Citizens for Midwivery offers facts as talking points

This is a really nice collection of talking points (in no particular order) from Citizens for Midwifery (CfM):

• Twenty-four states license direct entry midwives, several for more than twenty years. Twenty-two use or recognize the Certified Professional Midwife (CPM) credential administered by the North American Registry of Midwives (NARM) as the basis for licensing, and two states have voluntary licensing. In all theseyears, no state has repealed their midwifery law for any reason. Furthermore, in 9 states licensed midwives receive Medicaid reimbursement for their services. These records demonstrate that CPMs do not pose any threat to the health and safety of pregnant women and newborns.
  
• An economic analysis of the cost benefits of a licensed midwife program (Washington State) indicate that the cost savings to the health care system (public and private) is estimated to be ten times the cost of the program, even with this licensing program being the most expensive in the country. (Midwifery Licensure and Discipline Program in Washington State: Economic Costs and Benefits, (A report to the Washington Department of Health), Health Management Associates, October, 2007)
  
• Contrary to ACOG’s uninformed assertion, many rigorous scientific studies, published in leading medical journals, have found that for a healthy woman having a normal pregnancy, a planned, midwife-attended home birth is as safe as a hospital birth and with far lower rates of medical interventions. The most recent is also the largest study, based on prospective reporting for all the births attended by Certified Professional Midwives in 2000, published in 2005 in the British Medical Journal . ("Outcomes of planned home births with certified professional midwives: large prospective study in North America." Kenneth C Johnson, senior epidemiologist, Betty-Anne Daviss, project manager. BMJ 2005;330:1416 (18 June). Also see CfM’s summary fact sheet.
  
• About 99% of births in the US take place in hospitals. If standard obstetric practice is so good, why does the US rank so abysmally when it comes to maternal mortality and neonatal mortality?
  
• The Complete Mothers’ Index 2007 shows that mothers in the US have a higher lifetime risk of maternal mortality than the mothers in 27 other developed countries.
  
• The World Health Report (from the World Health Organization) indicates that the neonatal death rate (death in the first 28 days of life) is greater in the United States than in 35 other countries.
  
• ACOG claims that "complications can arise with little or no warning even among women with low-risk pregnancies". However, complications seen in low-risk women laboring in hospitals are often related to the many routine practices and interventions that disturb the birth process and cause or lead to complications and more interventions. In fact, most of these practices were adopted without being studied for safety, and many are still routine even after being studied and found to be either worthless or harmful or both. (Enkin et al. A Guide to Effective Care in Pregnancy and Childbirth) Midwives attending home births avoid unnecessary interventions and the use of drugs, allowing normal birth to proceed. They are trained and experienced in noticing any signs of problems and taking appropriate action, including transfer to medical care in a hospital when necessary, which is rarely. (see the BMJ article cited above)
  
• The press release states "ACOG acknowledges a woman’s right to make informed decisions regarding her delivery…" but goes on to say that ACOG does not support any of the alternatives to a doctor-controlled birth in hospital or birth center, or anyone who provide or supports home birth. So how is ACOG supporting informed decisions?
  
• ACOG claims that an "emerging contributor" to the rise in cesarean section rates is "maternal choice." However, there is no evidence for this claim. In fact, recent surveys of mothers found that less than 0.08% of pregnant women request a C-section. Applying these numbers to a recent figure for annual births, a scant 2,600 out of 4.1 million pregnant women actually requested a C-section. (Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection, October 2006.) Clearly, this number is so small it could not possibly explain the doubling of cesarean section rates in the last decade. Furthermore, when he was President of ACOG, Benjamin Harer publicly promoted maternal choice cesarean sections on popular TV news and talk shows, for reasons for which there was not evidence. (for example: Benjamin Harer on Good Morning America, 2000. Having actively worked to create a market for cesarean sections for no medical reason, based on lies and misinformation, ACOG is now blaming women for the increased cesarean rate??
  
• When attending births outside the hospital, both Certified Nurse Midwives and Certified Professional Midwives referred fewer than 5% of mothers for cesarean sections, while obstetricians were performing cesarean sections on nearly 20% of low risk mothers in hospitals. (see CfM fact sheet with references)
  
• Some women are going to choose to deliver their baby at home, for a variety of very legitimate religious, social, health or economic reasons. These women deserve to have the best care available the care of a well-trained midwife with experience in out-of-hospital settings. (Firefly Mama thinks this is the most important point!)
  
• While ACOG states that childbirth is a normal physiologic process, today’s obstetrical profession performs cesarean sections for nearly one third of births, induces labor in nearly half of births, and administers drugs of one kind or another to more than two thirds drugs that pass through the placenta and harm the baby. In fact, almost the only women who give birth with no interventions are those who give birth at home. (Listening to Mothers: Report of the First National U.S. Survey of Women’s Childbearing Experiences. New York: Maternity Center Association, October 2002.)
  
