Saturday, October 26, 2013

"Birth is beyond our control"

I wanted to share more with all of you the story of Acacia. Many readers had questions. I know certain questions will never be answered but in my conversations with Jenny (Acacia’s mother), I felt more of her perspective needed to be shared. 

My questions are in blue. Jenny's responses are in black. The bold areas are my emphasis.

To read the story of the birth and death of Acacia, click here

Thank you, Jenny, for being so brave to share your story.


Can you explain what your birth “philosophy” was going into your first pregnancy? What I mean is how did you view the process?

I didn’t have a cohesive idea about birth, but I had a sense that it was “natural” and therefore straightforward.  (I thought the same thing about breastfeeding, by the way - what a hoot that was.)  I heard that “interventions” and fear during labor could cause problems for the baby, so of course I wanted to avoid all that.  Although I did worry about all sorts of things going wrong, I also felt that “natural is better.”

My childhood experiences with authority had been very negative. People with power over me had used that power to hurt me. I wasn't able to articulate this at the time, but I wanted to protect my baby.  My gut sense was that to keep the baby safe, I needed to avoid people with "power," including doctors or midwives. I had very severe anxiety, and because it was untreated, it prevented me from accessing prenatal care - I was able to see a doctor about three times in the whole pregnancy.  

How did everything end up going at the hospital for the birth of your first? How did you handle it emotionally given your anxiety? How did you feel about it at the time and afterwards?

The hospital scared me.  Sometimes I thought about not going.  Surely we’d know if something was going wrong, right?  And if nothing was going wrong, wouldn’t it be ok to just stay home?  I didn’t want something bad to happen to the baby at the hospital.  Steven wasn’t thrilled about this idea, but said it was my body and therefore my choice.  I promised him I would go if I had any doubts.

When I finally went into labor, I had a couple big drips of blood as I was dilating.  I knew about bloody show, but something about the bloodiness of the blood made me uneasy, so I asked Steven to drive us to the hospital.  

The blood was normal and everything was fine.  I had an excruciating 10 hour labor, and I pushed for 2-3 hours.  She’d had some meconium in her waters, and once she was born, the nurse thought she was more blue that normal, so she had to go to the warming/resus table immediately.  They brought her back to me and I got to hold her, and I was so happy.  

Everyone was absolutely kind to me and explained everything.  No one lectured me or yelled at me.  They said they were glad I came to the hospital even though I was afraid, and in the end, I was glad too.  

Going into the birth of your second, did you still feel the same about birth, about it all being a pretty safe process if it was natural?

I had therapy in between my first and second pregnancies.  I still had a lot of anxiety, but I started from the premise that we needed prenatal care.  Because we had a child already, I knew how precious the baby and I were, and how much our family needed us to be well.  The stakes were more real.

I chose a hospital based midwifery group, and Steven came with me to many appointments.  I met all twelve midwives, and I cried coming and going sometimes, because it was not easy work to talk about my boundaries or my fears.  But by the end of my pregnancy I was very comfortable with my midwives.

I did still think "natural is better" and that the more interventions I could avoid, the better. I was still afraid of ending up with a c-section.  I still believed that birth was basically safe.  As my due date approached, the midwives and I were able to talk sensibly about non-stress tests and post-dates inductions and rates of stillbirth after 42 weeks.  I scheduled my first non-stress test and prepared myself for the idea that I might have an induction afterwards.  I tried not to dwell on my biggest fear, which was that I would go for the NST and end up with a c-section.   Despite knowing there are many good reasons for a c-section, in my mind, there was nothing in between the two events besides a diffuse fear that the c-section would be “unnecessary.”  I ended up giving birth two days before my 41 week NST.  

Do you feel you took good care of yourself during your pregnancy with Acacia?

With Acacia?  Oh yes.  I ate well; I was sensitive to my body.  I did special exercises to prepare my body for birth.  I was kind to myself so my kindness would overflow onto her.  I took warm baths.  I was pleased to be getting prenatal care.  Right before she was born, I took long walks among magnolia trees, and I felt very nourished by the sight of the flowers.  I used to grab her leg through my belly and hold it.  She had a very robust feeling leg.  Compared to my first pregnancy, I was unworried.  I was comfortable with my decisions about where I was going to give birth and with who, and I felt confident in my body.  I still worried about the pain.  I still worried about “the cascade of interventions.”  I made plans to help me be comfortable in the hospital.  I was looking forward to meeting my daughter very much.

You have spoken to me at lengths greater than what has been shared here regarding your extreme anxiety with hospitals and doctors and authoritative figures... to those out there that are dealing with a similar type of anxiety, do you have any advice you could share? To those who seem the greatest fear is the "cascade of interventions," do you have any thoughts you could share here as well? Any thoughts on how to advocate for oneself?

That’s tough.  Anxiety is kind of like living in a box.  Sometimes you know there’s a bigger world out there, and sometimes you can see it through the cracks, and sometimes you have no idea you live in a box.  Being in the box feels rational because anxiety has it’s own internal logic.   My anxiety once worked to protect me, even if it was maladaptive for my adult circumstances.  Learning that my anxiety served me taught me that I could work with my fear.  If something made me feel unsafe, I learned how to find safety instead of just running away.  Counseling helped the most, but medication can also be a useful tool.  There’s nothing shameful about having anxiety, but it’s unpleasant to live with and worth addressing when it interferes with your life.

As far as the “cascade of interventions” goes, or more accurately, my fear of “unnecessary interventions,” it’s normal to be frightened of things that are unfamiliar, and which involve blood and surgery.  I think it would have helped me to understand that it wasn’t my responsibility to predict the future. Decisions that might seem less than ideal in hindsight could be the best, most ethical decisions at the time.  Successfully averting an emergency can sometimes leave little evidence of the danger that inspired the interventions.

Birth is beyond our control, but we react to it as best as we can.  Not every choice is, or can be a choice.  We can react to labor pain, or birth complications, but we don’t get to choose whether or not they occur in the first place.  Confusing autonomy with control hurts women.  It’s very easy to become crushed by disappointment, guilt, shame, and hurt if we measure our autonomy by how well we control the uncontrollable instead of by how we react when the uncontrollable occurs.  

