Archive for August, 2009
Ohhhhhh mahhhhhhhhhhhh gawwwwwwwwwwwwwwwd, I don’t think I could have been wearing less comfortable jeans unless I’d been sweating and they were made of leather. Seriously. It was a pair of jeans that my mom bought me during a super-fast shopping trip while I was in Michigan a few weeks ago — it was literally hours before the wedding started. I found a really cute pair of jean capris and she went find a second pair just like it, and she couldn’t find the exact same ones, so she grabbed a “similar” pair, “similar” in this case meaning “looking somewhat like it except not meant to be worn in any situation where one might have to attempt sleeping in these pants.” To give you some idea, dear readers, of the extend of my discomfort, let me say this: there is a belt buckle sewn into the BACK of these jeans. Ugh.
In my defense, I was under the impression that this birth would move quickly. Also, in addition to torturing myself from the waist down, I hadn’t washed my hair that day. I think at one point the laboring mom actually looked at me and shuddered at my overall grossness.
After returning home, I immediately got on oldnavy.com and bought two pairs of cotton yoga pants, 2 cotton tshirts, and 2 long-sleeved shirts (I’m skinny now, so I get cold, yo). I’m going to make two birth bags and put one in my car and one in my house, and include the clothes, dental floss, travel toothbrush and toothpaste, travel deodorant, hair ties, and maybe some of those face cleaner wipes. Because I really never want to feel as gross during a birth as I have recently.
What I have learned recently: to trust the process.
There is such a huge difference for the mom and the experience when the provider trusts the process versus a provider who does not believe in what she’s doing. I can see that a lot of it is experience — it takes a lot of birth experiences to believe in birth. Sometimes things go wrong — without any warning — and often it doesn’t go the way it “should,” as prescribed by physicians in the 1950s. Here is Friedman’s Curve of expected dilation.
The Friedman Curve — which is adopted by hospitals and written in the blood of obstetricians — is kind of a hot mess. Here’s a quote from BirthSource about dilation
Current definitions of labor protraction and arrest may be too stringent, Dr. Jun Zhang of the National Institute of Child Health and Human Development, in Bethesda, Maryland said at the 2002 annual meeting of the Society for Maternal-Fetal Medicine. “And the long-accepted Friedman curve may not be an accurate description of normal labor progression, according to a new analysis of data from 1,329 nulliparous women aged 18-34 undergoing singleton, vertex presentation deliveries following spontaneous labor,” said Dr. Zhang.
Based on the speed of overall labor progression and current cervical dilation, Dr. Zhang and his colleagues calculated the expected traverse time for the cervix to reach the next centimeter and the expected rate of cervical dilation at each phase of labor. “Our curve is very different,” Dr. Zhang said, pointing out that on his curve the average was 5.5 hours for progression from 4 cm to 10 cm, compared with 2.5 hours on the Friedman curve.
“We also didn’t see a deceleration phase,” he said, noting that in 1978 Friedman modified his curve, but the distinctive sharp upturn remained, as did the deceleration phase. “Our data suggest that most women enter active labor at different times, mostly between 3 cm and 5 cm dilation, and even in the active phase the speed of progression varies from person to person,” he further explained. The median time for cervical dilation to progress from 4 cm to 5 cm in the present study is 1.7 hours. And for fetal descent, it could take 3 hours to progress from station +1 to +2, and an additional half hour from station +2 to delivery, he added. “Therefore, the definition of protracted descent or arrested descent appears to be too stringent in current practice,” according to Dr. Zhang.
Generally, when there is a plateau (stopping of progress) of two hours in Friedman’s curve while in a non-medicated active labor, or of three hours in active labor with an epidural, then “failure to progress” is the diagnosis and C-section is indicated. Of course, evaluation of the “4 Ps” — Power, Psyche, Passenger, and Passageway (basically this means the force of labor, mental preparedness of the mother, the size and position of the baby, and the size of the birth canal) must be made to see if there is a correctable measure.
