Belly Tales

Forget the Oscars (well, not entirely: Go, Juno, go!); the movie I really want to see is A Walk To Beautiful. Having already won several awards at film festivals around the world, the film follows five courageous women as they travel to the Addis Ababa Fistula Hospital in Ethiopa to find a cure for the obstetric fistulas they suffer from. Fistulas are an opening between the vagina and rectum or the vagina and urethrea which occurs after days and days of obstructed labor. In developed countries around the world, fistulas have become a thing of the past since the advent of cesarean birth (the last U.S. fistula hospital closed its doors in 1895), but in developing countries around the world, it’s still a very grim reality. Incontinent, with either feces or urine dripping from their vaginas, women with fistulas are often shunned by their communities, ostracized and forced to live lives of isolation. The cure for fistulas is a simple surgical procedure, but with access to modern health care often hundreds of miles away, the cure might as well exist on another continent. Just check out some of these facts:

• For every woman who dies from pregnancy-related complications, 20 women survive but experience terrible injuries and disabilities.
• In Ethiopia, there are 59 OB/GYNs and 1,000 midwives for a population of 77 million.
• One woman dies from pregnancy-related complications every minute worldwide; 95% of them live in Africa and Asia.
• More than 99% of The Fistula Hospital patients are illiterate. (The hospital teaches all patients the Amharic Fideles and the Oromiyffa alphabets.)
• Number of patients treated at the Addis Ababa Fistula Hospital every year: 1,200
• Number of obstetric fistula cases occurring in Ethiopia alone each year: 9,000
• Number of new obstetric fistula cases resulting from childbirth occurring worldwide each year: 100,000
• Number of new obstetric fistula cases resulting from childbirth occurring in the U.S. each year: 0.

The movie is playing at the Quad Cinemas in New York City right now, and has recently been extended through February 28th. I’m hoping to see it on Wed., and I’ll certainly write a review afterwards. Good stuff.

(Go Juno, go!)

I cut my very first episiotomy last week. It was my 70th delivery. Somehow, somewhere in the back of my mind I was thinking that my first episiotomy would come after a hundred births, at least….probably more. After all, there are absolutely no advantages to cutting routine episiotomies, and it seems like the reasons you’d actually need to cut one are few and far between. At the same time, I’ve been dreading this for quite some time. Back in January I had a rather scary and traumatic delivery where nearly everything that could have possibly torn on the woman did indeed tear: cervix, perineum (3rd degree laceration), bilateral sulcus tears, clitoris, labia and periurethrea. In retrospect, this had a lot more to do with the woman’s tissue integrity and nutritional status than it did with how I managed (or mismanaged) her birth, but I got some flack from a few of the doctors I work with regarding the blatant lack of episitomy with that delivery (it was a 9lb.13oz. baby, for the record, although none of us were anticipating such a large baby). The woman needed to be brought back to the operating room and sedated in order to complete the repairs, and I was called to the operating room by the doctors to watch some of the repair (I’m not sure if this was their well-intentioned way of teaching me how to do difficult repairs like this, or if it was their way of rubbing my nose in my mistakes, to teach me an altogether different sort of lesson). In any case, the question they kept asking was: why didn’t you cut an episiotomy?

Well, I didn’t cut one because it had never occurred to me that she would tear so badly (and in retrospect, if I had cut an episitomy, I’m pretty sure it would have been a 4th degree laceration rather than a 3rd, especially given how poor her tissue integrity was), and I’ve never seen any reason to cut an episiotomy just because you think it’s going to be a big baby (I’ve seen plenty of 9+ lbs. babies delivered over intact perineums, so why in the world would you actually cut??). Not to mention that the baby delivered so quickly that I barely had time to get my gloves on, let alone pick up a pair of scissors. I told the doctors that I had never cut an episiotomy before. I meant that I had never yet cut an episotomy, not that I never would cut one, but one of the doctors in particular thought that I was stating that I would never EVER cut an episiotomy, ever, and this person was so upset by this that they brought it to the attention of my supervisor. Anyway, to make a very long story short, the cutting (or not cutting) of episiotomies had been on my mind for awhile, and I knew that I would probably end up cutting one eventually, but I wasn’t sure when, and I was dreading it.

Just saying that makes it feel like some kind of rite of passage. Is that really the case? Does it have to be that way? Do all midwives have to cut an episiotomy at some point in their careers? Are there any midwives out there who have never cut an episiotomy, ever? I feel like in the case of hospital midwifery, the need for episiotomies is probably much more prevalent simply because the large number of interventions create more situations which call for episiotomies (and by this I mean situations which truly require an episiotomy, as opposed to routine episiotomies that are cut simply to speed up the birth process, or for convenience sake, etc., although those certainly occur more frequently in hospitals anyway).

