Language and Birth

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Words matter. They settle deep in the psyche and impact our emotions, our beliefs – our overall outlook on things. This is never truer than with pregnancy and childbirth. All pregnant women, but especially a woman pregnant with her first child, is in new and unchartered space, and the people who surround her and the things they say impact her labor and first experiences as a mother.

Mind your words around a pregnant woman, and especially around a woman in labor.

Anthropologists and communication scholars write about two different paradigms of birth. Robbie Davis Floyd, Texas anthropologist and author, writes and lectures about the “technocratic” and “ecology” models of birth, arguing that there is freedom and space in the ecology model, but that in the technocratic model, the woman’s body is seen a machine and the baby as the product. Other researchers write about the “obstetrical” model, which includes the surgical training of obstetricians, versus the “midwifery” model, which includes the midwifery model of care and the importance of continuous support for the laboring woman. In each model you see a different lexicon of words.

For instance, who actually “delivers” the baby? It’s more common in the obstetrical/technocratic model to hear that the physician delivers the baby. But, the original use of the Middle English verb to deliver was passive. The Oxford Dictionaries site points out that “a woman was delivered of a child. When active use first arose, the midwife or doctor was the agent, and the woman the object: ‘they sent, and beg’d I would deliver her’ [1676].” In the beginning, deliver referred to the woman’s experience, whether liberation or rescue from the labor, or the woman freed from the burden of pregnancy. Next it moved to the active form that focused upon the woman’s agency in her birth experience, and today it has moved the main action to the attendant. “Dr. X delivered my baby.”

At the core, within the midwifery model, pregnancy is viewed as a natural life event for childbearing women. And out of that belief, words such as power, trust, love, empowerment, choice, and energy are often used to describe pregnancy and birth. There might be references to the power of nature/ birth or the power of the mother’s abilities in labor. Doulas and midwives use words such “rushes” or “waves” or “surges” to refer to a woman’s contractions, words that conjure up the image of a powerful ocean crashing against the seaside or strong electrical currents. And the midwife serves as facilitator, not director, in the mother’s natural life event.

By contrast, within the obstetrical model, pregnancy is viewed in terms of norms, with the male body as normal. Floyd takes this idea further by saying the woman’s body is seen as machine, the baby as product, and that pregnancy is something to be controlled: the doctor or midwife “deliver” the product through their control over the process with words like induce, intervene, and medicate. If the norm is to not be pregnant, then the labor needs to be actively managed. The action is focused not on the woman who is in labor, but on the staff who perform the management.

Somewhere in between is the reality of birth, right? There are times when a labor or pregnancy can move outside the norm of regular birth. While the woman’s body is designed for giving birth, labor can get complicated. In that case, the obstetrical model, with its emphasis on management and intervention and the provider in action, is a necessary model. But, given that approximately 90% or more (some researchers believe the more accurate number to be 95%) of women can give birth, can deliver their babies without intervention, why are obstetrical/technocratic words so commonly used? And why does it matter?

Women in labor are highly sensitive and intuitive. For example, if a woman is in active labor, moving quickly through the stages, and arrives at the hospital only to hear a nurse tell her that she won’t be giving birth until the next morning, guess what? The labor slows and the baby is born in the morning. If a soon-to-be-grandmother is anxious about the birth and present in the delivery room, the slightest slip of the tongue can have a negative impact on the laboring woman. If she says, “All the women in our family have cesareans, you’re no different,” the labor will be harder, the woman will have to fight against the negativity, and if not adequately prepared or supported, she might end up with a cesarean that may or may not have been needed if the words that surrounded her were positive and affirming. If a nurse tells a mother who is ready to push that the doctor needs to arrive to deliver the baby, the mother may lose her sense of agency over the delivery and the contractions may slow or the pushing become difficult.

The power of suggestion takes on a heightened meaning during birth.

In an article on the Birth International site, Abby Sutcliffe writes:

During labour, women are particularly alert to what is being said by caregivers. Even though she may look as though she is lost is concentration during contractions, the labouring woman will hear, often acutely, what is being said around her. She looks to the midwife for confirmation that she is doing well, particularly with handling the pain. A few well-chosen words of encouragement and support can be far more effective than [medication] in achieving relaxation and confidence in the labouring woman. The midwife at a birth has great influence on the woman’s reactions and impressions, so be careful not to introduce your own feelings and biases into the room. This woman is not a “poor thing” who won’t cope without you — she is a strong, innately capable woman uniquely designed for giving birth easily, safely and enjoyably. If you truly believe this then you won’t need to watch your language, you will already be consciously feeding this information back to through your language and responses.

Birth is a highly personal experience. Each laboring woman brings into the birthing room a personal story that includes the past birth experiences of the women in her family, her own hopes and fears, and any other past experiences that impact the natural process of birth, such as past sexual trauma or body image issues. Birth is a natural life event, a part of a women’s greater sexuality and biology. The words that she hears can help or heed her progress; it’s up to the people who surround her to make it the most positive and successful experience possible. Care providers: pay attention to the words you use around a pregnant or laboring woman. Family members and support team: think before speaking—everyone in the labor room should examine their own biases and experiences, their own fears, or even trauma that may not have been dealt with in the past. For the laboring woman, words really do matter.