A long plateau is when a typical hospital provider generally starts to freak out (about malpractice, perhaps?) and push for interventions like breaking water, giving pitocin, and suggesting that the mom have an epidural so she can rest since she’s obviously exhausted — whether or not the client says she’s tired. I’ve had a lot of overnight labors. I’ve only ever attended one where the woman has said she’s exhausted. (And it was a woman who had not followed my suggestion that if her labor began while she was sleeping and she wasn’t have contractions yet, she should try to go back to sleep, or at least rest. That might have made a difference.)
In a different setting, with a different provider, nobody freaks out when the labor doesn’t progress as it “should.” In fact, there are no “shoulds.” As long as everyone is healthy — baby’s heart rate is fine; mom is eating and drinking and peeing and resting when she can — the labor simply continues. The provider might consider some alternatives that would gently move the labor along — changing positions frequently, homeopathic remedies, eating and drinking, resting, discussing any psychological issues the mom may have surrounding the labor and birth and impending motherhood — but she doesn’t force.
Trusting the process is somewhat different from sitting on my hands, which I wrote about last month. Sitting on my hands was at a birth where everything was progressing as it “should,” but I felt like something needed to be done. See, I’m inexperienced! Trusting the process is about stepping back and looking at the facts and making decisions based on this individual situation, while taking into account the midwife’s experiences.
A quick note about midwives who work in hospitals, also known as Certified Nurse Midwives. I believe that many of them trust the process, but the physician who is supervising them does not, and they are at his or her mercy. At a hospital birth recently, a machine kept malfunctioning and recording incorrect information; the baby was fine but it said that the baby was in distress. The CNM would come in and say that they had to get it fixed because if the attending physician saw the records, he would “go through the roof.” Did she trust the process? Well, yeah, she knew the baby was fine. But she was under the direction of the physician who clearly did NOT trust it — or maybe because he was supervising multiple labors simultaneously (without ever seeing anyone face-to-face) so he was unwilling to look at the individual labor.
Of all the websites I use for wasting time, The Cochrane Collaboration is probably the one I should make my homepage. Rather than learning how to make a hula hoop out of pvc-piping and a vice grip, the Cochrane Database has systematic non-biased reviews of health care studies.
About The Cochrane Reviews:
“Based on the best available information about healthcare interventions, Cochrane reviews explore the evidence for and against the effectiveness and appropriateness of treatments (medications, surgery, education, etc) in specific circumstances. Designed to facilitate the choices that doctors, patients, policy makers and others face in health care, the complete reviews are published in The Cochrane Library four times a year. Each issue contains all existing reviews, plus an increasing range of new and updated reviews.”
Some things I learned tonight from about 15 minutes spent on the Pregnancy and Childbirth Topics page:
- They spell cesarean, “Caesarean” — so if that’s what you’re looking for, there’s how to spell it. Otherwise you might not get any hits.
- In Amniotomy for Shortening Spontaneous Labour, the results were “The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”
- In Antibiotics for mastitis in breastfeeding women, “The review included two studies and approximately 125 women. One study compared two different antibiotics, and there were no differences between the two antibiotics for symptom relief. A second study comparing no treatment, breast emptying, and antibiotic therapy, with breast emptying suggested more rapid symptom relief with antibiotics. There is very little evidence on the effectiveness of antibiotic therapy, and more research is needed.”
- In Vaginal chlorhexidine during labour to prevent early-onset neonatal group B streptococcal infection, “The review of five trials (including approximately 2190 term and preterm infants) showed that although chlorhexidine reduced the number of bacteria that passed to the babies, the studies were not large enough to say whether it reduced GBS infections or not.”
I found the GBS study the most interesting, because you would assume that if the number of bacteria passed to the baby is reduced, the GBS infections would be reduced also, and it’s not (as far as the review shows. Probably more research is needed. Isn’t it always?)