• Apparently obstetricians are not trained to support normal birth, but oppose the very health care providers who are: midwives who are trained and experienced in attending births outside the hospital. The Certified Professional Midwife credential is the only maternity are credential that requires experience in out-of- hospital settings.

ICAN responds

ICAN’s Response to ACOG AND AABC Statements on VBAC and Homebirth
Redondo Beach, CA, February 7, 2008:

The International Cesarean Awareness Network would like to publicly condemn both the AABC (American Association of Birth Centers) and the ACOG (The American College of Obstetricians and Gynecologists) for their statements this week that limit not only women’s choices in birth but imply that birth is a fashion trend rather than a safety concern.

Since VBAC is the biological normal outcome of a pregnancy after cesarean, ICAN encourages women to get all of the facts about vaginal birth and elective repeat cesarean before making a choice. This decision should not include weighing the choices of your doctor’s malpractice payments but only be a concern of the mother, her baby and their health and safety.

Since some mothers will make the choice to give birth outside of the hospital, we encourage the AABC to not cave into ACOG’s demands that all women give birth in a hospital facility with a surgical specialist, but instead allow women to make their own choices about care providers, birth settings and risk factors. ICAN respects the intelligence of modern women and accepts that the amount of information available about VBAC and elective cesarean should serve as informed consent.

ICAN further encourages the governments of individual states to look closely at their cesarean rates (31.1% national cesarean rate as of 2006) and the informed consent laws that apply and help women to reach a standard of care that lowers the risks of major surgery and the risks of elective or coerced cesarean without medical indication. Women and children should not bear the brunt of malpractice risks being conveyed into physical, mental, emotional and spiritual health risks in order to protect their physicians.

Mission statement: ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery and promoting vaginal birth after cesarean. There are more than 94 ICAN Chapters across North America, which hold educational and support meetings for people interested in cesarean prevention and recovery.

AABC statement

ACOG statement

The Birth of Baby Boy LK

The Birth of Baby Boy LK
Monday, November 26, 2007 at 12:40 PM
9 lbs 13 oz and 21.75 inches

Original due date: November 23rd

2nd baby, VBAC attempt, repeat cesarean

Mommy M had been my good friend for a couple of years now, ever since the birth of our first kids, so I was thrilled when she announced she was pregnant again. It was even more exciting when she asked me to be her doula. Yippee! Nothing could be a greater honor than to assist a friend during the birth of a child. It is simply amazing.

Mommy’s first birth was a cesarean after she dilated to 8 cm but no further. With meconium in the water, slight non-reassuring heart tones, and several hours of no dilation, the cesarean was performed with zero complications. Turns out that 9 lb 3 oz baby boy was posterior. He was born on his due date.

This pregnancy started very differently because conception happened without the help of fertility meds! Mommy also decided to search for a new care provider. Her old OB was not supportive of a VBAC, so Mommy signed on with a midwife group who attended births at Generic Hospital. The new group was very supportive and was willing to work with Mommy to give her the best chances for a VBAC.

Fast forward to the end of pregnancy. The baby was measuring large again. Mommy was ready for him to be born. Her due date (Thanksgiving Day) came and went. She had several bouts of pre-labor, but things always fizzled out after a few hours. She was somewhere around 3-4 cm dilated and 60% effaced. I tried to reassure her that though frustrating, this was important early work and that it was doing something! Finally, Mommy’s house emptied of family and she settled in and got serious about birthing this child.

On Sunday, November 25th, 3 days after her due date, Mommy was watching football with Daddy, Big Brother, and Daddy’s parents when contractions got started again. Mommy estimates they started around 4:45 pm, though she didn’t start timing them until around 5:20. At this point they were 4-8 minutes apart and 35-60 seconds long. I had called her earlier in the day, just to check in and say hello. She called me back at around 6:45, but I had to return her call just a little bit later. At 7:10, we got to talk and she filled me in. She said these contractions were definitely strongly than anything she had felt so far, and at that point they’d been going on for about 2.5 hours. I suggested she call her midwives and let them know what was going on, and see what they thought she should do. Mommy feared heading to the hospital and having everything stop, but I felt it was important to get the midwife’s perspective on this. She made the call, and they encouraged her to come in. With the VBAC, they wanted to make sure that if this WAS it, she was monitored closely for her safety and the safety of her baby. I asked Mommy to call me when they were parking at the hospital and if the contractions were still coming strong, I was going to go ahead and leave.

At 8:15 pm, Mommy gave me a quick call and said they’d just arrived at the hospital and things were still going strong. I told her I would leave in about 20 minutes, and asked them to call me back once she was checked and we knew if the hospital would be keeping her or sending her home. By 8:40 pm, I was out the door and on my way to the city.

