Lamaze/ICEA Conference part 2

Saturday did not start well for me. I slept maybe 2 hours the night before, due to a combination of congestion and two little children who decided to wake up and either cry (Zari) or party (Dio) most of the night. I wondered how I would make it through the day...

But I didn't have much choice. My presentation--based on my article Attitudes Towards Home Birth in the US (PDF)--was in the morning. I arrived early and ran through my presentation to make sure I wouldn't go over time. I used prezi rather than PowerPoint, as I think it's a much more dynamic and visually interesting platform.

Safe or Selfish? Attitudes about home birth in the US on Prezi

I had a fun time giving the presentation. We had lots of discussion and comments both during and after my talk. Even though I was dead tired, I didn't feel it while I was speaking. We had to cut the discussion short to make it to the big celebratory luncheon. I sat with April, a lovely CPM from Dayton, Ohio, who works closely with Dr. Guy of Miami Valley Hospital in Dayton and Dr. Can't-Remember-His-Name in Cincinnati. These OBs are known for supporting women who want VBACs, vaginal breech births, vaginal twins & triplets, etc. She and I talked about her training (master's level degree from the Midwives College of Utah) and her reservations about the loopholes in the CPM certification process.

Later in the day, I found out that Geradine Simkins, president of MANA, and Dr. Raymond De Vries were both in my audience! I had never met them face-to-face before and so didn't know who they were at the time. I talked with Geradine afterwards for a while. She urged me to consider doing research with the home birth statistics MANA has been compiling over the past decade or so. She was especially curious about my suggestion that NARM upgrade the CPM certification into a 4-year university degree. We weren't able to talk much because of our busy schedules, so I'll have to continue our conversation via email or phone.

I did double duty in the afternoon breakout sessions. First, I listened to Christine Morton's presentation about the historical evolution of doulas and how the profession is intimately connected with the development of childbirth education. Really fascinating! I've "known" Christine online for a while--she's a sociologist at Stanford University and doula--but never saw her in person before the conference. I never had time to talk with her face-to-face, unfortunately. But here's a virtual wave hi, if you're reading!

I then ran to another session about MoreOB, an evidence-based program being adopted throughout Canada. The presenters were an obstetrician, Dr. Karen Bailey, and two nurses/childbirth educators, Liz DeMaere and Sharon Dalrymple. With MoreOB, what childbirth educators teach in the classroom is exactly what happens once the laboring woman arrives in the hospital. This is definitely not the case in most parts of the US, as attendees emphasized over and over again throughout the conference.

The speakers gave a case study about how MoreOB works in their hospital regarding fetal monitoring. The hospital staff has a clear set of guidelines for when to use intermittent auscultation (IA) and when to use continuous electronic fetal monitoring (cEFM). Basically, unless a woman has certain clearly-delineated risk factors, she will only be monitored with IA. If a nurse, midwife, or physician wants to use cEFM, they have to document which specific medical condition warrants using cEFM. If it does not meet the established criteria, they won't be allowed to use cEFM. And they'll receive a talking-to from the charge nurse!

I entered when Dr. Bailey was talking about the before and after experiences in her hospital. She works in a small rural hospital in High River, Alberta that cares for only low-risk laboring women. Before adopting MoreOB, every woman would automatically be hooked up to the fetal monitors and confined to bed. After MoreOB was put into place, no one goes on the monitors--no 20-minute admission strips, even--unless there's a very specific reason for it. At her hospital, that means almost everyone receives IA and is encouraged to stay out of bed. Dr. Bailey explained it like this: "I'm an old cowgirl. And every cowboy or cowgirl worth their salt knows that you can't just slip your feet into a good-fitting pair of cowboy boots. You have to wiggle and jump and shimmy your way into your boots!" (This said as she's hopping around the room on one foot demonstrating the gymnastics required to put on cowboy boots). She was adamant about keeping women walking and moving and out of bed. She joked about how they used to always know where to find the laboring women--in bed. But now, they never know where to find them. "Where's patient X? Not in her room? Not in the shower? Where could she be? Oh....probably the staircase!"

