Monday, March 31, 2008

The good, the bad, and the ugly

Just today I came across two UC stories. They illustrate the wide range of experiences women can have. One story is happy (she is a blogger I recently came across, and LDS too!); one is not (not because of anything that went wrong with the UC per se, but because of how people treated her when she decided to transfer to a hospital).

The second story illustrates some of the potential downsides of UC'ing in our current medical and legal climate. Some UC transfers go quite smoothly, and the hospital staff are respectful of the woman's wishes and of her birth experiences. But others can be nightmares. (The same can be said about midwife-attended home birth transfers.) I'm not sure what can be done to prevent this from happening to other women. In the second story, the physician's treatment of the woman precipitated a major obstetrical emergency. Legally, it would be considered assault and battery. The woman was screaming at the doctor to stop, yet the doctor persisted, ignoring the woman's very vigorous protests.

Both of these stories illustrate the benefit of having people to call upon during labor if the need arises. In the first story, the woman called a friend over to lend assistance with practical stuff like boiling water for the birth pool, so her husband could focus all of his attention on his laboring wife. In the second, the woman knew she needed another person's assistance when she was pushing, but had to call the EMTs and eventually transfer to the hospital because she didn't know anyone she could call on.

I had a friend lined up for my own labor in case I felt the need for female companionship. She was a mother of four children, two younger boys and two teenagers. I felt an instant affinity with her, and she had this very motherly sense about her that I really liked. It turns out I didn't need her company, but it was reassuring to me, and especially my husband, that we had someone we could call.


  1. Gosh, that story of the UC transfer made me sick, literally. What on earth was the doctor thinking??? That's just so wrong on so many levels. Poor mama. :o(

  2. So, wow. The first story was great, and the second was terrible.

    But, I can't tell for sure that the uterus coming out was the doctor's fault. Did I read that right? The uterus came out? I just don't get it.

    I had a nice lady doctor tug gently and slowly on my cord/placenta for almost an hour after my third labor because it wasn't detaching. I was told the reason she was taking such care was because the risk was that the cord would just break, leaving placenta in there.

    Maybe I should just accept this lady's account without question (and certainly I feel extreme sympathy for her trauma), but I feel like I want a trusted medical opinion before I make any judgements.

    But maybe that is where I differ from UC'ers all along?

  3. A uterus can be pulled out. Typically it comes out inside out, and thus is called a uterine inversion. Sometimes it only comes part way (so that just the fundus is through the cervix) but you CAN pull it all the way out. And this is why pulling on the cord is warned against in many a midwifery text.

    Also, from what I've been told by experienced midwives, the cord can snap when it's genuinely too short for the baby to be fully born, so I would suppose there is a risk of the cord snapping when being pulled. I guess whether you end up with snapping or inversion would just depend upon the case and its particulars. Cord traction is a standard part of active management of 3rd stage, I believe, so obviously it doesn't end in tragedy most of the time. There's a difference between gentle tugging and reefing, and sometimes things go the wrong way.

  4. Whether or not cords need to be pulled on after the birth depends on each caregiver's attitude about management (hate that word, but that's what it's called) of 3rd stage.

    I've never before heard that you need to pull on the cord to prevent it from breaking; that seems a bit counter-intuitive. Usually care providers do gentle cord traction to get the placenta born in a certain time frame (in many hospitals they want to see it born in a matter of minutes).

    In general, midwives leave the placenta alone--no tugging on the cord to help it detach--until it detaches and births spontaneously, unless of course there are signs of the placenta being partially detached and heavy bleeding (which may necessitate a manual placental removal to stem the bleeding from a partially separated placenta). If a long time has elapsed (depends on the midwife, again, but let's say over an hour or so), the midwife might encourage the woman to cough, squat, etc to see if the placenta will come out.

    Side note here: mine took 2 1/2 hours to come out. I tried squatting & pushing after about an hour and a half, because it was very uncomfortable with it still inside (those afterpains were awful with it in, and much better with it out) but it didn't want to budge. I was keeping an eye out for signs of heavy bleeding or signs of shock from concealed bleeding, but I didn't have any of those, so I decided not to hurry the placenta.

    In general, most physicians try to get the placenta delivered right away, and part of that routine means cord traction. Now, these are generalities of course, and there will be some crossover. In any case, there are wide ranges in the approach to 3rd stage among different care givers.

    A quick explanation of a midwifery perspective on third stage from Dr. Sarah J. Buckley (aka physiological third stage):

    What is most disturbing here--and of course we are only reading a short account--is that the doctor was doing a procedure which the mother was adamantly refusing and that was causing her great pain.