I am learning that the trick about obstetrics has everything to do with making the right intervention call at the right time. I think this might be more true of hospital births than homebirths simply because of the time pressures which are always nipping at your heels in a hospital, and the fact that so many interventions are available in the hospital setting v. the homebirth setting, and that each intervention then begets even more interventions in that notorious slippery-slope fashion. In any case, it all comes down to judgement; to knowing when something is needed versus when it’s superfluous, and this is such a delicate skill to learn, especially because the line between necessary and unecessary can be razor thin, and becuase it often fluctuates and changes throughout the birth, so that something which was unnecessary 10 hours ago when the tracing was gorgeous suddenly seems brutally necessary 12 hours later, when the tracing has changed. The judgement comes in anticipating these changes—at least as many of them as can be anticipated (which, given how unpredictable and fluid birth can be…is not actually that many). And of course, your experience affects your judgement, too. If you’ve seen several serious obstetric emergencies unfold before your eyes, if you’ve ever seen a baby or woman die, if you’ve been sued…your judgement calls are going to be very different from those who have never experienced any of these things.

Navelgazing Midwife was recently talking about this in two of her posts: The Myth of the Vertex and The Gray, Grey Messenger: Trust. Part of what you’re relying on in your care provider—be she midwife or doctor—is her judgement. That’s why she’s there. In the case of homebirth, it’s really obvious: the midwife is the guardian watching from the birth from the corner of the room. So long as everything is progressing smoothly, she won’t lift a finger to intervene, but if things begin to slide off the road of normalcy and something more is needed, you really want her to step in at that time and do what needs to be done. Ideally, in a relationship based on trust, if she says “we need to go to the hospital now”, you’ll believe her and trust her and call the ambulance, because you know she wouldn’t even be suggesting it if that weren’t truly the case. The reason she’s there is because she’s seen hundreds (maybe thousands of births) and she knows when things are normal versus when something needs to be done. The Myth of the Vertex in particular speaks to this. Just because the baby’s head is down does not necessarily gaurantee that everything will proceed smoothly to a vaginal birth. When everything doesn’t go exactly to plan, it’s not a betrayal on the part of the midwife, it’s her responding to the changing circumstances of the birth by doing what needs to be done—recognizing the change, and knowing what needs to happen next. That’s her job. That’s her judgement call right there. That’s why she’s there. That’s what you’re paying her for.

I know this sounds very defensive. To be honest, I feel incredibly defensive about this. I feel like I need to stand up on stump and say: I cut an episiotomy, but here are all my reasons for doing so, and I really think it was what was needed at the time. That’s how strongly I feel about episiotomies. It wasn’t a phony episiotomy. It wasn’t cut just to cut one. I feel like I need to somehow justify this act to the woman, her family, the universe. I didn’t want to cut it! But in this situation, I think she absolutely needed one. She’d been pushing for over 2.5 hours, the baby had been sitting on the perineum at +3 station (i.e. the point where the head remains under the pubic bone in between pushes, and crowning is usually imminent) for the past half hour without crowning, and the baby’s heart rate was really starting to reflect the baby’s exhaustion, with variable decels that were deepening with each contraction into the 60s. She was exhausted herself after a long, hard primip labor. She had had some stadol earlier in the labor, but never an epidural, and she was feeling the burn and sting of crowning but couldn’t manage to push the baby past that point. Even after I cut the episiotomy, the baby still didn’t come out right away. We tried the Ritken maneuver, but that still didn’t bring the baby’s head up and out. Finally, in the end she needed a vacuum to help deliver the baby (and if I hadn’t cut an episiotomy, the doctor would have at this point to apply the vacuum).

Ugh. Having just typed all of that out…it suddenly seems pathetic: my sad attempt to try to justify why I cut an episiotomy. I’m sure someone will call me on it and say, bold as brass: she didn’t need one, you were wrong to cut one. Maybe I was. Or maybe I’m making way too big a deal of this? I don’t know why I’m typing all of this out, why I feel the need to hyper-analyze my defensiveness—in essence, defend my defensiveness. I made a judgement call, I cut an episiotomy, I think it was necessary. That should be that. And yet, as a midwife, I view myself as a defender of intact perineums everywhere. I feel like I let this woman down in some way. I feel that so clearly and so strongly, and yet, at the same time I find myself praying that I will always be able to make the right judgement call at the right moment—that in the future, when a woman really does need an episiotomy, I won’t hesitate. I’ll do what needs to be done.

This is a messy post, as Dark Daughta would say. In her book, that’s actually a compliment. I never promised I’d have all of the answers. My response to my first episiotomy has been very complex; it’s kind of taken my by surprise, how much this has affected me. How I feel about it has been varying tremendously from day to day, minute to minute. I promised to chronicle my adventures as a new midwife— the good, the bad, the ugly, the messy….so here you go. I’m still trying to figure out how I feel about this one. It’s all a work in progress.

