comedy of errors

So on this lovely morning I find myself driving to a birth. Cruising through a main street of town, I think "I am going to make great time." Then I get behind 2 cars, the front of which is driving 25 in a 35 mph zone. Really?!

The car turns at the next major intersection, and I briefly rejoice by stepping on the accelerator, until a posse of bike dudes decked out in serious bike gear crosses the street and merges into traffic. Grrr...

The other car and I slowly maneuver past the biker posse. Then I turn onto the rural 2-lane highway and find myself behind a garbage truck! I manage to pass the one car between us, but every time I dip left past the truck to gauge traffic, I see an oncoming car.

The garbage truck finally turns...at the same intersection as I. "Screw this," I say as I motor past the truck illegally, but safely.

A hearse pulls out in front of me.

Actual cost of driving time=10 minutes.
Cost of comedic effect=priceless.

color me whiney

what happened to the revolution?

I really want a doula at my birth, but...

I really want a natural birth, but...

I really want a VBAC, but...

I really want a homebirth, but...

Someone once said "There is no 'but' that is not followed by an excuse."

Really wish people would say what they feel, and do what they want. And take some responsibility for their choices. Like this:

I want to have an epidural and feel absolutely no pain from the very first twinge of a contraction.

I don't want a doula at my birth, I just went through the motions of looking for one because my girlfriends all hired doulas.

I do want a doula but my doctor's practice doesn't work with doulas and I don't want to rock the boat or look more closely at why the practice is so unfriendly to labor support, because that would mean looking more closely at myself.

I don't want to try to have a VBAC because it is scary and feels out of control; I'd rather live through a predictable, familiar process than try something new and fail. or try something new and succeed. And I don't really trust my body but I am too afraid to say so.

I don't want a homebirth because it's too much pressure and I do honestly feel safer in the hospital, and gee how silly I was when I, a grown woman, said "I do want a homebirth but my husband won't let me."

I know I said my doctor pressured me into the c-section, but honestly I was so tired of being in labor that I didn't want to struggle any more. It was nice to know it would all be over soon and I would get to hold my baby.

I know I said my doctor made me get induced but I really was done being pregnant and impatient waiting for labor to begin.

Once we start to speak honestly about our birth choices, when the facades fall away, then the revolution can get back on track. There are very few women holding the threads of honest birthing. Whatever their choices may be, when they are made authentically, I salute them .

posterior and breech births

Hospital shifts and classes are over! Yesterday we celebrated with a 12-hour Changing Woman ceremony at a gorgeous retreat center in the hills above the city. I am finally caught up on sleep and that means my brain is quasi-functional to blog once more.

These births actually occurred 2 weeks ago: the posterior presentation birth on Saturday and the breech birth on Sunday night. Taken together, the pair makes an interesting contrast.

I could tell by palpation in the dilation/labor room that Carmen's baby was lying directly posterior. Verified this by taking heart tones with my fetoscope: the heartbeat was clearest right around Carmen's navel. This position did not seem to concern any of the hospital personnel. Of course C. was laboring almost flat on her back, providing little impetus for her baby to rotate.

Once determined to be completely dilated, Carmen made the 20 foot trek to the Sala de Parto. She exhaustedly purple-pushed for about 45 minutes. The Obstetra placed his forearm across her fundus and began some steady pressure. Nada.

Meanwhile, as soon as the baby's head was beginning to show, an Intern cut a generous episiotomy through Carmen's perineum, ensuing a minor torrent of blood and rendering her yoni a pulpy wreck.

The Obstetra inserted his fingers and pressed them against the baby's head, attempting to assist rotation from posterior to anterior.

Maria and I simultaneously pressed inwards on Carmen's hips to open her pelvic outlet a bit wider. The Obstetra climbed atop a stepstool and leaned his full weight onto Carmen's fundus, jabbing rhythmically as though administering CPR chest compressions. And slowly, finally, the baby made his entrance.

Questions:
1. What would have happened if Carmen had not been laboring flat on her back?
2. What if she had not been exhorted to push once declared "complete"?
3. What if she had been able to push her baby out in a position other than lithotomy?
4. How horrifed do you think I was?


