Grandmas

Two baby boys born in the last ten days. Both were quick births, both had some weird stuff afterwards. Both are fine now!

At both births, there were family members present who were nurses.

At the second birth, it was the baby's grandma who was the nurse. She was quite, um, critical, of many of the things we did. She used an almost accusatory tone to state (to MountainMama and her daughter, not to me),

"You should have turned all the lights on in the room."
"You should have covered the baby's head as soon as it was out."
"You shouldn't have waited so long to do the baby's vitals."
"You should have used the bulb syringe."
"You should have taken the baby's oxygen levels."

Oh my. I should have done a great deal more educating that I did at the home visit. Because the baby's mother had had a homebirth with me before, I figured I didn't need to. But the grandma was not present at that earlier birth.

So, I did explain to the baby's mother why we did and didn't do many of the things, but grandma still is feeling very judgemental about our competence.

Turn all the lights on? For what purpose, exactly? We're not in the hospital and I don't need the hubble telescope lights to catch a baby. I could see what I needed to see. Cover the baby's head? We don't do that in a warm room when baby is skin to skin and covered in a warm towel. It's just not necessary when we don't cut the cord right away. "He was cold" says the mom. No, he wasn't. His temperature measured exactly normal.

Why wait so long to do the vitals? What do you mean? We did them at 1 minute and at 5 minutes for the APGAR just like we're supposed to. Do you mean the full newborn exam? Yes? Well, what is the rush for that? (He might lose weight. What? In two hours? LOL) In the hospital they don't do them until the next day when the peds make their rounds.

Why didn't we suction? Because we don't do that routinely. Most babies are perfectly capable of clearing their breathing passages. Most babies get a decent squeeze on the way out. Suctioning with the bulb syringe can cause a vagal response in the baby. If we must suction, we use a delee. But we don't do it routinely.

Why didn't we take the baby's oxygen levels? What on earth do you mean? A pulse-oximeter? Yes? Why would we do that? They don't do that in the hospital routinely either. If the baby is pink, breathing and has a good heartrate, there is no reason to think their pulse-ox would be low. And if they NEEDED their pulse-ox taken, they need to be in the hospital.

Sigh. It was weird for me to be feeling defensive about the stuff that is so normal and usual to me. Why did I feel defensive? Because the grandma didn't ask me any questions. Just made the accusatory statements to her daughter and to MountainMama. "You should have done this. You should have done that." "Should"ing all over us.

I guess I have to make a better effort and educating grandmas that are going to be at the birth. I did meet her at the home visit and gave her ample opportunity to ask questions, but she said she didn't have any. Next time, I will give the information anyway.

A Prophet is Never Heard in Her Own Town

There is a lady in my church who just had an elective repeat C-section today.

This in itself is not shocking or notable. What gets me is that with her first baby, she took my natural childbirth classes, hired a doula and really wanted to have her baby vaginally without drugs. So she said. More on that in a minute.

With her first baby, she got the story from her OB that she had "low fluid" and needed to be induced right away. Conveniently, she was 41 and 3, just the gestation her doc wanted to induce her at. Prostaglandin gel did nothing. So, start pit in the AM. That didn't work either. So the doc broke her water against her request to leave it intact. Guess what? Lots of water came out. She got an epidural. Was NPO for about 30 hours. Got to 10, pushed for a bit, then was sectioned. Familiar story? Her husband had called me several times for info/advice throughout. I told him to FEED HER and that they would never get the baby out if she didn't get some nourishment. He promptly got her some food, which she refused because the doctor had told her not to eat.

Fast forward to this pregnancy. Right off the bat, she SAYS she wants a VBAC. I recommend her a different OB, one that I (used to) trust, who has done really well with VBACs in the past. I offer to doula for them for FREE.

Throughout her pregnancy I would ask her how it was going, trying to stand back and only offer tips/advice when asked. It was hard to do, I tell you. She told me she was waffling between actually doing the VBAC and being scared of uterine rupture. We had a discussion about the real relative risks (another post for another day folks) and she said she "knew" all that, but was still not sure.

