Empowering Birth Blog

Are you in labor?

So the second question my friend's birth brought up is when are you in labor?  My friend noted that she was a bit confused as to when her midwife wanted her to slow down labor and when she was supposed to follow her labor instinct, which included choosing positions that would speed up labor.  So deciding when to slow down labor and when to let it run its course probably depends a lot on answering the question, "Are you in labor?"  The midwife seemed to think my friend was in active labor because she was 4 centimeters dilated and requested that my friend stay at the hospital because things could happen very quickly (she was sent home 24 hours later and returned the next day to birth her baby).  There is, however, a lot more to labor then dilating.  How strong are the contractions, how effaced are you, how ripe is your cervix?   Again I have to reference the tape on Prolonged Labor by Diane E. Barnes, CNM and Gertrude L. Welsh, CNM, NP from "Midwifery Today's Clinical Tape Package".  In order avoid improperly labeling a labor as prolonged, the midwives take a good hard look at whether a mom is in labor.  They look for adequate contractions (your uterus should feel as hard as your forehead during a contraction) and cervical change (softening, ripening, change in the position within the pelvis as well as dilation).  They look carefully for other reasons, such as lack of rest/nourishment/hydration, infections (especially UTI) and build-up of lactic acid in the uterus, that might cause contractions but don't indicate labor.  The midwives warn against starting the labor clock until there are adequate contractions AND cervical change in order to avoid labeling a labor prolonged when it hasn't even begun.   I think it is even more important to be careful about noting when labor starts if your client is going to give birth in the hospital. 

My friend began to experience regular contractions on Tuesday morning and had her baby on Friday morning (72 hours later), but did she really have a 72 hour labor?  Did the clock start on Tuesday or did it start when the contractions started to really pick up despite the wine/rest/hot bath?  If you start the clock later, perhaps mom won't feel as though she has been in labor forever.  And was it the fact that it was a pre-term labor the reason the midwife was less clear about when it was ok for my friend to assume positions that would speed things along?  Until it was determined that there was no turning back, why speed things along?

And wouldn't it be nice if caregivers were better at explaining prodromal labor and didn't tell their client's that there will be a baby around the corner just because mom is 80% effaced and 3 centimeters dilated (a mom can hang out like that for days, even weeks).  Babies come when they come.  There are times when we would all love to know when they will come but that is knowledge we can't have.

So much to think about!  So much to learn!

Premature Labor?

My friend just had a 72 hour labor.  WOW, 72 hours, now there is a number that could get a mom really discouraged.  It was preterm labor (35 and 1/2 weeks) and her midwife offered morphine to help her rest (which would mean staying at the hospital), I suggested home, rest, hot bath, and wine.  So this birth has gotten me thinking about two things.  One, when is a mom in labor, and two, what is a good way for mom to get rest/slow down contractions.  I don't think I am ambitious enough to tackle both in one blog post so let's start with helping mom rest/slowing down labor.

In Spiritual Midwifery, Ina May writes:

"If there is no bloody show and there is no or very little dilation of the cervix (less than 1 cm), give the mother a full glass of water followed by a glass of wine.  Alcohol is a depressant, and it suppresses the release of oxytocin from the pituitary gland.  It works well for stopping labor in the third trimester.  Alcohol should not be given in the first two trimesters to inhibit labor because of possible damage to the developing baby.  The woman should stay in bed and everything should be as nice and quiet around her as possible."1

Now my friend was 4 centimeters dilated, not one, but the midwife was offering morphine so my thought was, if wine works (and there is no history of alcoholism in the family), why not?  And the wine was indeed a tremendous help.  It slowed down my friend's contractions, helped her manage a long labor, and possibly helped keep the baby in her an extra two plus days, which got the baby a lot closer to 36 weeks.

So a few days after my friend's birth, I was listening to the tape on Prolonged Labor by Diane E. Barnes, CNM and Gertrude L. Welsh, CNM, NP from "Midwifery Today's Clinical Tape Package" and the CNMs were discussing ways to help mom sleep when she is faced with a potentially long labor or just really needs some rest.  Instead of morphine, they recommend 50mg of Vistaril and 1000 mg of Tylenol.  If the mom's contractions are more painful, they suggest giving a Tylenol #3 (with codeine) in addition to two regular Tylenol). Apparently the midwives have had success promoting the Tylenol/Vistaril combination to hospital doctors as an alternative to morphine.   Among other things, lack of rest, nourishment and hydration can also encourage pre-term contractions, so before tackling the problem of how to help mom rest/slow down those contractions, you should ask mom are you hydrated/how much rest have you had/what have you been eating, etc. etc.?

Which brings me to another thought.  One of the midwives on the tape noted that she didn't believe in Braxton-Hicks contractions before 36 weeks.  She felt that contractions before 36 weeks were due to an irritable uterus or a sign of potential preterm labor.  What an interesting way to think about uterine contractions.  If there is no such thing as Braxton-Hicks contractions before 36 weeks, then if you experienced contractions before 36 weeks, you might think to yourself, I need to hydrate/rest/nourish myself.  If Braxton-Hicks contractions can be experienced before 36 weeks, you might think to yourself, oh, there goes my uterus again.