Next night:
Jessica is brought into the Sala de Parto on a gurney, accompanied by two doctors. I am washing up from a prior birth. Jessica is completely dilated and her baby is presenting breech. "Parto vaginale?" I inquire dumbfoundedly. "Si!"

Cool.

As soon as Jessica is positioned up on the table of torture, a window of glossy white shows between her legs. The doctors are joking around and gowning up, arranging instruments, and preparing to break her membranes. Suddently the next contraction blossoms and Jessica's membranes balloon fantastically from her yoni. SPLASH! All over the doctor, the floor, the wall.

And two pinkish purple legs wiggle between two chestnut legs.

The doctor grabs the baby's legs, gently tugs for a minute, then picks up the episiotomy scissors. Even though Jessica has birthed before, apparently the doctor thinks she needs extra room this time. He is still chatty and not quite paying attention. Before he can actually do anything, the baby girl's body births up to her neck.

Now the adrenaline in the room is palpable. The Obstetra on for the night has realized the situation and gowned up. She and the doctor both grasp the baby and begin to hoist her upwards to deliver the head.

Except there is this crazy gringa volunteer standing against the wall jibbering at them in English: "Wait for the nape of the neck! You can't see the nape of the neck!"

Too late. Head flexes and sweeps across the perineum. 6 lb. baby girl is born to a triumphant mother. Double footling breech. Sweet.

unconventional hospital births, part two

Tuesday night/Wednesday morning, several hours after Luisa's birth (below)...

Virginiana arrived at the hospital at 3:35 am, in active labor with her third child. Pregnant women are first seen and admitted through the gynecology section of the emergency room. So this mama didn't appear in the Sala de Dilatacion until close to 4 am.

She paced around, one hand affixed to her back, puffing through her surges. Also present were one other laboring woman, an intern, and me. Most of the staff (Obstetra & interns) were busy in the Sala de Parto, and the intern floated in and out.

I offered Virginiana some juice which she gladly quaffed. Around 4:15 the intern noticed V still had her street clothes on and promptly proffered a gown. V complied, leaving her undies in place, then climbed into bed and laid flat on her back. Women become subtly transformed when they don hospital vestments; the act establishes an immediate power differential. (read Birth as an American Rite of Passage by Robbie Davis-Floyd)

Despite her compliance with the system, V still labored very much in tune with her inner rhythms. She began to sound grunty at the peak of her contractions. I listened to her baby with my fetoscope and its heart sounded great. V said "Quiero pujar" so I ran into the bustling delivery room and dutifully notified the Obstetra. When I reentered the dilation/labor room, the intern asked me to take V's blood pressure. Um, hello? She wants to push and we are assessing vitals?!!

About 4:20 am the intern had left the room for a moment and returned. V told us again "Quiero pujar" and then mentioned something about cabeza. Alarmed, the intern pulled down in succession the sheets and V's underwear. We saw that Virginiana's bag of waters had burst, and a lime-sized portion of baby head glistened in her yoni.

"Get some gloves!" the intern commanded. Okay. Gloves on. I placed one hand on V's perineum and the other on the baby's head. It was textbook. The head emerged & restituted LOT to look at mama's right thigh. At the next contraction out she came, a 5 lb. peanut girl, covered in vernix.

By this point my friend Liz and a few interns had entered the room. Liz whispered "nice one" and somebody handed me hemostats and scissors. Gently and deliberately I separated baby from mama. A nursery nurse stood impatiently at the foot of the bed, towel ready to receive la niña.

An intern jabbed mama in the hip with pitocin as the Obstetra arrived to claim her authority over the scene. A few moments later V's abdominal contour changed as her womb visibly elongated, heralding placental separation. I began to reach for the umbilical cord but the Obstetra wouldn't have it. She then signaled when she felt it was time and I applied steady traction to birth the placenta. I was just about to begin twisting to coax out the trailing amnion & chorion when the Obstetra took over, so she could demonstrate her membrane-delivering prowess. Humph.

After cleanup and perineal assessment (no tears--yeah!) Virginiana remained in the same bed in the Sala de Dilatacion. Mama and baby reunited at 5:10 for cuddles and mama milk, and amazingly, the father was allowed in to see his family.

Birth is not an emergency. It's an emergence.

unconventional hospital births, part one

before reading this, please scroll down and read the previous post which sets the scene.