Pregnant women deserve to feel supported and respected – empowered – to deliver her baby. No matter the final outcome—whether natural, or a birth with medication or a cesarean section—positive language in the birthing room puts the woman at the center of the action, so that she is in the best position to successfully deliver her baby.

 

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The Physiology of Birth

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photo courtesy of Adelaide Birth Photography

Birth is often a mystery—at least that’s what we’re led to believe. But closer examination reveals basic physiological truths that underpin normal birth for both the mother and baby. Certain truisms can indicate risk, such as a pregnant woman’s prenatal nutrition and medical history, but, in the end, birth is a complex orchestration of hormones, proteins, neurology, and basic psychology for the mother. The teasing apart of these elements allows us to understand the perfectly designed biological process of childbirth.

What We Know About the Onset of Labor

There is surprisingly little known about what causes labor. In the beginning of pregnancy, the woman’s immune system is suppressed to insure that the forming embryo implants successfully and the biological process sets in motion. In fact, if a woman’s immune system is too active, miscarriage can occur in the early months. Later in the pregnancy, when the baby is full term and labor begins naturally, though, there is less consensus about the exact cause of labor. Science is only just beginning to understand the onset of labor.

There’s strong evidence the baby may have something to do with initiating labor. When the baby reaches 32 weeks, a surface protein, a soap like substance or surfacent, coats the inside of the baby’s lungs to keep the alveoli open, a critical shift that will allow the baby to breathe outside the uterus. The surfacent consists of six fats and 4 proteins and continues to be produced until around the child’s eighth birthday, when the lungs are fully developed. Eventually one of the proteins, SP-A, is produced in the baby’s maturing lungs in utero. This protein activates immune cells (macrophages) to migrate to the uterine wall, creating a chemical, inflammatory, reaction, which may be the official start of a natural labor. Studies have been done with mice in which the SP-A is blocked; the mice remain pregnant beyond normal gestation. So, in a nutshell, the baby’s development—more importantly, the baby’s maturing lungs that signal when they are ready to breathe outside the uterus—may be the instigator, signaling for labor to begin.

On the mother’s part, hormones play an important role. Prostaglandin is the hormone that softens the cervix and oxytocin increases and triggers contractions. Also at play are estrogen, progesterone, cortisol, and CRH—corticotrophn. When the baby drops in the mother’s pelvis, the hormones assist, and the cervix begins to relax and thin.

The hormones; the baby’s position; and the immune cells, in concert with the uterus, all work together to trigger the full onset of labor. And hormones continue to work to the mother’s advantage as she progresses through the rest of the labor.

Hormones in Undisturbed Labor Defined

Any woman who has had a natural birth or observed a natural birth knows that undisturbed labor is intuitive and powerful, an intricate dance between mother and baby and the people assisting the mother. The mother often knows what she most needs, even in the most complicated of situations, because of the uninterrupted intuitive interplay between mother and baby.

Sarah Buckley, MD, an Australian obstetrician, writes and speaks extensively on the hormones at play in undisturbed birth. The key hormones in birth include oxytocin, beta-endorphin, adrenaline (epinephrine), and noradrenaline (norepinephrine), and are identical to the pattern of hormone release in lovemaking. “As the hormones of love, pleasure and transcendence, excitement, and tender mothering, respectively, these form the major components of an ecstatic cocktail of hormones that nature prescribes to aid birthing mothers of all mammalian species,” Buckley writes in “Gentle Birth, Gentle Mothering.”

The cocktail of hormones build up and peak around the time of birth or soon after and subside and reorganize over the hours and days after the birth. All of these hormones are produced primarily in the hypothalamus and each serve an important function in natural labor: oxytocin, the love hormone, stimulates contractions, and higher levels of oxytocin are also beneficial for contracting the uterus after birth to prevent hemorrhaging; beta-endorphin serves as a stress hormone, more specifically as a pain-reliever that in high amounts can slow the production of oxytocin, thereby helping to modulate the pain of labor; and adrenaline and noradrenaline—fight or flight hormones—rise at the end of labor, giving the mother extra energy for the pushing and initiating the ejection impulse necessary for the final stage of labor.

Karen Strange, CPM, who teaches NRP training from the baby’s perspective, teaches birth workers to observe and expect the laboring mother to “pause” after the baby arrives. Strange teaches that there is a natural sequencing to birth for both mother and baby, and the pause or resting allows them to have a time of integration. Oxytocin, the love hormone, is at its highest in the hour after the birth, and mothers and babies begin the bonding process during that sacred hour. But noradrenaline also plays a role. “Noradrenaline, as part of the ecstatic cocktail, is also implicated in instinctive mothering behavior. Mice bred to be deficient in noradrenaline will not care for their young after birth unless noradrenaline is injected back into their system,” writes Buckley.

Why Environment Matters

Michael Odent, French obstetrician and surgeon, studied the environments for birth in the 1980s. He introduced low lighting, birthing pools, and singing into the birthing rooms at the hospital where he practiced in Paris. Eventually he became involved in home birth and started a research center in London. He found that low lighting, less observation, warm water, and a more homelike environment aided women in labor. Looking at the hormones at play—the very same hormones that are involved in lovemaking—it’s easy to see why a woman’s labor might be aided by the elements he studied. Traditionally women have birthed in a home, or even outside. The hospital environment became a new normal in the 20th century as surgical and other interventions began to rise, an environment Odent refers to as the masculinization of the birth environment.