    Anyway, I wasn't trying to teach some overall moral lesson here (doctors are evil; avoid them like the plague, etc) but the contrast between the two stories just struck me, since I read them at almost the same time yesterday. It's unfortunate that the second woman wasn't able to have the support to either conclude the birth at home, or to have a more respectful & less traumatic experience at the hospital.

  5. oh, I wrote a too-long comment and it vanished. Well, it's contrasts like this that made me choose the middle road of a midwife attended home birth. I think it serves women well to point them to stories like this Rixa, stories like both of these. The good ones are awesome, but the bad make midwives look like a pretty nifty idea. And by all means people, use the inspiration from the good stories!!!

  6. Oh, I found it! My too-long comment: (sorry for double posting)

    OMG I nearly fainted reading that.

    "if I had one more pair of hands, she would move and be out quickly. Unfortunately we don’t know anyone, at least anyone we feel comfortable enough with to invite to our birth"

    If this was indeed a case of 'punishment' or 'OB freakout', then I must say this is exactly one of those things that makes me pray that women reconsider that certain less than perfect midwife, if she's the only one around, that they don't feel comfortable with. Are we just talking about different levels of comfort? a midwife you are maybe not best friends with, versus a doctor who might pull out your uterus, cut an extra large episiotomy, section you, snarl at you, whatever? I don't know this mom or her circumstances, and this comment is not AT ALL intended for her to ponder in the state she is... but for others for future reference... wow.

  7. Darn it, Judit, I always love your long comments!

    I do think it's important to have a realistic picture of what you're getting into with any scenario, rather than walking in some fantasy land. That goes for UC, that goes for midwife-attended home birth, for hospital births with OBs, for any situation really. Such as: "My OB would *never* do an intervention unless it was truly needed." "Home births are safe and you always have time to get to a hospital if an emergency arises." "My CNM said epidurals are safe for the mother and the baby." "If I just trust my body nothing bad will ever happen and I won't feel any pain."

    At the same time, it's so important to have those amazing, inspiring, empowering stories so we have something to look towards as a vision of what could/should be happening.

  8. Thanks for the explanations, Lynette and Rixa.

    One thing, I think what I called "pulling" is what you call "traction"? My emphasis was on the GENTLY part, which my dr said was to prevent the cord breaking, which made me wonder why this lady's cord didn't just break under that awful pulling instead of yanking the whole uterus out.

    Even reading the first story, I am overwhelmed thinking of all the energy and time I would have to invest in order to feel ready for a homebirth.

    And I don't think I'm stupid or lazy; it's just overwhelming and scary, even for a college-educated mother of three who grew up hearing delivery stories at the dinner table. (my dad is a D.O. FP dr who delivered over 1000 babies).

    Hearing the second story, I am thinking this is not an effective argument for UC -- that poor woman is not someone I can admire or wish to emulate. She comes off as not very educated or prepared or . . .

    And, would I rather have a midwife who "is not my best friend" or a dr that I see all my pregnancy and do my best to build a relationship/understanding with? Well.

    I've had 3 different women OBs, and though now I wish I'd heard of UC and thought about approaching my own labors differently, I was very happy with them and their responsiveness to me at the time.

  9. One thing to keep in mind is that preparation for a midwife-attended home birth isn't the same animal as preparation for a UC. When you have a midwife, you are hiring her for her expertise, knowledge, skills, etc. You don't have to do the same amount of research and preparation as you do (or should) for a UC. Of course, I am sure some home birthers do that anyway even if they have midwives, if they're really into knowing about birth...

    And of course what is really fun and exciting for one person might be totally not fun and overwhelming to another. I think I'd feel the same way about preparing for a hospital birth as you would for a UC. And that's okay.

    I wasn't intending story #2 to be an argument for or against UC. It was more a look at the possibilities of that experience. Of course, story #2 is definitely the exception; you rarely find something like that occurring. But there is no uniform "UC experience," just as there is no universal "hospital/OB experience."

  10. Good points, Rixa. Every birth is different, I'm sure, regardless of where or how it is attended.

    I wanted to clarify what I meant by "education." When I envision preparing for a natural birth or a midwife-attended birth or something (not quite able to envision UC), a big thing I would want to do is basically apprentice myself to a midwife and follow her through many births.

    So I guess this is one of my big stumbling blocks for understanding/embracing UC. It's probably just a well-engrained cultural thing. If I can't become an expert, then I need an expert there with me. And I have very high expectations of what an "expert" would be. And I couldn't give birth on my own until I could consider myself an expert. (And while I trust "feminine intuition" and "birth" on some level, it doesn't equate with "expert." Perhaps I am a hopeless product of the patriarchal machine.)