We then moved into three small groups, each tackling a common scenario in US hospitals: augmentation, induction, and restriction of food/drink. We were instructed to discuss how to implement evidence-based, consistent policies, similar to what their hospital has done, for these various scenarios. I joined the induction group, which Dr. Bailey was part of. Our group, I sensed, felt extremely hampered and frustrated with how little they felt they could do to change the rampant rates of both elective and quasi-medical inductions (i.e., for a "big baby" or being "overdue" at 40 weeks and 1 day). Where Dr. Bailey works, they only do elective inductions for really extreme circumstances--such as a grand multip with a history of 30-minute labors who lives two hours away from the hospital and a really big snowstorm is moving in (close to a direct quote from Dr. Bailey). They don't start offering inductions for post-dates until 41 weeks 3 days. So if a physician wants to book a patient for an induction, and the induction doesn't meet certain evidence-based criteria, the charge nurse will tell the doctor--and I quote Dr. Bailey--"Bullshit."

The last session on Saturday was a general session by Dr. Warren P. Newton. He teaches at the UNC School of Medicine and works with UNC's department of Family Medicine. He spoke about developing a systems approach to health care. While the quality of individual physician-patient (or midwife-client) interactions is key, we also need to ensure that everyone has equal access to such care. He explained the implementation of the Family Centered Medical Home into the UNC Family Medicine Center and demonstrated very impressive results: much less waiting time for appointments, better health outcomes, etc. I'm still fuzzy on what exactly a FCMH is and how it different from standard medical care systems, but it was very intriguing.

The last part of his presentation explained how he applies these approaches to maternal-child care. His staff includes family physicians, nurse-midwives, nurse practitioners, and acupuncturists. They have really impressive numbers with their maternity patients. They do about 350 births/year and have a primary cesarean rate twice as low as the overall primary c/s rate at UNC. Their practice's epidural rate is 25%, compared to 82% for the rest of the hospital's maternity patients. (He noted that not allowing the anesthesiologists into the woman's room soon after admission to "talk about her pain relief options" and "assess her airway in case she needs an emergency cesarean under general anesthesia" had a significant impact on lowering the epidural rate.) He's also been involved in backing up the only freestanding birth center currently in North Carolina, the Women's Birth and Wellness Center, which does about 400 births per year. He demonstrated a strong belief in the normality of the childbearing process and of women's inherent ability to give birth, especially when given the time and space to do so.

By time 5:15 pm rolled around, I was beat. I could hardly stand upright and was feeling quite unwell. I wanted to stay longer and talk, but I needed to get back to the kids, eat dinner, and go to bed. My sister and I split a Tylenol PM; the sleep aid is benadryl, so it was perfect for our congested noses. (Thanks to April for finding someone with medications on hand!) It did the trick, and I was able to have a good night's sleep (which meant I only woke up 3 times to pee, and Dio only woke up once at 2am.) My apologies to anyone who thought I seemed disinterested or distracted on Saturday...it was just the fatigue!

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Litigation and the obstetric mindset

While doing research for an article I'm writing, I spent a lot of time on the OB-GYN-L forums, where OBs and the occasional family physician or midwife discuss various ob-gyn topics amongst themselves. I read through the past five years of discussions to gather the various perspectives OBs hold on home birth. I often got sidetracked into reading threads not directly related to home birth, such as posts about about VBAC or breech. I was amazed at how terrified OBS are of being sued. Over and over, the OBs on this forum caution each other to be careful, that every patient is a potential litogen, that if any little (or big) thing goes wrong, the patient will turn around and sue, claiming that they were not properly informed of X or Y risk. And, unfortunately, this does happen often enough to somewhat justify that fear.

I identified several themes arising regarding litigation and home birth. Many OBs are more supportive of home birth personally than they are professionally. In other words, if their malpractice insurance carriers or hospital administration allowed it, more physicians would be willing to collaborate with or backup home birth midwives and their clients. However, in today's litigious climate and with the restrictions dictated by the hospitals they work at, they are unwilling to risk a lawsuit, termination of employment, or "going bare" (working without malpractice insurance) in order to provide support to home birthers. From a November 2006 OB-GYN-L conversation about the legalities of backing up home birth midwives:

Anna Meenan, MD, FAAFP: The legal system is definitely the stumbling block, but if OB's were really serious about working with and supporting midwives, it might be possible to put in place legislation protecting receiving hospitals and OB's in all states.

Ronald E. Ainsworth, MD, FACOG: It's not just the legal system per se. My malpractice carrier will not cover me for any birth that is a planned out of hospital delivery that I agreed to provide backup coverage for. I'm a proponent of patient choice and autonomy, but not at the risk of my career or financial ruin to myself and my family....It's not just "boost rates or cancel insurance," my carrier excludes any coverage for malpractice arising out of a prearranged relationship with a patient who attempts out of hospital delivery. That means I would be practicing bare. NO THANK YOU!!