Buckley writes, “For birth to proceed optimally, this more primitive part of the brain needs to take precedence over our neocortex—our “new” or higher brain—which is the seat of our rational mind. This shift in consciousness, which some have called “going to another planet,” is aided by (and also aids) the release of birthing hormones such as beta-endorphin, and is inhibited by circumstances that increase alertness, such as bright lighting, conversation, and expectations of rationality.”

Finely Tuned Dance

Low lighting, quiet, and support for the increasing irrational and more instinctual feelings of the birthing mother all support undisturbed labor. Midwives are trained to follow the mother. By following her cues and trusting in the complex orchestration of hormones, the healthcare provider receives vital information for understanding how the labor is progressing. What is most important is that the mother feels safe to travel to that other planet and that labor starts naturally and remains undisturbed. Biology most often takes care of the rest.

The physiology of birth includes a finely tuned dance between mother and baby, between immune cells and proteins and the uterine wall, and between the mother and her environment. If birth is treated more like a medical procedure, more like a masculine [refers to culture, not to men specifically] and rational endeavor, the more removed the mother will become from all the benefits nature provides. The physiology of birth, when allowed to proceed uninterrupted in normal birth, provides a hormonal roadmap for a successful birth and bonding.

“Giving birth and being born brings us into the essence of creation, where the human spirit is courageous and bold and the body, a miracle of wisdom.”

-Harriette Hartigan, midwife, author, and photographer

The Immunological Paradox of Pregnancy

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photo credit: Carmen Hibbins

For most women, navigating pregnancy is difficult. There are decisions to be made: maternity care, labor preferences, place of birth, newborn care, breastfeeding, etc. Not to mention vaccines. Currently the CDC recommends the influenza vaccine for all pregnant women. When making the decision to accept or decline the flu vaccine, it’s important to first understand a pregnant woman’s immune system, as well as the ingredients in different kinds of flu vaccines.

The immune system is a complicated system of cells, tissues, and lymphoid organs—a giant communication network. When cells receive alarms about antigens in the body (viruses, bacteria, parasites, fungi), they produce chemicals that seek to destroy the antigens ability to invade the body. Recently research has shown the importance of a healthy gut for a strong immune system – and for brain health. Really, we are only just beginning to understand the complexity of human immunity.

What we do know is that a woman’s immune system changes significantly from the moment of conception. The innate immune system, the immediate response part, is activated, which results in an increase in white blood cells (monocytes and granulocytes) and the pregnant woman’s production of natural killer (NK) cells decreases. Research has shown that a critical balance of immune cells as well the factors they produce are vital to a healthy pregnancy. Interfering with a pregnant woman’s immune responses is thought to have a negative effect, in particular in the early stages of the pregnancy. The decreased immunity and increase in white blood cells ensures implantation and the development of the placenta. Without it, the fetus can be rejected. Thus, the vast majority of vaccines aren’t indicated for pregnant women and they are generally avoided if possible.

The immunological paradox of pregnancy is complicated, delicate, and beautiful in the way only nature can be.

So what exactly are the risks and benefits of the flu vaccine? The benefit is easy to define: influenza poses a substantial risk for the pregnant woman, in particular during the later months of pregnancy. The woman’s altered immune state can leave her susceptible to certain infections and viruses, and when she contracts the flu it can be hard for her fight it. The CDC states:

Flu is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women (and women up to two weeks postpartum) more prone to severe illness from flu, as well as to hospitalizations and even death. Pregnant women with flu also have a greater chance for serious problems for their developing baby, including premature labor and delivery.

The risks of influenza are real, despite the large number of women who have healthy, safe pregnancies without contracting the flu. So what about risks associated with the vaccine? Most of the research on vaccines is conducted on non-pregnant subjects, so researchers are careful to qualify results. The consensus tends to be: less vaccines overall for pregnant women, but the flu vaccine is indicated given the risks associated with the flu.

Current research focuses on the type of flu vaccines. Most flu vaccines are considered “non-adjuvanted.” An adjuvant is an additive used to increase the immune response to a vaccine. Adjuvant vaccines are important during pandemic times, as adjuvants allow more vaccines to be produced using less antigens and are therefore more cost effective. But adjuvants are pro-inflammatory and can aggravate other immune issues. Given the altered immune system of a pregnant woman, most researchers suggest that only non-adjuvanted flu vaccines be administered.

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The WHO organization issued the Safety of Immunization during Pregnancy report in 2014. The research is far from conclusive, but the WHO takes a careful look at results from studies around the world. In terms of the flu vaccine, they conclude:

Pregnant women and infants suffer disproportionately from severe outcomes of influenza. The effectiveness of influenza vaccine in pregnant women has been demonstrated, with transfer of maternally derived antibodies to the infant providing additional protection. The excellent and robust safety profile of multiple inactivated influenza vaccine preparations over many decades, and the potential complications of influenza disease during pregnancy, support WHO recommendations that pregnant women should be vaccinated. Ongoing clinical studies of the effectiveness, safety, and benefits of influenza vaccination in pregnant women in diverse settings will provide additional data that will aid countries in assessing influenza vaccine use for their own population.