The American College of Obstetricians and Gynecologists (ACOG) recently issued a Statement on Homebirth which condemns homebirth and all those who are willing to attend homebirth (aka midwives), concluding that only “…the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets the standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.”

Many other websites have covered this topic in exhaustive detail, so I’ll refer you to them in just a moment, but first a few comments of my own. As Rixa rightly pointed out on her blog The True Face of Birth, ACOG’s sudden acceptance of out-of-hospital birth facilities (i.e. freestanding birth centers) flies directly in the face of their earlier November, 2006 Statement on the subject, where they were adamant that the hospital “is the safest setting for labor, delivery, and the immediate postpartum period,” and that “ACOG strongly opposes out-of-hospital births.” I wonder what caused the sudden change of heart? If you recall, during the time, ACOG and the American Association of Birth Centers (AABC) were not on such buddy-buddy terms. In fact, the AACB wrote a scathing denouncement of ACOG’s statement. Opposing out of hospital birth included births that occurred in freestanding birth centers as well as in homes. I guess in deciding to attack homebirth directly, maybe ACOG decided that it would be better off having the AACB as an ally rather than an enemy, and included freestanding birth centers in its list of “acceptable birthing places” this time around. Who knows. There has got to be so much back-room wheeling and dealing and politics involved in all of this that one can only wonder at the motives. But crucially, why must support of freestanding birth centers be at the expense of homebirth?

It’s also interesting to note that the ACNM has yet to issue a response to this. Is that because they’re partly mollified by ACOG’s acceptance of certified nurse-midwives to the exclusion of all other midwives? From the ACOG statement: “For women who choose a midwife to help deliver their baby, it is critical that they choose only ACNM-certified or AMCB-certified midwives that collaborate with a physician to deliver their baby in a hospital, hospital-based birthing center, or properly accredited freestanding birth center.” Making distinctions like that among midwives in our country (CNMs v. CPMs) only hurts our profession as a whole and is going to get the overall profession of midwifery absolutely no where, but I’ve already written about this ad nauseum. And what about the hundreds of Certified-Nurse Midwives/ Certified Midwives who attend homebirths? Dear ACNM: Just because the majority fo CNMs/CMs work in hospitals doesn’t mean that those who work in homes don’t need a response statement from you. You’re still the professional organization for ALL Certified Nurse Midwives and Certified Midwives—even those who perform homebirth. If you won’t stand up for a woman’s right to give birth in a home, at least stand up for the midwives you represent who deliver in homes….even if it means butting heads with your beloved ACOG.

As Rixa conjectured, maybe all of this is indeed in response to Ricki Lake and Abby Epstein’s documentary The Business of Being Born, which has done a terrific job of raising awareness regarding homebirth. The real question we need to continue to ask ourselves is this: Why is it that America, with all of it’s insistence on hospital birth and safety, still has one of the highest rates of neonatal and maternal mortality among developed countries? That question lies at the heart of The Business of Being Born, and clearly, the American way of doing birth, for all its emphasis on hospitals and safety, has not adequately addressed this. What we need is a statement from ACOG more along the lines of the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM), which both jointly support homebirth, in sharp contrast to what ACOG has churned out (kudos to Rixa for finding and posting this in its entirety). Just read the first few lines of the document:

The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.^1–3

What a refreshingly different point of view. Surely American women aren’t that different from British women? Surely our healthcare systems are not that different? Why can homebirth be safe on one side of the pond, and unsafe on the other? Yeah, you guessed it: one side is actually basing its policy on research and fact, while the other is pandering in fear, uncertainty and doubt. And don’t forget the economics at work here. ACOG is a professional organization supporting and marketing the services of its members: obstetricians. In other words, a lobby. Again as the Business of Being Born points out, the bottom line is always the bottom line. If we had a national healthcare system like the NHS, where homebirth actually translates to increased savings, rather than a competitive profit-driven healthcare system and a surplus of obstetricians, we’d probably be seeing a lot more governtment-funded support for homebirth.

This is the line that really sticks in my craw: “The main goal should be a healthy and safe outcome for both mother and baby. Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.” You selfish, selfish mothers, trying to enjoy your relaxing, all-natural births at the expense of your babies! The mother and the baby have become hopelessly estranged in the minds of American medicine, and the emphasis (and increasingly, the legal rights) of the baby are always seen as more important than those of the mother. Rather than motherbaby, where the two are linked and the health and wellbeing (physical, mental and emotional) of one is dependent on the other, we have fetal rights outstripping maternal rights, in courts as well as in hospitals. Why can’t modern medicine seem to get it through its skull: what’s good for the mother is ALSO GOOD FOR THE BABY. The two are not diametrically opposed. When a woman feels safe, supported and relaxed, she’s able to sink into her labor and allow her birth to unfold in the manner that’s best for the baby, without all of the stress hormones and cortisol, without all of the fear….and more often than not, with stunningly good outcomes.

