essentialmidwifery

Birthy Thoughts by Jane E. Drichta and Jodilyn Owen

Viola October 22, 2012

Filed under: Jane,Uganda — EssentialMidwifery @ 8:49 am
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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!!  Photo: Baby Patrick and his gorgeous mother, Viola. Sometimes even 4th babies have two day labors.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.

 

A Visit to the Kasana Hospital Part 1-Jane October 17, 2012

Filed under: Uganda,Uncategorized — EssentialMidwifery @ 12:27 am
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I can’t look away, and on some level, I don’t want to.  The young boy, maybe 7 years old, arches his back again, his entire body spasming, his face stuck in a grotesque and totally involuntary leer.  Sweat pours off his body, running down his neck, pooling on the black vinyl mattress. His mother, standing by his side, moves to support his head, but is stopped by a nurse, who explains softly that she could hurt his neck muscles, and to let the seizure take its course.  Not that it matters.  This boy has tetanus, and this boy is going to die.Tetanus is treated with metronidazole, diazepam, and tetanus immune globulin, none of which are available in this Level 4 Health Center that serves Kasana and the surrounding countryside.  The staff has only comfort measures to offer, and in this “hospital” nothing is comfortable.

It is hot inside the small run down building, sunlight and its attendant heat streaming in though the massive holes in the roof.  Add to that the humidity that naturally occurs when you have lots of people, especially lots of sick people, gasping in one room, rebreathing the same air over and over.  There is no ventilation, save the afore mentioned holes, and the stench is incredible.  And for now, it has all narrowed to this boy, this child and his mother, who can do nothing but watch, her tears adding just that much more moisture into a room already overburdened with misery.

Americans are mostly vaccinated against this disease, and even in those who do manage to acquire it, there is a 90% recovery rate. Not here. Here there is nothing to be done.  This hospital does not have the necessary drugs, nor does the bigger one a few towns away.  They will transport the boy anyway, to the larger hospital, but it is still hopeless.  Even with the needed drugs, by the time the spams, called opisthotonos, have reached this level of intensity, it is almost always too late.  They are strong enough to tear muscles, to cause fractures.  And they often affect the muscles surrounding the airway, causing brreathing difficulties. This family, at the very least, does have the money to transport their child.  Hundreds of others do not.  If you do not have the money for drugs or fuel, you or your child dies.  That is the harshest of realities.  Ostensibly medical care in Uganda is free, but if the hospital does not have the drugs you need, then it is up to your family to procure it from an outside pharmacy. But, what happens when the pharmacy does not have the drugs?  You die.  Just like this child, probably infected while playing outside in the dirt, just as children do the world over.  One child and one mother.

Everyone on our trip is a mother.  We have birthed our children into the world, transforming ourselves at the same time.  To look at this Ugandan woman, to share in her knowledge that her child is dying, and to be able to hold that seems impossible. How do we even do that?  Why don’t our hearts just crack wide open and we all just die right there?

On some level, I think they do.  I have held this vigil before, holding babies and children in my arms as they pass from one world to the next.  I’ve sat with parents, held mothers as they screamed their grief and anger and disbelief to the universe, when it seems there is no good or rightness in the cosmos.  To watch a child die is the unfairest of the unfair, and it is no different here than anywhere.

So I can’t look away.  It it an intrusion, to observe someone’s pain when you are in no position to help?  I don’t know.  Probably in America it would be.  Death is seen as private, and grief inconvenient.  We are so uncomfortable with death that we try to wish it away, pretending it doesn’t exist and those whom it touches are somehow weak, and perhaps even to blame.  But here, death, like life, is communal, part of a rich tapestry of family and community.  And so I offer myself as a witness, joining her world for a few moments, a silent chronicler of one mother’s worst nightmare.

 

Of netbooks, imodium and joy-Jane September 23, 2012

Filed under: Uncategorized — EssentialMidwifery @ 9:23 pm
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You know that feeling when you come home from work, take off your bra, (oh, you know you do!)and slide into some old, well worn, slippers?  That aaahhhhh made of contentment and peace?  That’s exactly how I feel right now, typing this on my old travelling netbook.  The keys are too small and clacky, the Internet speed is measured in seconds, and its been through three power cords.  I got this little beauty in 2008, when my father was ill, so I could carry it back and forth with me to St. Louis.  Since then, it has seen The Philippines, Uganda, Whidbey Island, Portland, London, and a bunch of other places, near and far.  And now we’re off again, back to Uganda to teach and learn and see.