In any case, my friend said no to the morphine, returned home after laboring in the hospital for a while, took a few hot baths, rested, had a glass or two of wine, and these things seemed to slow her labor down, keep baby inside for a few more days, and gave her the energy she needed to birth her baby when the time came.  I should add that my Midwifery Tape on Prolonged Labor did not recommend wine due to fetal alcohol syndrome, but if Ina May recommends it, alcoholism doesn't run in the family, and you are in your third trimester, I can't help but think it seems like a good idea.  A mom I know who is German mentioned that a glass of wine or beer is a common recommendation for moms in early labor.  What do you think?  Oh, and if you have Spiritual Midwifery, there is a great birth story on page 70 of a mom who uses wine to stop pre-term labor.

Post to be continued....

1 Ina May Gaskin, Spiritual Midwifery, Fourth Edition (Summertown, TN:Book Publishing Company, 2002) 425.

RN?

I am toying with the idea of pursuing an RN.  There is an accelerated program at Johns Hopkins for people who have an advanced degree.  If I could get in, I could complete my studies in only 13.5 months! I've been thinking a lot about how to add to my knowledge base while the kids are young and I don't want to be an apprentice that is continuously on call.  Since six months at Maternidad La Luz is not a realistic option for a mom of three, I was thinking an RN (specialize in labor and delivery of course) might be another way to increase my knowledge of birth (become adept at putting in IVs etc. etc.) until the kids are all in school full-time.  Another benefit of an RN would be to better understand birth in hospitals, with the future goal of having necessary transports go more smoothly, and to better understand the current system of obstetrical care so that I can successfully communicate necessary reforms to the medical community.  An organizer at heart, I have always felt that I would become involved in organizing for better births on some level in the future.  As an RN (as well as CPM of course!), will the medical community be better able to hear me?

I have to admit, I think the RN idea was planted in my head after reading Navelgazing Midwife's blog entry written after reflecting on The Business of Being Born.  After my initial reading I thought, good post, but didn't realize that the post would end up marinating in my head.

And finally, I wanted to include a link to another blog I found (thanks for linking to me!).  So check out Bellies and Babies! Some day I will have to update the blog links on my menu, make my blog more exciting, etc. etc. etc., but for the moment, I am just grabbing a minute here and there to write!

Too busy growing a baby

I know, I haven't posted for a week, but this baby growing thing takes work!  I am SOOOOO tired.  And I have also begun my apprentice-ship!  I've done a few births with my midwife but to date have not had a regular schedule nor have I been introduced as her apprentice.  Last Tuesday I woke up at the crack of dawn, hurriedly gathered my things together, ate breakfast, packed an ample amount of snacks, and headed up to Frederick, a good hour and fifteen minutes north of DC, without traffic.  I met my midwife and accompanied her for the day on home prenatal visits.  At each stop I palpated the mom's belly to determine position as each mom, took fetal heart tones, and assessed blood pressure.  I was introduced as her apprentice/student.  Oh the joy of riding all day long in a car and visiting mommies with a seasoned midwife that I love dearly.  I will be following my midwife around and/or accompanying her at one of her three offices for prenatals every other week and occasionally on additional days as well.  I am going to try and fit as many prenatal and post-partum visits in as possible before the baby comes, take six months off before I resume prenatal visits and two and 1/2 years after the birth before I resume attending births. 

So there just isn't that much time for blogging.  I am learning to acknowledge that I can't do everything and evenings, I am just too tired to blog.  I used to blog during nap time, and will continue to do so a couple times a week, but usually I end up sleeping the entire time Fen is down.  My midwife suggested that perhaps I am having twins but I think my extreme exhaustion is due to the fact that my body is still producing a lot of milk.  With Khady, my milk dried up by three and a half months but I am almost four months and my body insists on producing copious amounts of milk.  It is an awful lot of work to produce milk AND a baby.  No wonder I eat all the time!

And sometimes when I have free time I just want to relax, like right now.  I am reading a fantastic book, Eat, Love, Pray and I am making turkey stock and turkey soup. Time to check the broth!

An Intense Week at The Farm

The seven midwives that teach at the Farm are:
Ina May Gaskin, CPM
Pamela Hunt, CPM
Joanne Santana, RN, CPM
Carol Nelson, CPM
Deborah Flowers, RN, CPM
Stacie Hunt, CPM
Jeanne Madrid, CPM

If you have a copy of Spiritual Midwifery, turn to page nine and you will see pictures of Ina May, Pamela, Carol, Deborah, and Joanna.  Stacie Hunt is Pamela Hunt's daughter-in-law.  Jeanne Madrid shared her story of Mulci's birth from Ina May's Guide to Childbirth (pg. 74).  Seeing these women in person, after having read their stories, and reread their stories, was like seeing a super-hero come to life.