It’s hard to give a really nuanced answer to the question about self-advocacy because every person’s situation is different.  For a person who was taught that having boundaries is dangerous, communication is not an easy thing to do.  Systemic factors such as racism and classism also impact the way that many women in the U.S. will experience and access maternity care. Any answer is going to be limited by these and other factors.

It can be helpful to ask as many question as you need to, before the birth, during, and after.   It’s also helpful to go into birth with a set of ordered priorities, so that if a complication arises, you know which goals you hold paramount and which you can set aside.  You do have rights; knowing them, and knowing who to complain to can help as well.   As much as it is possible to have a respectful dialog with care providers, that will help too.  

After the birth and death of Acacia you started to share your story with others... I have seen firsthand some of the appalling responses... Knowing the complication, I know that it is not something that can be remedied at home... no matter who may have been there with you during delivery, you would have been transferred.... and yet some seem very desperate to believe that it could have been prevented with the right person with you, as if a midwife or the right paramedic could remedy *any* potential complication. Why do you think that is?

I'm a grieving mother. Acacia’s first coos, first words, and first steps will never exist. To share her with the world, I talk about her birth and her death.  For some people, the idea of a baby dying is incomprehensible and it’s very natural to try to push those possibilities off and say, “That couldn’t happen to me.  I would make better choices.”  It’s too scary to think about otherwise.  There may be an element of hubris, too, in thinking it’s possible to be superhuman in an emergency, or thinking that reading something on the internet makes one an expert.  But I think it’s mostly fear.

People don't have to worry about the unthinkable happening to their babies if they can make up a narrative in which it wouldn't. After we learned what it was, I read everything I could find about my daughter's complication.  I questioned her doctors and my midwives endlessly. I made up a hundred different stories about how she could have lived, but in the end they are just stories. If we could have done anything different, we would have. To this day I wish I would have skipped the bath and just gone to the hospital.  This is wishful thinking too, because there was no indication that I needed to be in the hospital that early in my labor.  

How do you feel about birth now, after Acacia?

I don’t count on the process of birth.  My body is strong and wonderful, but it’s falliable.   I count on my care providers to be sensitive and cautious, and I count on my own resilience.  My third child is due in the spring, and I am doing what I can: prenatal care, screenings, ultrasounds, taking my vitamins, exercise, and a practice of gentleness.  Perhaps I will get to walk among the magnolias again.  I plan on going to the hospital at the first sign of labor.  Fear comes to me occasionally, but it’s an old friend, now.

My main concerns are brain damage and death.  My midwives know that if the baby doesn’t seem to be tolerating labor well, I prefer a non-emergency c-section to waiting and increasing the chances of an emergency developing.  This is no guarantee that the baby and I will make it through with minimal injuries, but it’s enough for me.

I'm struggling with how to ask this question as I don't want it be a question used to get an answer to scare pregnant women, so I'll just ask it and see where it goes... if you could say anything to someone who believes that birth is "as safe as safe gets" or who believes that "trusting birth" is all it takes to have a good outcome (and perhaps with a midwife present), what would it be?

Each of us makes our decisions based on what levels of risk we are comfortable with.  I can’t tell others what to do, because it’s such a personal decision, but I can share about what it feels like to be on the other side of a birth accident that occurred outside of the hospital.  

I have made my peace with my daughter’s death, and have found pockets of incredible beauty and holiness in our time with her.  This is a mystery to me, because that peace includes acknowledging that there's nothing beautiful about an innocent baby suffering. There was nothing wonderful about deciding to withdraw life support interventions from our dying, brain damaged baby so she could have a peaceful death.  

Even if absolute risk may be low, the impact of birth complications can be catastrophically high.  I can’t control whether or not these complications will occur, or even that I will be in the right place at the right time, and yet, I still will try because I think there is value in trying to avert things that are terrible, even if we can't guarantee we will be successful.  There’s value in trying to avert death or terrible injuries, even though all life ends in death and we cannot avoid all injuries.  Uncertainty is part of being human. This might sound bleak, but it's a very peaceful place to be.

"Magnolia" photo courtesy of fionaandneil

Friday, October 11, 2013

Acacia's Story

Today’s post is a guest post from a loss mom. This is Jenny’s story (in her words) of the birth and death of her daughter, Acacia.

"I've been deliberately vague about the complication that my daughter suffered because some people have been unable to resist the urge to pick over the details of her birth and suggest that if we'd had "better" paramedics, or a midwife, something could have gone differently. This is both unhelpful and unrealistic. The paramedics' quick thinking meant we had a chance to get to know her before she died. But no matter what anyone tells you, paramedics do not have operating rooms, surgical teams, anesthesiologists, blood transfusions, neonatalogists, neonatal nurses, or respiratory therapists hidden away on that ambulance.  They just don't.  And neither do midwives.  The best, most experienced homebirth CNM in our area transfers at the drop of a hat exactly because she hopes to avoid injuries like the one my daughter suffered. 

Unfortunately, what happened to my daughter was something no one could have predicted.  My daughter's complication is one of those events every OB and midwife fears.  The only thing that could have made a substantial difference to her outcome was a change in our location prior to the event - if we'd been in the hospital instead of in my kitchen. 


Before I had my first child, I was terrified of doctors.  I had unrelated trauma that made trusting anyone an ordeal.  What I read and heard about natural childbirth left me believing that in a hospital, I would be medically battered, strapped to a bed, shamed, touched without my consent, and bullied into accepting interventions I did not want.  Nevertheless, when my time came, I asked my boyfriend to drive us to the hospital - "why" would be too big of a story to go into here.  Imagine my relief when I was treated with kindness, dignity and respect.  We brought our firstborn daughter home at three days old.