At 9:00 I got a call from Daddy. He said Mommy was 4-5 cm and about 90% effaced, so they were staying at the hospital. WAHOO!!! This was it! I arrived at 10:30 and found them walking the halls. Mommy said her contractions were 3-5 minutes apart and about 60 seconds long. She was beautiful in her gown and fancy fuzzy socks. She had a telemetry unit for the continuous electronic fetal monitor, so Mommy was able to walk and roam and change positions to her heart’s content, as long as the belts kept the monitor in place. Mommy and Daddy looked excited and optimistic. They hugged often and were beautiful support for each other. Mommy continuously checked in with Daddy, almost as often as we checked in with her. It was a fantastic environment to be laboring in. I settled in, checked that everyone had water and encouraged eating since they’d both skipped dinner. Throughout the evening, I occasionally grabbed the camera and took some shots of Mommy and Daddy as they welcomed the labor and worked together to birth their son.

By 11:05 pm, Mommy made another bathroom trip and then continued standing and walking. She said that though she was feeling some discomfort in her back, it wasn’t excruciating. It didn’t sound like the typical back labor I heard stories about, but Mommy did say it felt just like it did during Big Brother’s birth, so I was a little concerned about baby’s position. When I asked her about it, Mommy said they’d been told baby was probably occiput transverse based on where his heartbeat was. At 11:35 pm, she asked for a birth ball so I hunted one down from the nurses. Mommy started looking more serious. Daddy turned on some music as Mommy hung out on the birth ball, and the midwife and the nurse adjusted her belts. At around midnight, Mommy requested some food and was told “clear liquids” only, so she enjoyed her chicken broth as best she could.

By 12:15 am, Mommy was back up and walking again, just going with the flow. I talked to her about her activity and what she felt was going on. Daddy was getting tired and Mommy ordered him to sleep, so he laid down to rest. We turned off the lights, turned on a few electronic candles, and set the room into “rest” mode. Mommy made another bathroom trip and then at 12:40 laid down to get some rest. Her right side was more comfortable to her, and it allowed the belts to stay in place, so that is what she did.

For the next hour, Mommy tried to rest and I just observed from the rocking chair. Her contractions were varying quite a bit. First they were 7 minutes apart and 80 seconds long, then 2.5 minutes apart and 90 seconds long, then 4.5 minutes apart and 90 seconds long. The midwife visited again and reiterated that she felt this was early labor because of the contraction pattern, but acknowledged that Mommy’s contractions seemed to be feeling stronger. A phlebotomist dropped in for a visit, and disrupted the rest time by turning on the lights and speaking very loudly. Mommy needed another blood draw because they’d messed up the last sample. Finally she left and Mommy was able to rest a bit.

While resting, Mommy seemed to drift to sleep, but then be shocked awake by each contraction. She was able to stay in position and breathe through each contraction, but I could tell they were growing quite uncomfortable. At times Mommy would let out a soft whisper of an “Ow” but otherwise, she was very quiet and determined to rest.

By 1:40 am, Mommy needed to pee again (yay! We were doing a good job with the water!). Contractions were between 3 and 7 minutes apart and 70-120 seconds long. They seemed to be getting stronger. The nurse popped in for another monitor check. Throughout the evening, the nurse visited at least a dozen times because the monitor fell out of place. While we knew these visits were necessary, they were quite disruptive, as they always flicked the lights on and spoke very loudly. Still, Daddy managed to sleep through much of it.

At 1:50 am, Mommy headed out to walk the halls again and then laid down again after that. Again, her right side was most comfortable, so she went with that. For the next hour, it was blissfully quiet and Mommy and Daddy were both able to sleep. Mommy was breathing beautifully through each contraction and would snooze in between. Contractions were 6-7 minutes apart. I draped myself in a towel (it was freezing in the room) and relaxed in the rocking chair.

Shortly after 3 am, Mommy got up to pee again and decided to try sitting/reclining in the bed for a bit. At 3:15, the midwife visited and offered another cervix check. Mommy wanted to know, so she got set up for the check. She was 6 cm and 90-95% effaced with baby’s head at -2 station and a bulging bag of waters. Contractions were still 6-7 minutes apart. This dilation was only a small change from 6+ hours ago, but it was progress, so we held on to that. The midwife suggested breaking her water (which she had also mentioned a couple of times earlier too), and Mommy politely but firmly declined. Mommy asked about the baby’s position, and the midwife indicated she believed the baby was anterior, but that she couldn’t feel the babies skull without breaking her water. The midwife suggested a shower or the tub. Mommy said she wanted to save the tub for later when things were more intense, and she certainly didn’t want to slow anything down at this point. But a shower sounded like a great idea. She asked me what I thought she should do and I agreed a shower sounded great – something different! The midwife additionally suggested Mommy try some manual nipple stimulation while in the shower and see if it brought on stronger contractions. So by 3:30 she hopped in for a good 20 minutes. Because of the telemetry unit for the EFM, she was able to stay on the monitors while in the shower.