I love being a doula, and helping women give birth, but sometimes being at a hospital can be so disheartening. Hospital protocol often has nothing to do with research. Withholding food and drink in labor to prevent aspiration “just in case” moms need an emergency c-section under general anesthesia is ridiculous — in a study that included 78,000 laboring women who ate and drank, there was not one case of aspiration (source: The Thinking Woman’s Guide to a Better Birth). Continuous fetal monitoring for low-risk pregnant women doesn’t improve outcomes any more than intermittent monitoring, and may in fact raise rates of c-sections due to the high false-positive rate (same source). And yet, I see the former at every birth, and the latter pretty frequently. Women who are essentially told to run a marathon are told in the same breath to go the distance without food or water. An IV is not meal replacement — in fact, they often overload the mom with too much fluid, causing her kidneys to work overtime — and they are invasive and painful.
Glad the next two births I’m scheduled to attend are not at hospitals.
In which I did something that I honestly didn’t remember that midwives do back when I signed up for this!
Guess what I did?
Leigh and I had briefly discussed that I would begin giving injections (using B12 as practice) but I haven’t started that yet. Meanwhile, we were with an extremely easygoing client who needed an injection, and she graciously allowed me to shoot her up. Thanks!
Add this to the list of things that I had totally forgotten that midwives do on occasion. People think midwifery is about catching babies but that’s just a small part of it. Most of it is about care during pregnancy and postpartum; childbirth is just one day. Although it all seems to come down to that one day!
I’m working on a routine for our days at home so that I can keep my house on the right side of CPS’s version of clean, get some school work done (mine), get some school work done (kids), and allow all of us a chance to
waste time on the computer enjoy free time. So far it’s wake up, brush teeth and get dressed, clean up rooms a little, have breakfast, free time for kids (while I do some school), school time for kids, lunch, quiet time/nap, more learning, clean downstairs, plaaaaaaaaaaaaaay etc dinner husband home. I hope it will work out — I absolutely need some time during the day for school work; I can’t do it all at night. Some nights I have interviews with potential clients, or prenatal visits or postpartum visits.
(Yes, I hold every baby in my left arm, and only wear solid-color shirts.)
Here’s what I’ve learned lately: I can’t predict anything. I can’t assume anything. Even when the evidence is there after hours of labor and I’m thinking that I know — I know! — in which direction the labor is heading, I usually don’t.
I have learned to turn off that aspect of my brain during labor and just focus on the task at hand, like holding an emesis basin while a mom throws up into it. Otherwise I start thinking, “Wow this really isn’t going well, I hope she doesn’t end up with a C—” (and baby is born vaginally 20 minutes later.) “Wow, this is going fantastic, this baby is going to be here in an hour–” (and 17 hours later, the baby is born.)
It seems antithetical to the idea of holistic midwifery to put my ideas and my experiences on someone else. Every birth is different. I learn something new at each birth. And what I’ve learned over the last few years is that I just can’t predict anything. Women surprise me. Labors surprise me.
I’ve progressed a little in my school, I’m now in “Orientation” and have requested my curriculum. My mentor just graduated and took the NARM exam. Recently I talked to another student who told me that I’m making my assignments more difficult than I need to; I’m over-thinking them. Really? Me? The woman who can’t order food without having an internal dialogue (complete with debate of the pros and cons) between a grass-fed hamburger that is cooked medium versus medium-well?
I guess it’s really not that surprising.
and Just Do It.
Copyright 2009. Please do not copy or repost.
The first book about pregnancy I read was “The Girlfriends Guide to Pregnancy.” As much as I want to denigrate the content of the book, especially from the perspective of a student midwife, I enjoyed it at the time. I recall fondly laughing out loud at some of Vicki Iovine’s descriptions of various complaints of pregnancy, because I could relate!
My first pregnancy was unplanned and unexpected, and initially I did not have the support of my family or my then-boyfriend, so laughter and lightness were hard to come by. Looking back, I cannot completely ignore that positive effect of reading it. I do remember specifically that she’d had two c-sections and two vaginal births, and she rated them about equally. At the time, I thought, “How is that possible? One is surgery!”