When I was pregnant with our second child, I felt that my previous experience in the hospital had been decent enough to repeat. Many of my peers had or were having home births and I eagerly listened to their stories. But as nice as they sounded, I decided that three days in the hospital would allow me to rest up before launching into the challenge of being a mother of two. Planning a second hospital birth was a housekeeping decision. I was not particularly worried about safety because through playground chats and reading about natural childbirth on the internet, I'd come to accept the notion that "birth without interventions is best," and that women should "trust birth." Underneath it all was a belief that birth is basically safe. When I talked about birth with other moms, we sometimes wondered if this intervention or that intervention had really been necessary. But we seldom, if ever, talked about death as though it were a real possibility.

Then my daughter, my second child, died because one of those "rare" split-second, every minute counts birth emergencies. Despite living just minutes from two hospitals (mine, and the one with the best NICU in the area), we did not make it in time. My labor was irregular then suddenly intensified. Just as I was putting on my shoes to go to the hospital, I started involuntarily pushing and my water broke.  I couldn't make it down the stairs, so my boyfriend called 911.

The paramedics arrived promptly and by the time they did, she was crowning. They did all they could while I gave birth there on my kitchen floor, paralyzed by labor and unable to speak. But as close to the hospital as we were, we might as well have been an hour away. 

We didn't know at the time, but moments before our 911 call, she experienced a complication. Because of that complication, she did not breathe at birth, and was in need of some very specialized help - the kind of help you can only get from a well-oiled pediatric team in a hospital. The paramedics attempted to start her breathing, gave her oxygen, cut her cord, took her, called ahead in the ambulance, and were met by NICU staff at the entrance of the ER. My boyfriend says a a swarm of people began treating her the moment she arrived, and she was not yet ten minutes old.  

My daughter lived four days, and despite being treated with a cooling blanket, she suffered total brain damage and the breakdown of her body following the long oxygen deprivation. Together with her care team, we chose to have her healing supported by technology as long as there was a possibility she could actually heal. However, as the days went on, we learned that her kidneys and her gut were destroyed. Her other organs were following close behind and her body could not recover. We brought family and friends to meet her, and then we chose to discontinue any intervention that did not add to her comfort.  Her dad and I got to spend several hours holding her and watching the sunset with her.  These were some of the most beautiful and holy hours of my life.

After I came home without my daughter, I searched for stories similar to what had happened to her and was horrified to find that they mostly happened to women and babies who'd had planned home births.  Getting out of the house always took longer than anyone would have imagined, and devastating brain damage was always the result. Women who happened to be in a hospital when similar birth accidents occurred generally got scary crash c-sections and mostly - though not always - took their living children home.  I met a mother in the NICU whose baby was born in the hospital, didn't breathe for eight minutes, and received the same cooling blanket treatment my daughter would receive. Her daughter was going home healthy and neurologically intact. What other differences there were between her daughter and mine, I can only guess, but any baby who doesn't breathe for eight minutes was almost certainly in trouble before birth too. It took eight minutes just to get my daughter to the place where she could receive the breathing help and blood transfusion she needed.

At one time, I had fervently believed that my body knew just what to do, but I came to resent every time I'd ever read "trust birth" or "birth is safe" or "our bodies were made to do this" or "all you need is instinct" and "interventions are what cause complications." Every time that I read, "If an emergency happens we will just go to the hospital." As if it were that easy. The paramedics had arrived to my house before we anyone suspected anything was wrong. I also resented the fact that I had feared a c-section more than I had feared my child dying. I resented the fact that I had worried about the "cascade of interventions" more than I had worried about brain damage. I had been worried about all the wrong things.

In the hospital, we were treated with more compassion than I have ever encountered in my life. From the moment we arrived in the emergency room to long after we left our daughter, newly dead and swaddled, they focused not just on the physical, not just on her health and mine, but our whole family system, our feelings, her comfort, our comfort, her humanity. Her essential value as a person was at the center of every decision, from the one to try to save her, to the one to let her go.

The doctors and hospital midwives were more than willing to admit that they didn't have all the answers, and that sometimes things happen that can't be prevented or fixed. They refused to speculate - if only I'd done this or that. All they would say is, "If you had been in the hospital, we could have done x, y, and z. We can give you percentages on how often that is successful, but we can't promise your outcome would have been different. I wish we could. I wish we could tell you this will never happen again. But we're not gods." And in a small way, that saved me because it was the truth. The truth is we never had a guarantee.

I'm not telling my daughter's story to say that women should not have home births - that's not my decision to make for others. But I am telling her story because I think that the notion that "birth is safe as life gets" is a shaky one. No decision should be made on that premise. Birth is not as safe as life gets. Mothers and babies can die and the human race will go on. Most of the time, people get lucky, and things go off well enough. When shit goes bad, it has the potential to go really, really bad. We cannot control whether our babies survive birth by eating a special diet, doing the right stretches, or with positive thinking. I was low risk as can be. My baby didn't die because I failed to trust birth or my body. She didn't die because unnecessary interventions interfered with her natural process. She died because sometimes, in the absence of the right kind of help, and sometimes even despite it, birth kills.

I miss her little face. Not a day goes by that I don't regret the fact that I never heard her cry, that I will never hear her cry, or that I never got to see her as the healthy baby she was before she was born.

My boyfriend lost his child. My older daughter lost her sister. Our brothers and sisters lost a niece. Our parents lost their grandchild. My friends lost a dear new baby to love and watch grow up.

She wasn't mine alone to lose.”

Baby Acacia after resuscitation

Click here to read more from Jenny's mother on her experiences and thoughts regarding birth - where they once were and where they are now, after their loss.

Thursday, August 8, 2013

OBs and Midwives: The Double Standard

We can blame OBs but we cannot blame midwives.

In a hospital: interventions, inductions, c-sections --> fault of the OB

Yes, a mother must give consent for an epidural. Yes, a mother has to give consent for an induction. Yes, a mother has to give consent for a c-section. But it's still the OB's fault. They offered. They unrightfully scared the mother. And so on.

On the flip side....

At a home birth: death, brain damage, injury --> fault of the PARENT

Yes, you read that correctly.