By 4:00 am, Mommy was back out of the shower and ready for more action. The nipple stimulation didn’t seem to help a whole lot, but things didn’t slow down either. Mommy did agree the shower felt great! I demonstrated some lunges to her, and she worked on that with Daddy’s support a while. Because of the extended time with little progress, I continued to worry about baby’s position. The midwife had recently said she thought the baby was anterior, so I began to wonder about the position of his head. Could it be asynclitic? If malpositioned at all, the lunges might help and Mommy found that they felt really good.

Mommy had been reaching for her back during some of the contractions, so I asked her if I could help her by providing pressure to her back. She agreed, and it seemed to really help. So for a while, we three worked as a team. Mommy stood in the middle, content and talkative until a contraction hit when she would lift her leg onto the bench and lunge and sway with the energy. Daddy was facing Mommy and would hold her shoulders and support her balance. I was behind her providing pressure to the sore spots on her back. Throughout this entire time, I was amazed at how “normal” Mommy seemed between the contractions. It really seemed like her. It was an enjoyable time to spend with these expecting parents.

At 4:30, Mommy retreated to the birth ball again. This remained one of her favorite positions. We talked a little about emotions. I asked Mommy about being scared, and she acknowledged that she was (afraid of the pain). We talked a bit about how things really did need to get harder, but that it was good and necessary for this birth to move forward. Mommy seemed ready to accept what needed to happen.

At 5, the nurse checked Mommy’s blood pressure again (which was perfect). Mommy decided some jello sounded good, so I visited the nurses’ station to get that ordered. Mommy visited the bathroom again too. Contractions seemed to be getting still stronger and closer together with her new activity, sometimes as close as 90 seconds apart. At 5:30, Mommy decided to lay down again (right side). She was growing tired. Contractions spaced back out again to 4-6 minutes apart, sometimes 7.5 minutes apart. Back pressure continued to be helpful. After another 30 minutes, Mommy was back up to pee again, and then she went for a walk.

Just as the midwife’s shift was ending, she came in to check on Mommy one last time. She offered another cervix check, and Mommy agreed. I was so hopeful that all the activity over the last 3+ hours had resulted in dilation, but was skeptical because the contractions just didn’t seem strong enough, and they were still so variable in pattern. Sure enough, Mommy was 6-7 cm dilated, 95% effaced, and baby was still at a -2 station. I was feeling very frustrated for Mommy. Again, the midwife offered to break her water, and again Mommy declined with the plan to save it as a last resort. Shortly after the check, Mommy visited the bathroom again. We discussed a plan to get things going. I suggested we continue with the activity. The lunges seemed to speed things up. I also suggested we try acupressure, belly lifts (in hopes this may resolve any malposition we weren’t detecting), more position changes including hands and knees, and Mommy take another shower. Mommy began doing lunges.

By 7:30, Mommy had been visited by the new midwife, the old nurse, and the new nurse. All of them, including the old midwife expressed concern for how slowly things were going. The new midwife seemed very willing to work with Mommy and try hard to get things going, but she did acknowledge she would shortly be required to consult with the OB on call. Dr. OB was the OB, and the midwife said she would want to come in and meet Mommy before potentially meeting her in the operating room. I immediately felt uncomfortable with this change in language – suddenly we were talking about operating! I guess the reality was soon approaching, and Mommy seemed to know this deep down, but it was still hard for me to see this path before us when we still had so many tricks to try. Baby was doing fine and seemed very healthy, and Mommy was willing to keep working, so I didn’t see why we had to start talking about operating all ready.

Mommy also asked the midwife about using a breast pump for the nipple stimulation – something I suggested she ask about. The midwife said because Mommy was a VBAC, she was uncomfortable using the breast pump. While frustrated that she wouldn’t let us use one, I was pleased to realize she was acknowledging how strong nipple stimulation can be! The midwife also argued for AROM at this time, and suggested it was probably time to really consider it. Mommy suggested we wait just a little longer and really try hard to get things going, and that if at the next visit progress hadn’t been made, she would consent. The midwife agreed this was a good plan.

After she left, I snuck down to the cafeteria for a quick breakfast, giving Mommy and Daddy some much-needed alone time. I returned to find out through Mommy, through the nurse, through the midwife, that the OB was going to put Mommy on a shorter timeline. We were all worried about this news.

At 7:45 am, the OB came for a visit. She was very calculated in her language and movements. As she walked in the room, I felt immediately she just wanted this surgery to get going. I think Mommy could sense it too, as she later expressed how much she disliked this doctor. The OB discussed some time limits. She asked Mommy where she got stuck in her last labor (8cm) and where she was now (6cm). She asked about the size of the baby (estimated 9.5+ lbs). She strongly urged Mommy to allow the midwife to break her water. She suggested we do this immediately, or plan to move right on to surgery. She said if the AROM didn’t get things going, we just move on to surgery. And with that, she turned to leave and saluted Mommy on the way out while saying, “Hopefully things will get going, or else I’ll see you in the operating room.”