The list of topics covered in full:

• The role of the midwife assistant
• Basic sterile technique, packing and sterilizing instruments, and drawing up injections for suturing
• Anatomy and physiology of female reproduction
• Introduction to midwife assistant skills
• Baby's position, station, engagement, dilation checks (using both pregnant women and extremely life-like models)
• Introduction to charting, record keeping and medical terminology
• Oxygen set up and use
• Midwife assistant's role in postpartum care of the mother: fetal circulation, immediate postpartum care, cord clamping technique, collecting cord blood
• Introduction to newborn assessment and postpartum care of the baby and Apgar scoring
• History of midwifery
• History of The Farm Midwifery Center
• Breastfeeding tips for the midwife assistant
• Cultural differences in childbirth education
• Care of the laboring woman
• Bloodborn pathogens and the midwife, OSHA/ARC standards
• NARM certification: what it is and what is involved in becoming a CPM

What I've been thinking about since I've been back:

• I need to take better precautions about protecting myself and family from possible germs picked up at births.  Things I need to do: purchase eye glasses to protect my eyes, throw crocs in a bucket of bleach when I get home, etc. etc.
• Vitamin K....  I haven't been very pro vitamin K but two babies on The Farm were born with Vitamin K bleeding deficiency disease and now they offer vitamin K at birth.  Oral Vitamin K sounds pretty harmless and I also learned that (according to Diseases of the Newborn by Shaffer and Avery) in a 20 year study done at Johns Hopkins where the mothers were given 1cc before birth, there were no cases of hemorragic disease of the newborn.  Certainly seems harmless to give mom a shot of Vitamin K before the birth.
• Rhogam.  I think I just might offer a shot to all Rh- moms after the birth.  Those little blood-typing cards don't always work and I come from a family that lost A LOT of babies to blood incompatibility.  This might be one of those cases where the benefits, especially when given after birth, out-weigh the minute risks.  Of course a mom can always decline.
• I have SO much to learn.  I mean, I already knew this, but sometimes I get the impression that people think that midwives read a few books and then go out there and catch babies.  Well, I am sure some do but the majority spend A LOT of time on their education and their knowledge base is extensive.  I want to know my stuff through and through and it is going to take several more years for me to get there.  I must keep reminding myself that there is no rush.  If all goes well, I should be a midwife in about 5 years?  That includes two years without attending births once baby number three is born.

The Farm

I know, I know, I've been back over a week and no posts about The Farm.  It is almost as if writing about my experience will take away from the magic of the week.  The Farm was not just a crash course in learning how to be a midwife's apprentice, it was a spiritual, sensual, woman-centered experience.  From swimming in the delicious waters of the Farm's watering hole to walking the long path (about a mile and a half) to dinner every night and passing Ina May's house, to sitting tucked under crocheted blankets on Pamela Hunt's porch listening to Ina May and Pamela talk about birth in their rocking chairs, I spent one incredible week on The Farm.

Fifteen strong searching woman and our teachers (we were taught by not one but SEVEN different midwives) spent a week together on 1,750 acres of mostly untouched forested land in Summertown,Tennessee.  We were in class from 8:30 in the morning until 9-9:30 at night with only a break for lunch, time to get a swim in at the swimming hole in the afternoon, and dinner.  Any other subject besides midwifery would have had me nodding off and on through the classes by day two.  As it was, I made it through but arrived home on Sunday evening, exhausted to the very core of my being and wandered dazed and half a sleep through much of last week.

The past two years I've jumped at every chance to learn about birth.  I attended the ALACE labor assistant training, MANA conference and the neonatal resuscitation program and my midwife has given me several lessons but for the most part I have been self-taught.  I read many books and attended the births of friend's whenever possible so that I could practice vaginal exams without feeling too guilty about keeping a laboring mom on her back longer then was comfortable (they were very understanding and I am very thankful to have had so many pregnant friends willing to be my "guinea pigs").  I attended the Farm workshop in order to obtain more formal midwifery training, particularly those skills needed to be a useful apprentice.  It was extremely helpful to work on the Farm models learning how to check for dilation (the model looked something like this).  Instead of a trying to keep my vaginal exam time to a minimum, I was able to explore the extremely life-like model (the only big difference was the model was cool to the touch) and ask the midwife questions as I checked for station, dilation, effacement etc.  We took blood pressures all week, learned how to do newborn exams, draw up injections, count fetal heart tones, check for baby's position and much much more.

Dinner each night was with Louise Hagler, the author of several vegetarian cookbooks.  While not a big fan of soy (I am quite the meat-eater when pregnant) the food was delicious and the conversation lively as doulas, midwives, and aspiring midwives, shared birth tips and stories.  Two of the nights I bowed out and had dinner with my family.  We were staying in a cabin perfect for a family with two young children.  It was stocked with toys, the kids room had bunk beds, and outside was a swing set, sand box, and numerous toys for digging and riding.  The first few days back Khady regularly noted that we didn't have as many toys as The Farm did. 

Ah, what a wonderful week!  It went by too quickly and though it is a long time from now, I am already looking forward to our next trip to The Farm.  I plan on attending the Advanced Skills workshop for midwives in 2009.  I had originally planned to attend it next year but it will be held in August when our latest arrival will be about three-four months, too young to handle long days away from mom.