Sorry, parents, but this is something you need to understand up front. You need to take responsibility for your decision to have a home birth if something goes wrong. Regardless of the details, people in the home birth community will ban together and bail out the midwife and do whatever they need to do to protect her. It has happened and continues to happen over and over and over again. Expecting accountability = persecution or a witch hunt!

If you have a home birth loss and if it was due to negligence on your midwife's behalf, you may be met with comments such as these... these are actual comments made to (or referring to) home birth loss moms. I have cut and pasted them. These are, sadly, just a very small sampling of the types of parent-blaming comments I have read!!

"at any time she felt it was needed, she could tell them she wanted to be transferred... I am sorry for the parents who lost their precious child, but they made the choice to have the child there (at a free-standing birth center), and they made the choice to stay even when complications arose."  (the mom she is referring to actually had no idea complications had come up… so much for informed consent!)

"What's abhorrent is the need to carry malpractice insurance because we are such a sue happy country because no one can take responsibility for their choices. There is NEVER any guarantee that things would have turned out differently if other choices had been made no matter what the "professional" people claim."

"They weren't hostages. They could have called an ambulance themselves, right? Just asking."

"I find it disheartening that the parents are not accepting any accountability themselves for the decision they made."

"I truly feel bad for the [family]. However, with all the resources we have at our finger tips, doing research on something so important only after a tragedy happens is somewhat negligent in itself."

"When we can let go of the blame in a child's death, we heal!"


So let’s turn those comments around for mom’s who have had what they believe to be an unnecessary c-section:

“When we can let go of the blame in a c-section, we heal!”

"I truly feel bad for the [family]. However, with all the resources we have at our finger tips, doing research on something so important only after a c-section happens is somewhat negligent in itself."

"I find it disheartening that the parents are not accepting any accountability themselves for the decision they made to consent to have a c-section."

"They weren't hostages. They could have told the OB that they will not consent to a c-section, right? Just asking."

"What's abhorrent is the need to carry malpractice insurance because we are such a sue happy country because no one can take responsibility for their choices. There is NEVER any guarantee that things would have turned out differently if other choices had been made no matter what the "professional" people claim."  (sweet!! OB’s, just ask your patients to own up to the outcome 100% and you no longer need to pay thousands and thousands of dollars for your malpractice insurance!!)

"at any time she felt it was needed, she could tell them she refused a c-section... I am sorry for the mom that she had to have a c-section, but they made the choice to sign the form.”

Harsh, huh?

B/c most home birth midwives do not carry malpractice insurance and b/c they really don't have a governing body (like a medical board), there really is no recourse if a midwife practices negligently here in the USA. Even if she does so multiple times. She can keep right on practicing. So your chances of being able to have any justice in the shape of a lawsuit or such is slim to none. And to top it off, you have people that will back your midwife regardless of her actions and tell you to basically suck it up and take responsibility. 

I cannot even imagine what it would feel like to not only lose your baby due to a negligent care provider, but then on top of it, having to read about how people are blaming them - the parents. The PARENTS are negligent when death happens at a home birth. The PARENTS didn't do enough research. The PARENTS didn't speak up. The PARENTS should know when things become dangerous - even if they are being assured by their PROFESSIONAL CARE PROVIDER that it is not dangerous.

You can only complain about informed consent in a hospital setting. Not at a home birth. A midwife is infallible, basically. Parents - be prepared to 100% own your home birth outcome!!

Does this sound fair? No. But it’s the sad reality of the situation and something that was so shocking/horrifying/heartbreaking for me to see in the home birth community. Blame your OB and you'll find an entire community that has your back, that will share in that blame you cast on your OB, that will coddle you and love on you and "empower" you by telling you "it's not your fault, shame on that doctor of yours!!" But if things go wrong at your home birth and you again want to blame your care provider - your home birth midwife - well, don't expect that same community to stand behind you. B/c they are behind the midwife.


Please note: The point of this blog post is not to say that OBs are never at fault and that women are never mistreated in a hospital. The point is, if negligence happens on behalf of  a care provider, there should be recourse and accountability. A woman is not expected to know as much as her professional care giver, no matter where she chooses to give birth. Responsibility falls on the care giver to act ethically, in the best interest of the patient. This is why every health care professional in the United States is required to have malpractice insurance… except home birth midwives.

Monday, July 15, 2013

Home vs Hospital: The Equipment

Home birth midwives carry with them certain items to use in case of an emergency - b/c no matter how low risk a mom might be, emergencies can and do happen in childbirth and as such, they need to be prepared. I've heard or read many, many times from mothers/fathers/couples that have chosen home birth (or freestanding birth center) that “their midwife carries with them all the necessary equipment in case an emergency arises.” So I want to present a clear cut list for each setting of the equipment available in case of an emergency.

There is a slew of equipment needed and provided in both situations that I am not going to get into - such as gauze pads, chux pads, sterile gloves, etc. What I'm focusing on is the equipment used either to detect issues or for life saving measures.

Here's what a (typical) certified home birth midwife will bring with her to a home birth:
  • Fetoscope or Doppler (or both) - to detect the heart rate of the baby
  • One oxygen tank
  • Infant mask (used with oxygen tank)
  • Adult mask (used with oxygen tank)
  • Blood pressure cuff
  • Suturing items - to stitch tears for the mother
  • Thermometer - to check for fever for mother, which can indicate uterine infection
  • Lidocaine - to numb mom locally while she is being stitched up
  • Pitocin - in case of postpartum hemorrhage
  • Methergine - in case of postpartum hemorrhage
  • Bulb syringe - to clear airways of the baby, especially in case resuscitation is needed
  • IV equipment - if mom needs antibiotics in case of GBS or prolonged rupture of membranes
  • Pegnancy and labor records and charting, including blood type - in case of transfer, to ensure accuracy and increase speed
  • A midwife may or may not have an assistant with her
  • Midwife should be current in the following skills:
    • Neonatal Resuscitation (chest compressions and mouth-to-mouth)
    • Basic Life Support (some may have Advanced Life Support training)
I would ask your midwife ahead of time to make sure she carries (at least) these above items and has (at least) those certifications. The items should be in good working order, drugs should not be expired and midwife should be very familiar with exactly how to use each of these items and medications. Be your own advocate! Don't be afraid to ask questions ahead of time.