In any case, you should go read the rest of Rixa’s post on The True Face of Birth ASAP: 10 Responses to ACOG’s statement on homebirth, as well as the other responses cropping up around the blogosphere.

I’ve sort of fallen off of the blogging bandwagon, but what’s the point of a blog if you can’t be political with it? So, with that in mind, we now take a break from our regularly scheduled midwifery for this brief political message:

I’m voting for Barack Obama

I like the fact that he’s run a very clean campaign and refused corporate lobby money. I like the fact that he’s an idealist—people try so hard to call him naive and inexperienced because he’s idealistic and hopeful—but why should we vote for our fears rather than our hope? How deliciously refreshing to be voting for a candidate that you actually like: someone who inspires you and makes you hopeful, rather than voting for the candidate that you dislike the least! There’s an excitement and an energy in his grassroots movement which is sweeping the country right now that’s really got me excited, so much so that I’ve actually given money to his campaign. My donation was then matched by another Obama supporter in California, and we’ve since gotten into an e-mail correspondence. I like the sense that his campaign is driven by hundreds of thousands of little guys like me, and that our combined small-fry donations are actually adding up to a lot.

I think this country needs a radical change in leadership, and while I really like Hillary (I’ve voted for her twice as a Senator), she and her husband have been the darlings of the Democratic party for over 20 years now. Clinton ran on an anti-establishment platform of change in 1992, but now he and Hillary have become the establishment. It’s time for some new blood. It’s Obama, not Hillary, who’s most successfully running on Clinton’s legacy of change.

Some of our greatest presidents have had very little Washington experience. Abraham Lincoln served only one undistinguished term in the House before becoming president. “Looking at the 19 presidents since 1900, three of the greatest were among those with the fewest years in electoral politics.Teddy Roosevelt had been a governor for two years and vice president for six months; Woodrow Wilson, a governor for just two years; and Franklin Roosevelt, a governor for four years. None ever served in Congress.” [1] Even Clinton himself came in with gubernatorial experience, but not a whiff of congressional first-hand know-how.

I’m impressed by Obama’s history of being able to unite both sides of the aisle and craft true bipartisan legislation. I like his constancy and his character; when you actually look at his record (short though it might be), you quickly realize that he’s someone who sticks to his guns. I like the fact that he’s been opposed to war in Iraq from the start. I’d much rather vote for someone with good judgement and little experience than someone with lots of experience but judgement calls which they’ve since regretted. “Obama is an inner-directed man in a profession filled with insecure outer-directed ones. He was forged by the process of discovering his own identity from the scattered facts of his childhood, a process that is described in finely observed detail in “Dreams From My Father.” Once he completed that process, he has been astonishingly constant.” [2]

I think Barack Obama is more electable than Hillary Clinton. This is partly because I know many people—Republicans, Independents, and even some Democrats—who don’t just dislike Hillary….they DESPISE her. I don’t know why, I don’t understand it, but I know that it’s a very personal, deep-seated hatred, and that many people feel this way about her. My number one goal is to get a Democrat in office as the president, and I feel that a Hillary nomination will be a blessing in disguise for the Republican party. They’ll sling mud, they’ll get dirty, they’ll draw upon that strange RABID Hillary hatred, and maybe they’ll win because of it. I don’t want to give them that chance. I think that Obama has the potential to reach out and win the vote of not only Democrats, but Independents and *even* some moderate Republicans. He’s running a campaign that’s trying to beat the Red State/ Blue State mentality, which isn’t something that Hillary (who’s too firmly entrenched as a Democratic bastion) can transcend. As for the question of whether or not he can withstand the Republican mud-slinging machine….well, Hillary hasn’t exactly been kind to him, but she hasn’t been able to dig up anything on him yet. Maybe because there ISN’T anything to dig up.

Finally, I don’t think it’s possible for America to fall much lower in the esteem of the international community. We need a new face, a new message to be sending to the world to redeem our great country from the ravages and stupidity of the Bush years. I feel that Obama, as a relative unknown, is best poised to start with a clean slate in the opinion of the world. Barrack HUSSEIN Obama—fathered by a Kenyan, growing up in Hawaii and Indonesia, attending a Muslim high school—offers an opportunity to rebrand the face of America in the eyes of the world which Hillary just can’t match. [3]

I like Hillary. When this election started last year, I was pretty certain I was going to be a staunch Hillary supporter to the end. The fact that I’m voting for someone else instead really surprises me. I’m a strong feminist, and I do think the time is ripe for a female president. However, I don’t think she’s the right candidate. I think she’s more divisive than unifying in this current climate, and I think the Republicans will have a field day with her record and her history (anyone in the mood for an ugly recap of the Monica Lewinsky affair or WhiteWater? I’m certainly not!! ). I think Obama offers a new start and a new opportunity to actually get beyond the partisan divide which has been the crux of Baby Boomer politics. If Hillary ends up winning, I’d be happy to vote for her in the general election, but I think Obama is the better choice.

