in my neighborhood. They are sweet and cute and screechy and vomit-y, and all the things that you could reasonably expect little people to be. It also means that occasionally, between physical therapy exercises, massage, and wiping spit-up off my shirt, I get to watch some CNN. Like many people, both men and women, who I hang with, I was shocked to hear Democratic strategist Hilary Rosen’s comments regarding Ann Romney and her decision to stay at home with her boys, rather than work outside the home. Now this is not a political blog, and I won’t go into my own personal beliefs here, although I will say that I value good manners from all parties. What struck me, and seemingly much of the rest of America is the fact that once again, women are being divided, and once again, we are doing it to ourselves.
This lack of cohesiveness is certainly nothing new in feminism, and regrettably, it is nothing new in the birthing community. But, you know what they say about familiarity, and I am certainly feeling a bit of contempt right now for a situation that’s a-brewing in the Seattle vbac community. Let me tell you a story:
Once upon a time, Dear Ones, there was a little community hospital. It didn’t have a Level III NICU, but it had nurses who would gently love your baby to sleep at the desk, if you needed a nap yourself. It didn’t have flat screen tvs or a bath tub in every room, but the rooms were large enough to stroll around, and the showers were big enough for two. There was an ob group there, and a few independent nurse midwives who had privileges, as well as a family practice doc or two for variety. They had nurse anestethists, rather than dedicated anesthesiologists, and all seemed to work very well for a while. Oh, and they did vbac. Lots and lots of vbac.
But the only constant is change, Dear Ones, and progress must be made. The flat screens went in, and the ob group gradually morphed into another set of personalities. The nurses still loved on the babies, most of the independent midwives eventually left, and an official CNM group was established. Oh, and the vbacs went away.
You might think, Dear Ones, that this is the end of the story, that this is one more rant about how the opportunity to vbac is being slowly taken away. But no. Actually, now the vbacs are coming back! The obs are willing to accommodate vbac on a case by case basis, depending primarily on the reason for the primary cesarean. They are especially fond of those reasons that are “non-repeating. “ In obstetrical language, this includes a breech baby, placenta previa, and basically any other condition where you had to schedule a c-section before the labor waves hit you. It also helps if you have had a previous vaginal birth, have no underlying health conditions, like long walks on the beach, and are a Capricorn. (Ok, that was a bit snarky. You caught me.)
So you would think we would be celebrating, right? After all, isn’t any vbac a cause for celebration? Yes. Yes, of course. But I’m still upset, and I’ll tell you why.
While there is some statistical difference between the “success” rates of vbacs based on the initial section, it also really really doesn’t matter. If the Big Bad Wolf of VBAC is uterine rupture, why does it matter how the scar got there in the first place? If we are going to be scared of scars, let’s really commit to it. Let’s be really really scared. Let’s have a vbac ban that is honest. Let’s not try to hide our own fear behind a colorful wall of half examined statistics and rupture stories our colleagues told us on the nightshift. Nights are dark and cold, and even the extra cardigan in your locker can’t protect you from half buried truths, based on old school traditions and your sister’s scheduled repeat cesarean.
Even ACOG clearly states that VBAC is a “safe and reasonable choice for most women,” who have had one c-section, and even for “some women” with two.[i] It says nothing about “non-repeating” conditions, although it does specify that a suspected big baby, carrying twins, or going over 40 weeks are not reasons for a mother to be denied a VBAC. (It actually says denied a TOLAC-trial of labor-but that language is another post for another time.)
And, by the way, vbac is successful 75% of the time.[ii] This is actually a better chance than an every day, run of the mill, first time mama, who has a 67.3% chance of a vaginal birth.[iii] And by the way, in 1965, the C-section rate was only 4.5%[iv] Just sayin’.
Jodilyn and I have said for over a decade that 99% of a vbac happens in the mind, not in the uterus. The research, the personal exploration, the soul searching, the intense wanting, means everything. A supportive provider certainly helps, as does a partner who is on board. But at the very end of the day, it is a mother’s journey. She needs allies, certainly, but the journey is definitively her own. She is the one who has to fight the doubts, and ultimately believe that she is not broken. She may be a bit bent in spirit, but eventually most women can believe that most of the time, her uterus and her mind are strong.
So what does it do to a mother who is already working through her process, when she is told that not only does she have to live with the results of her c-section, but that she didn’t have the right kind of labor before her section? And what does it do to her faith in the medical professionals who tell her that, when she realizes this is a completely arbitrary distinction?
[i] American College of Obstetricians and Gynecologists. (1999). ACOG Practice Bulletin No. 5: Vaginal birth after previous cesarean delivery. Washington DC.