If you’re pregnant, weigh the risks and benefits, and take into account any specific immunity issues. Is your immune system weakened for any reason? What is the risk of exposure? Do you tend to contract the flu? What is your family history in terms of vaccine reactions? Are you high risk for any other reason? Talk over the risks and benefits with your care provider. Ultimately, the decision is yours. Your pregnancy is your pregnancy, and a mother’s intuition is often the best guide.

If you choose to have the flu vaccine administered during your pregnancy, be sure that the vaccine is non-adjuvanted/inactivated. In the next blog post on Birth Outside the Box, we’ll discuss ways to naturally boost your immunity during pregnancy – ways to help you counteract the altered immune state that nature has carefully designed to ensure a successful pregnancy. Garlic? Diet? Sleep? Exercise? We’ll cover it all!

The Shaming Has to Stop

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Get ready for a major soapbox post.

I get it. Those of us who choose to birth outside the box are different. We make choices that don’t necessarily follow mainstream society norms. Our choices may not be in alignment with what is embraced by the obstetrical model of care. Our choices may make medical professionals feel uncomfortable, challenged, exposed. I get it, really I do.

But…

That doesn’t give a healthcare professional the right to deny care in order to shame women and midwives, to bully us, or to punish us into submission because a laboring woman didn’t choose what the medical professional thinks we should do for ourselves, for our children, or for our clients.

Yes, this really happens. All. The. Time.

And, it never should. Ever.

For the most part, people who choose to give birth outside of the hospital feel that giving birth in a hospital is like using a sledgehammer push a thumbtack into a cork board—way too much fuss for something that most people can do on their own—and that a healthy woman having a normal birth in a hospital is asking for trouble. It isn’t that doctors have bad intentions. Most of the time, doctors and nurses have the very best of intentions. But, once a woman walks into a hospital, she will need to be “treated.” And, once a normal labor is “treated” (read, “interfere with”), risk is introduced.

People who choose to give birth outside of the hospital view the medical community as a necessary resource if the normal process doesn’t go normally. Most of us don’t hesitate to seek medical care if there is a need. Yet, why would a woman hesitate? Why do so many of home birthers/birth center birthers distrust the medical community? The lack of trust in the medical community exists because women have been burned many times, and women share their stories with each other.

As a midwife, I’ve personally seen patients yelled at, forced to have vaginal exams despite an explicit refusal, and verbally abused (put down, shamed, coerced, threatened). Doctors have yelled at me, attempted to discredit me in front of my clients, and threatened me with complaints. Why? Is it because something was done wrong? No, quite the contrary. All of these things happened because of a hospital transfer when a mom needed non-emergency help. Yes, these examples occurred during non-emergency transfer situations.

You might think, “Well, during a birth, the hospital staff acts this way because they worry about liability.” OK, let’s assume a medical professional was upset about that. Does that warrant abusive treatment of women and midwives? Quite honestly, does their bias or fear of liability even matter? Their job is to treat whoever comes through the doors of the hospital. Federal EMTALA laws protect a woman’s right to be treated in labor. ACOG supports patient autonomy even if the provider feels the woman’s choices are in conflict with the provider’s belief that her choices are unwise. A practitioner’s unprofessional behavior actually increases the provider’s liability by failing to respect patient autonomy and by refusing to provide the same level of care they would give to any other patient they serve.

This lack of professionalism experienced in the hospital sometimes extends beyond the birth. This is where I feel like the treatment is almost entirely punitive. While I can understand the frustration and stress of a provider who receives an in-labor hospital transfer, this type of post-birth discrimination seems like coercion and punishment for a family making choices that a provider does not personally support.

After a normal, healthy birth, the midwife’s scope of practice is normal newborn care throughout the first 6 weeks. The midwife conducts all of the usual assessments and then recommends the family see a pediatrician for a normal well baby visit at the end of the six-week period. The family calls to make an appointment.

Hold the phone! Wait a second, they won’t see the baby? Why not? Some practices won’t see the baby because the baby was born at home. Say what? They won’t see the baby for 6 months because they didn’t get the vitamin K shot? You’ve got to be kidding me!

Do physicians have the right to deny those people care because they disagree with their choices? For instance, is it OK for a pediatrician to refuse to accept a patient into care because the mother doesn’t breastfeed her baby? Would it be OK if a pediatrician refused care for families who homeschool? No, of course not. Yet, in many cases, with the population of families we serve, if a family has refused for their newborn anything from the mainstream model (such as a Vitamin K shot or erythromycin eye ointment or hepatitis B vaccine), they encounter judgment, fear, or a refusal of service.

It is unethical to refuse care in an attempt to coerce or bully a patient into consenting to care they have refused. It is unethical to refuse care as a way to punish families for their choice to give birth in a way that you do not agree with. It’s morally wrong.