One OB, Garry E. Siegel, described how a malpractice attorney advised his practice to specifically state that they did not participate in home births in any way, as a cover-your-butt policy:

A couple of years ago we had a little "run" of home births, likely planned, in our CNM patients. Long story short, while not debating the safety of home birth (because there are studies that likely prove it is OK in low risk patients, though it would take a gigantic study to show a difference if one exists), a wise attorney from our Med Mal carrier asked us if we TOLD patients up front that we don't participate. Well, we didn't, but now all new OB patients read and sign a form that includes, among other things, a statement that says:
This practice does not participate in home births in any capacity.
If patients want to discuss this, we don't accept them or discharge them.
If they deliver at home "behind our back," we were up front! (Jan 28, 2008)

Obstetrician Barbara Nichol talked about how terrible it is to be sued--something that almost all OBs experience at least once during their careers. Her remark was set in a longer comment about the need to treat home birth transfers respectfully, rather than antagonistically:

90 percent of us get sued. It's an unbelievably awful experience even when you did nothing wrong, and it's worse when there's some real question on that point. I admit to a lot of frustration and upset when an obvious litogen (e.g. local favorite: refusing GBS prophy because 'antibiotics cause asthma', don't get me started on this nightmare of junk science) walks through the door, but communicating those emotions to the patient just starts things off on the wrong foot altogether, as I'm sure y'all know already.

Litigation isn't always about who is truly at fault, but about who has the deepest pockets. Because many home birth midwives choose not to carry malpractice insurance--including the CNM I used for Dio's birth--if there is a lawsuit, it will often pass onto those with the largest insurance premiums, regardless of fault. From a discussion about liability when a physician assumes care for a home birth transfer:

Unfortunately, IMHO, the hooker here is the legal system. When a patient who chooses OOH birth does have a problem, and is brought to the hospital (as RESPONSIBLE midwives will do), it's often the physician and the hospital who bear the brunt of the family's anger and frustration, and often find themselves in a lawsuit, brought on by a patient with whom they have not had the opportunity to develop rapport, etc. That's why many obs are unwilling to support this situation. Is this fair? probably not. It is, however, sometimes a matter of self-preservation. (Larry Glazerman MD, St. Luke's Center for Advanced Gynecologic Care, Nov 26 2006)

A midwife on the OB-GYN-L list responded to Dr. Glazerman:

Unfortunately, Dr. Glazerman, you're correct. The distrust and antipathy goes both ways, though. Women who transfer from a home birth are often treated very rudely by physicians and hospital staff, even to the point of having CPS called b/c they attempted home birth. Midwives' records are ignored and patients treated as if they had no prenatal care. Time is wasted and valuable information ignored. (Jamie, Nov 27, 2006)

Another physician, D. Ashley Hill, joined the conversation and added these remarks:

As the recipient of several surprise train wrecks from planned home deliveries or lay birth deliveries gone bad, I agree that very often "the hospital" and "those doctors" end up being the bad guys. Most patients are not pleasant after 6 hours of hard pushing followed by an eclamptic seizure and postpartum atony with hemorrhage. Typically they don't like hospitals or physicians to start with and are on the lookout for anything else to go badly.
What many of our non-US colleagues may not know is that in our legal system the lawyers preferentially attack the party with the best insurance, regardless of the level of fault, therefore there is little impetus for lawyers to go after the person who attended the home delivery. Instead, they go after the doctor and the hospital where the patient ended up when things went awry at home. (Nov 26 2006)

I was also surprised that many OBs feel trapped by the system, portraying themselves as victims and malpractice lawyers as The Big Bad Guys. Physicians comment about how ACOG "is a hostage of the legal system," how "the legal system is the king (or queen)," or how "trial lawyers run the whole show."

If you want some really fascinating reading, browse through the OB-GYN-L archives and read threads about VBAC or home birth. It's kind of like watching a car accident--you know you should turn away, but it's just so morbidly fascinating that you can't stop looking. (Select a month, and then click on "thread" view. Read from bottom to top, since the earliest posts are on the bottom.)