[ii] Coassolo, K. M., Stamilio, D. M., Pare, E., Peipert, J. F., Stevens, E., Nelson, D., et al. (2005). Safety and Efficacy of Vaginal Birth After Cesarean Attempts at or Beyond 40 Weeks Gestation. Obstetrics & Gynecology, 106, 700-6.
[iii] National Center for Health Statistics
[iv] Taffel SM, Placek PJ, Liss T. Trends in the United States cesarean section rate and reasons for the 1980-85 rise. Am J Public Health 1987;77:955-9.
On Grandmothers-Jane April 2, 2012
There are as many kinds of mother-daughter relationships as there are mothers and daughters, and I for one, can’t do that kind of math. I’m an English major. And when it comes to baby having, things get even more complicated. I’ve had clients who couldn’t imagine giving birth without their mothers,others who didn’t call their mother until the baby was 3 months old, and everything in between. Like most aspects of the client-midwife experience, it is certainly not my job to get in the middle of those sorts of things. No good can come from that.
However, if the pregnant mama has the type of relationship where she does feel comfortable with her mother’s presence, there is magic to be seen at these births. Babies wash out of us, riding a primordial slip and slide of blood, water, and change. A woman becomes a mother in one instant, a man a father. And for the mother of the mother, she is suddenly thrust up the ladder a rung, Whether she is ready or not, she is now a Wise Woman.
So speaking to the grandmothers, even if you consciously reject the Wise Woman title, your soul knows better. You have undergone your own metamorphosis, brought on by your own baby’s labor. Watching a person you love in pain, is incredibly difficult, particularly if that person is your child, The same cellular connection that existed when you nursed your baby, or held her as her teenage heart broke into a million pieces, or swelled with pride as she stood up for right, still exists. That fierce protectiveness that infused your every move when she was an infant? Still there. When she was small, you would have done more than died for her if anything threatened her safety; you would have killed for her. And it might come as a surprise to realize that you still would.
But here, in the labor room, hopefully lit by candles and love, there is nothing to defend against, nothing to fight. Mama Bear has to go into hibernation. Watching your daughter discovering her own strength, to see her feel her own sacredness, is a journey all its own. Just as she must surrender to forces larger than herself, so must you surrender your desires and expectations. She will find her way, and you have to do nothing but get out of her way. And it is so so hard.
For many grandmothers, this is the most they have touched their daughters in many years. But in labor, in some ways, you can almost go back in time. You can embrace your child again, without reservation, hold her physically again as she moans into your breast again, looking to you to make it all okay. And while you can’t take away her physical sensations, you can imbue her with the courage and fortitude that is hers by womanly right. It is as if she grows up all over again, in a compressed amount of time, right before your eyes. She begins small and frightened, moves through uncertainty and doubt, and then in one instant, as her own child eases out of her body, her confidence and self trust shine through again.
Grandmothers then too are ready to take their new place in their family’s world. For your daughter was not the only one who was birthed into another form of self that day. Welcome to the world, Wise Woman!
The Quintessential Togetherness. January 31, 2012
I’ve been thinking about the recent publicity regarding the rise in homebirth rates. You’ll hear Jane and I repeating our mantra in our sleep, “relationship, relationship, relationship…it’s all about the relationship mothers have with their provider.” Can the provider be trusted to provide continuity of care and individualized attention? Can the provider be trusted to guard the space and values of each family they work with? Can the provider do their work without needing the spotlight, a.k.a. can they in fact “catch” and not “deliver” ? Can they do it all while preserving the relationship most fundamental to humanity? Can they offer support, resources, and guidance without actually providing precise google-map type directions for how things will be, how long it will take to get there, and what roads parents will or will not take? A midwife is constantly thinking “re-routing!” as she adjusts her services to meet the needs and wishes of her clients. My grandfather used to point out (via drawings on napkins in restaurants) that the fastest way between two points is a straight line, but it’s not necessarily the right path to take.
Ok. Spoiler Alert: I whole heartedly believe that the safest place for a woman to birth is where she feels safest. Home. Birth Center. Hospital. Riding a float in the Macy’s Day Parade. What I’m about to say really isn’t about that, it’s about what I’ve seen and what I believe about why women are choosing homebirth.
The word “quintessential” is a pretty common adjective. It’s used to demonstrate the most likely or perfect example of something. I was staring at the ceiling today, trying to take a wee break from studying (and by wee break, I mean a small interlude, not a bathroom run). I was missing my friends and the strangers in Vanuatu who would never have let me sit at that table alone while staring at the ceiling. I miss the togetherness of that culture. Which got me thinking about how we create close relationships.