The shame that is heaped on families who’ve chosen a path outside of the mainstream standards has created a culture of resistance and distrust, and that’s not good for anyone. Women and their families should be able to count on a multi-tiered model of care. If a woman plans to give birth at home and the labor takes a turn, she should be given a high quality of care during her transfer, and when she becomes a patient at a hospital. What if instead of shaming, a medical professional chose compassion? Understanding? And what if the medical professional were trained to see themselves as an important part of the picture for women who choose to birth at a birth center or at home?

The shaming has to stop. The punishment has to stop. Is it any wonder we don’t trust you? The distrust has been built on years of mistreatment. It rests on the shoulders of those in the medical community who lack professionalism, who don’t separate their own personal choices and/or training from the choices of the women and midwives who come to them in good faith and in order to see a labor to a successful and safe conclusion.

This dynamic needs to change. Show women that you can treat them with the same respect their midwives show them. Help women to make informed choices, and then respect their right to informed refusal (without trying to make them feel bad about the final decisions). Welcome us—the birth team and the laboring women—so we feel we can come to you for help when it’s needed. Welcome us, so we don’t feel like we want to wait a little longer to see if things get better because we’re scared of how we’ll be received when we arrive at the hospital. Welcome us, so we know we can share our stories fully and honestly with you, without fear of mocking or teasing—or retaliation against our clients.

If the goal is truly to provide good care and not to punish people whose views differ from your own, it’s time to do something to make a change for the good. Every time we interact with you, you have a golden opportunity to let the medical profession shine. Don’t blow it. Help us walk towards you instead of away from you.

If you’re a doctor or a nurse and you support families who make choices that aren’t in alignment with your protocols, this post is not about you. Or, maybe it is. Maybe this is a love story about you. You are the people who give me that glimmer of hope that change is possible and that midwives, consumers, and the medical community can work together to make outcomes better for mothers and babies, and make the experience better for all of us.

The Differences Between Hospital and Out-of-Hospital Birth

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People who have never given birth outside of a hospital may have no idea of the differences between hospital and out-of-hospital birth. What’s the big deal? You can have a natural birth in the hospital. Why would someone want to have their baby at a birth center or (gasp!) at home? The answer is not so black and white.

Can you have a natural birth in the hospital?

Well, that all depends on what you call “natural,” but yes, to varying degrees, you can have a “natural birth” in the hospital. There are many labor & delivery nurses who are excellent at supporting natural hospital births, and there are many doctors and midwives who are supportive as well. Some hospitals have adopted policies that are more tolerant (even encouraging) of birth plans or that allow doulas in the birth room. Those are steps in the right direction. And many women have found creative ways to ensure a natural birth, such as waiting until transition to head to the Labor & Delivery floor, or laboring while roaming the halls of the hospital with a labor coach (a partner or doula or friend). Of course, a birth plan as an avoidance of interventions, rather than as a vision of an ideal birth, seems to really miss the point in a lot of ways. Should birth really be about strategic plans for dodging unwanted interference in your baby’s birth?

Let’s break this down. You’ve hired your care provider because you’ve heard great things about them, they have a great reputation, their statistics are great.. etcetera… Pushing the boundaries within a set system is one thing, but can you ask your care provider to be someone they’re not? A great hospital-based provider is skilled at hospital birth and what hospital birth has to offer you. A great birth center or home birth midwife is skilled at the midwifery model care. The models are not the same. As anyone who has seen birth both in and out of the hospital will tell you, there are a few key differences between the two:

The provider on call attends the birth at the hospital.

If your care provider is part of a group practice, who will actually attend your birth? If it’s a combination of physicians and midwives, are you guaranteed a midwife to attend you? Are all of the providers on board with your birth plan? You may have a favorite midwife or physician in the practice, but what are the chances that your favorite provider will attend the birth?

Most out-of-hospital practices are solo providers, although some are small group practices. In a solo practice, there is a rare possibility that your midwife will be unavailable due to illness or family emergency-after all, we’re only human! If you hired an out-of-hospital provider, do you know who the backup provider is?

All of the above are important questions to ask as you consider your birth options and whether to give birth in the hospital or out. What is most important is that you are comfortable with your decisions and ultimately your birth experience.

In the hospital, it’s the nurses who take care of you, not the doctors.

You spent weeks researching practices, settling on the one practice you think will best support your birth plan. Your doctor is a local superhero. But, who takes care of you at the hospital?

During your time in labor, the nurses will take care of you. Nurses are the amazing unsung heroes in the hospital. They are the ones who do the heavy lifting (literally, as well as figuratively) in patient care. They’re often over-worked and underpaid. We love nurses, yet even though they are awesome, they are also people you’ve never met before. Nurses are the ones who will be with you, almost single-handedly helping you with your labor. What if your philosophies on birth don’t match? Nurses vary in their training in natural labor support techniques. How do you know if you’ll be the lucky mom to get the super nurse who really knows her way around a rebozo or who does her best to be at the bedside as often as possible? Answer: You don’t. It’s a roll of the dice.

Once you get to the hospital, you’ll be checked in by the L&D staff. If you are seen by a doctor or midwife, it might be a provider from your group, or it might be an OB hospitalist, a physician who only sees patients in the hospital and does not have a private practice. If you’re admitted, you’ll most likely be monitored and “treated” per your provider’s standing orders. It’s good to know beforehand what orders are standard for your care provider. Your nurse will keep in contact with your provider and will update and consult with them, as needed, typically by phone. If you have questions about the orders or want to refuse something, you will have to wait until the nurse can reach the provider.