I am trying very hard to understand the obstetric mindset when it comes to risk, malpractice, and litigation in relation to choices such as VBAC or home birth. I can kind of understand why OBs act and think the way they do, and I have been trying very hard to see things through their eyes. But on the other hand, their attitudes and behavior directly impact women's bodies, women's birth experiences, and women's range of childbirth-related choices. But still, I do understand what a hard place many of them are in, and the blame is multivalent: partly from patient litigation (real or imagined), partly from malpractice insurance or hospital policies, partly from personal experience (such as attending a VBAC with a bad outcome), and partly from personal preference ("I don't see why any woman would want a VBAC--what's the big deal about having a cesarean?").

I was discussing this with a family doctor friend. Below are her perspectives on OBs and litigation, from the experience of a family physician trained in a medical setting and who works alongside OBs, but who herself practices with a very holistic, minimally interventive style of care. Below are her comments, reposted with her permission:

*****

On OBs and lawsuits: I can understand part of it, and part of it is an incomprehensible mystery to me. OB, as a surgical specialty, has a much different "flavor" than the FP [family practice] world I trained in. OBs are surgeons, and many have an "I can fix that!" kind of personality, where issues are seen as black and white, and they rely heavily on their judgment and skills and quick decision making. Surgical training is much more hierarchical than generalist training, and I think that builds in much more of the power issues that we see in medicine so much. OBs primarily view their clients as patients, and their decisions as scientific and don't concern themselves with the softer, social/emotional issues. Because of the power play issues and the idea that the OB is the knowledgeable important person in the relationship, I think this leads to a lot more worry on their part of the consequences of their decisions. The average OB is trained and socialized to be the decision maker and leader in the doctor-patient relationship, and to bear the responsibility for the outcome. They are also socialized to be very risk aversive - but only the risks that impact them the most. There is this overriding cultural expectation that OBs are expected to produce a perfect baby every time - but in reality, I think OBs propagate this much more than their clients do. I think so much could change if OBs (and many other kinds of doctors) could let go of the power differential and allow themselves to be seen as human.

As a family doc, even though I trained in a highly traditional medical setting, I was still trained by family docs, with a strong flavor of know-the-evidence, partner-with-your-patients type style. I think midwives, of course, lean even farther into the psychosocial part of their relationship with clients in their training. I think the more partnership or service style of practice leads to less fear that you will be held solely responsible for your decisions. Our generalist training, and in midwives' case, their woman-centered training, shifts more responsibility onto clients themselves, and I think leaves us feeling less worried about litigation, and more worried about quality care.

Of course these are big generalizations, and there are exceptions to everything, but in general the culture of the surgical specialty of OB is just so different than the culture of midwives, or even family docs.

I don't worry about getting sued very much. It rarely enters my mind as a factor in decision making. I worry a lot more about educating, and about encouraging my clients to make their own decisions. I worry about forming good relationships, providing room for disappointment to be expressed when things don't go the way we hoped, and making our decision making processes completely transparent and understandable to my clients. I worry about making sure my clients understand that there is a lot of uncertainty sometimes in what we do, that no outcome is guaranteed, and that I strive for excellence and hope for luck along the way, too. I hope that the relationships I form with my clients will mean that they can tell the difference between malpractice, and an honest human being doing their best.

Part of the lawsuit crazy fear really does seem incomprehensible to me, though. When I was pregnant with my fourth child, I went to a friend (or more acquaintance) who is an OB for prenatal care, and we had the weirdest argument over me being tested for gonorrhea and chlamydia in early pregnancy. I didn't want to be tested because I have zero risk, and it costs money. She kept saying that it was important to be tested, regardless of risk, because of "medical legal reasons." We went around and around until I finally said: "Look, 'medical legal reasons' only come into play if I sue you, and I can assure and guarantee you right now that I'm never going to sue you for not testing me for gonorrhea and chlamydia. I understand the risks and benefits of being tested, and I refuse. Period." She was terribly flustered that I'd brought up the word "sue" and terribly flustered that I said "refuse" and was clearly uncomfortable and it was so strange to me. In my practice, I matter-of-factly explain the benefits of being tested, and if clients choose not to be, I feel quite content that even if they are making the wrong decision, it's their decision and their consequences so I don't have to be personally invested in it - while she clearly couldn't let go of the idea that by not following the "standard of care" I could somehow accuse her of malpractice later. I still can't understand why so many OBs are so terrified of being held responsible for outcomes they can't control - why are they so frightened of allowing the decision making to rest with the folks who have to live with their decisions!?

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What if you never saw a birth like this?