At one point, I finally asked her if she was still interested in me being her doula, as she hadn't said anything and she was now 32 weeks. She replied that as of now, she was planning a cesarean. I was surprised and asked her why? She responded that first, her placenta was over the cervix at that time (okay, totally understandable) and that the doctor told her the baby was already 4 WHOLE POUNDS and that if the baby got over 8 pounds, he wouldn't want her to try and push. Um what? (By 34 weeks, her placenta was out of the danger zone)

I bit back the words that were tripping over themselves in a rush to get past my lips. "But...but..." I said. "C-section is major surgery. Lots of VBAC women have bigger babies than their first." She knows.

So then, on Sunday, Preacherman announces that her scheduled section is for Thursday. I hear her say behind me that she hopes to go into labor before then.

After the service, I turn around and tell her that if she really wants to go into labor before then that I have some tips. She asks if I have anything other than sex. I tell her, sure, there's lots of things. I mention a few things but offer for her to come over and I'll do a slow stretch of her cervix. She says, "But that hurts." I say, "Not when I do it." She tells me that it has "always" hurt when she's had it done before (only one other baby, remember) and I tell her she's never had it done by a midwife. She laments that she thought this doctor was "going to let her VBAC". I remind her she doesn't have to have the section. She says she knows, but her husband wants her to have it. He doesn't like that she was crabby with her last labor. Seriously!?

I ask her why Thursday for the section? She says, well the doc told her that either she had to be induced or have a section, and she knew the risks to induction, so she chose the section. I ask again why Thursday? Well, it's her due date of course. And "he" doesn't want the baby to get too big. I remind her that the last few weeks the baby is putting on fat, which squishes.

Every single solution I gave her only led to another roadblock.

If she just wanted a section, why couldn't she just say, "I'm having a section. This is what we've decided." Every time she SAID she wanted a natural birth, but it was someone else's fault why she couldn't, I tried to give her information to help her achieve what she said she wanted. I can only conclude that her "desire" for a natural birth was really just for show for me. But what is the point of that exactly? Why say one thing and do another thing altogether? Does she think that I will think the c-section is great if she can make me believe she was the victim? I'm glad she and her baby are okay. I'm glad she didn't have any complications.

Eventually, she walks out the door and I don't hear from her again.

PreacherMan went up to the hospital last night to visit her. She's really pleased with her birth and her baby. How big was this huge baby that she would never have been able to birth? Can you guess? 7 lb. 6 oz. Yep.

Makes me sad. I'm not going to apologize for having an opinion. Everyone has them. Barring medical complications, an unmedicated vaginal birth is optimal for mother and baby. If I believed that all births are equal, I wouldn't be a midwife.

Undress From the Waist Down

I was asked in the comments how often I do a VE (Vaginal Exam) and since I have a lot of thoughts about this topic, I thought I would just make a post.

I don't like to do VEs. Women don't like to have them done. How often do I do them? When there seems to be a clinical need for one, or we need the information to make a care decision. I also will do them reluctantly if begged by the woman, after I've tried to talk her out of it.

Prenatal vaginal exams are largely useless when done routinely. They are uncomfortable and give misleading information. Moms can be 4 cm and still walk around for 10 days like that. Or they can have a long, closed cervix and have their baby 7 hours later. I have actually heard of women whose doctors told them if they hadn't made "progress" in dilation from one prenatal visit to the next that they would need a cesarean!

The amount of dilation also is not related in any way I've ever seen with how long labor lasts. Faerylady was 5 cm for two weeks before her fifth child was born and she labored for 15 hours to get to 10 cm. I was only 3 cm. 30 minutes before my third child was born.

Many doctors and some midwives will do VEs at the end of pregnancy so they can "rough the cervix up" or "get things going", often without consent or even the woman's knowledge. The mom just knows that the VE is very painful, and she has lots of contractions and maybe some bloody show when she leaves the office. But many times labor doesn't commence. This can lead to trips to the hospital when the mom thinks she's going to have her baby.