Daddy immediately embraced Mommy as she began to cry. This had been a rough hour, with visitor after visitor expressing doubts. Mommy had been in labor for about 15 hours, during which time she’d hardly slept or eaten, and she’d only dilated about 1 cm. I sensed that Mommy was tired, and disappointed. She talked about “having been down this road before.” I couldn’t help but cry too. The 3 of us just circled together and released our frustration. And then, we discussed really getting serious.

At 8, Mommy got back in the shower with instructions from me to be more aggressive with the nipple stimulation. By 8:30 she was back out. Contractions were definitely closer together, sometimes only 90 seconds apart and 60 seconds long, but still weren’t strong enough. Daddy ran down to the cafeteria for some breakfast, so Mommy and I had some time to work together. At 8:45 I instructed Mommy on applying acupressure on her Hoku point on her hand. She tried this for a few cycles, but didn’t notice any increase in intensity with contractions. So I moved on to trying acupressure at her Spleen 6 point on her legs. I kept up with this for quite some time. While contractions were longer and closer together, they still just didn’t seem strong enough. At 9:00, I alternated the acupressure with belly lifts using the rebozo. Mommy said these felt really good. We watched the EFM to make sure the lifts weren’t affected the baby’s heartbeat. Everything looked good. While doing this, one of the nurses visited and commented that we were doing something right, because the contractions were getting closer together. She looked confused at seeing Mommy wrapped in the rebozo with me down on the floor pressing on her legs. It made me chuckle…she probably really wondered what the crazy doula was doing to her labor patient.

The midwife came in to break Mommy’s water, but Daddy was still gone and then she got a page, so the AROM was temporarily held off. This was a blessing in a way, as it gave us one last hour to try all our tricks and to focus on powerful contractions. We continued the acupressure, belly lifts, lunges, rocking, standing, and leaning on the bed. Once Daddy returned, I retreated to the bathroom to pump (something I’d done every 3-6 hours all night). While in the bathroom, I could hear that the midwife returned and was ready to check Mommy. Bad news. There was no change in dilation. So Mommy consented to AROM. Thankfully, the fluid was clear. Mommy was moved to an upright sitting position in the bed. The way the bed was cranked up, Mommy looked like a Queen up on her pedestal. Immediately afterwards, she didn’t seem to notice any difference with the AROM. But things changed quickly. The midwife had suggested that Mommy needed to dilate 1.5-2 cm/hour now to avoid a cesarean, which seemed really fast to me. Little did I know Mommy would have NO problem with this.

Within 5 minutes, things were ramping up. The contractions seemed to be overwhelming her. They were now less than 2 minutes apart and 75-90 seconds long. Within minutes, Mommy started verbalizing doubt that she could not do this. I recognized this as transition and told Mommy I thought she was there. She didn’t believe me. She thought it was too soon. The contractions were just killing her in this sitting position, so she asked me to get the nurse so she could be hooked back up to the telemetry unit so she could move around again. I walked out the nurses station and got the nurse’s attention and she acknowledged that Mommy was really getting slammed (she’d been watching the monitor). The midwife was also at the station, so she came in the room too.

By 10:10, Mommy was getting hooked back to the telemetry unit. The midwife suggested IV fluids. She said she often saw this response to AROM because of dehydration, and that the fluids may make the contractions more manageable and a little more spaced. Mommy declined at first, but after getting hit by another couple of contractions, agreed. By now she was off the bed. I held her in a standing position through a couple of contractions, and then eased her back onto the birth ball. Contractions were just coming strong and hard, and after just a minute on the birth ball, Mommy let out a tell-tale grunt. The nurse, the midwife and I all looked up at each other and smiled. Mommy’s body was bearing down. It was 10:15 am.

The midwife and the nurse checked in with Mommy and asked her what she was feeling. Mommy wasn’t sure, but it was strong! Mommy’s sounds were pushing grunts. I looked to Daddy and mouthed that Mommy was doing great, and that things were moving fast. At about the same time, the baby’s heart rate dipped a bit. It was enough of a drop to concern the midwife, and Mommy was just getting overwhelmed by the contractions, so the midwife told Mommy she wanted to get her back on the bed to check what was happening. Mommy didn’t want to move. She didn’t think she COULD move. But with help, they got her up to standing and discovered bloody show. This was a very good sign!