One of my readers, doctorjen, submitted this birth story for the book giveaway. I am reposting it here with her permission. She is a family practice physician who works in a small rural hospital. I always enjoy reading stories of the births she attends.

Sometimes I attend a birth that reminds me how different my experience is than many hospital providers. This birth was very powerful and beautiful, and reminds me again how awesomely powerful women's bodies are. It was not an easy birth, but the hard parts were still handled by the mama and her baby with amazing power and just a little help. I know that most hospital practitioners have never seen a birth like this - and I wonder how my view of birth would be different if I never had either.

B. is another one of my teenage clients. Unlike many of my teen moms that come of difficult backgrounds, B. was an excellent student, with loving, supportive parents. B.'s pregnancy was a huge shock to her family, and to her large circle of loving family friends. The circle of friends includes the family that are executive directors of the maternity home I often do prenatal care for. This family had known B. since birth, and despite their career being focused on caring for women with unintended pregnancies, B.'s was still a big shock. Family and friends both recovered well from the initial shock, and B.'s mom especially was very supportive and wonderful throughout the pregnancy, attending all her visits and being happy about the baby, even though she was disappointed about the timing.

B. was sort of a high maintenance pregnant client. She'd obviously been the petted baby of her family, and reacted strongly to all the discomforts of pregnancy. She had quite a number of unscheduled visits for belly pain, back pain, nasal congestion, pelvic pressure - you name it. She had multiple visits to labor and delivery for pre-term contractions (never true pre-term labor.) Her family, and even her boyfriend, always responded to her with loving concern, and attempts to make her feel better. I have to admit to getting a little frustrated with her - but did my best to keep it to myself.

During the third trimester, B. "studied" childbirth with a couple of family friends. Both of them had taken a Bradley class, and they went over their work book and notes with her. She also borrowed several books from me, and wrote a term paper in her junior English class on the risks of epidurals. She wrote a birth plan that looked very Bradleyish, and included not wanting to be induced and not wanting any pain medicines. Having at this point seen her in tears so often due to back pain, or Braxton Hicks contractions, I privately wondered about this birth plan - was it hers, or the friends? The one friend had a lovely unmedicated VBAC with me 3 years ago and she and her mother (who is the executive director of the maternity home) planned to be at the birth as support people.

As B. approached her due date, she stopped complaining about contractions. She joked about how ironic it was that she'd had them for months and now they were gone when she wanted them. Her due date passed, with no interest on her part in induction - she never even mentioned it, despite mentioning often how much she wanted to see her baby. At 41 weeks, she was scheduled for a biophysical profile. B. called on the way to the ultrasound to say she was having a little bit of pink tinged mucus when she wiped. By the time the ultrasound was done and she went up to labor and delivery for the NST portion, she was still having a little bloody show, and now having some irregular contractions as well. She asked a labor nurse to check her. The nurse called (my favorite nurse again) and said she thought B. was trying to start laboring. She was 1 cm dilated and 60% effaced, with irregular contractions (about 10 o'clock in the morning.) The ultrasound, however, showed a decent sized straight posterior baby. The nurse told me she'd suggested that B. go home and spend as much time on hands and knees as she could stand, and try to get this baby to turn around. She had appointment with me later in the afternoon, and planned to keep it.

Around 3 pm, B. came for her appointment. She told me the contractions had slowly been getting stronger and a little closer together all day long. She also told me she'd been crawling around as much as she could, and had her mom rubbing her back and was feeling contractions mostly in her back. She asked me if I'd check her again. During the visit, she had 3 strong contractions, and during the 3rd one, she started to cry, and when her mom asked her what was wrong she said "This just hurts so much!" I checked her a few minutes later, and she was now 3 cms and 80% effaced. B. was cheered up that she was actually making change. To my surprise, she said she wasn't ready to go to the hospital yet. I suggested she go home, eat supper, take a soak in the tub, a nap if she could manage it, and that I guessed she'd be back to the hospital later this evening. Her boyfriend was due to give a speech in a college class that evening, and decided to try to still get there to give it, while her mom planned to stay with her.

Around 8 pm, B. arrived back to the hospital. At this point, her contractions were every 3 minutes, and she was breathing hard with them and having a lot of pain and pressure in her back. Her whole support team arrived with her - boyfriend (who'd gotten an A on the speech), mom, dad, family friends (the mom and daughter who were to be her designated labor support) The nurse called me and said B. was now 4 cms dilated and 90% effaced, and contracting regularly. I came in to see her at this point. B. was bouncing on the birth ball when I got there, and one of the friends was kneeling on the floor pushing on her back. B. was obviously working hard now, but excited that she might soon see her baby. Although she mentioned that she was hurting, she also seemed calm and determined, and although she asked for the support she needed ("Rub my back!" "Where's my drink?" "I'm hot!") she didn't talk about pain medicine.