Luisa is a 25 year old mother of 2. I attended her second child´s birth earlier this morning. She was admitted to the hospital around 9:30 am yesterday, unusual because her cervix was only dilated 3 cm. She spent the day laboring in the maternidad room, and around midnight came to the dilatation room. Her cervix had not changed much and her baby was very high in her pelvis. She mostly labored upright, tuning into her body and changing positions at will. The busy staff left her alone while I took turns providing labor support to her and several other women. Luisa experienced a lot of low back pain and appreciated my counterpressure to her sacrum.

At 1:40 am she was assessed and found to be dilated to 9 cm. But the baby was still very high. The Obstetra (University-trained medical model quasi-midwife) decided to break her bag of waters and see if that would bring the baby's head down. If not, a cesarean section was threatened.

Luisa began to push a little at the peak of her contractions. This is really common as women open up the last 2 centimeters or so. The Obstetra and all her intern students were attending women in the delivery room, so I was alone with Luisa and Andrea. Luisa clearly felt uncomfortable sitting in the enlarging puddle of amniotic fluid, so she edged to the side of the bed and I dropped the wet linens on the floor beneath her legs. I placed a dry sheet behind her in case she decided to get back up there.

Her contractions became quite intense and she grabbed me and held on with each surge. Several times she cried out "Ayudame!" (Help me!).

At 2:25 or thereabouts, she stood up, clasped me with both hands, squatted down low and emitted a primal, guttural roar. I heard a sploosh! and assumed more amniotic fluid was emanating from her yoni. I looked down.

I saw 2 greyish-purple legs kicking around.

"OH MY GOD!" I yelled, scooping the baby off the floor and placing him onto the dry sheet on the bed. He was slightly blue but had excellent muscle tone, cry, and respiratory effort. Babies are really resilient.

Luisa stood next to the bed, still coming back from her labor journey, very much in an altered state. Blood trickled down her legs, mingling with the amniotic fluid and terminal meconium at her feet. Meanwhile her earthside baby was gently transitioning and pinking up thanks to his still-intact umbilical cord.

By this point the Obstetra and several interns had run into the room, assessed the situation, and gathered their tools. They immediately set to work cutting and clamping the umbilical cord, because that's their modus operandi. Baby boy was whisked away to nursery for evaluation. (He is totally fine.) Luisa reclined on the bed, where she received a routine shot of pitocin in her hip, and her placental delivery was actively facilitated. She did visit the delivery room after all this morning, for a second degree laceration repair. Probably she tore through the episiotomy site from her first baby. (Insert your own opinion about episiotomies and perineal integrity here.) All the while, the Obstetra chided her and tried to feed her a huge guilt sandwich for pushing out her baby onto the floor without telling anyone.


Lady, it's over. Birth happens. Let it go.


Luisa was a woman birthing in her power. What a privilege to witness.

institutional birth in Cuzco

Sala de parto

posing in the sala de dilatacion

sala de dilatacion
(notice the bigass oxygen tank with no wheels)

Sat in birth circle this afternoon, where we share our clinical experiences and ground them in different paradigms. Lots of tears and self-righteous indignation and outrage at what we are seeing and feeling. Whapio popped in at the end and dropped a little mind-blowing tidbit: "Your work here will be done when you feel so much gratitude that you don't want to leave the hospital. You will have learned humility, to truly serve, and that is midwifery.¨

based on my experiences and the stories of my sisters, I am starting to grasp an overall picture of hospital birth here:

-women are screened in the emergency room for admittance. they are assessed for vital signs, cervical dilation & effacement, integrity of membranes, and fetal heart tones. if between 4-5 cm dilation and there is room at the hospital, they are admitted.

-women labor in the Sala de Dilatacion--dilation room. husbands, sisters, parents or other significant others must stay in the hall behind 2 sets of double doors. Nobody updates them with any information. Patients are given a gown and assigned a bed. A few remain in their own clothing or some combination of hospital gown and their own vestments. Most women get right in bed and lie flat on their backs, alone, in a bright and often noisy room. In the hospital where I work, up to 4 women are in labor at once.