By 10:20, Mommy was up on the bed on her right (preferred) side and continued bearing down with each contraction. Daddy was by her side, holding her and whispering in her ear words of love and support. It was obvious how strong his support was to Mommy during this time. The midwife checked and found she was almost fully dilated, with just a lip of cervix remaining and baby was at 0 station! Mommy had FLOWN right by transition. Unfortunately, the baby’s heart rate was dropping down under 90 bpm and remaining low for extended periods after each contraction. The midwife and nurse worked with Mommy to turn her to her left side, which Mommy resisted, but they got her turned rather quickly. At the same time, the nurse prepared an oxygen mask and put it on Mommy to try and give the baby as much oxygen as possible. I could tell this position was not very comfortable for Mommy, but she knew it was important for her baby.

At 10:35 the midwife checked Mommy again and she was fully dilated. The heart decels started to improve, so Mommy was able to remove the mask shortly. Pushing now begins in earnest. Mommy started pushing with her legs pulled up and rolled slightly to her left. She pushed in this position for a while, and the baby was bulging low in her bottom with each push. She didn’t believe us when we said she was DOING IT. I asked her if she thought we were lying, and she said yes! She was doing a fabulous job, putting all her energy in each push. In between contractions, which were now between 1.5 and 3 minutes apart, she appeared to drift off to sleep. By 11:00, it seemed a position change might help bring the baby down further. So the midwife and nurse got the squat bar set up for Mommy to try. In transitioning to the squat, Mommy was hit by a contraction and collapsed into a kneeling position, where she remained for a contraction or two. She then got up and prepared to use the squat bar. This seemed to be a very powerful position for her, as she continued to bring the baby down.

At 11:10 am, the midwife checked again and felt the baby was at about a +2 station, but that a caput (swelling) was forming on his head. She suggested Mommy lay back into a reclined position and prop her feet on the squat bar for support. Mommy then used the bar to push off of, and then was sometimes encouraged to grab her legs and pull them up high against her in an exaggerated lithotomy position. At times the midwife said she could even see the baby’s hair. I was so excited. It seemed Mommy was really going to do this!

Thirty minutes later, nothing had changed and Mommy was not only tired, but really starting to doubt. The midwife, nurse, Daddy, and myself were continuing to give her support and encouragement. Mommy continued to ask though, “Is the baby going to come out?” The midwife was honest and said the baby hadn’t come down much anymore, and it was obvious Mommy was pushing very hard. She needed the OB for a second opinion now that they’d been pushing for over an hour. Mommy voiced her dislike for this OB, but there was no one else available and it was clear another opinion was necessary. So the OB was called. Meanwhile, Mommy continued to push. At 11:45 am, the OB arrives and examines Mommy. She said the presenting part was all caput, and that the head was actually at around a +1. This meant in about 90 minutes of pushing and bearing down, the baby had only moved from a 0 to a +1 station. This was difficult news. Mommy was trying so hard. She was changing positions and trying all kinds of different pushes. She was doing everything right. But the baby wasn’t coming down past the pubic bone. And Mommy was DONE. Because the presenting part was all caput, the OB said she could not do an assisted (forceps or vacuum) delivery. She said the baby wasn’t coming out, and that Mommy had tried very hard, but that it was time to go get the baby out. The cesarean was recommended, and Mommy agreed.

For the next 15 minutes, people were rushing around getting Mommy ready for surgery. Mommy immediately requested pain medication, so the anesthesiologist came in very shortly. There was some discussion over whether the surgery would happen immediately or later, but once it was resolved Mommy was informed of the risks of her impending spinal. The OB discussed the risks of the repeat cesarean, and Mommy signed her consent. Daddy rushed around and tried to pack up the room, then suited up for the operating room. Mommy, Daddy and I had previously discussed me accompanying them in the operating room, but the nurse told me they do not allow that in this hospital. So I stayed behind and packed up the room. At 12 noon, Mommy was wheeled away. After packing the bags, I retreated to the waiting room, expecting to hear something in an hour or so.

The waiting room was an uncomfortable place. There was a television which blasted Scooby Doo cartoons, and there were several families waiting for their own exciting news – and they all seemed to speak a different language. I was tired, needed more caffeine, and needed to pump, but I didn’t want to leave the waiting room in case I missed Daddy coming to tell me about the birth. So I stayed and tried to relax, making a few phone calls to check in at home. I also found two messages from friends – Lauren and Kendra – who’d called to hear how things were going.

By 1:30, I still hadn’t heard anything, so I decided to ask the receptionist. She called recovery and said Mommy had just arrived there, and it would be at least another 2 hours before anyone was allowed in. I couldn’t believe it! Nearly 4 hours of isolation for a cesarean? I had no idea. I knew I couldn’t stay that long. I was so tired, and every hour I stayed at the hospital was making it harder for me to drive home safely. So I asked the receptionist if I could get a message to Daddy. He said he would come out and speak to me. So finally, I got the word that Mommy and baby Baby Boy LK were fine. Baby Boy LK was born at 12:40 pm and weighed 9 lbs 13 oz! What a big boy! I was so delighted to hear they were well. Daddy confirmed for me that after Mommy received her spinal, she was content and happy with the decision to move to a cesarean. He said she talked about having tried everything to get him out, and that this was how Baby Boy LK was choosing to be born. I was happy to hear her feelings about this. I really wanted to talk with her, but this was not the time. So I gave Daddy a big hug, congratulated him on the birth of his son, and took my leave.