Its is actually kind of a riot that I’m using this computer right now, as my regular laptop is sitting just over there on the counter, and I haven’t even left home.  But I wanted to get in the mood, indulge in a little travel foreplay, if you will.  I’ve already done most of the packing.  My clothes are drying right now: 3 skirts, 4 t shirts and a metric ton of underwear.  This girl has her priorities firmly in place.  I’ve sorted the drugs into catagories, and packed them in either the carry on or the regular rucksack:  Def Con 1 prescriptions, ie malaria prophylaxis, ambien for the plane. Def Con 1 non-prescription, incuding advil and tums.  Then we get down to the Def Con2 prescriptions, Cipro, Bactrin and a wee tiny bit of vicodin because this midwife’s back is not as young as it used to be.  And finally we have the Def Con 2 non-prescription, which basically includes everything else Walgreens sells with an emphasis on things that make you poop less.  Poop is a Big Deal in many of the places I frequent, and one bout of norovirus made me never take solid food for granted again.

I’ve also packed some donations of medical supplies, (although I have to run out and pick some more up), and the teaching supplies we need for the training.  We are all pack mules, but I feel like I’m as stripped down as possible.  I’m taking my doppler as well.  Please don’t judge me, birthy friends!  I come with love and good intention. I promise.   I know the controversy, and I’m consciously choosing to put that aside.  We have the luxury of choosing not to listen or get ultrasounds, or do any of the things that our accident of first world birth allows us to do.  If we feel our baby isn’t moving, or we have any concerns at all about her wellbeing, we have these technologies readily available to us.  But Ugandan women do not.  If their baby isn’t moving, they either go to the clinic where the midwives use steths and fetoscopes to try and get an idea of what is going on, or they don’t do anything and pray.  For the ten days that I’m there, they are going to have access to a doppler.  Hopefully it will just be used for happy doings; the vast majority of women I know love to hear that little heart jumping away in there, and I assume Ugandan women will enjoy it too.  And if it needs to be pulled out for a darker purpose, it will be there for that as well.

So now I’m down to the last errands.  Off to the ATM, Freddies, Kinkos, and my office to grab a few odds and ends.  And tonight I’m going to practice my Lugandan.  I wonder how you say, “Ready or not, here I come?”

 

Back to Uganda! (Jane) August 11, 2012

Filed under: Birthy Thoughts,Jane,Not-so-birthy Thoughts,Uganda — EssentialMidwifery @ 7:07 pm
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Its official!  I’m headed back, and this time I’m bringing friends, some of whom I know, and some of whom I am looking forward to meeting.  In a few short weeks,  I’m leading a team of awesome doula trainers, and we will be sharing our knowledge and skills with the Ugandan midwives, several aspiring Canadian doulas, and each other.  Many of these women have never travelled internationally at all, let alone to a developing country.  I wish I could see the trip through their eyes, because I’m curious like that.  I want to know everything…why they want to come, what they hope to accomplish, how I can  support them.  We’ll discuss all of that, of course, and I will do the best I can, but in the end, it’s just like birthing.  (Hey, I’m a midwife.  I can make a birth metaphor out of two pieces of gum, a string, and a small poodle.  I’m McGyver with a doppler.)

Everyone who is going on this trip has different experience with birth, with travel, with education, with life.  As a leader, I feel it is my obligation to meet each participant where they are, to facilitate growth and provide a safe little cocoon in which to process and relax.  But I can’t force my idea of what they should be experiencing onto them.  It has been so interesting just to watch different folks’ reactions to the preparations, trying not to butt into their processes and tell them what I think they should do. Everyone has different ideas about vaccines, ebola danger, political instability, the lack of infrastructure, what technology to bring, etc etc etc.  I’ve tried so hard to offer choices, to tell them my experiences, and then just shut up and get out-of-the-way.  It’s not my birth, it’s not my birth, it’s not my birth.  I have no expectations around this trip, except to offer who I am, and then to sit back and let the labor take its course.

The constant, of course, is Uganda, with everything that that implies.  After all, Africa always wins.  Those of you who came along with me on the blog last year may remember that I couldn’t find string in Kasana, and had to disassemble a mop to make a project work.  (see, I wasn’t kidding with the McGyver bit.)  That experience has become my symbol of flexibility, of creative thinking, of letting go.  It will be so interesting to see what symbols the other team members gather, which little image or event worms its way into their brains, and stays with them back home.

All I can do is my very best, and trust the process.  After all, its always worked before.

 

Sticky Hearts–Jodilyn July 8, 2012

Filed under: Birthy Thoughts,Jane and Jodilyn — EssentialMidwifery @ 10:32 pm
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Midwifery is a profession practiced by daylight for clinic visits.  Timed, scheduled, and pretty predictable, these visits last between thirty and sixty minutes and cover all of the details and measurements of how a mother is feeling, and how her baby is thriving.  We spend a lot of time just talking and hearing about mothers’ lives and day-to-day struggles and joys.