-amazingly to my North American mind, Fetal Heart Rate is seldom assessed. FHR is not routinely checked after Rupture of Membranes, whether Spontaneous (SROM) or Artificial (AROM). AROM is performed often, using a sterilized half of a hemostatic forceps.

-the women may drink, but it is not offered or encouraged. they also may get up to pee when they want to, but again this is not assessed or encouraged in any way.

-the room between the dilation room and the bathroom is a storage area containing a mop, a sink, and piles of stainless steel bedpans, stacked-up buckets containing placentas, and large orange trash cans full of blood and used gauze from prior births.

-a saline IV is routinely placed at approximately 8 cm dilation. It remains throughout birth and into the first hours postpartum.

-many chatty interns are present in the Dilation room but they do not provide any labor support. They occasionally assess vitals, insert an IV, check dilation, etc. but barely speak to the women for whom they are providing care. They will absentmindedly tap on a patient´s bed, place their clipboards on her legs, giggle about their boyfriends, dance to the radio, or noisily bounce the new birth ball gifted from our program. An aura of respect is sorely lacking.

-They don't like the women to get noisy when labor is intense, so there is lots of encouragement to be quiet and breathe. ¨Tranquile, Respire¨. If the woman cannot obey, they are given a medication similar to Demerol, without consent.

-Pitocin augmentation is common and again, given without consent. I have seen it administered several times at complete dilation, when labor often takes a natural pause as the womb-an gathers her energy for the next phase. I have witnessed it given 3 times within 2 hours to the same woman: via IV in the dilatation room, IV in the delivery room, and IM in the delivery room post-birth (she was not hemorrhaging).

-when it is time to push out the baby, the woman must walk to the Sala de Parto (Delivery Room), climb up onto a table, lie flat on her back or on a slight incline, and place her calves up into stirrups.

-every first-time mother, or woman having her first vaginal birth, receives a generous episiotomy. they fervently believe this helps prevent the perineal muscles from tearing. from every observation, it does exactly the opposite. sometimes the episiotomy is cut prior to full head crowning, rendering the woman's perineum a gushing mess.

-baby heads are grasped from the yoni and delivered, then roughly restituted prior to true physiologic restitution.

-baby is very briefly allowed to rest on mom's abdomen as its cord is immediately clamped and cut. then baby is whisked across the hall to be assessed, not to reunite with its mother for at least an hour.

-third stage: mom receives a shot of pitocin in her hip. her uterus is vigorously kneaded and massaged (yes, before the placenta is out). The cord is milked upwards and the hemostat re-clamped close to her introitus. Traction upwards and downwards is performed, ignoring the curve of carus, and often ignoring the need to guard the uterus above the pubis.

-after the placenta is delivered, the perineum is assessed and sutured, often painfully slowly.

-the woman is wheeled to a recovery room right next to the Sala de Parto. After an arbitrary length of time, someone brings her a baby wrapped in 3 or 4 layers of fabric. Babies generally remain with their mothers from this time forward. Eventually the mamatoto are wheeled to the Maternidad ward where they stay until they are stable. Average stay post-uncomplicated birth is 24 hours.

-cesarean sections are given for suspected oligohydramnios, placenta previa, and the common ¨big baby¨ diagnosis. For a cesarean, all women begin in Dilatacion where they change into a gown, hat, and long cloth boots. Next they must climb onto a gurney and receive an IV. They are wheeled down the hall, out 3 sets of double doors into the cold night, across a bumpy sidewalk, and through a courtyard to the building which houses the OR.


I have tried to keep many personal opinions out of this so you may formulate your own. It is quite easy to stand in judgment when the doctors, obstetras, interns, and technicas really do have positive intentions and are often doing what they can with very limited resources. Still, I cannot keep totally silent when I know in my heart and soul that birth can be so much more than a medicalized event!

More reflections soon on Vertical Birth laws, classist attitudes towards Quechua women, and some specific birth experiences.

various & sundry birth notes

I'm on call for an imminent birth and I'm leaving in 5 days. Am I sleeping? No. Packing? No. Watching my Spanish DVD? A little. What I'm really doing is eating chocolate, browsing and blogging.

Thanks to Citizens for Midwifery I've learned that Sheri Menelli's book Journey Into Motherhood is a free e-book now. Every pregnant woman would be wise to turn off "A Baby Story" and read this positive, empowering, inspiring book instead.