In my 90 minute drive home, I started having a hard time staying awake, so had to stop and stand in the cold air to make it all the way. I collapsed into my bed at 3:45 pm, but my mind couldn’t shut off for a while. I thought about all the things we did during the labor and felt good about all our efforts. Still, I couldn’t help but wonder what was holding little (big) Baby Boy LK up. When I spoke to Mommy the next day, I learned that he was posterior afterall! I couldn’t believe it! Mommy said the midwife discussed this with her, and suggested that perhaps there was something about Mommy’s hip structure that encouraged babies to swing posterior as they descended, because Baby Boy LK had been anterior earlier in the labor. Still, I couldn’t help but kick myself, wishing we’d spent some quality time in hands-and-knees, just in case.

As a doula, this was a great experience for me because we got to try so many things during the labor. It was my first all-night birth, and my first cesarean. This was also my first experience walking away and wondering if we just tried one or two more things, if that would have changed the outacome. I know that we all did our best, and that is what I should remember. And Mommy is really happy with the outcome, having made it all the way to pushing and getting to try that in several positions. Mommy later said she felt this even healed her some from her first birth, because she realized the transition feelings she had at the end of her first birth were really about as hard as it would get, so she no longer felt she’d wimped out. And having her second baby choose the “side door” as Mommy puts it, despite multiple tricks to invite him out the “front door”, validated the necessity of her first cesarean too. Overall, it was an incredible experience for all of us. I feel blessed to have been a part of this event, and only wish I could have seen Mommy and Baby Boy LK after the birth. I’m so proud of Mommy for working with her body and allowing her baby to receive all those precious squeezes. And Daddy was an amazing partner, always supportive and attentive to Mommy.

Congratulations to the Family! Thank you for allowing me to be with you on this important day. And welcome Baby Boy LK!

Almost a VBAC

She was so close. The midwife said she could see the baby's hair. It seems crazy to me that we could see the baby's hair, but he wouldn't come down anymore. I guess I don't have a very good image of the pelvis, cause I really thought that once we could see the head, there was no way he wasn't coming out. But he didn't come out.

This mom was absolutely amazing. Baby #1 was a cesarean after 15 hour labor, 5 hours of which was at 8 cm. She never got past an 8. During the stall, they tried breaking her water (and found light mec), tried an epidural (and got slight decels), and when he wouldn't drop and she didn't dilate, they went to cesarean. Turns out baby was posterior. He was a 9.5 lb baby on his due date.

With baby #2, he decided to come 4 days after his due date. We knew he would be big. One major goal was to encourage baby away from posterior. Well, mom was 4 cm before labor even started, and when checking into the hospital she was 4-5 cm. 14 hours later, she was 6 cm. Her labor pattern was still variable, and contractions really should have been stronger. Something was amiss. We tried tons of things to encourage good positioning (the midwife said baby was anterior, but I was leery of asynclitism) and to bring on stronger contractions. The OB on call started interferring and demanded either progress or a cesarean. So mom agreed to AROM at 6 cm. A few minutes later, she was getting slammed with back-to-back 90-second contractions. I knew it was transition. She didn't believe me. Twenty minutes after the AROM, she started pushing. Unfortunately, in 90 minutes of the most incredible pushing I've ever seen in a half-dozen different positions, baby had only gone from 0 to +1 station. Mom was done. She was in terrible pain. The OB came in, took one look, and said the baby wasn't coming out. So off to cesarean she goes. Baby was 9 lbs 13 oz. And he was posterior afterall.

Unfortunately, because of the long recovery after surgery, I wasn't able to see mom and baby before I really needed to head home. This was my first all-night birth. I had 90 minutes to drive home. I talked to the mom today and she sounded really happy with her experience. We tried so many different things and she got so much further than last time. Having it end this way also gives her a sense of justification for her first cesarean too. In the end, she pretty much had a complete vaginal birth, except for the ring of fire part.

As a doula, this is the first cesarean client I've had, and it is the first client who didn't achieve exactly what she was shooting for. I have mixed feelings about it. I'm THRILLED she got to push and feel that power for so long. I just can't help second-guessing what we did. Could we have tried a different position? Should she have pushed for longer? Was this going to be a cesarean no matter what? I guess it shouldn't matter as long as mom is happy.

