When I was a graduate student in Iowa and trying to conceive my first child, I was working as a doula and apprenticing with a direct-entry midwife. After we moved to Illinois, I started assisting a home birth CNM at prenatal visits and births occurring in my area. This pregnancy, I am living in a new state and for the first time in several years, I am not a part of the local midwifery community. This is part of the reason that I felt the need to initiate care with a home birth midwife here; I no longer had access to midwifery care, advice, or skills except through a formal, paying midwife-client relationship. There are a few things that I want access to: during pregnancy, I like checking my hemoglobin levels early in pregnancy and again around 28 weeks to be sure that my blood volume has expanded adequately (hemoglobin levels should drop by the 28-week check; if they are stable or rising, that is cause for concern). I want someone to check me for tears after the birth, suture/Dermabond if necessary, and to do bloodwork in case I want a Rhogam shot. While I could in theory go to a hospital for those postpartum services, it would be extremely disruptive and kind of pointless to get in the car hours after having a home birth!
I also find myself wanting the option of having skilled assistance during labor for certain rare emergency situations: shoulder dystocia primarily, and to a lesser degree rapid postpartum hemorrhage or the baby needing resuscitation (the latter is the least worrisome to me, even though it is probably the most common of the three scenarios I listed, since I am trained in neonatal resuscitation). This wasn’t as much of a concern during my first pregnancy, but I find it weighing more heavily on my mind this time. I suspect it’s because, now that I have a child of my own, the idea of losing a baby is no longer an abstraction to me. I wouldn’t say at all that I was simply being callous or naïve the first time around, just that the possibility of losing a child is more palpable to me now.
I was happy to learn that a home birth midwife lived only 20 miles away from our new house—the closest I have ever lived to a home birth provider in many years. Although I could pay out-of-pocket for a midwife, I was quite happy to find that she was a CNM who could accept my insurance. This means that instead of paying $3,600 for her global fee, my out-of-pocket expenses are around $1,000 ($500 for the deductible and another $500 for the 20% co-pay). Labwork and birth pool rental are additional; she rents out heated, jetted Spa-In-A-Box pools, but I won’t need that now that I have a free La Bassine.
I met with the midwife early on in my pregnancy to talk about what I was looking for and figure out if she would work for me. I talked about my first birth and how I was looking for a hands-off midwife who would respect my need for privacy. I had a few specifics I quizzed her about: was she willing to not listen to heart tones at all? (No; she’d like to listen every 30 minutes. But otherwise she is fine staying out of the room while I am laboring.) Was she willing to stay in another room during the actual birth? (No, she’d prefer to be in the room as the baby is being born to keep an eye on possible problems). I am actually quite fine with having heart tones checked. I understand from a midwife’s perspective why it is important to listen. If I am inviting a midwife to the birth, she does need to have a way to know if the baby is responding well to labor.
The second point is more of a stickler for me, and it’s been on my mind a lot recently. I feel very strongly about keeping the “birth bubble” intact in the immediate postpartum period. Even many home birth midwives tend to do a lot of stuff right after the birth: putting a hat on the baby, rubbing it gently with towels, speaking with the mother, suctioning the baby’s nose and mouth, taking a full set of vitals every few minutes (baby’s heart rate & respiration rate, mom’s blood pressure, etc), feeling if the placenta has detached, etc. While these activities are not terribly interventive in the grand scheme of things—after all, baby is usually still in the mother’s arms—they do “wake the mother” and take her away from that critical time in which her primary task, physiologically speaking, is to produce high levels of oxytocin to help the uterus clamp down efficiently, the placenta to detach cleanly and completely, and thus prevent a postpartum hemorrhage. In Michel Odent’s article “The First Hour Following Birth: Don’t Wake the Mother!”, he explains how midwives ought to behave in the immediate postpartum period:
They first make sure the room is warm enough. During the third stage women never complain that it is too hot. If they are shivering, it means the place is not warm enough. In the case of a homebirth, the only important tool to prepare is a transportable heater that can be plugged in any place and at any time and can be used to warm blankets or towels. Their other goal is to make sure the mother is not distracted at all while looking at the baby’s eyes and feeling contact with the baby’s skin. There are countless avoidable ways of distracting mother and baby at that stage. The mother can be distracted because she feels observed or guided, because somebody is talking, because the birth attendant wants to cut the cord before the delivery of the placenta, because the telephone rings, or because a light is suddenly switched on, etc. At that stage, after a birth in physiological conditions, the mother is still in a particular state of consciousness, as if "on another planet." Her neocortex is still more or less at rest. The watchword should be, "Don’t wake up the mother!"Pamela Hines-Powell has written about this as well (and I interviewed her more in depth about what she does/does not do at births for my dissertation). Immediately postpartum, her default routine—what she does unless the mother requests otherwise—is to stay silent, out of the mother’s line of vision, and quietly observe the mother and baby from several feet away. No one but the parents touches the baby for the first hour or so after the birth. The midwives only step in to assist or interact once the mother initiates contact (barring, of course, an emergency situation). For example, here are a few of her common birth & postpartum practices, taken from a longer post about her midwife identity crisis:
- Routine vaginal exams - during labor or prenatally. It’s not uncommon for us to never touch a woman’s vagina - or even see her vulva - until the baby is crowning (if we can see it) or afterwards when looking for tears/lacerations.
- I’m not going to do perineal massage or even support of the perineum (some women with land births like to have some rectal counterpressure) as baby is being born…but I’m not likely to do anything at all during second stage in water births…blame it on me trying to protect my back and not wanting my shirt wet, but really it’s because the mother does it all on her own - and she knows best.
- I do not - nor does my wonderful assistant - usually touch the baby for a good hour or so after the birth. No routine checking the heart rate - we look and observe tone and respiratory effort. Only if that is in question will we come closer and do vitals or listen to heart rate.
- I typically do not do much face to face labor support, breathing reminders or talk women through labor contractions other than a very occasional gentle reminder of why she is doing this or that her body is working so well with her baby. If a woman needs more than that, I’m there, but my default is to stay in the background and support women to find their own way of laboring (and they have a tendency to breathe pretty well without instruction, too!) .
I talked over these things at length yesterday with my good friend Jen, who has experience both giving birth and attending births. She had her first baby in a birth center, her second at home with a CNM, and her third unassisted, with a midwife hired as a photographer. She is also apprenticing with a home birth midwife, so has seen birth from the other end of things, so to speak, including several more complicated/complex births. At the end of our conversation, she suggested that I, or this new baby, might need something that this midwife can offer. Perhaps my task this time is to learn how to move past my fears about having a midwife and to embrace this pregnancy and this birth journey for what it needs to be, rather than always comparing it against Zari’s pregnancy and birth. I think she was very wise to say this. Maybe there’s something unexpected that will arise during this pregnancy or birth that is spurring me to seek midwifery care. Maybe I need to learn how to let people into my life and accept assistance. I am a very independent, self-reliant person, and I always want to do things by myself. I have already proven that I can give birth alone, that I can do it all without assistance. Perhaps I don’t need go through that particular rite of passage this time.
I am eager to talk through these issues with the midwife the next time we meet, since I need to move beyond the unproductive anxiety that I have been feeling. I don’t like that this pregnancy has been so dominated by these unsettled concerns. Now that my birth is drawing nearer, I need to turn my emotional and mental energy in a more positive, productive direction, towards creating the birth that I desire rather than worry that it might not work out the right way. I know that my concerns are minor in the grand scheme of things—you know, compared to people dying of AIDS or extreme poverty or domestic violence or whatever—but they are still real and important to me.