I started to reflect on the births I have attended here in the greater Seattle area (because of course when I wonder about anything I have to wonder first if birth affects that thing and how exactly it accomplishes it). The hundreds of them. I see little flashes. Early on, those first births as a hired and paid doula, where I was supposed to be smart about this stuff and know just what to do. Running out to the waiting room to call a more experienced doula for ideas. Learning to let the text book information sink to the back of my head and actually respond to the mother. The way a woman’s face changed as she was pushing, and how time stood still and all I could see was the force of birthing. More flashes of firsts: The first time a nurse gave me (me!) the code to the nutrition room (oohlala) so I could retrieve some ice water (the sacred nectar of hospital birth). The first time someone’s water broke on me (followed by two more times that same week). The first time a mother I was working with went to the OR. The first time I smelled thick meconium mixed with that metallic odor of too much blood which portends a massive hemorrhage which was also the first time I saw a mother and a baby in steep decline in the same moment. The first time someone told me that they had attended a birth that seemed a lot like rape (I was notably judgmental about this statement and couldn’t believe that this woman was sooooo dramatic). The first time I attended a birth that felt like watching someone be raped (after I finished throwing up I called the other doula to apologize and she lovingly let me vent).
The first time I went to a homebirth. The first hospital birth after a run of eight homebirths. The sheer terror I felt at the silence of that birth, at the language at that birth, so markedly different than the midwives I had just been over-exposed to. Of the total lack of raw power and connection between the mother and baby during that labor. The weird, unrelated chatting. The way the staff spoke with the mother as if she was totally inept about absolutely everything. The way they forced the baby to nurse without actually noticing what state of being the baby was in. Don’t mind me, brand new person who never felt, heard, or saw anything in this world before, while I overstimulate you with all this rubbing, thumping, sucking, talking, and stuffing of your mother’s breast into your mouth while pressing on your head with a force most adults would not appreciate….
It’s clear they are doing their j-o-b’s as they were instructed to, but there was no consideration for the variables of humanity of the mother or the baby. What about just watching as the mother explores her newborn in her own time, in her own way? What about allowing them to teach each other about the comfort, security, and nourishment that mom has to offer and those incredible newborn gazes which suck us in and make us fall in love if the baby is in the right state and the experience is organic?
I have been to some stunningly beautiful hospital births. But here’s the truth: It’s not the same. Even drug free and naked and vociferous, it is not the same. And the reason why, I realized, as I stared up at that ceiling in anygivenseattlecoffeeshop, is the quintessential togetherness that pregnancy and birth so dramatically and eloquently demonstrate when left to their own devices. Midwives know there is a mother and a baby. We actually call them motherbaby. They are a dyad. Inextricable from one another. The baby needs the mother for food and oxygen supply and comfort and love. The mother needs the baby to help her come into her mother-self. To see the power in her body and potential of life and the bulkiness of what it means to really really love. To lose sight of the small stuff; the control, the management, the ability to shave her legs all by herself.
The language of a hospital birth separates mother from baby. Blames the condition of the mother in any given moment on the baby. Questions the mother’s ability to continue to provide nourishment and oxygen for her baby on this single day when she has been doing it to perfection for the previous 260-280 days of her life (unmonitored, without permission, without apology, without doubt). The baby is seen as an imminent threat, the mother as an unfit and incapable hostess. The examples are too numerous to cite, just ask a doula for one or two and she’ll go pale and give you ten or twenty.
Motherbaby: Quintessential Togetherness. Bound by blood and water, time and love. She brings him life and security, he brings her motherhood—that gracious, spacious, place beyond measure where women are bolted to the basic cellular formula for the entire universe. We don’t do it alone, we don’t do it separate from our babies in even one single way. We do it together in concert with them in every single way.
I am a midwife now who sometimes attends births as a doula. It’s a lot easier as a midwife. The technical responsibilities are greater. But I never have to listen to a provider try to crack apart a mother’s relationship with her baby. I don’t have to think about what to say to try to help that mother find healing and strength and connectedness. Everything I do is about promoting that relationship and sense of what is right for the two of them, at the same time, together. Everything I do is about letting the mother’s sense of self and baby dictate what comes next. My terms are not that she will follow my protocols or accept my rules. My terms are that she seeks to understand what she does not, that she asks all of the questions that cross her mind, that she speaks her heart and shares her thoughts, hopes, fears, and desires. My terms are that the two of them work through birthing together using all of the resources they want to. Did you know that a mother and newborn know each other by smell within hours of life? They can pick each other out of a lineup with just their noses. That is so incredibly intimate. Who would ever mess with a system that provides for that level of connection?
It’s no wonder there’s been a 30% increase in homebirths of late… faced with the opportunity to spend the prenatal clinic hours with a provider who wants to promote and support that togetherness, faced with the opportunity to stay as together as they’ve been for the entire pregnancy during birthing, faced with the options that matter so deeply. The decision isn’t the quick or the easy one, but it is clear why, for so many women, it is the right one.