The first book about birth that I read was “The Thinking Woman’s Guide to a Better Birth,” by Henci Goer. I read it later in the same pregnancy – which turned out to be twins – while on bedrest for Twin-to-Twin Transfusion Syndrome. I was given the book by my doula, Gretchen Humphries, who is a VBACtivist and writer on VBAC-related topics, after she had twins by c-section and two HBACs. I had never read a birth-related book before. It was incredibly eye-opening.
Prior to reading it, I didn’t realize that I had a choice in anything relating to my pregnancy and birth. I just thought the doctor I was seeing – an obstetrician in a high-risk clinic; a maternal-fetal medicine specialist and a twins expert – had my best interest in mind. (In retrospect, I’m not saying he didn’t. But I assumed it because he was my doctor, not because of how he treated me.)
After reading The Thinking Woman’s Guide, I realized that I had to be my own advocate. I specifically remember asking about telemetry monitors, and my doctor gave me a funny look, which I later interpreted – after becoming a doula and seeing that same look exchanged between my clients and their providers – as his realization that I’d become one of “those” types of patients. The annoying type; the type who asks a lot of questions and want a lot of answers, and want to understand the research behind the protocols.
As my pregnancy with my twins progressed, I had a lot of NSTs and BPPs. Baby A, the donor twin, was smaller and seemed growth-restricted. One doctor in the clinic I attended recommended a c-section at 33 weeks, but I refused. I ended up consenting to an induction at 34 weeks due to possible IUGR in baby A. I had cervidil, and did not need pitocin; I had a vaginal birth eight hours after my induction, with a feet-first baby B who was 2lbs bigger than baby A.
I really credit reading “The Thinking Woman’s Guide” to helping empower me. In turn, I wanted to help empower others. Birth is so different when a woman can say, “I chose this,” versus “The doctor did this…” At first I thought that every woman wanted to be empowered during her pregnancy and birth. Later I realized that many don’t. However, those who do need the support of other empowered women, especially those who have had an empowered birth.
Today I went to a homeschool conference. I have four children — monozygotic (“identical”) twin boys who are 6 years old, a 4 year old girl who is very sneaky, and a 2 year old girl with ringlets — and we’re going to start homeschooling this year. Or we already are, I guess. Of course the day wouldn’t be complete if upon parking at the conference location I hadn’t immediately run in one of my sister student midwives and had a quick discussion about recent births we’ve attended. But mostly my morning focused on learning more about homeschooling.
My biggest concern used to be spending 24/7 with my children; but as I’ve been doing it all summer and we’ve all survived, now I’m mostly concerned about finding the time to homeschool, do my own school, attend prenatals and births and postpartums, and keep the house clean enough that CPS isn’t called to our house based on reports of squallor. Did I mention we also have three dogs who all shed profusely? Oh, and also keep everyone fed at regular intervals.
I think in my heart, I’m an unschooler. I’m really not looking forward to sitting down with my kids for a specific amount of time and teaching a specific… thing. I’d really rather just kind of let them learn about laundry piles and how to maintain them, and why keeping the door shut to the least insulated room in the house keeps our upstairs somewhat cooler, and how to get dog hair out of the corners where it all seems to converge, daily. I’d rather just let them count their Cheerios and learn the left side of the sink from the right side of the sink for putting their bowls on the proper side, and learn to read by watching TV with Closed Captioning — because I can’t watch TV without using Closed Captioning. I like to see exactly what everyone is saying.
However, that all said, I would like them to read — at least so they can stop bugging me about “what does this say? what does that say?” — and write and learn a foreign language and maybe an instrument. Math, I don’t really care about, and science is more of Dustin’s thing. He’s a chemist; I don’t even know why the sky is blue.
So, I’m dutifully looking into “curriculum,” and have decided that it will consist of Teach Your Child To Read in 100 Easy Lessons, Handwriting Without Tears, and Math-U-See. Also, Sing Song Latin — one of the only useful lessons from high school was learning Latin and Greek root words and prefixes and suffixes; thank you, Mrs. Taft — art supplies including Stockmar Crayons, some kids’ music, and playing outside.