The provider may briefly check in during your labor, but typically they are not continuously present until you are pushing and the head is visible. Their training rests on the ability to take action if something unexpected happens. They are surgeons and the best option for a high risk situation, which happens in a small percentage of births.

Out-of-hospital midwives are the people who take care of you at your home or birth center. Together, with a birth assistant, they provide continuous labor support from beginning to end – and they determine when and if you need someone as highly trained as an OB or a transfer to a hospital. Rather than treat every laboring woman as if they are the minority of women who have complications, out-of-hospital midwives treat laboring women as the if they are the majority, who will not have complications, all the while keeping an eye on whether a complication could occur and when/if to transfer the mother to an OB’s care – much like the maternity models in most of the developed world.

Your nurse is taking care of more than one person at a time.

No matter how awesome your nurse is, she is only one person, and is most likely taking care of multiple women at the same time. It’s not realistic to expect a one-on-one continuous physical presence and support from your labor nurse. The hospital system is set up with floors of patients who are typically divided among the nurses for twelve hour shifts. The care will fluctuate based on caseload, changing shift hours, and the preferences of the nurses in term of hands-on care. There will be no chance to meet the nurses who will attend you before you are admitted. And no choice in terms of which nurse is assigned to you.

On the flip side, hiring a midwife means that you have a chance to interview and pick the right provider for your care, including a back-up midwife. Whether the primary midwife or the back-up midwife, you will have a good sense of exactly who will be providing continuous labor support during your birth.

They work in shifts.

Nurses typically work in 12 hour shifts. Unfortunately, labor doesn’t often fit neatly within one 12 hour shift. Your labor will typically straddle two shifts, or maybe more. While getting through contractions, you may have to shift gears and adapt to a new support person- right before transition, or even right in the middle of pushing.

The typical out-of-hospital provider does not work in shifts. She’s there with you from the beginning to the end.

A different team takes care of your baby.

Every hospital has different protocols and rules about labor and delivery care. The nurses who attend your labor and delivery will likely not be the nurses who take care of your new baby. With the lack of continuity in care for the family, mistakes can be made, such as giving a breastfed baby formula or giving a baby a pacifier when the mom doesn’t want one offered to the baby (in the event it causes nipple confusion and adds stress to the new breastfeeding relationship.)

Usually, the father or another family member can be assigned to accompany the baby whenever he/she leaves the mother, to ensure that no unwanted procedures were carried out despite their wishes to the contrary. Even with this safeguard though, the pediatric team still can’t possibly know the whole picture.

They haven’t been with the family throughout the entirety of prenatal care and birth, so they don’t know you in the same way your midwife would.

Yet another team takes care of you during postpartum.

With midwifery care, the mother’s care, the baby’s care, and the family’s care are all provided by the same team. In fact, the postpartum care is also provided by the midwife who attended the birth.

A different philosophy.

You’re “allowed” to do something, you’re “not allowed” to do something. If your wishes conflict with a physician’s preferences, you might be asked to sign an AMA (Against Medical Advice) form, which can feel intimidating when in the throes of labor. It’s important to remember that hospitals are large institutions with rules and regulations that are applied to every woman, despite the wide differences between them.

Obstetricians handle emergency situations well. In emergencies, the obstetrician is the necessary authority and operates from that perspective.

But in the case of normal birth, the woman is just as important of an authority. When she is able to follow her intuition and pay close attention to her body, with minimal interruption, she can communicate valuable information to her caregiver.

Midwives are trained to respect this authority in normal birth. The philosophy of midwives is that the midwife/client relationship is a partnership and decision-making is shared.

A different outcome.

Hospital and out-of-hospital birth are two very different things. It’s hard for me, as someone who has had it both ways, and who has seen many births both ways, to minimize the difference in outcomes. Personally, my hospital births left me feeling less powerful and capable as a woman and new mother. My home births helped me to feel empowered, intelligent-like I was the expert when it came to my new baby’s needs. There really isn’t a way to quantify that kind of effect, or to easily measure how it impacts your mothering in the long run. Or even to measure how it affects the child long-term. It’s easy to measure the physical benefits of a natural birth.  But it can also have an unexpected and very healing impact on a mother’s life, just when she is embarking on new motherhood with a newborn. The unquantifiable effects of home birth may, in some ways, be the very reason that home birth is the optimal birth choice for so many women. And this may be the biggest difference of all.

Whose birth is it anyway?

IMG_2894

Why does it seem that so much about birth has to do with who controls what? For many people who choose to give birth outside the box, some of the most irritating things about the hospital environment have to do with control. The hospital seems to have a great need to control every aspect of the birth and hospital stay of the mother and baby. They have rules about just about everything!