Winding Down…–Jodilyn July 25, 2011
Thursday was humid and sweaty. I felt like I was moving through Jello and time was going soooo sloooow. One of the midwives asked me, “Will today ever end?” I don’t know what was going on unless they all felt the effects of the humidity as well or this is just one of those common workplace occurrences where everyone has slow-days.
We had several moms in early labor and lots of paper work to catch-up on. We attacked the paper work, the tidying that never ends, making empty beds, mopping up…on and on. I did a bunch of newborn exams and spent a lot of time hanging out with the twin’s family. The dad was there to help get mom and the girls home and we chatted about their older son’s reaction to the babies and seeing mom and dad holding them. Parenting is a universal challenge—we talked about Touchpoints (thank you Dr. Brazelton) and I shared some stories from when the kids were little. Dad owns a tour company and they invited me to come and see “their little island” which reminded me of MamaMia : )
Of course everyone decided to have their baby at the same time—we had four mamas going within ten minutes of each other and they threw me into one to work with a student. I had assessed this mother throughout the day and she would only let me touch her, telling the student and the other senior midwife who came in that she would have none of their fingers in her body. Ok. I actually wanted to support this student through it as she needs the hands-on. At this point, strangely, I am feeling like I have done a lot of births and don’t need to do more. (time to come home?!) But I understood her position and respected it. To make a very long story short she had a super tight fit and pushed for an hour and half, which is like 4 hours of pushing at home—it is unheard of. She was bleeding ahead of the baby and complaining of acute pain. We kept tabs on the mother in the bed across from her and they were having parallel experiences. We prepared for both of them to have some serious bleeds and just asked the doctors to come hang out. All the other babies were born first—3 girls. This mother was insisting that she wanted a boy. I slipped in once, “ok, it might be a girl too” and then held my peace—she would have to make hers or not make hers when the baby was born and I just decided I am wrong to interfere with her hopes and push reality on her when she is clearly a)not ready for that idea and b)in possession of 50% chance of getting what she wants. The other mother had a high tear that required suturing by a physician and after baby was born so did this mom. Baby was indeed a boy (!) and she asked me to go out and tell dad. I went to tell him—he was a young 20 years old. I asked him to come and see the babe but he wanted to know first what it was. I told him it was a boy and he told me he actually knew that already so it was no surprise to him—he had had a very strong dream and had no doubts. He made the transition from playing it cool to being uber excited quite rapidly and jumped up and snapped my finger—a trick the locals do which he later gave me detailed instructions in so I can show Jeffrey. He wooted and hollered and danced around and clapped me on the back and kept saying, “alright! alright!”
Friday I filled out and folded dozens of “blue cards” which are health records that parents use keep to track immunizations, well-child visits and any notes a provider would like to make mention of. I also filled out and folded dozens of birth certificates. So the next many many babies born in this hospital will have my signature on their birth certificate. Which is kind of funny, considering I am not even a citizen here. I am doing a lot of newborn exams as I have to pass my exam in the fall and have to match my scoring to the examiner’s scoring in order to be certified.
The weekend was all atwitter with building booths around the perimeter of the park for a week of celebration. The booths are made by stripping the bark off of branches and then notching them at the ends so they fit together. A whole frame is made in this way. Ceilings and walls are made of woven leaves. Each booth is about 10×5 or 10×7, depending on the use and they all share a wall with the one next to them. Everyone was busy preparing, either with the weaving or the framing and then the moving. That’s right, the moving. Families move into these booths and use the front to sell goods—mostly food–and the rear to sleep in. It is like a week-long Seafair from the old days when peons like us could pitch tents and actually enjoy themselves without spending a fortune. All Sunday afternoon people were hauling pots, pans, sleeping mats and household goods down to the park. Many of the houses are empty. Chicken road is well represented with a few booths that are triple-wides in a row. So now it is easy to visit my friends, I just go to their corner of the park and hang out.
Sunday at 3:00 began the festivities of Children’s Day with a parade led by the Big Chiefs from several islands, the minister of finance of Vanuatu, and several other dignitaries. Behind them came the band and then the children and then the stragglers. This parade does not work like our parades where everyone starts at the start and ends at the end. This one started with the Chiefs and the band and a few children and they parade around the neighborhood and people wait on the street to see them and then join in at the end of the line so that by the end of the parade, when the procession marched onto the field there was a hodge-podge of people of all ages tagging along. The prize has to go to my father-in-law’s counterpart here who ran around the corner from his house, got a big hat and stuck a Vanuatu flag in it and then waited for his grandkids to come down the street. They clearly thought they had lost him and laughed and laughed at his prank. He swooped up one of them and joined in the parade. I happened to have been on the corner he ran to and he told me his joke while he got his hat situated. Grandpa’s are da bomb. I have been listening to so many stories lately and a lot of them are about grandfathers. I will share one in a later post.