This quote on the Unnecesarean blog made me chuckle, at first:
"Most American women have already had an OB rip them a new one with no evidence to back their decision—it’s called an episiotomy."

Then it made me sad.

There is some debate whether episiotomy or hysterectomy is the most frequent surgery performed on women. There is no question that most episiotomies are cut without a woman's fully informed consent.

Bewildered by this news story making the rounds. A woman gave birth on an airplane and the attending doctors are lauded as heroes. I think the woman is the true hero!

• the birth went fine, but upon landing the mother and baby were rushed to the hospital, strapped to a stretcher and bundled in what appears to be a giant carpet. what was the emergency, pray tell? it's too bad the doctors did not pronounce mother and baby healthy, sending them to their destination in a more peaceful fashion.
• one of the doctors reports: "we took the baby out...we took the placenta out." How powerful you are. Did you really remove these items from a passive woman's body, or were you perhaps honored to receive them as she gave birth?
• I'm ever so grateful somebody onboard donated some formula. Whatever else would the poor, starving newborn be able to eat?!!! (Imagine the headlines: Mother Gives Birth In Flight and Breastfeeds Infant. Scandalous.)

obstetric rape at Rush

sad story about a woman who suffered needlessly during the birth of her fifth child.

the doctor, who was not her regular OB:

-belittled, intimidated and verbally abused everyone around him: residents, nurses, colleagues on the phone, and the patient and her husband.

-chatted loudly on his cell phone about abortions and a woman who "has no business being pregnant", while in his laboring patient's room! I have heard countless nurses and midwives make unnecessary side chatter during labor, even midwives who claim that they never talk during labor, but this guy wins the insensitivity prize by a mile.

-deliberately withheld pain medication after it had been requested by the patient AND the anesthesiologist had already been called to the floor

-deliberately placed the patient in an uncomfortable position, causing her great pain and stressing a preexisting injury

-performed a rough and painful vaginal exam despite her pleas for him to stop

-artificially ruptured membranes without patient consent, and then lied to the resident that they had ruptured spontaneously

-repeatedly told the patient that she was going to hemorrhage (based on zero evidence) and that she and her baby would die

-inserted a catheter during a contraction, ignoring her requests to wait until it had subsided

-continuously exhorted the patient to "shut up and push" after he determined her cervix to be 8 cm dilated, rather than waiting for it to open completely and a spontaneous pushing urge to develop (I would wager he has rarely, if ever, witnessed a spontaneous pushing urge!)

-nearly dropped the baby

-would not allow the mother or father to hold their healthy baby immediately

-called for a larger-gauge needle than is normally stocked by that hospital's L & D for injecting local anesthesia into her perineum. periurethral repair was performed in a very painful manner. requests for more anesthesia were ignored.

-told a nurse he had denied this patient any analgesia because "sometimes pain is the best teacher."



I am 'trying real hard to be the shepherd', i.e. trying not to proclaim that what this doctor needs is a hefty dose of his own medicine. An eye for an eye makes the whole world blind.

This, folks, is why some women will not set foot in a hospital to give birth. Is anyone listening?!



note: some of these details come from the official complaint filed in Cook County Circuit Court.

another chance to ignore the evidence

tonight I wax cynical.

a cautious thumbs up to this bit of research stating it is perfectly normal for the active phase of first-stage labor to "stall". Often the stall is viewed as abnormal, a reason to hasten surgical delivery. I'd prefer the authors use the more positive term "plateau" in lieu of "stall". Semantics aside, defining a "stall" or "plateau" is predicated on the near-universal obstetric assumption that progress=cervical dilation.

there are different ways for this quite normal plateau phenomenon to play out. contractions may continue with full vigor and frequency, or they may space apart somewhat, or they could stop completely. in each of these scenarios, cervical dilation ceases for a while (our wondrous cervices can even reduce in dilation, per the brilliant Ina May Gaskin's Sphincter Law).

what else could be happening during the "stall"?
-baby is rotating into optimal alignment with mother's spine and pelvis
-an asynclitic (cocked to one side) head is centering
-the uterus is gathering its strength for the work ahead
-the baby is descending
-adrenaline and oxytocin are waging an inner battle for dominance
-the woman is craving/receiving some much-needed nutrition & hydration
-the woman and her partner, or mother, or sister are working through some emotional blockages

The study authors exclaim: "we found that just by being patient, one-third of...women could have avoided the more dangerous and costly surgical approach." So perhaps Friedman's curve mandating 1 cm dilation per hour can now be cast aside as a terribly outmoded and ridiculously machinistic view of human physiology. Perhaps.