For the next few hours, B. got in and out of the tub (we were having issues getting it hot enough, so she'd stay in until she was cool, then get out while we drained and refilled it) walked in the halls, bounced on the ball, drank juice, and leaned on her support team. For a long while, the contractions seemed to stay about the same, and then, they started to become less frequent instead of more frequent. B. started to be tired, and crabby, and struggled to stay on top of contractions. She'd not wanted a lot of cervical exams, so we kept trying to help her be comfortable. Finally, around 2 am, when B.'s contractions were only about every 7-8 minutes now, and she was falling asleep between them and waking up struggling to cope with them, I asked her if she wanted a cervical exam, and she said she did. I checked, and she was still 4 cms dilated, and 90% effaced. B. was really discouraged at this point. She'd now been laboring since about 7 in the morning, and had had absolutely no change since arriving to the hospital 6 hours ago.

We discussed options at this point. First of all, I told B. that her baby was fine, she was fine, she was coping beautifully and keeping up her hydration, peeing well, and overall doing great - so there was no medical need to do anything at this point. We could just wait and see what happened. I suggested if she wanted to wait, that we try dimming the lights, and tucking her up on her side in bed with all kinds of pillows for support, and she see if she could rest. She was exhausted at this point, and sometimes dozing off between contractions. Second, if she didn't feel like resting was an option, and she didn't want to just continue waiting, we could try something to augment her labor - either AROM or Pitocin. She asked a lot about what either intervention would mean. (Pitocin would mean continuous monitoring, and being stuck to the IV pole - AROM would commit her to delivery, might make contractions more painful, and might encourage the baby to stay in a poor position - but would leave her with the freedom to still move and be off the monitor,) She cried a little at this point, and said she was just so tired, and scared, and not wanting to hurt anymore. Her mom, who is very emotional, cried too, and said she felt so helpless to help her daughter feel better. Her dad, the boyfriend, and the family friends were all for AROM, wanting to get this show on the road. Seeing her distress, I suggested that she try just resting for a while, that there was no need to make a decision right now, and she calmed down and said she'd try that.

A few minutes later, at about 2:15 am, we had her tucked as comfortably as we could on her side, with pillows under her leg and arm, and mom rubbing her lower back still. We turned off the lights, and the nurse and I told her we'd be right outside the door if she wanted us. For 30 minutes or so, she was quiet, and we hoped she was able to sleep a little. Then, we started to hear her moaning through contractions and breathing hard again, although the contractions were still 7-8 minutes apart. Finally, around 3:15 am, her dad came out of the room and said B. would like to talk to me.

B. said again that she was so tired, and just so worried that doing anything would make her hurt more. I told her honestly that it may well make her hurt more - but I was also a little worried that she was so tired now, that if we waited a few more hours and she was still unable to rest that she would just be that much more tired and still in the same position. I assured her again that she didn't have to make any decision urgently, because she and the baby were fine. She thought for a moment and said she thought she'd like to try having her water broken. I checked her again - still 4 cms, 90% effaced, 0 station - and hooked her membranes with an amnihook, and clear fluid spilled out. B. had been lying in bed at this point, but the very next contraction, she sat straight upright, called for her friend to rub her back, and rocked back and forth. "That was much stronger!" she said, "I can't do this lying down!" We encouraged her to get up, and the next few contractions, which came faster and faster, she walked in the room, and leaned over her mother during a contraction. Soon, she was breathing harder, moaning through contractions, and saying this laboring stuff was not much fun. She wondered if getting in the tub would still help, and we decided to find out.

Once B. was soaking in the tub again, she was smiling some more. Contractions continued to come every 3 minutes or so, but she felt less pressure and less and less discomfort in her back. Since she was more comfortable, and anyway had such good support, I decided to lie down for a bit. By 4:15, I was snuggled in a recliner with some blankets from the blanket warmer and was able to doze. I slept fitfully off and on until the nurse woke me at 5:45. "B. is pushing a little with contractions, and she wants you" she said.