The parade entered the field and the Big Chiefs were called to do an opening ceremony, which is actually a ceremony once reserved for the start of wars between villages, and the singing sounded much more war-like than happy-Children’s-Day-like. They went to the middle of the field and exchanged Kava. There were several chiefs present and they started to dance in a circle. After a moment a group of grandmothers (I kid you not, some of them are great-grandmothers) ran to the center of the field and started dancing around the chiefs, much to the delight of the onlookers. The chief from Pentecost saw them and stepped out of the chief’s circle and danced with the grandmothers instead. This was extremely popular and there were loud cat-calls from the audience, who stood around the perimeter of the field.
Then came the speeches. I had been warned. But I’ll just say that I listened to about 6 of them over an hour and a half and then headed back to my room to call home and say happy birthday to Jeffrey and drink water. I could hear them talking for another 2 hours so it was a good decision. I had the chance to skype with Jane and I’m not sure what exactly happened but there was an extremely high rate of laughter and accusations leveled at each other regarding something to do with acting like 12-year olds. Looking back, I’m not sure if 12 isn’t too mature. Either way, just one more thing making me feel ready to come home. I talked a long time with the kids and Benjy as well which was so great–also, making me feel ready to come home. I am really happy to have these feelings. I was kind of worried when I got here about how I would manage to get on a plane and leave. Ever.
The partying went into the wee hours of the morning and this morning was the only morning since I have been here that the neighborhood was not awake with the sun. I walked to the pool and it was still pretty quiet with the exception of a few toddlers who rose at the usual hour and teenagers who hadn’t gone to bed yet. This will continue on for a week—even now there is a huge game of soccer going on the field and a live band playing music. And it’s only 10:00am.
I am winding down my work hours as I want to see some more sights here before returning home and am frankly wanting fresh air. All of the weeks in the hospital and the fumes from the cleaning agent still make my eyes water and set my gagger off. I have caught a lot of babies. I have delivered quite a few. I feel confident about suturing, dystocias, breeches, twins, internal exams, and mothers with friable tissue. But not so confident that I will ever approach birth without knowing that regardless of what I know, the mother knows more and the baby knows more and as a team they know best about how to birth and be born.
And not so confident that I would ever assume I could midwife better, just because I midwife differently than my colleagues, mentors, or peers. This place has knocked the judgment out of me. I hope that I can go on to support those in my profession with an open heart and genuine curiosity about who they are and how they arrive at decision points.
And certainly not so confident that I will ever stop learning or wanting to know more about why things unfold in the way that they do. I am so lucky that the people I work with are information seekers and that they not only put up with my endless energy for getting to the bottom of things but they one-up me or encourage me or sit patiently with me as we talk these things out again and again so that we can all be better for the families we serve.
Waterbirth, Waterbirth, Waterbirth–Jane July 19, 2011
At one point, almost 90% of the births I attended took place in the water. It has dropped off a little, due to some speedy babies that wouldn’t wait for the tub to be filled, but there is just no denying that this is a very popular way to birth. I was excited to hear Shanti’s take on it, and share what we have learned over the years.
They have a built in tub there, but it is really much too small and much too deep. Its lovely, of course, as is everything there, but I’m afraid it just wouldn’t really work. Luckily, Kristin, the coordinator, already knew that, so I wasn’t breaking anybody’s heart with that observation. They assured me that they could just pull out all the tile and build another one, quite quickly. (Now, I don’t want to judge, but “quite quickly?” Well, we will see.)
I was asked to give a workshop on the down and dirty details of waterbirth, and I was delighted to. It was so off the wall, so unheard of, that I actually think it could work out fine. See, Shanti is fighting a battle with their midwives. They have all been trained in the classic 1950′s Western model of birth. Even getting them to acknowledge that there are better positions than McRoberts has been a bit of a challenge. They begged me to ask Kristin to get rid of the large queen sized beds with the homemade quilts in the birthing room, and get them some real hospital beds. They said the beds were too low, and were hurting their back. (I can completely sympathize with that, of course) However, when I gently asked if they could just climb up on the beds with their mamas, well, let’s just say my suggestion wasn’t met with overwhelming enthusiasm. I did, after much roleplaying and coaxing get several of them to promise to at least try it. So again,we will see.
And don’t even get me started on the episiotomy issue. I’ve been reading Jodilyn’s struggle with this, and I can only nod vigorously. They ladies love to cut. (When they found out I had never ever done one, I think I actually lost some of their respect. I had to make it up later by bringing chocolate to share.)