So there you go: that basically sums up why I’m voting for Barack Obama. I’d love to hear your thoughts on this!! Who are you voting for, and why? And if anything I’ve said helped tip your hat into the Obama ring, go give him $20 at www.barackobama.com and join his grassroots movement—you too can have your donation matched by someone in another state who is believing, just like you.

[1] NY Times Op-Ed 1/20/08

[2] NY Times Op-Ed 12/18/07

[3] The Atlantic: Goodbye To All That

I’ve been sick as a dog for the past three days, for the second time this season (I was so sick right before Thanksgiving that I actually lost my voice and had to call in sick to work…something which I NEVER do).  Luckily I’ve had the past 3 days off to recover, but I’m due to be back at work again tomorrow, and I’m not sure how my voice will hold up.  I keep coughing up icky green stuff, and I feel like this is potentially moving into my lungs.  I’m so rarely sick!  It must be all of the chronic stress of being a new midwife which has absolutely blitzed my immune system.  Joy.  At least I’m over the contagious part of it, so that when I’m at work tomorrow I won’t be getting pregnant women ill as well.

In any case, I’m not up for writing much of anything, but I found another amazing video over at Sage Femme’s, and thought I’d share it too.  It’s been up at Sage Femme’s for awhile, and I’ve seen it before, but since I only just recently learned how to embed You Tube videos, might as well polish the new skills, w00t!  This one is ultimately brought to you by the folks over at International Cesarean Awareness Network.  Just goes to show what a bogus diagnosis “cephalo-pelvic disproportion” (CPD) often is, and what a VBAC can accomplish when it’s actually allowed to proceed (which is why the declining VBAC rate is an absolute tragedy).  Baby heads are made to mold, and pelvises are made to stretch.  Given enough time and patience, I believe that almost all babies, regardless of size, will make their way into the world.   And just look at the triumph on these women’s faces.  Talk about blowing a raspberry to the entire technocratic fear-based model of birth!

I just discovered the most amazing videos over on You Tube about a traditional midwife working in Mexico. I’m sure many of you have probably seen them already, but I was just blown away!! It’s amazing to watch the way she uses her hands to massage, assess, palpate…turn a breech baby. A midwife’s greatest tool is her hands. I wonder how many of the women I see in the clinic come from traditional midwifery practices like this. American midwifery must seem very different to them. At it’s heart, I think the respect and tenderness and kindness to pregnant women remains the same, but we could learn so much from traditional practices like this. It makes me want to quit my job, fly down to Mexico and study with her for a year. In any case, enjoy!

The other day I discovered a postcard at my local yoga center urging women to participate in a birth survey, which instantly piqued my interest; apparently this survey has already been going on for some time, although I have only now heard about it. A little research has revealed that the Coalition for Improving Maternity Services (CIMS) has launched a new program entitled The Transparency in Maternity Care Project, which is intended to research and explore maternity care in this country, with an emphasis on improving the transparency of maternity care. Unlike other areas of medicine, hospitals and maternity care providers are still pretty cagey when it comes to being open with their numbers. What is the c-section rate for specific doctors or hospitals? What is the VBAC rate? How many providers perform episiotomies? How many elective cesareans or inductions occur annually? Hard numbers like this are always notoriously hard to come by. And of coruse, beyond the actual numbers themselves, women’s experiences with maternity care providers and services and overall satisfaction is often something which is overlooked. It seems like The Transparency in Maternity Care Project is trying to fix all of that, and is acting as a follow-up to the Listening to Mothers surveys which occurred in 2002 and 2006. Like Listening to Mothers I and II, a survey lies at the heart of The Transparency in Maternity Care Project, which can be found at the following website: www.TheBirthSurvey.com. The pilot survey is occurring in New York City right now, between July 2007 and July 2008.

There were many reasons to choose New York City as our pilot site.

First: New York is a large, high profile city offering a wide variety of birth options.

It is a densely populated and well-networked urban center. There is easy access to multiple press/media outlets. Approximately 125,000 births occur in NYC per year. Forty-four hospitals provide maternity care services. The majority of the country’s obstetricians are trained in NYC. Two Free-standing Birth Centers are in operation. An established homebirth community thrives. Nearly 10% of births in NY are attended by midwives.

Second: The Grassroots Advocates Committee will be piloting the project in partnership with Choices in Childbirth (CIC), an active grassroots organization based in NYC.