Back in B.'s room, the scene had taken on a much more intense feel. Somewhere along the line B. had shed all her clothes. She had the external fetal monitor strap on, and not one other thing. She was standing up, and during a contraction leaned forward holding up hanging from her mom's shoulders, and the friend was rubbing hard on her back (the friend later told me she was sure she'd left bruises since B. wanted such hard rubbing!) B. was sweating, and breathing hard. "Please, can't I just push?" she wanted to know, and I asked her if she felt like pushing. She said not really, but she just wanted it to be over. I suggested she just wait until her body started pushing. She reached out and grabbed my arm and said "Then please, won't you give me some pain medicine?" This was the first I'd heard her mention it since she walked in the door. I tried to talk to her about it - saying I thought she was close to having her baby, but she just kept saying "oh please, please do something!" Her support people (who've attended many births) both suggested that she was in transition, and tried to remind her what that is like. Her mom started to cry again, and said it was just so hard for her to see B. in pain. I had to agree it was hard to see her hurting and wished there was something to do for her. I told her we'd have to do an exam if she truly wanted pain medicine, and she willingly flopped down on the bed and said "Just check me then!" I did - but she was 8 cms or so dilated, with the cervix just stretching away during the exam, and the baby's head descending through it. Too late for IV pain meds, and even an epidural might not make it in time. Hearing this news, B. said again she did not want an epidural, so just forget it!

B. hopped back out of bed immediately, and went back to leaning on her mom. She was still working hard, but looked determined again. She'd snap at whoever was rubbing her back "Harder! Don't stop!" and snap at the boyfriend to bring her drink right now. After 10 minutes or so, she suddenly plopped down on the floor - completely naked, leaking amniotic fluid all over, sweating, breathing hard - flat on her rear end on the floor. Her mom sat down behind her, and soon she flopped backwards into her mom's lap. Mom sat cross legged, and B. laid with her upper body in mom's lap, curled her arms around mom's arms, and rolled back and forth with contractions. We could easily see each contraction build across her belly, and almost the outline of the baby since she was thin to begin with. After just a few contractions, she said she was having more pressure in her butt, but still no real urge to push, but couldn't I just check her again and couldn't she try to push the baby out anyway. And furthermore, she was not getting off this floor, couldn't I just get down here on the floor and check her anyway?

I can get on the floor of course, and after convincing her to at least slide a clean bed pad between her rear end and the (possibly yucky) hospital floor, I did a quick exam. Tiny anterior lip, with the baby pretty much through the cervix. B. said she just wanted to try to push, and I encourage her to wait for a true urge, but didn't think she'd hurt anything by pushing. Lying in her mom's lap with her arms curled under and gripping mom's arms, B. pushed with the next contraction. For the first couple contractions, she pushed in short bursts, or just grunted a little. Even so, we could soon see the outline of the baby's head bulging the perineum. B.'s mom's leg fell asleep, and she asked B. if she could move, and B. snapped "Don't you dare move!" The mom took a deep breath and held as still as she could. After a couple more contractions, B. said her tailbone hurt, and I asked her if she wanted to move. "I am NOT getting in that bed!" she said with a serious glare. I meekly replied that I just meant maybe she could try squatting or kneeling and get off her tailbone. She thought for a moment and said she'd try that.

B. slowly turned over - it taking quite a bit of effort to get off the ground at this point. She made it over to her knees, and I suggested she hold on to the bed. Her boyfriend lay down across the bed with his head at the side of the bed, and she knelt at the bedside, holding his forearms for support, and resting her head on his shoulder. He whispered encouragement to her - and told her he was sorry for doing this to her - and she held on to him for dear life. The poor mom finally made it to her feet with her asleep leg, and the support people moved to supporting the mom, who was just overwhelmed at the intensity of it all at this point. B.'s dad had been in and out of the room, and now was back in, but in the corner of the room. He could see B.'s head over the bed, but not the rest of her. The mom and the 2 friends stayed behind B., wanting to see the baby. Shift change happened just then, and the 3 new nurses joined the 2 I already had in the room. I knelt on the floor next to B. Although it sounds like a huge crowd, it was very quiet and intense in the room. The only sounds were B. working hard, and her boyfriend encouraging her, and the nurse or I telling her how wonderful she was doing. Within just a couple pushes, baby's head was staying visible even between pushes.