Now keep in mind, if the midwife is not certified she will not have access to things like Pitocin (or any medications), Oxygen, an IV, etc or any item that could get her in trouble with the law for practicing medicine without a license (at least, she will not have legal access to such items).

A Paramedic will have the knowledge, skill and certain equipment to be able to help in the case of an emergency. However, while a Paramedic can certainly provide life saving support, they should not be considered a fool proof back-up plan. Quoting a Paramedic: “We can do neonate intubations but we do them SO seldom that it’s not a skill all medics are up to par on. This goes for babies & pregnancy in general. In an emergency childbirth scenario where minutes can make the difference in life and death, NOTHING in an ambulance can save a baby; it can only be a very temporary bandaid while we drive as fast as we can to the closest hospital.”

Response Time:
In a non-emergent transfer, travel time or response time will likely not be an issue. However, being "5 minutes from the hospital" may not be close enough when minutes can make the difference between a perfectly healthy life and death or neurological damage or injury or blood loss resulting in a transfusion or hysterectomy. Regardless of the scenario, emergency or not, a home birth transfer will take much longer than 5 minutes to get a laboring woman in her home (or birth center) to a hospital, in the right hands at the hospital, admitted, monitored and ready for a doctor to deliver a baby. I address this in my first blog post under the section "Is Our Hospital Really Close Enough" giving the example of a home birth transfer I attended as a doula; it was a very eye-opening experience for me. 

  • All of the above listed home birth equipment and medications, plus…
  • Electronic Fetal Monitor (EFM) - this detects the baby’s heart rate and the contractions. EFM vs Doppler gives nurses a much clearer picture of the baby's heart rate to make sure baby is getting all the oxygen baby needs. Heart rate variability is normal for the baby but it's important to know when changes to the heart rate occur in relation to when contractions happen. A heart rate of 155 BPM might sound healthy and wonderful when checked every 10 minutes or so but with decels at the end of a contraction, it can be a serious sign of distress. The decels may be so slight that unless you are looking at a print out (the EFM strip), you would not know they are happening.
  • An endless supply of oxygen
  • Cytotec - for postpartum hemorrhage
  • Vacuum and/or forceps (though forceps are not common anymore) - if the baby’s health depends on immediate delivery, a vacuum can be used to help guide the baby through the birth canal while the mother pushes
  • Blood Bank - for postpartum hemorrhage requiring a blood transfusion
  • Operating Room and all personnel needed for an emergency c-section or for postpartum hemorrhage treatment/surgery (see Sara's birth of her son - an emergency surgical repair saved Sara's life after she suffered a cervical laceration; see Amber's experience as a doula and Becky's birth of her second child - immediate emergency c-sections saved the lives of those two babies)
  • Ventilator - a machine that facilitates breathing (see Christine's Birth Story of Baby Penelope and how a ventilator saved her daughter's life when she was born)
  • Specialized diagnostic equipment and staff
  • A skilled team of nurses and doctors that are current in the following skills (these skills are frequently used either on the job or through hospital drills):
    • Neonatal Resuscitation
    • Advanced Life Support
    • Intubation (and obviously the equipment for such) – provides a much more effective way to oxygenate a person (of any age) compared to resuscitation
Also keep in mind, to be trained in Neonatal Resuscitation or Life Support every few years and practicing only on a dummy is very different than using those skills on-the-job in a true emergency, on a real mother or baby. In a hospital, you have other sets of eyes and hands to help, to shout direction or take over in case someone freezes or forgets under pressure, you have a back-up for your back-up for your back-up. They will be able to tend to baby AND mother at the same time, if needed.

From a nurse midwife student: "Not only is there a team full of certified, competent people, but in a hospital, they are running dystocia drills or practicing for other obstetric emergencies. These are people who have practiced working together, who have assigned roles, and in addition to all the drills, have seen their share of real emergencies. They not only have a pediatric and adult code teams, but depending on size and type of hospital, they may also have OB rapid response and code teams as well,as they do in my hospital. It's a well oiled machine."

Nurses will keep a watchful eye on mother/baby in the hospital not just during the immediate postpartum period but for the length of their stay, checking vitals and looking for signs of infection, breathing complications, arrhythmia, postpartum hemorrhage, seizure, undetected birth defects, etc.

It is true that an Operating Room may or may not be available immediately when an emergency c-section is needed. In some cases, a doctor can have a baby born via cesarean in less than 5 minutes, including travel time from the Labor and Delivery Room to the Operating Room. In other cases, it may take longer depending on the availability of the Operating Room, anesthesiologist and obstetrician. However, the added commute from a home or birth center will certainly not help facilitate a c-section any quicker – in addition to travel time, the hospital must do its due diligence to admit the mother and monitor the baby and mother before performing any emergency surgery. 

Monday, June 3, 2013

Dear NUCB-aspiring Mama

Dear mothers-to-be:

This letter is especially for you if you are hoping to have a natural unmedicated childbirth (NUCB) with as minimal interventions as possible.

I hope your pregnancy is going well. I hope you are able to enjoy it as it truly is a miracle to have a life growing inside of you... this little life that you are going to come to love in a way that you cannot yet even fathom.

But right now, your focus may be on the birth. It's a big day!

You want to feel empowered, you want to feel fearless. You want to trust birth. I get it. I've been there and I know many other mamas that have been there, too. I'm a birth doula. My sole purpose is to be there for the mother to help her have the experience she desires. I cherish the role I have as a doula and take it very seriously. It is an honor and a privilege to be with a woman as her doula!

For my own personal reasons, my preference has been non-medicated, minimal intervention (unless interventions became needed, which they did not). It is how I gave birth to both of our children and going forward, if we decide to have more, it is still my preference. I truly understand the desire for a NUCB.