CIC is well connected with the NYC birth community. CIC publishes The New York Guide to a Healthy Birth – in 2007, 20,000 copies advertising The Birth Survey will be distributed free to the public. A member of the GAC and CIC is based in NYC and will be engaged in the day-to-day oversight of the pilot.

Third: New York State is one of only two states with a Maternity Information Act.

The MIA provides the public with legal access to intervention rates at the facility level. Choices in Childbirth is connected with the NYS Department of Health and has already collected the intervention rates for all New York hospitals.

So, if you live in NYC and have given birth in NYC, here’s your chance to discuss your experience and provide valuable information and feedback about birth in our country. Please participate in the birth survey ASAP. As for the rest of the country, the project plans to unveil a national survey next summer, but if you’re super motivated, you can provide feedback about your birth experience at www.drscore.com.

Sometimes birth is not normal. Sometimes there really are complications and problems which need to be dealt with in a hospital setting. Sometimes a medical approach to birth is exactly what’s needed. Sometimes interventions during birth ARE lifesaving. Yesterday was a perfect example of that. I was helping to take care of a woman who was incredibly high risk and had the odds stacked against her in terms of her chance of having a normal, uncomplicated delivery. She was severely anemic, and had been throughout her pregnancy; and not just the usual anemia of pregnancy—no, this was a woman who had a hemoglobin of 6.5 at one point during her 3rd trimester, and a hematocrit of 19%. (To put that in perspective, bear in mind that normal is a Hemoglobin of 12-13 or greater, and a hematocrit of 32-33% or greater.) She had been seen by Hematology several times during her pregnancy and had had numerous anemia work-ups. It all pointed to iron-deficiency anemia, and she was taking iron replacement therapy, but there’s only so much that this can do. At one point during her pregnancy she had been offered a blood transfusion, which she had refused. When she was admitted, her hemoglobin was 7.8 and her hematocrit was 21%—numbers which didn’t demand an immediate transfusion, but which were very concerning given the fact that she was going to give birth, and giving birth means losing blood, and if you’re severely anemic you don’t really have any blood to lose. Our professor used to say that if a woman is severely anemic, she “can’t tolerate” a hemorrhage…which is what…a polite way of saying that she’ll die?

In addition to the severe anemia, she was also preeclamptic. Her baby had oligohydramnios, probably caused by the preeclampsia (unchecked hypertension and poor placental perfusion can lead to intrauterine growth restriction and oligohydramnios, both of which are not good signs). She had protein in her urine, was hyper-reflexive, and was starting to have toxic symptoms (blurry vision, headaches, visual changes, epigastric pain, edema). She was admitted for an induction of labor immediately on account of the oligohydramnios and preeclampsia. To my way of thinking, this was the right call. With preeclampsia, you don’t want a patient sitting around at home with skyrocketing blood pressure—it can lead to siezures if untreated, and the only cure is birth. Similarly, oligohydramnios indicates chronic, long-term insult to the baby, which sadly means that the womb is no longer the best environment for fetal well-being.

This was her second baby. Her cervix was 3 centimers dilated at the start of the induction, so rather than using a cervical ripening agent like cytotec or cervadil, pitocin was started instead. Because she was preeclamptic, she was also started on Magnesium Sulfate, which prevents preeclamptic seizures by causing systemic smooth muscle relaxation. Mag is an awful drug. It makes you weak and hot and sweaty, and it often complicates inductions because it’s hard to induce contractions when a woman is receiving a medication which is causing all of her muscles to relax. Pitocin and magnesium are always at odds with each other. I think a lot of preeclamptic inductions fail because of the magnesium.

Anyway, maybe it was because of the magnesium, maybe it was because her first labor was also a very long, drawn-out labor, but in any case, her progress was very slow. I admitted her on Friday, and she was still in labor when I came back 12 hours later, on Saturday. She hadn’t made much progress; she was only 4 centimeters dilated when the doctor checked her that morning, and was still 4 centimeters when the doctor checked again 3 hours later. Her bag of water was broken by the doctor, an intrauterine pressure catheter was inserted to measure the actual strength of the contractions, and the pitocin was duly increased. And increased, and increased. It got as high as 28 miliunits/min., which was as high as I’ve seen it in a long time. Her contractions were adequte (because of the IUPC, we were counting montivideo units, and yes, they were adequate), but they were always irregular. When I checked her again 3 hours after the IUPC had been placed, she was only 5 centimeters dilated, and it was a tight 5 (I was worried that I was being too generous, and that the doctor would come behind me and check her again and decide that she was still only 4 centimeters, that she hadn’t made any progress, and that she would therefore need a cesarean for failure to progress).