But change is slow. practitioners often stick with the first approach they learned (old dogs/new tricks & all). being patient works fine in a low-volume setting where the staff and beds are plentiful. yes, surgical birth is costly--costly to women's postpartum quality-of-life and future obstetric choices. costly to insurance companies. but it sure is one heckuva money maker for hospitals and doctors.

Even if practitioners and hospitals consider change, what of the birthing women who hear story after story of disempowered birth, who do not trust the process, do not trust their bodies, who were brought forth from their own mothers by unnatural means and have no cellular memory of normal birth? What of these modern birthing women who are inculcated in a culture of birth fear? how to rouse our sisters' somnolent warriors?

I'd like to think the admonition to "be patient" could resonate within the heart of every compassionate birth attendant. I'd like to see a reversal of the alarming upswing of unnecessary cesarean births. Just not sure this particular drop in the bucket will quench my thirst.

ping!

adventures at altitude

Exciting news: in January I will be catching babies in Cuzco, Peru, and attending midwifery classes with one of my favorite teachers. I plan to blog my adventures, so stay tuned.

And for any Matrona detractors out there, I leave you with the wisdom of ol' Robert Zimmerman:

Come mothers and fathers
Throughout the land
And don't criticize
What you can't understand
Your sons and your daughters
Are beyond your command
Your old road is
Rapidly agin'.
Please get out of the new one
If you can't lend your hand
For the times they are a-changin'.



Seek the source, heed not idle gossip.

Doula-ing & Birth Plans

Huge epiphany while vacuuming last night: I don't need to look at another birth plan. Even if I were to land in the midst of a couple's birth with no prior knowledge of them, their provider, or their fervent hopes & dreams, I could be a fabulous doula for them.

Birth plans are most useful for a mom and dad-to-be in honing their options and communicating their wishes BEFORE THE BIRTH. They can bring the plan to a prenatal visit with their midwife or doctor and hold a frank discussion about routine procedures, episiotomy statistics, etc. It can be a good way to assess if your care provider and you are seeing eye-to-eye, or if you're getting red flags about opening up and birthing with this person. As a dear friend and wise lady says "You can't order spaghetti at McDonalds." You have to order from what's on the menu. For example, if you envision a hands-off birth while your doctor believes that it is her role to provide perineal massage while your yoni is stretching around your baby's head, how are you going to achieve the birth you want?

I have a list of common events/interventions/ medications etc. that I review with parents prenatally to see if they have any questions or want more information. A birth plan helps me eyeball what their choices are or if they even know they have choices at all. But it's not necessary. We can have our discussion, they can convey their desires to me prenatally and at the birth without the magic paper. And their choices can change in an instant!

There is one OB/CNM practice here that offers its patients a pre-formed birth plan with checkboxes. It's the same mentality I use when offering my three-year-old "choices". Ultimately I am controlling the outcome while giving only the illusion of choice.

So how can I be a fabulous doula if dropped into a stranger's birth from a time machine? (Wow, can I wear a cape, too?) I can continuously reflect what I see happening back to the couple. "I see the doctor wants to place an internal fetal monitor." I can ask them if they have questions. "Do you have any questions about that?" I might even ask if they give consent if they have not indicated yes or no. "Are you okay with that?" Or ask them if they want time to mull things over. I can offer them comfort and love, mothering the mother (and father if need be!). And I can release my "stuff", my expectations, my shoulds, because it's not my birth.

I do realize that asking these questions means using lots of words, which engages the neocortex, taking a woman out of her instinctive primal birth zone. By not knowing a couple's wishes or vision I might need to use more language. However, if they are birthing in a place where I need to be talking so much, chances are there is already other chatter happening that has pulled mama away from her inner wildebeest.