I think this is a bad idea for a few reasons, the biggest of which is that the mucus plug has bactericidal properties and protects mother and baby to some degree against infection. Doing a VE, especially a rough stretch and sweep VE, disturbs and removes much of this protective plug. Stripping the membranes is contraindicated in women with Group B Strep. Some women decline testing, and we dont' know their GBS status.

What are some reasons I would do an exam prenatally? I would do a VE if I couldn't tell what the presenting part is. I would do a very gentle VE if I had a mom having a lot of preterm contractions. I would do a long, slow stretch (usually takes about 20 minutes) if I had a mom that was very overdue and we knew she was GBS negative. And I would do one at the mother's request, but with informed consent about the limitations of the information.

Like any intervention/test/procedure, the question needs to be asked "What are you going to do with the information." If it won't affect the care of mother or baby, and there is no change that can/should be made, and if the information can be misleading, why do it?

As far as labor: I still rarely do them. On first timers, I do like to do a VE on arrival at their house. VBACs also. For the primes, it is because they can look like they are in the throes of transition, and be a tight, posterior 1 cm. For VBACs it is because I don't play with obstructed labor and a scarred uterus. If a VBAC isn't making good dilation progress in the face of strong regular contractions, we transport. I still only check every few hours though.

There are lots of moms I have served who I have never checked at all. Many women I can tell where they are in labor with external means -- emotional signposts, the "red line thermometer" between their butt cheeks, the tone of their voices, the quality and intensity of the contractions. Often during pushing, I will tell the moms to reach in and tell me where their baby is and if they are making progress or not. If they are unsure, I will offer to check. As long as they note progress and the heart tones are good, I keep my hands to myself. If we had low heart tones, I get more aggressive with coaching pushing of course.

When else would I check in labor? Again at maternal request. Or if she seems to be complete, but is getting discouraged and/or wanting to push but afraid to. I check any time I hear a problem with heart tones to determine if birth is imminent. And I check if it's been several hours with no discernable external signs of progress.

I always, always ask. The mom can always say no. And I've had so many women remark with suprise, "That didn't even hurt!" It's not supposed to.

It Never Rains, but it Pours

My first solo flight and two babies were born before noon yesterday. One was a multip, "E" having her 5th baby. She lives 2 minutes from my house. I missed the birth. But, I wasn't at home when she was close to having her baby.

4:18 AM, phone call from my primip ("C") due 1/23/08. "My water just broke." Water was clear, baby moving good, mild contractions every 5 minutes or so. She was going to try and sleep more. I told her to call by 7 AM or sooner if things changed. She said she'd been having mild contractions since about 3:30 AM.

5:25 AM phone call from E. "I'm having ctx about every five minutes. No bloody show, but some diarrhea." She says she's ready for me to come. I warn her that I have a first timer whose water just broke an hour ago.

I get dressed, call MountainMama, brush my teeth.

5:30 AM phone call. C's husband. "Her contractions are a lot stronger now." I hear her BELLOWING in the background. That, "I'm going to push soon" bellow. I make a split second decision that she sounds like she's further along and I need to go to her. I call MountainMama back and tell her to go to E and assess. I call three different midwives before I find one who can try and make it. She lives 2 hours away.

6:06 AM arrive at the primip. Her ctx are on top of each other. She's really vocalizing. I check her and she's 2 cm, but the cervix is soooooooooooooo thin, that I wonder how it's even not all the way open. I've never felt a cervix so thin. If I didn't have some experience, I would have probably called her complete, but there it was -- that little tissue paper thin cervix. I knew that was a harbinger of a fast labor! I call the other midwife and tell her what's up. I call MountainMama. The other mom seems (behavior signpost-wise) "maybe 6 cm". I ask her to please try and check her (she's never done that before) and call me back. I tell her that if E starts to look close to birth, she should call me so I can come. She says she's fine, really. I say, well, they hired me as their midwife and I need to be there if I can.