I was really worried about this woman and this baby. I was worried about a severe hemorrhage. She had so many risk factors leading up to it; she was on magnesium, which relaxes the uterus and makes postpartum uterine atony more likely. She had been on pitocin for almost 24 hours, which tires out the uterus and makes postpartum uterine atony more likely. And because she was severely anemic, she couldn’t hemorrhage. She had no blood to loose. I was worried that after another three hours of little or no progress, she would give birth by cesarean, which means that her blood loss would be at least 800 cc. She didn’t have 800 cc to lose.

At least the tracing was always reassuring. I’m sure that if, at any point the tracing had begun to look anything other than beautiful, there would have been an immediate cesarean. Her urine output was always good, her magnesium levels were always on target (never too high or too low), and all of the medications we were giving her seemed to be doing their jobs. The woman seemed to be taking everything in stride, as well. I was amazed by her strength. She never panicked, even when she first found out that she had preeclampsia and would need to be induced. She had an epidural and was comfortable. She slept for several hours at a time, as did the rest of her family (her partner and grandmother, both in their chairs with their mouths open, snoring). She asked a few questions here and there, but for the most part, she seemed to trust that things would be okay. She must have known something that I didn’t. I was worrying plenty for the both of us.

Three hours after my last exam, I was unsure of what to do. I didn’t want to check her again and have to be the one to discover that she was still only 5 centimetrs dilated, and then have to notify the doctor and watch the entire thing get written off as “failure to progress”. On the other hand, we’re supposed to round on the women we’re taking care of every 2 hours, and I was trying very hard to be on top of things; it was already an hour past when I was supposed to check her and write a note. I called my preceptor on the phone and discussed the situation with her. We decided to write a note on her well-being, lab values and fetal status, but defer the exam for another hour, if possible. I hung up the phone and walked to the room, only to discover that the doctor was already there, and had just checked her. She was fully dilated.

I didn’t even have time to marvel over how she’d managed to go from 5 centimeters to fully in 3 hours…not that this is an impossible thing at all (many 2nd time moms do the entire labor in 3 hours or less), but she had been making such slow progress, and her body was battling the magnesium every step of the way. I was so incredibly, pleasantly surprised! I barely had enough time to get my gloves on before the baby’s head was crowning. He wasn’t a very large baby. She pushed him out in 6 minutes, and he began to scream and wave his arms around. Her partner cut the cord. The pediatricians were there on account of the prolonged magnesium exposure in the baby, but everything was fine.

The placenta came out 4 minutes after the baby, and we began to massage her uterus immediately. It wasn’t firm right away, but it firmed up with massage. We ran 40 units of pitocin in 1 liter of IV fluid (we couldn’t give her methergine because her blood pressure was too high, since methergine can cause a stroke if given to hypertensive women) and…please, no heavy bleeding…please, no hemorrhage…please, let it stop….and it did. She lost blood, but a normal amount. She had a small, first degree laceration which we quickly repaired so that it wouldn’t bleed very much.

And that was it. All of those risk factors, all of those hurdles to overcome, and in spite of it all, a normal birth. Even with the doctor in the room. Even with multiple IV lines, and packed units of red blood cells ready and waiting in case she hemorrhaged. Even with an induction that lasted 28+ hours, and heavy medications competing against each other. Even with a midwife that was worried about so many things that could have potentially gone wrong, which didn’t. Even in high risk situations, with all sorts of complications, even with a prenatal course and labor which is anything but normal….normal birth can and does still occur.

Who ever would have guessed that this would be possible: a blood product substitute made from plastic, and which may be available for use in the next few years.  Unbelievable.  What will we come up with next??

I got an e-mail the other day from a colleague at work who was passing on to a whole bunch of us a forwarded e-mail that she had received. Here’s the content of what the e-mail said. It was entitled “Urine Dip”:

Like a lot of folks in this state, I have a job. I work - they pay me. I pay my taxes and the government distributes my taxes as it sees fit. In order to get that paycheck, I am required to pass a random urine test with which I have no problem. What I DO have a problem with is the distribution of my taxes to people who DON’T have to pass a urine test. Shouldn’t one have to pass a urine test to get a welfare check because I have to pass one to earn it for them?

Please understand, I have no problem with helping people get back on their feet. I DO, on the other hand, have a problem with helping someone sitting on their ASS, doing drugs, while I work. Can you imagine how much money the state would save if people had to pass a urine test to get a public assistance check?

Pass this along if you agree or simply delete if you don’t. Hope you all will pass it along, though. Something has to change in this country — and soon!

My colleague hadn’t written this e-mail. It was a forwarded chain letter, and all she was doing was forwarding it to the rest of us. She did ask us what we thought about it, though. My initial desire was to dash of an immediate (and very heated) response to everyone on the recipient list. Cooler heads prevailed, however (I am still a very new employee, and I’m not sure how I feel about making enemies this early in the game), but I did want the opportunity to air my thouughts on this. So hello my delicious little annonymouse blog, aka venting-opportunity-extraordinaire.