  • There are rules about the birth tub — IF there’s a tub, you can stay in it for labor, but typically not for the birth, and sometimes not at all if your membranes have ruptured (depending on the hospital).
  • There are rules about the hours that your loved ones can be with you — partner 24/7, grandparents can stay until midnight, children until 8pm, etc.
  • Rules about bathing your baby — the baby is considered a biohazard, so most hospitals require the baby must be bathed ___ hours after the birth.
  • Rules about whether your baby can go home in the car seat you brought with you — don’t even get me started about the car seat test!
  • Rules about whether you can even take your baby home from the hospital — can’t take the baby home if you don’t have a car seat. Not a bad rule, but a rule nonetheless.
  • Rules about doulas — some hospitals don’t even allow them!
  • Rules about what you can eat and drink — pretty much nothing, although your labor partner should eat and drink frequently to keep his strength up. (Hmmm… who’s the one laboring here?)
  • Rules about the Vitamin K and Erythromycin ointment — they look at you like you just grew a third eye if you even question it.
  • Rules about how many people can be in the room — usually no more than 3 plus the laboring woman (depending on the hospital, some are more lenient) and usually only 1 if the birth is a cesarean birth. But, there can be as many hospital staff members as the hospital wants.
  • Rules about having to have an IV — must have it unless your doctor “allows” you to opt for a hep-lock instead.

Yeesh! All of those rules! How does the presence of these rules affect a laboring woman? My thought is that just having someone else calling the shots on things you may or may not care much about, hands your power over to that person or institution for the things you do very deeply care about. The woman gives up her power and her responsibility to think for herself because the institution has a rule for every decision she would normally have to make for herself. Giving up this power and responsibility for the most basic decisions about food, comfort, companionship, and her baby’s treatment puts her in a position of relinquishing control of the bigger decisions by default. She’s already accepted the hospital and doctor as the decision makers for her basic needs, so how could she have the gumption to question the more complex decisions they make for her? Birth becomes something that is done to her, rather than by her.

When listening to women talk about their hospital births, how often do you hear something like this: “I’m not sure why, but they did ____ to me. I’m sure they had their reasons.” Or, perhaps, something like this: “The doctor allowed me to _____.” Something like that would just not fly in midwifery care! In midwifery, the woman takes part in just about every decision made. She becomes informed about the options available, she learns about the objective evidence regarding the risks vs. benefits of those choices, hears her provider’s perspective about her own clinical experience, considers that information along with her own goals and preferences, and then makes a decision about her care based upon this informed choice process. This participative style of decision making is the cornerstone of midwifery care.

Are there rules for out-of-hospital birth with midwives? Sure, of course there are. Each midwife has her own practice guidelines, and there is a community standard of care, but midwives support the mother’s informed choices, even if those choices are not exactly the choices we would make for ourselves. Skip the eye ointment and the vitamin K? If you’re informed about the risks and benefits and feel like that’s the best choice for your family, yes, of course. Eat and drink in labor? Absolutely. In fact, most midwives insist upon it. Get in the water after membranes have ruptured? Sure, why not? Have your loved ones with you 24/7? Absolutely. We wouldn’t have it any other way, provided that’s what you want. Skip the bath? It’s your baby, why not? If someone is worried about disease, they can wash themselves after they touch the baby! Car seat? Yes, but we’re not going to do the car seat test! Ultrasounds? If you want them, you can get them, but that’s up to you. Want to catch your own baby? Go for it, but if you want your midwife to do it, she’d be happy to do so.

The point is that you have as much control as you want to have. You have choices in your birth. Your midwife might guide you, and she might point you to information to help you make decisions about your care, but having a midwife means you have the control to make the choices you believe are best. It’s your birth. You own your choices, which means you own your birth.

My 1966 Baby Book

On the eve of my 50th birthday, I just re-read my baby book. Yep, I know, when was the last time you did that? I figured, hey, I’m going to turn 50 tomorrow, so I thought I’d look at my baby book for a trip down memory lane. A few years ago, I wrote a blog post about my baby book when I was organizing my photo albums. I thought tonight would be a good night to revisit that post and update it with some pictures and a little commentary.

 

Mom-and-Grandpa

My beautiful Mom and my Grandpa two days before I was born.

So, this baby book was quite a treasure trove. There was, of course, a lot of really great stuff in there about my growth and development as a toddler, which was a lot of fun to read. It was great to see my mom as a young mother, noting the same things I noted about my own kids’ babyhoods. I can just see her in her psychedelic 1960’s outfits, with her Sophia Loren eye makeup and bouffant hairdo, chasing little me around trying to get me to eat my pureed peas.

 

My-Firsts

I love this! All of my “firsts” documented!

My mom deserves all of the glory for raising me to be the person I am today. She did a lot, and with very little support from anyone. She was a very young mother, only 19 when I was born. My parents divorced when I was very young, and my mother raised me on her own. How she did it, I’ll never know. She worked two, sometimes three jobs to keep us fed and clothed and keep a roof over our heads. Financially, we were very poor, but we never lacked for fun or love. Mom always made sure of that. She did her absolute best for me, and it is because of that I have always worked to do more, to give more, to be more.

Doing her best for me began with doing her best for my birth. I was born in 1966, back at a time when most moms were knocked out for birth. The natural childbirth movement was just starting to gather momentum back then. Dr. Bradley had just published Husband Coached Childbirth the year before, but I don’t think my mom had read it before my birth. She did, however, read Grantly Dick-Read’s Childbirth Without Fear.