I think the main issue here is that out of hospital birth is not seen as a beautiful, candle lit experience, where the mother is surrounded by people of her choosing, and comes gracefully into her power as a woman. No, here it is a dark and dirty affair, usually with no trained attendant, the threat of hemorrhage, or other disasters lurking just over there in the corner. The hospital is a place of (relative) safety, even though that little bit of increased safety comes at a huge moral price. Shanti is trying to change that. But its slow going, especially when you have to start with your staff.
But waterbirth? They had hardly even heard of it, so they had no preconceived ideas. And that, I have found, is one of the best places to start from a teaching standpoint. We talked for hours, first dispelling the normal waterbirth questions that everybody from my mother to the guy in the supermarket have asked me. No, the baby won’t drown. No, you shouldn’t leave the baby underwater for a long time. Yes, we tend to see less tears. Yes, it IS hard to cut an episiotomy in the water. How great of you to notice!) Etc etc.
Then, one of my favorite midwives asked the question: “How do you run a resuscitation?” And just like that, we were off, off in a completely juicy conversation regarding the physiology of delayed cord clamping, the unseen yet oh so powerful bond between a mother and her child, how the midwife’s own attitude and demeanor can influence outcomes, when to actively help and when to encourage from the sidelines…oh, it was wonderful! We had almost no common ground to start with; they have not been trained in NRP in the same way that I have, so we really had to start from square one, because we really weren’t even talking about the same thing. But once we defined our terms a bit, we were deeply engaged in one of those meaty philosophical discussions that all midwives love. (It was a bit more difficult because of the language barrier, but we kept at it.)
By the end, they were excited about waterbirth, and I think, even a little bit eager to try it out. Annet even wanted to skype me in on their first one, to help guide them. I wonder how the mother will feel about that! And I hope its not a long birth, because there is no electricity at the center. But those are just details. I’m sure we will work it out. The point is that we are starting to give these mothers options, options that they have never even heard of before. And with options comes choice, and with choice comes dignity. And that is what all mothers deserve.
Working nights has its distinct advantages and disadvantages…it is quite rough as the senior midwives on at night deliver babies using a method called “chinning” which is quite rough on both mother and baby. This is the method taught in 1940’s and 50’s Obstetrics. It is brutal to watch and I have taken to actually looking away just to preserve my sanity.
I did have one of them ask me why we leave the placenta instead of clamping and cutting it right away and she was really amazed to learn about the transfer of blood from placenta to baby that takes place. I saw the light turn on as I explained the physiology of it to her. She has now taken to waiting until the cord stops pulsing before cutting. I am always impressed when someone in the middle or end of their career wants to learn and grow in their knowledge and skills and she surprised me with her eager discussion.
A senior midwife has just returned from 3 months at the hospital on another island so I met her for the first time last night. We were sitting with a mom who had been induced using Cytotec. This off-label use of the drug causes terrible labors. I have seen many back in the day at home (it is not used as often in the US anymore due to piles of research and controversy about its safety) and recall with perfect clarity the vomiting, the intense pain, the constant contraction as the uterus clamps down and will not release for extended periods of time. This mother was having a classic cytotec birth. I explained this to the students who were kind of baffled by her behavior. She was literally out of her mind and laying on the bed groaning and rolling from side to side. I stood next to her and placed a hand on her chest, below her neck. She stilled and reached up and looped her arm through mine. I rubbed her forehead with my thumb and she rolled towards the other midwife who was on the other side of the bed and puked. The look of surprise on the other midwife’s face was something else. Women don’t typically throw up here. This is only the second one I’ve seen who has. Somehow the shower of vomit narrowly missed the midwife and she barked at a student to go get a bowl and the mop and clean it up. Sometimes it just sucks to be the lowest one on the totem pole. I mean, you have no responsibility which is awesome, but you also get the grunt work. After all was tidy the midwife I normally work with at night came in. These two proceeded to tell me their life story—they have been friends since they were small and slip into stories and laughter at each other and themselves. All of the sudden one of them starts singing, “Darling I’ll miss you…Remember I’ll always be true…And then while I’m away I’ll write home everyday…” they trail off, forgetting the words to this classic Beatles tune. I pick up where they left off and it prompts them to continue with their concert, which becomes a medley. I have my hand on the mother and feel her still. I look at her and her mouth is agape in clear wonderment at this turn of events. There is a popular Fijian musician who apparently came and sang at the conference in the Solomon Islands last week. The midwife who was there proceeds to reenact both his singing and the response of the Fijian midwives, nurses, and doctors. This included fanning and screaming “Oh Sossi, you’re so sexy! You’re so sexy!” I have to say that I was so completely entertained by this woman—I could not peel my eyes away. I was having fantasies of bringing in a Kareoke machine and setting her loose. The mother also seemed to be taken with the show but felt too lousy to enjoy it.