You may be thinking that fear has no place in birth. What you have read, what you have watched, what you have heard is all sending you the message that trusting birth is all you need to do. Trust your body, trust your baby, trust birth. You might be thinking that.... a hospital will turn your birth into a medical event; a doctor is only concerned with the bottom line; a "medwife" (a CNM) has become too brainwashed by the medical world. They all have fear in their hearts and minds and don't believe in the natural process of birth… or at least, they don’t believe enough.

What you may not realize is that those seeds of fear have already been planted in you. You likely now fear interventions, hospitals, hospital personnel - if you are giving birth in a hospital (especially if it's not your first choice to do so), you may be thinking you are going to have to put up a "fight" to get the birth experience you are hoping for. Your mind and body are being conditioned to tense up when you head to the hospital. This is not going to help you emotionally cope with labor nor is it going to help your body if you are full of tension. You may be like me -- some one who had no reason to fear a hospital other than b/c of what I was led to believe by others, by books, by movies but NOT by personal experience.

Or you may fear your hospital b/c you had a bad experience with a prior birth. Talk to your doctor about it. Tell him or her that you need help processing it. Your doctor and the nurses that assisted in your birth are the ONLY ones who know the details of your situation. Perhaps in hindsight certain measures were "unnecessary" but at the time, they may have been the safest, most ethical way to proceed. For anyone else to make assumptions on whether or not your birth should have unfolded the way it did is JUST making assumptions... and filling your head with fear and doubt and anger and essentially, making you feel foolish for consenting to the measures taken. Don’t allow someone take advantage of you like that.

Perhaps your experience was traumatic, you may have been neglected, you may have had a horrible care giver, etc. If that is the case, I am truly sorry and I hope that you are able to speak to a professional to work through what happened. A fear of anything that can lead to anxiety attacks or irrational choices (such as avoiding hospitals or proper medical care at any cost) is not healthy and can be dangerous.

While I have seen and greatly appreciate the strides our maternity system is making, not all hospitals are perfect. Not every care giver is going have A+ bedside manners and not everyone will be in a wonderful, welcoming, plenty-of-sleep-and-able-to-brighten-your-day mood every single day at their job - we are all human. We all have off days. Not all hospitals have beautiful, updated maternity suites and can provide the ambiance and experience you would get in the intimate setting of your own home. But birth is not just about ambiance and experience. More than anything, it's about having a healthy and safe baby and mom. If it wasn't, there would never be any home birth transfers. The end goal ultimately (and rightfully) outweighs the process - any ethical birth worker would agree.

You may be thinking that your desire for a natural childbirth is setting you up to feel empowered. And it can be a very empowering experience! But I have heard many, many times that it ends up doing the opposite. Women end up feeling like they have failed completely if their birth experience doesn't end up the exact way they hope. It may be a smaller matter that ends up bugging you for days or weeks or maybe even longer... or your "worst case scenario" may have unfolded -- even with a healthy baby to hold and your body recovering well.

A less than ideal birth experience is not the worst case scenario. In this day and age in our country, the loss of a baby or mother in childbirth is so rare that it's easy to take for granted that childbirth is not without risks. Our perinatal mortality rate here in the USA is fantastic. But it is not perfect. No country in the world has a perfect perinatal and maternal mortality rate. Loss happens. It happens b/c childbirth is not without risks -- no matter where you give birth, no matter how healthy a mother and her baby may be, no matter how low risk a pregnancy might be before labor begins.

While the birth experience is important, it is not everything. We don't get pregnant to just give birth. We don't carry a baby for 40 weeks to just give birth. Labor and birth are a matter of hours (maybe days) but raising your child is what you will (hopefully) do every day for the rest your life.

While, to you, your birth experience may inspire you as a mother - it may help you personally feel more connected or fit to take on the ups and downs as a mother - but it does not mean that someone whose experience was the complete opposite will be any more or less fit to be a mother, any more or less connected, any more or less anything. Our babies - whether they are born vaginally, surgically, or by someone else's body - are our children. Our bond with them is beyond so much more than any single moment in time.

Please don't lose sight of what it's all about. Don't go into your birth thinking it will be a fight. Ask questions (please do!) but don’t attack anyone or assume they are against you. There are so many hospital personnel that love their job and want to do everything they can to give you the experience you desire. Go into your birth with a kind heart and open mind, with good energy, a welcoming attitude and the excitement that you will soon meet your baby! And please, don't let your plan become so rigid that it becomes an obsession – especially at the potential risk to yourself or your baby.

At the end of the day, you can love your birth experience as much as you want, but it will never love you back. Your child will.


Doula Dani

Saturday, April 20, 2013

Birth Isn't Medical

My kids will be able to drive their own cars some day. My husband and I will do our best to teach them to drive safely and will also have them take a driver's ed class. In an effort to reiterate how important it is to be a defensive, safe driver, my husband and I will share some personal stories of losses we have experienced in our lives due to reckless driving, sadly because we have both experienced such losses of either dear friend or relative. Are the stories meant to scare our children? No. They may scare them, true. But they will be told in our efforts to be completely honest with them as to why we want them to drive safely and that it’s ok to tell a friend “slow down” or similar if they are driving with a friend who is driving recklessly.

If the odds are with them, they will never be involved in a fatal car accident.

Is driving a car anything like having a baby? No, not really. Not physically or emotionally. But they both have risks. Many factors in both cases can turn relatively small risks into very large risks.

I once read in a forum a simple sentence that spoke volumes to me. When I read it, it made complete sense to me and it has stuck with me ever since. It was this simple sentence: Birth isn't medical... until it is.

Birth isn't an illness. And I don't personally believe it is an accident waiting to happen. But that doesn't mean an accident can't happen. If the odds are with a low risk pregnant woman, she'll have an uneventful, safe labor and delivery. But low risk does not mean no risk. How can we predict when birth will become a medical event? Do we just trust that if someone takes good care of themselves during pregnancy, then all will be well? What about those who do everything "right" during pregnancy and labor but still end up in an emergency situation?

I wanted to share stories - real life stories - of events when birth became medical, and in some cases, when it became a down right emergency. It's in those moments - moment when being around professionals who know what to do and how to do it with many hands and minds to help - that it is very clear that birth isn't medical. Until it is.