Under ideal circumstances, these visits give us more energy for the work we do.  They leave us feeling inspired and connected with each other and the mothers we serve.  Even as the family ramps up preparations and excitement for their birth, we are also ramping up.  We talk a lot about what we expect from a certain birth, challenges that may come, emotional hurdles we will be there to coach a mother through.  We laugh at the funny things toddlers say and do and bask in the remnants of oxytocin expecting mothers leave behind them like a trail of glitter, everywhere they go.  It does not feel like work-work, it’s a special kind of heart work that happens to require plenty of knowledge and experience.

At a recent birth we sat through the night with a lovely mother, who was intent on moving heaven and earth all on her own to have this baby on her terms.  She had a lousy experience with her first birth and no desire to repeat that.  She didn’t need much from us through the night, just the knowledge of our presence was a comfort to her as she labored.  As the sun rose and we made plans with our own families to make sure our children could get to school or work and all of the minute details it takes to get the day started, this mom turned a corner in her labor.  We stretched and made coffee and settled in for the exhilarating moments ahead.  Mom did birth her baby, in her home, on her terms, surrounded by people who believed in her.  A few days later we did it all again with another family.  It may sound like each birth is some repetition of the one before, but the truth is that each mother is unique, and even after hundreds of births I can still say that every birth is different.  Every family brings me new lessons and insights into birth, the meaning of family, and my understanding of the world. And I’m just one midwife. Every week midwives all over the city, the country, and indeed the world go to homes in the middle of the night, rearrange their family schedules to accommodate their absences, sit with women through the long hours as they labor, encourage them through the hard parts, cheer with them in the joyous moments, and watch over the birth of wonderful babies who bless us with their presence.

When the moms and babies are tucked in with their families and resting and I drive away from these births I rarely view the time I just spent as work.  I feel these families on my heart; like little post-it notes, they stick there and are warm and welcome additions to my person. They expand my capacity for seeing love in the world and feeling that there is goodness to be had.  The work of midwifery is sometimes just work-work, but most often it is heart work.  And I carry it with me on my sticky heart, full of the stories, joys, and triumphs of the families I have been lucky enough to serve during this vital time.

 

“False Labor”: Misnomer of Grand Proportions–Jodilyn May 21, 2012

Filed under: Birthy Thoughts,Jane and Jodilyn — EssentialMidwifery @ 4:17 pm
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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

Filed under: Uncategorized — EssentialMidwifery @ 1:29 am
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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

Filed under: Birthy Thoughts — EssentialMidwifery @ 2:53 am
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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!

 

VBAC-less in Seattle February 17, 2012

Filed under: Birthy Thoughts,Jane — EssentialMidwifery @ 12:49 am
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It is no secret that Jodilyn and I are completely and utterly committed to vaginal birth after caesarean. We believe in the right to birth your baby vaginally, whether in your own home, a hospital, a field, hanging from a trapeze…you get the idea.  We believe in intentional birth, one that is the fulfillment of carefully considered thought and soul work, and not one forced into an impersonal mold by circumstances.  In short, we believe that everyone has the right to birth the way they see fit.

Only, what happens when you can’t? We have been so lucky here in Seattle, because while the actual number of providers doing vbacs has remained fairly low, there has traditionally been a nice mixture of types of providers.  We have homebirth midwives, hospital midwives, family practice doctors, obstetricians, and even a few perinatologists.  Unfortunately this has changed radically over the past year.

Hospital midwives who do vbac are in short supply here in the greater Seattle area, and getting shorter.  We have lost two major midwifery groups, and one extremely popular independent practitioner.  We now have only two hospital midwifery groups in Seattle  proper who do vbacs, and one of those are severely restricted due to insurance limitations.  While we do have many doctors who deliver vbac babies, they are, in fact doctors.  They may be delightful people, but they practice under many limitations, some self imposed, some practice or hospital based, and some pushed upon them by insurance companies and malpractice issues.  They are not midwives.

And midwifery care IS the answer here.  If anyone needs the focused care and tender compassion of a midwife, it is the vbac-ing mother.  The long office visits, the search for answers from her last pregnancy, the wading through pages and pages of safety studies…these are not the exclusive territory of homebirth midwives.  It is the right  of ALL midwives, regardless of where they serve, to hold a woman as the tears come during prenatal visits, to flush with anger alongside her for indignities done, and questions left unanswered.  ALL midwives should be privileged to wipe the sweat from a laboring vbac-ing mama’s face, to bring her water, to sing to her softly in the tub.  And ALL midwives should have the opportunity to discover the humility and strength that  reside in their souls in a way that is only possible when they stand silent in the birthing space, the one solitary being who truly and absolutely believes in this mother, body and spirit.

It is honor beyond measure to attend these women in their most creative time.  And I am so sad for the midwives who are being denied this.  I want our sisters back.

 

The Quintessential Togetherness. January 31, 2012

Filed under: Birthy Thoughts,Jodilyn — EssentialMidwifery @ 7:13 am
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Well Harumph….

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.

 

 
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