Mother was stuck with an anterior lip—something I am convinced most mothers have but we don’t worry about because we don’t know about them because we are keeping our hands out of their most intimate private places and leaving the baby to do the work of birth as much as possible. With the help of the nursing student who has become accustomed to my ways, the mother got on her hands and knees for four contractions, on her left side for two, and then rolled onto her back and pushed her baby out.
The next birth was also a primip but everything was slow going. I have come to expect the friable tissue when things go that slowly here…a lack of coordination of the uterus was clear as her contractions were quite short despite the fact that baby was so low. The baby’s heart rate was very low due to the never-ending head compression and it felt like time to birth. We gave her what we call a “whiff” of synto—a super small dose just to inspire the uterus a bit and it clicked her contractions right into the strength she needed to push the baby out. I put my stethoscope on the baby’s back and listened to its heart and lungs as they kicked into gear. I caught a glimpse of the cord and noticed it looked strange, with big bubbles of Wharton’s jelly staggered up the length of the cord. I was helping the student with the placenta which looked odd when it came out and sure enough the membranes dissolved before they were totally out. Thus I went on my first true fishing expedition. I have had to coax them out before when they trail or break but there is still a visible bit there. This was about looking for bits and pieces. I gave myself a pep talk—I knew that it would hurt her but the other choice was to let her bleed endlessly. I proceeded to fish bits and pieces from near and far until I could find no more. I watched her bleeding and wondered if there were some left. I tried again but got none. I asked the other midwife to check as well—they do this all the time so have experienced hands. She found no more but I paid attention to how she held her hand and her methodology. Learning, learning, always learning…
After getting both mothers and babies settled in they asked me to do a CTG on a mother with twins. I went to fetch her—she has asymptomatic pre-eclampsia and was sleeping in the private room of the hospital. I brought her to the room and she sat down and cried. She looked like a Samoan princess—tall and with a regal face and posture and gigantic belly full of babies. I sat down next to her and put my arm around her and she started talking in English (!) She was afraid. She did not understand this hospital and just wanted her babies to be healthy and did not want a cesarean birth. She did not want to take medicine to make her numb so they could operate on her. She did not want to feel so out of control. Oh mama. Oh mama. How hard it is to come into a strange place and feel that people will do things to you without your permission. How frightening not to understand why or have things explained to you. Of course you are stressed out. You have been housing and loving these babies for 36 weeks. You are not a woman anymore. You are a fierce lion-mama and you feel protective. You have the power to take down anyone who comes near you and you feel that power in surges over and over and over again throughout the day as a parade of doctors and midwives and students come in to “feel the babies”, ignoring the person that you are. She nods in vigorous agreement. “Yes, like a lion! I want to claw them!” I nod and listen to her tell me her story.
She was married in 2009 to a man she met at a church conference in Samoa. They had exchanged letters and one day he appeared at her house with his family and spoke with her parents and the two families happily became one as they married. They moved to his home here in Vanuatu where he runs day tours to a small island and is quite successful. They hoped for babies but none came. A woman she knows in Samoa had her 8th child and could not provide for him. She asked this young couple to adopt him. They have loved him hard. He is the child of their heart and he cries when his daddy goes to work each day. About 30 weeks ago she started feeling ill and vomiting. She came to the hospital where they told her she was pregnant. She could not believe it. They rejoiced and he comes home every day for lunch—not to eat but to take care of the baby so that she can rest for a half hour. She has a good man. She went home to visit her family in Samoa for Christmas and visited the hospital there where she was told she has twins. She called home and told her husband and he was so stunned he just kept repeating, “it can’t be, it can’t be.” But it is, and they are so excited. And now she has learned that both babies are head down but she doesn’t know anything about birth because her girlfriends at home started to tell her how much it hurt and she felt that was bad preparation so stopped listening to them.
We had a little childbirth education class. I talked with her about the physiology of the sensations. She asked questions, and we talked and talked. After an hour and a half she was ready for the CTG. The machine here does not handle twins very well but I tricked it into giving a reading on one baby, and a reading on the contractions. I used a handheld Doppler intermittently throughout the 20 minutes to listen to the second baby and wrote its heart rate on the strip of paper issuing forth from the little machine. Babies sound wonderful. She held my hand and we walked back to her room and she asked if she could eat some dinner. I encouraged her to prepare as if she was going to run a marathon, plenty to eat and drink. Because the worst that will happen is she will go into labor tonight and feel like she has to throw-up and so-what if she does! She should take care of herself. She was smiling and happy and beautiful. It was nearing the end of my shift and I went to review the CTG results with the head midwife. She asked me to go and get a full set of vitals from her before I left. I went back in and her mother, who had been sitting in the corner on a chair looking at me suspiciously before stood up and hugged me and smiled and said thank you. I checked her blood pressure, her temperature, her pulse and told her to get a good dinner and sleep, and left them alone for the night. All I want to do is go in and see how she is doing today but my shift doesn’t start for another hour.