I was born at Forbes Air Force Base hospital in Topeka, Kansas. Here’s a picture of it. From what I understand, the hospital no longer exists, and I think the Air Force Base is no longer there either.

Forbes-Hospital

My dad wasn’t allowed in the room with my mom. My mother, having read Childbirth Without Fear, decided she wanted a natural childbirth. I, like many first babies, was late. According to my mom’s calculations, I was 3 weeks late. She ended up being induced. Despite the induction, mom insisted on having no pain medication. She says she remembers the pain was like waves, and she would just visualize ocean waves during the contractions to get through it. She remembers a very nice nurse who was very comforting and maternal towards her during her labor. When mom started to push, the doctor had the nurse strap a face mask to her leg. It had trilene gas, a popular anesthetic at the time. The nurse said it would be there for her if she needed it, and she could just grab it and inhale if the pain became too much to bear. At the moment of crowning, when mom was startled by the intensity of that moment, she grabbed the mask and inhaled, not knowing it wasn’t going to get any more difficult than it was right then, and she was knocked out. When she came to, she remembers hearing me cry, and she thought I was a cat meowing.

Baby-Kim

Baby Kim Rae Armstrong. Born May 26, 1966. 7# 4 oz., 19 1/2″ long.

When mom tells the story of my birth, she gets really angry, and rightly so. She made it all the way to the end and then took the drugs because she didn’t know she was at the end. She never had any more children, so she missed her one chance to experience the moment of the birth of her child. As a woman who has experienced that moment for all 5 of my children, I really feel like my mom got ripped off.

I always thought that story was so sad, but I was so proud of my mom for trying hard for a natural birth back in those days. She was the only woman in the maternity ward who chose to breastfeed too. My mom was such a rebel. At the young age of 19, she knew already just how important natural birth and breastfeeding are. I am forever thankful for her choices and so proud of her for taking that path.

So, I was reading my baby book today and thinking about all that my mother went through when I was born, all of the challenges she faced. The baby book she had for me was part baby book/album and part baby care guide. It was really interesting to read what they had to say about birth, breastfeeding, and baby care. Here are some snippets I found particularly telling about the mindset surrounding birthing back in 1966:

Hospital Routines:

“If you believe you are going into labor, do not eat any food until you speak with your doctor. Anesthetics are best tolerated on an empty stomach.”

“After the doctor has examined you, he usually orders the nurse to give you an enema.”

” ‘Natural Childbirth’ is a term that has been accepted by those mothers wishing to experience the birth of their babies without the aid of analgesia and anesthesia. Even those mothers, however, are frequently given a local anesthesia.”

“When you recover from your anesthesia and delivery, you will, of course, be tired and so you may fall off into a natural sleep for three to four hours. Following this rest … your first interest will be your baby and the nurse will bring him into your room as soon as you ask to see him.”

“(Rooming in) requires special nursing routines and special regulations concerning visitors that most hospitals do not customarily allow.”

Feeding:

“Most hospitals thoughtfully give the mother a bottle containing enough formula for 24 hours on her day of discharge from the hospital. This takes the pressure off the first day at home and makes the preparation of the first formula a pleasure rather than a hasty chore. You will be given a copy of the formula the baby has been receiving, and with the demonstration of formula preparation which you observed the day prior to discharge fresh in your mind, you will find that formula making is much easier than you may have anticipated.”

“All normal newborns receive a 2 1/2% sugar water solution twelve hours after birth and at intervals during the following twelve hours. 24 hours after birth, the baby is put to the mother’s breast for three to five minutes every four hours for one day. Feeding time is then gradually increased to the normal period of 20 minutes.”

Infant Identification:

Baby-identification

“Some hospitals expose the infant to enough ultra-violet light to sunburn his name on his skin. Others place a large piece of adhesive on the infant’s back upon which his mother’s name is recorded.”

Seriously? WOW. I knew it was bad then, but wow. My mom traversed some pretty high obstacles just to even breastfeed back then. I saw in my baby book that she remained in the hospital until June 1st, which was 6 days after I was born. I can’t imagine not seeing my baby until 4 hours after the birth, nor can I imagine only being “allowed” to breastfeed my baby 24 hours after the birth, and then for only 3-5 minutes every 4 hours. Can you believe the stuff about the sugar water and not nursing for the first 24 hours??? The sunburn thing is absolutely barbaric!

My baby book was a real eye-opener in so many ways. It gave me a whole new respect for my mother’s courage and determination in the face of a very well-established system of obstetrical care. I find it absolutely amazing that she was able to do as much as she did. In fact, I find it pretty amazing that anyone breastfed or had natural births back then. It is pretty mind-boggling to think of what a radical shift in philosophy the natural childbirth movement was back then. It makes my current efforts seem tame by comparison. Now, when people call me a radical or a rebel, I’ll wear that label with pride and a little smile because I know I’m not nearly the rebel my mom’s generation was. I aspire to be that kind of rebel.

Mom

One of my most favorite pictures of my mom, taken in the hospital shortly after I was born. She was a 19 year old new mother and just radiant. Probably working on the very baby book I’m writing about here.