    I might agree that many doctors/hospitals seem to not be very "expert" at the business of labor & delivery either, but I'm just not sure that I (or many other women) have the time/energy/inclination to become experts.

  11. I was one of those who was so into birthing that I prepared as if no one else would be there, except I also hired a midwife and built a rltnship w/ her etc. Exactly because of the UC stories. Are UC women inspiring pioneers? Yes, for showing us how stunningly unexpectedly normal normal birth is. Are those experiences changing how th rest of us approach birth? Absolutely. For better AND for worse. It's sad if we are becoming suspicious of home birth midwives' agenda, but it's awesome when we own our experiences so profoundly, through preparation and the self-reliance.

  12. Hi Rixa

    I have been reading your blog for about a month now and really like it. You show a different side of home birthing than I have ever seen, you don't hate doctors!
    I think these story illustrates exactly what I think needs to happen here in the US as far as home birthing is conncerned. Women need to have a way to birth at home and then feel supported if/when they need to transfer to a hospital. We need better relationships with OB's so that we can go in just for the little help we need at the end, if that is all we want, but you can't do that in the system we have now.

    I had a home birth with my first, and I needed to be transfered badly, I live in Oregon where there are no laws protecting women from midwives. The midwives in this state do not need to be licensed and need no training, I was lied to and it was implied to me that the midwife attending my birth was at least an RN, not the case! They wouldn't transfer me because they had such a bad wrap with the hospitals around here (wonder why??!)

    Anyway, my last two births were in the hospital on e with an epidural, on my back , feet in sturips, I knew all I needed to do was get up and move so she could come out but I couldn't.

    The last birth was induced, (my first had shoulder dysticia they are still freaked out about, oh and was about 10 pounds) I went natural after that with an amazing woman who is a midwife in Holland, I waled squatted and finally gave birth on all fours at her advice, it was heaven, later that day I told my husband, this isn't our last!
    I am pregnant again and Henry will be one on thursday. It was almost totally due to the nurse I had!

    I don't know why I felt compeled to share my story with you (short as it was) but I LOVE your bolgg, keep up the good work.

    Katie from Oregon
    PS what does UC mean unassisted?

  13. why didn't the cord break, wonders anonymous? because umbilical cords are STRONG. in my limited experience I have only seen one cord evulsed by a care provider, and the placenta was so adherent it took 3 care providers ultimately to get it out. good thing the cord evulsed rather than inverting her womb. (It was about one step shy of being a placenta accreta). in retrospect the mama whose cord snapped had not been eating very well, and her placenta was "mushy"--not great tissue integrity. but in general, cords are very strong and placentas adhere well to the uterus until it's time to be released, because these two strengths fortify LIFE.

  14. At the first birth I attended as a doula, there was a fast pushing stage (10 min) In the mom's birth plan it said, no cord traction. But within a minute or two the OB was pulling on the cord and the cord did break. The OB made some comment about "It must have been very thin" Then she had to go in and manually remove the placenta.

    Then in a birth the my doula partner went to, the did do cord traction about 30 min after the baby was born and the uterus inverted.

    I think it this story is especially horrible, because the mom was saying. "DON'T" Why don't doctors listen to mothers? It is our body, we know what is going on inside!

    The other story was great! I wish the other mom had someone she could have called. Just a little extra support, may have helped avoid that horrible situation at the hospital.

  15. As a mama considering unassisted birth, I realized that I could only feel comfortable knowing I had someone I could call if I needed, even just for a question, or like in this mama's case, another set of hands. I am lucky to have found a midwife who is willing to be on call while I'm birthing my next child. And I hope that a friend (and doula) will be willing to be present if I ask her to be. I somewhat worry that she would not be comfortable with the UC idea, and avoid the situation.

    By posting this, Rixa just reaffirmed that my instinct to have "back-up" is a good one.

    And as a note about the 2nd mother's birth story, what the OB did was malpractice in at least two ways: violating a mother's informed consent and preforming a procedure that ended with a horrific outcome that should never happen. The OB could also be brought up on assault and battery charges as well.

    I don't know if I'll hear more about this mama and how her recovery goes, but I will not be one bit surprised if she experiences either major depression, or Post Traumatic Stress Disorder caused by those events in the hospital. I pray that she can overcome it, and not fall into the trap of wishing suicide over the endless looping recollections of that experience. (spoken by one who knows, even though my experience was much less abusive).


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