I am back where I started six weeks ago—that humanity always matters. Kindness and communication transcend culture, skin color, and the “way things have always been done”. Fear will always rule where knowledge is lacking—in one woman or in a society of people. And while midwives can’t solve all of the problems of a society, we can always ease the fear of the woman in front of us by sharing the truths in the most complete ways we can find to do so (even when they are unhappy truths). Did I miss a birth? Actually, I missed two. And I feel I was the beneficiary of this woman’s sharing of her-self and the story of her family. Today I don’t want to go see and what that busy ward will bring me in terms of experience and skill development. I just want to see her and sit with her and hopefully welcome those babies and tell them what a great mama they have.
Gestational Age Workshop-Jane July 13, 2011
So, let’s say you are living in an imaginary developing nation called, just for the sake of arugument, Huganda. And in the great country of Huganda, there is little access to, well, anything. And that’s usually fairly ok, as you are a midwife, and make a pretty good salarly working for this NGO called, just for the sake of argument, Manti Huganda.
Now, Manti Huganda has been trying so hard to do everything by the book in the great country of Huganda, as it is new and wants badly to be a recognizable force of positive change. So Manti has some rules, like they do not accept anyone over 20 weeks, and they transfer mamas out of care when they hit 41.5 weeks, or if they deliver before 37 weeks.
(Now we who live in the great country of (just for the sake of argument) Lamerica, or maybe Janada, especially those of us who may have some more liberal ideas about mothers and babies, and all of their inherent perfect timing in regards to birthing, may not understand these rules, and why Manti is interested in playing by them. Its ok. Just accept it. In Huganda, rules can get you into a place, and then, you can work to change them. It will be ok.)
But on a practical level, how can you abide by the rules you have set, if the mamas don’t? What if they have no idea when the first day of their last period was, and they cannot afford a dating ultrasound? What if they are measuring small because of bad nutrition? Or, conversely, measuring big because of bad nutrition? What if you, as the midwife, only had one tape measure anyway, and now its lost, and who knows if they even sell tape measures in Kasana?
(This is not as weird as it sounds. We could not even buy string. We were told four times that we would have to go to Kampala. Finally, we bought stove wicks and pulled them apart. And let’s not even get on the subject of zip locks. I may, at one point have offered to trade both Anna and Rachel for a box of gallon sized. )
Oh, and let’s also assume that Manti doesn’t have a gestational wheel, and has to rely on manual calculations. I think someone should donate a few to them. Let me know if you’d like to get in on that. I know an organization called, for the sake of argument, deesentialschmidwifery, that will probably throw a few over the ocean.
So if dates are not known, and ultrasounds are too expensive, and you’ve lost your tape measure, how do you determine gestational age? This was the question the lovely Annet posed. We were going to have to get creative. Old School.
The first thing I asked our next ambiguously pregnant woman was whether or not they had felt the baby move. Back in the day, this ws really the only reliable way you even knew you were pregnant for sure. Until delivery, that is) Most first time moms feel those first fluttery kicks around 16 weeks. But some feel them as early as 13, and some as late as 25. Second and subsequent pregnancies are usually felt earlier, but this is not a hard and fast rule. So now, we can narrow our mama’s pregnancy to between 12 and 25 weeks. Not extremely helpful.
Here’s where palpation comes in, and as its one of the things I like doing best in the world, I was eager to show these techniques to Annet and this lovely mother, who was wondering when the heck she was actually going to birth her first baby. If she were only 12 weeks along, we would barely be able to feel her uterus just beginning to poke over her pubic bone. At 16 weeks, the top of the uterus would be about halfway between her pubic bone and her belly button, and by 20 weeks, it should be at just about the umbilicus. And when the baby is done cooking, it should be about level with xyphoid process at the bottom of the sternum.
See? That just clears it right up, doesn’t it?
Of course, there is always the copyrighted Shrugging technique, where the attendant smiles ruefully (this is an important part of the protocol), and slowly raises her shoulders towards the ears, holding the pose for a second or two, before lowering them, saying, “Well, we can always Ballard or Dubowitz them when they come out.” These are assessment scales used to measure certain infant behaviors and physical properties to make an educated guess on the age of the baby.)
And that, my friends, is how we determine gestational age. And also, just maybe, how we can get around a few of those pesky rules, and renew our trust that babies come when they are meant to, even if that time is “early” or “late.” Even a baby that arrives unexpectedly, and needs some help, might be telling us that she was better out than in, that something in the interuterine environment was not as healthy as it could have been. We can still believe in that baby and that mama’s innate wisdom, while providing the best support for both of them that we can. And that, I believe, is more important than anything else.