7:25 MountainMama calls The multip is 9 cm. I quick check the primip. She's 5 cm (it's only been an hour and 10 minutes) now. I tell C I'm going to go catch the other baby and I'll be back within 2 hours. She doesn't want me to leave, but understands. I call the other midwife, she's still 45 minutes out, but I’m 30 minutes away myself.

I get on the road. 10 minutes later, I get a call from my apprentice. Baby is out. SHOOT!!!! I call the other midwife and turn around to go back to the primip.

Get back to her at like 7:50. By 9 AM, she has a tiny sliver of lip and she's getting grunty. MountainMama arrives at 9:25 am. At 9:55 C is complete and pushing. Heart tones were low 100's and I tell her we need to have a baby pretty quick. She pushes like a champ and at 10:26 we have a baby boy with a nuchal cord and hand.

Neither mom bled, neither tore. Both are ecstatic with their babies! The primip was 38 weeks and 3 and the multip was 41 and 3. Both had calcified, used up placentas. Isn't that funny?

I feel REALLY BAD that I missed the multips birth. It was a judgment call I had to make. I felt that if the multip had her baby without me there, she would be fine, but the primip might freak out a little more.

As that prime's baby crowned, she started to cry and say, "My son! My son! There's my baby!" I told her, "reach down and take your baby!" and she did and burst into tears of joy, clutching her wet purple baby to her chest and crowing, "He's perfect! He's beautiful! We have a son!" I cried. I don't often cry at births anymore, but I sobbed like a baby myself at this one. The primip's mom and dad were driving from their home 15 hours away. As soon as the baby was out, they called Grandma and Grandpa on speaker phone and announced the baby. The grandparents were also yelling and crying and rejoicing. It was the most beautiful thing I've seen in a long time.

And I LOVE WHAT I DO!

I am convinced that if everyone in the world could love what they do as much as I do, there would be no war. I know it's not all sunshine and roses. I know there will be days when I will have sorrow, pain, or want to quit. But right at this moment, I am over the moon.

The Morning After

So, I woke up this morning and had two thoughts:

"Yay!! I'm on my own!"

and

"HOLY CRAP! I'm on my own!"

No longer will I have a senior midwife standing over my shoulder to look at for confirmation when I make a decision. No longer will have have the assurance that someone that knows more than me and has seen more than me will soon be walking in the door.

The birth yesterday was great, nothing I couldn't handle... she bled a little, had some thick sludgy mec after the baby's head, some transient tachypnea, but nothing I couldn't handle.

I know I can do it, but it is really scary. And exhilirating. And a huge, awesome responsibility.

I DID IT

This morning, I attended my last birth as an apprentice. I did it!!!

VBAC birth, lovely and sweet, no big horrible things, just birth.

I'm a "real" midwife now! What a wonderful feeling of accomplishment!

I owe God thanks for giving me the strength and perseverance to finish this long and sometimes difficult road

I owe my family thanks for their unwavering support, encouragement and willingness to give up their wife and mother for days at a time to serve other families.

I owe Faerylady thanks for being willing to stick with me even when I was an "adolescent apprentice" and downright unbearable at times. And also for long-distance apprenticing me which wasn't easy on her, her practice or her car!

I'm done!!!!!

I'm planning on taking the NARM in August, so I just have to get all that paperwork in order and study, study, study!

Don't worry, constant readers, there will be plenty of midwifey goodness in the future. I intend on continuing this blog.

Prayers and Positive Thoughts Please

As my lady gets closer to birth.... she's due tomorrow. Again, to refresh, if Faerylady makes it, and this lady doesn't transport, this will be the last one. I will be DONE. Today happens to be my birthday, so today would be a nice day for her to have her baby, although no call yet and usually moms with toddlers don't have their babies during the day. We'll see! So, my specific request for you to pray for is that she have her baby, that a senior midwife makes it to the birth, and that she doesn't transport. She is a VBAC, but she got to 10 cm with her first and they could see head and use forceps before they called the section. She can have a baby.