Mega update

I've lost all sense of time. Seriously, minutes pass in seconds, days pass in minutes, and weeks pass in the blink of an eye. I remember as a kid when life passed at the slowest snail's pace, but now it is more like a rocketship. Somebody put on the brakes, will ya?

Life in our household has been continuing full-steam ahead. Nothing major has happened in the last week, except for the most minor case of the sniffles in both kids. My computer at school (where I have the most uninterrupted time to blog) doesn't like Blogger, so I've been unable to post from there and frankly, posting time at home is almost non-existent lately.

So the VBAC birth that was going on last week obviously ended. I was not called to stay the primary doula. Baby was born later that night via emergency cesarean, after a transfer from the birthing center for what the doula described as "scary" decelerations. While at the hospital, the mom was able to continue laboring all the way to 8 cm (that is 7 cm further than she got last time), but then FHT took such a serious dive a cesarean was performed immediately. Turns out there was a serious cord entanglement going on, and baby wasn't coming out without bringing the placenta with it. Healthy boy, 9.5 lbs. Mom is really happy she got to experience so much labor.

In other news, daycare woes continue. Ava is now registered for 3 afternoons a week starting after Thanksgiving, but that is not a convenient schedule for us at all. With some luck, all the right changes will take place in the next 6 weeks, and we'll get both kids in there for 2 full days/week by January 1. Cross your fingers for us. We're still on the waiting list for the campus daycare center, but it looks like that will be July before space is available.

We've been getting our wills and advanced directives together around here. We already had a will, but seeing my aunt's death and the aftermath associated with her will and assets, I've realized how important it is to have everything meticulously prepared. I've been learning about trusts. There are just so many ways to take care of your loved ones after you die. Confusing stuff. Not like we have much to leave em (and not like we plan on dieing for 50 years), but I wanna make sure they get every penny!

Potty training! I think we are officially potty-trained here. Accidents are extremely rare now and almost predictable because of the circumstances. We still haven't tackled nap or night training because Ava has no access to the potty during those times, but it is coming soon.

Night weaning! Alder has night-weaned himself. This has been going on for about 2 weeks. I can't believe it. Last night he slept for 10.5 hours STRAIGHT. And he's not even 6 months. I'm so thankful we've gotten here with absolutely no urging on our part. Franny, I hope your next one takes a cue from Alder. Granted, things were still very rough 2 months ago, but to completely sleep through the night ON HIS OWN at less than 6 months...that is just worth almost anything.

Not much else going on. Keith and I are dreaming of our new minivan that we hope to get next summer.

Oh, and 2 days ago I finished writing the final manuscript of my dissertation. It needs major editing, and I still have to write a brief introduction and brief conclusion to the whole dissertation, but that should only take a couple of days. I can't believe I'm almost there. Hopeful defense date in late January.

And one more thing! I'm on the verge of signing up for my first class towards the long path to midwifery. I'm thinking this will be a one or two classes at a time, maybe a couple of times a year thing...so the entire curriculum will take probably 5+ years (I'm thinking of going for the AS degree which includes the CPM first, then possibly the MSM if I'm still into school and all). But that sounds about right to me. I have no apprenticeship lined up anyway. It takes time to figure those things out, and until I'm done with the PhD and have earned a little money, I can't even fathom an apprenticeship with no income.

Okay, that is all now.

VBAC 2

Today I got a call from another doula who was late in the 2nd day of attending a birth. I'm her back-up doula, and things were starting to get really tough for her and the mom. She needed to just talk things out for a bit. This client is a VBAC too, and so far the labor seems to be progressing (or NOT progressing) along the same line as her first birth that ended in cesarean. And she is now 9 days overdue. It is hard to not be there, especially when given this glimpse into where things are at the moment. It sounds an aweful lot like there are some emotional hang-ups for both the mom and the midwife. I just hope things start to show progress. This mom is such a sweetheart and has worked so hard for the chance to birth naturally. She chose her doula before she chose her care provider, so I know the doula (and me as back-up) feels pressure to support her the best way possible. What a tough position overall. I'll be thinking about them until I hear a baby is born (or until I get the call to take over when doula #1 needs a break).

VBAC

Yesterday I had a prenatal doula visit with my next client who is due. She's 37.5 weeks now and gearing up for her VBAC. I can't explain how excited I am for her about that upcoming labor and birth. She is so prepared and ready to meet this challenge. I have 100% confidence that her body and her baby can do this. Granted, her baby is most definitely going to be on the large side, and if he is posterior like his big brother was, it could be a darn hard labor that just might possibly end in another c-section. But there has been so much learning for this family that has happened since the last birth, I think the entire thing will be a whole new experience. They fired their old OB who blatantly refused to entertain the idea of a VBAC. They found a midwife group that attends at a hospital (their preference was for a hospital birth) with decent support for VBACs. They hired me. They searched their souls for the best choices for their family. And they've packed their bags.

I look forward to posting a great birth story here very soon.