I’m tired just thinking about it. And this does not even account for time to do laundry!
Seriously, we might be living in squallor! I cannot procrastinate my own school work, I cannot skip prenatals or births or postpartums; something’s gotta give. And it will probably be the house.
I’m wildly lucky to be married to Dustin, who is totally impervious to filth. Totally impervious. He has many good qualities, but that may be his best. Of course, when I’m actually ready to strap on my shoulder-length rubber gloves and tackle the bathrooms, he seems totally miffed, but I’d rather have someone who doesn’t mind the mess than someone anal-retentive. Or COD, as my bff Emily calls it. That’s OCD properly alphabetized, of course.
You know, those giant horses that clop-clop-clop really loudly? That’s how people on the coolrunning.com website describe overweight runners. There’s even a group called Lady Clydes. Lovely. I have tons of extra skin since my surgery, and my sister swears that running will help. However, my broken toe still hurts, so the treadmill will probably maintain it’s usefulness as a towel-holder for another month til I feel 100%.
Sleeping in my bed is another hobby. I miss sleeping late, and I miss my bed. I used to get into bed on Saturday nights and read People magazine; now I leave it in the bathroom and thanks to my weight-loss surgery and its effect on my intestines, I usually get it all read within a week.
I have this thing. I’ll call it a thing. It’s like my achilles heel. It’s a thing I see at births that drives me a little crazy, that I vow I will absolutely never do.
I know how silly that sounds. It actually sounds like I’m a total birth newbie — if I weren’t, I’d realize that nothing about birth is absolute, and it’s stupid to take such a hard line, especially when I haven’t seen that many births. Birth is not black and white, and midwives — midwives! — value autonomy and individual decision-making over generalizations like “I NEVER do XYZ to clients,” or “I ALWAYS do ABC to clients.”
In fact, when I was pregnant with my last child, and looking for a homebirth midwife, I interviewed someone over the phone who had a blanket policy for all clients — when labor started, the client had to take an enema. This midwife insisted on it, in all circumstances. Immediately a giant red flag went up, and I did not hire that midwife.
So why do I feel so strongly about my thing?
In my idealized version of reality, I’m a midwife who sits on my hands and simply watches a woman birth her baby with no assistance from me. (See my post about knitting during births.) In my idealized version of reality, I’m Ina May Gaskin, with silver Princess Leia hair and no make-up and long patchwork denim skirts.
In reality, sitting on my hands is uncomfortable for me, and I can only assume I will continue feeling that way. I don’t want to do every intervention, but I definitely have a hard time just watching and waiting.
I think my strong feelings come from my own experiences, and that of a close lovely friend who has had 5 babies. The truth is, I have always messed with my body during labor in some way. I’ve taken castor oil, an enema, I’ve had my membranes stripped, I’ve done the breast pump, I’ve had sex solely for the purpose of getting the baby out, I’ve taken black and blue cohosh. I’ve tried it all, everything you can do at home that toes the line of “natural” induction methods. And I regret it.
And so, as I become a midwife, I guess I want to save my clients — from MY bad experiences.
But, the rub is, maybe those same things aren’t bad experiences for others; maybe they will do them and not regret them; maybe they will do them and feel grateful. I always have to remember that these are not my births. I have to remind myself, my births are over, done. And I can’t undo them, or redo them, no matter how many births I attend. Honestly I don’t want to, not consciously. (All that pain… throwing up… no thanks.)
So, among all the things I’m learning — Braxton hicks contractions start at six WEEKS! Engagement is the point when the widest diameter of the presenting part has passed through the inlet of the true pelvis! PROM occurs in 10% of all pregnancies, PPROM occurs in 2% of pregnancies! — I’m learning about myself also, and how I can be the most effective midwife for my clients. For them. Not for me.