I'm sharing them in an effort to spread awareness. Not to scare you. Information is power. Not just the good, happy information. All information. 

Thank you to all those who shared their stories with me!


Christine’s birth of her third daughter:
"Penelope was my third vaginal birth after a low-risk pregnancy. Labor and delivery was fine, no complications or issues. It wasn’t until after she was born that we learned there was a problem. We didn’t even notice it, actually. She looked fine to me. Our nurse just didn’t think she looked and sounded right so she thought giving her a little oxygen would help. Quickly, she realized she needed to call a team in for help – which happened within minutes, maybe seconds. Once they arrived they very quickly determined that Penelope was having trouble breathing and she needed to be placed immediately on a ventilator - giving her oxygen was not enough for her. They prepared to move her to a hospital that was better equipped to take care of her. Before transporting, the medical team determined she had a diaphragmatic hernia. Basically, there was a hole in her diaphragm, which restricted her lungs, making it very challenging for her to breathe without a ventilator until after her surgery. Diaphragmatic hernias can be much worse. Penelope was lucky in that her defect was small and she has thrived TREMENDOUSLY! I feel very grateful to have been under the care of such amazing nurses and doctors in a hospital, where they were able to immediately save her life and save her from suffering any neurological damage due to her inability to breathe on her own. She is now a happy, healthy toddler!"

Baby Penelope

Anj's birth of her first son:
"Short version is labor started at 40W6D, he flunked the initial cEFM (continuous electronic fetal monitoring), eventually his heart rate went high with low variability and he was born emergent c-section after apparently bleeding out in utero for suspected Vasa Previa. His APGARs were 1 and 8 which is damned impressive for a baby that was born almost completely flat.

The critical components were continuous electronic fetal monitoring, skilled team for resuscitation, NICU, Blood Bank for his transfusion soon after birth - and of course the operating room and OB. My attending was a CNM. She could make the calls, but obviously not perform the surgery."

Amber's experience as a doula at the birth of one of her clients:
“This birth was a VBA2C (vaginal birth after 2 cesarean sections) in a hospital. Picture perfect labor and then complete placental abruption. The mother was in the operating room under general anesthesia with baby born in under 4 minutes. OB said that the abruption had nothing to do with the VBAC.”

Sara's birth of her son:
"I woke up with SROM (spontaneous rupture of membranes; aka water broke) at 38 weeks and 3 days after a completely uncomplicated pregnancy. Contractions didn't really start until around noon; I arrived at the hospital around 3pm and was dilated to 9 cm. I had a completely unmedicated birth (not even a heplock), with intermittent monitoring. My son was born at 5:44pm after a delivery that my CNM described as "textbook." Then I delivered the placenta and began hemorrhaging. While my CNM began a manual examination of my uterus, the L&D nurses were giving me pitocin, cytotec, running an I.V., and paging the attending OB. Within 15 minutes, I was wheeled back to the operating room for repair of a cervical laceration. I managed to avoid a blood transfusion thanks to prompt care, and because the OB did an expert job on the repair, I did not have cervical incompetence during my next pregnancy. I am grateful for hospital birth and competent providers."

An anonymous OB:
“The thing that always scares the bejeepers out of me is someone whose labor is just moving along beautifully with a gorgeous monitor strip and suddenly the fetal heart rate tanks, and you just can't get it back up. It's the cord. It's pinched, thin, twisted, prolapsed, or whatever, and it comes seemingly from out of the blue.”

Sarah’s birth of her third child:
“I had a home birth for my third child. My labor was going along fine if not a little fast. While I was pushing, my midwife picked up on low heart tones. They were around 50-60 BPM. They weren't recovering after the contractions. The midwife did not hesitate to say that we needed to transfer immediately, for that I consider myself very lucky. It was a forty minute drive to the hospital. I was in the backseat of our van with my rear end in the air, fighting through the most intense contractions, praying that the baby would be alive when we arrived at the hospital. When we got there, the baby's HR had picked back up. I started pushing again, only to have the HR dip dangerously low again. I headed into the OR for a c-section. It turns out that he was positioned poorly and the umbilical cord was wrapped three times around his neck tightly, and very short. His shoulders were also huge and wide. I believe the nuchal cord saved us from a tragic shoulder dystocia. There was no way that he was going to come out vaginally. I have had people tell me that ‘nuchal cords are no big deal, they happen all the time, you just have to slip it off the head.’ That may be so in some cases, but not always and not in my case. I am eternally grateful for the hospital staff for safely delivering my son.”

Desiree’s birth of her first child:
“Normal pregnancy, delivered day before due date, 7.5 hour unmedicated labor (except one round of abx for GBS), had mobility, expectant third stage... then, horrible postpartum hemorrhage requiring two IV uterotonics and internal massage, and left my HGB at a 6.”

Becky’s birth of her second child:
“My first birth was an uncomplicated vaginal birth. For my second, I was the picture of low risk until my daughter's cord prolapsed - in the hospital. We had to change floors, but they got her out in four minutes - including travel time. Her APGARs were 7 and 9.

The scary part is I didn't believe I was in labor, I thought that I was having Braxton Hicks. My husband and mother forced me to go to the hospital. If I had been anywhere else- even the hallway- my story would be very different.”

Myrisa’s birth stories of her first two children:
“For my first baby, I was 30. Low risk pregnancy. On my due date, my water broke, and my mucus plug fell into the toilet. Long story short, took 48 hours for me to get to 10 cm and pushed for 3 hours. Baby was beautiful, 9 pounds 5 oz, 21 inches. Then after what seemed like an eternity, my placenta still would not come. Over an hour later it still wouldn't come. I started bleeding badly but I did not know, as I was so tired and groggy. The room filled with people and an anesthesiologist was there numbing me up from the waist down. I didn't know what was going on and I passed out. I had post partum hemorrhage because of a retained placenta with accreta and I nearly lost my uterus. They had to scrape the placenta off the wall of my uterus since it would not contract; the placenta came out in pieces. They almost gave me a blood transfusion but instead kept me a couple days extra just to watch me. It took me a good 2 months to recover completely and to not walk without a limp.