What do I think about this? Well, I think it’s a very condescending, priviledged and uneducated point of view. It’s an excuse that people make for not having to care as much about “those people who do drugs” or “those people on welfare” or “those people who sit around on their asses doing drugs while I’m working”. While there are always a few people who are bound to take advantage of a system like welfare or medicaid, I don’t think the majority fall into this group. Ask yourself how you would feel if you were receiving welfare–would you be sitting back on your ass, taking advantage of it, and doing drugs? I think many people are embarrassed and ashamed to be on welfare, but unfortunately, the system focuses on the hand-out aspect of it, rather than on teaching and educating and empowering and giving people the tools and resources they need to get off of welfare. I think it creates a system of dependency and complacency, and I think THAT’S what needs to change.

Those of us with good jobs are privileged in so many ways we may not even recognize. How did we get those jobs? Because we have an education. How did we get that education? Because we were blessed with an attitude or an upbringing or a teacher or a mentor or a relative or a friend who believed in us and taught us that education is important, and that it matters. How did we pay for that education? Because we were blessed with scholarships or grants or friends or relatives who could help us out, or banks that had enough faith in our future potential that they were willing to loan us money, and because we were blessed with enough cultural capital to know how to ask a bank for money in the first place. Or because we were blessed with the knowledge that education is worth it, even if it takes you 7 years to pay for every cent of it yourself from your hard-earned paycheck at MacDonalds. How did we get into college? Because we were blessed enough to finish high school; because many of us we weren’t growing up with violence or drug abuse in the home, because most of us had a stable life and a roof over our heads and food to eat and time in the evenings to do homework and someone there who was going to make sure we DID our homework. Of course we had to work for it, and want it, and put in lots of our own hard-earned blood, sweat and tears, but the desire to get where we are right now is something we shouldn’t take for granted, and not something that everyone is lucky enough to have. The “well, why don’t they just get a job?” attitude is a blanket statement of privilege, which fails to acknowledge how difficult it is to obtain a good job, and all the ways that getting an education and therefore getting a good job is a learned behavior, and a cultural gift, and that not everyone is lucky enough to have that passed on to them and instilled in them, especially at a young age.

The other fallacy in this is the fact that drug use is an ADDICTION. What makes people take drugs in the first place? Depression, loneliness, feelings of helplessness and despair? A sense that they’re trapped, that there’s no way out, that life is shit and there’s nothing to do but try to enjoy what little time you’ve got on this earth in any way you can? Trying to belong to a particular group, trying to fit in, trying to feel like you’ve got a community or a family or friends? Whatever the reasons, the decision to habitually use drugs rarely stems from carefree flower-child experimentation or laziness. People who start to use drugs are driven to it because something is pretty damn bad in their life in the first place, and then, once they’ve started….they can’t stop. Hence the ADDICTION part of it.

To make it sound so easy and so simple–I have a job, I don’t use drugs, I take a urine test, so why can’t “those people” do the same?–is a very narrow-minded point of view, and fails to address any of the larger issues; it’s patronising, simplistic and judgemental, at its very core, and because we all know that the majority of people on welfare are certainly not white, it’s also racist at its core. Cutting people off from the help they need by forcing them to take a urine test before receiving public assistance will probably only make things worse, not better, and only addresses the symptom, rather than the root of the problem. The root of the problem is: what is it in this person’s life which drove them to take drugs in the first place, and how can we address that and help that? I don’t believe in free hand-outs either, but drug addiction is not something that people can just stop overnight, no matter how much they might want to (and usually if they’re deep in addiction, they don’t want to anyway), and it’s not something that people can usually do on their own. It’s so easy for the non-addicted to say to someone who’s addicted…well, just stop using, get off your lazy ass and quit doing drugs…but has that person ever stopped to consider just how HARD that is? Have you actually put yourself in the other person’s shoes, and tried to walk a mile in them? Help, compassion, non-judgement and true understanding would go a lot further, in my very humble opinion, than the “get off your lazy ass and quit abusing the government dole” attitude. Respect for “those people” would make a huge difference, too, but if you see “those people” as lazy (and if you see them as “those people” in the first place)…you’re never going to be able to respect them enough to make any kind of positive change.

Where does the midwifery come into all of this? LISTEN TO WOMEN and DON’T JUDGE. Those two lessons, all over again. The respect and the need to be able to put yourself in someone else’s shoes is inherent in that.

Now, the next question is…should I go ahead and send this back to everyone on the e-mail list? What’s it worth? Making a good impression at my new job and not pissing people off right off the bat…or speaking my mind and being upfront and honest about my beliefs, even at the expense of creating work conflict? Aargh, really tough call.