I viewed that as a bad birth experience, and I decided on a homebirth with the next baby. I found a CPM. No complications. Labor day came right on her due date. I tolerated the labor well; it only lasted 7 hours this time. But when it came to pushing, I was in the labor tub and I delivered her head, but I could not deliver her body. The midwife and her assistant hurriedly got me on all fours (Gaskin maneuver) and I pushed - nothing happened. They rushed me out of the tub and I had to walk to the bed with the baby's head dangling between my legs. They laid me on the bed and put my legs up (McRobert's maneuver). After a short while of her seemingly twisting the baby around, she finally popped out. No cries were heard. I was getting scared, and I couldn't see her because she was on the bed between my legs still and they were doing CPR on her. After what seemed to be a looong time, I finally heard her sputter, then cry. They put her on my chest. I was just so relieved to see her alive! She was 9 pounds 12 oz, 22.5 inches. I had no clue what happened, and was just really grateful my baby was ok. Turns out, as my midwife later told me, she had pretty bad shoulder dystocia and she came out with meconium. My baby luckily had no birth injury, and is a totally healthy 3 year old now.”

Karen’s birth of her son:
“I had an unmedicated birth in a hospital at 41 weeks. It was my second birth and the patterns of contractions were textbook perfect. I had a great doula. No cEFM just intermittent monitoring. There was meconium while I pushed. When he was born, his first APGAR was 5, but it came up to 9 for the second. My husband watched them work on him and told me later it scared him a little.

When my placenta came out, I noticed my doctor looking down at it with a worried look. I had retained placenta. And no epidural. My doctor had to use his hand to remove the rest of the placenta (thank goodness for my doula!). I knew it had to happen and was a risk of natural childbirth so I have never felt violated for that action. It was handled quickly and professionally and I left the hospital with a healthy baby.”

Another anonymous OB:
“I had one of my patients come into Labor and Delivery b/c she couldn’t remember the last time she felt her baby move. She was laughing and felt embarrassed and thought she was being over paranoid. We monitored her and performed an ultrasound. A perfectly healthy, low risk mom and perfectly healthy little baby… she was 39 weeks pregnant... Her baby had passed away.  It was a cord accident, it was pinched too tightly. It was heartbreaking. We sat and cried together….

[As far as during labor,] I know two patients that have had Amniotic Fluid Embolisms. One happened during my residency and the other actually just happened a few months ago to a woman under the care of one of my partners. Both women and both babies amazingly survived. In the case of my partner, we had just had a drill days before it happened to cover this sort of scenario. It took a lot of hands to get the baby out and to work on the mother at the same time.”

Melissa’s birth of her first son:
After my first son was born, all seemed to be OK. It wasn’t until several hours later on after his birth the nurse noticed an issue when I was trying to nurse him. She thought he was turning a little blue so she calmly took him back to the nursery for the pediatrician on call to examine him. His oxygen saturations were not what they should have been so he was given oxygen. At this point I was so crazy exhausted that I was slipping in and out of sleep and I remember hearing him crying as they did various tests to him. Eventually my son was transferred from the small community hospital I had given birth in to one with a NICU. They did an echo several days later and diagnosed him as having a heart defect. After that he was transferred yet again to a hospital where he could get his heart surgeries. It was quite the introduction into motherhood let me tell you.”

Sarah’s birth and death of their first child:
“I delivered our first child, Kate, after receiving all of my prenatal care at an independent birth center. Though I had an uncomplicated pregnancy, as I passed 41 weeks I still hadn’t gone into labor.  I had a biophysical profile ultrasound, which I was told would indicate if my baby was doing well and if it was OK for me to continue my pregnancy.  The test result was an 8 out of the 8 total potential points in a biophysical ultrasound, but the test also indicated that my total amniotic fluid was below the acceptable level.  Our midwives told us that it was acceptable to continue waiting for my body to go into labor.

I went into labor a few days after I was 42 weeks pregnant and spent nine hours at the birth center in early labor. The midwives conducted intermittent monitoring of Kate’s heart rate and started hearing her heart beating irregularly. After an exam, they also noticed that my amniotic fluid was heavily stained with meconium. I was transferred from the birth center to a local hospital approximately 6 miles away.

After being monitored at the hospital, Kate’s and my vital signs started crashing, so I had an immediate, emergency C-section. In the operating room, I heard a nurse say that Kate’s heartbeat was in the 20’s (when normal is over 120). When Kate was delivered without a heartbeat, doctors resuscitated her, but it took over 10 minutes. In surgery, the doctors discovered that my uterus had ruptured, greatly complicating the procedure. I had never had any type of surgery on my uterus before and a uterine rupture on an unscarred uterus is very rare (possibly in the range of 1:20,000 births).  

When I’d recovered sufficiently from the anesthetic, we went to see Kate in the neonatal intensive care unit (NICU).  As advised by the doctors, we disconnected Kate from life support. There was nothing anybody could do for her. I held her while she died. Kate's official cause of death was asphyxia from aspirated meconium; it had gotten into the alveoli in her lungs and she could not transfer oxygen into her bloodstream. We don't know if she tried breathing when my uterus ruptured because it cut off her oxygen supply, or if my placenta had some time earlier stopped working, or even abrupted (separated from my uterus).

Even if you do everything perfectly and have no complications you cannot control whether you will have a uterine rupture, a placental abruption, a hemorrhage, or some other problem that prevents the flow of blood and oxygen to the baby.

When you are on the rare side of a statistic (such as the low chance of uterine rupture), the rarity becomes irrelevant, when the risk becomes reality.  If I’d been anywhere other than the hospital when my uterus ruptured, I, too, most likely would’ve died or would not have been able to have another child.

Though we can’t know for sure what role my being two-plus weeks overdue played in Kate’s death, the heavy meconium, which was present long enough to have stained her fingernails, indicated that she should’ve been delivered much earlier than when I went into labor.”

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