With the next contraction, B. slowly pushed her baby's head out, and mom started to cry, dad across the room started to cry, the friends cheered, the boyfriend started to cry. Even though B. was kneeling on the floor, I could see the baby's head emerge, and then almost look sucked back against the perineum - a turtle sign that immediately made me think of a shoulder dystocia. Baby was LOA, having turned I think somewhere late in labor. I waited for B. to take a few breaths, and asked her if she could push again, and she started to push. The baby didn't move at all and her face suffused with purple while B. pushed. I reached for the head and pushed up gently to see if the anterior shoulder would be freed - but it didn't budge. While B. pushed, I switched directions and tried to free the posterior shoulder - but it didn't budge. B. took a few more breaths, and when she started to push again, I lifted the head up again, and with a slight popping sensation, the baby's anterior shoulder came free, and almost immediately the whole baby slid out into my hands. There were 2 tight wraps of cord around the neck, but baby splashed right out. B. heaved a huge sob of relief and dropped her head and shoulders down on the bed. One of the nurses squatted on the floor with me and unwound the cord, and dried the baby's face as she coughed a couple times, and then started to cry. With the first cry the whole room erupted into laughter and tears and whoops of joy.

Within a minute or so, B. was looking around for her baby. A nurse threw a clean pad down on the bed, and B. stood up, lifted her leg up while I passed the baby under to her hands, crawled onto the bed holding the baby, and sat cross legged on the bed holding her baby to her chest. (Only teenagers are that athletic in the minute after birth!) Her boyfriend wrapped his arms around them both, and we put a couple warm blankets around them all, and everyone sort of stepped back and breathed some sighs of relief ourselves. Baby was born at 7:17 am, about 24 hours after labor started, 11 hours or so after she'd come to the hospital, but just 4 hours after she'd been 4 cms and had her water broken.

After a while of sitting and holding her baby, B. started to feel more cramping and more uncomfortable and wanted to get the placenta out. She lay back on a few pillows, still holding her baby to her bare chest. We clamped the cord, and the boyfriend cut it with shaking hands, while everyone else took pictures. B. pushed once, and the placenta was out. While B. was pushing the baby's head out, since she was kneeling and leaning forward, I could easily see her perineum. The head had slid out slowly and atraumatically and I didn't think she'd had any tears at that point. However, as the shoulders came, there'd been a sudden little gush of blood, and I worried that the popping sensation as the shoulder came was a perineal tear. Sure enough, I could see a midline tear. At first, I though it was just the skin, but as I tried to follow it downward, I couldn't quite see the base of it. Worried about the extent of this tear, I decided to take apart the bed and put B.'s legs in the foot pedals and get decent light to see what was what.

Unfortunately, the tear turned out to be a partial 3rd degree laceration. The sphincter capsule and muscle fibers hung loose in the middle. I explained to B. that she would need some local anesthesia and stitches. This sounded like a just terrible idea to her at this point, but I was able to inject the local pretty much without her feeling much (sometimes the vagina and perineum are numbish from the stretching of the baby and overload of the nerves.) While B. snuggled her baby, and drank a Sprite lying down, I repaired the sphincter, then the perineal muscle layer, then the skin. The tear didn't go quite all the way through the sphincter, and the rectal mucosa was all intact.

Soon, we were done, and B. wanted to have the baby weighed. This skinny 17 rd old had managed to push out an 8 lb 13 oz baby girl - in less than 30 minutes! I asked B. if she was upset about not getting pain medicine and she said "Heck, no!" and that she'd have been very disappointed if she'd gotten pain medicine that close to the baby's birth after getting through all that labor on her own. We helped B. put the baby to breast, and cleaned up the room. B.'s baby mostly did not leave her arms for the next 24 hours, but snuggled with her mama, and nursed, and was loved. The next morning, the nurse who came on in the morning did her assessment exam - and was shocked to find crepitus over the right clavicle, and the baby wincing whenever she touched it. An xray showed that her right clavicle was broken. Looking back, I'm sure that was actually the pop I felt as the shoulder came free. Fortunately, babies' clavicles heal easily, and she has no nerve damage or other problems and just needs to have no one pull on her arm while she's healing. B. felt great, despite the long labor, the extensive perineal repair, and the lack of sleep. She positively glowed while describing her birth - and was so in love with the baby.

See, the thing about this kind of birth is that this mama had it in her to do it. All she needed was the space to do it in. She just needed folks around her to believe she could. It was not an easy birth, or a short birth, or an uncomplicated birth. It was ordinary and yet sacred, moving and extraordinary. Mostly, we just encouraged this young mama to do what felt right to her, and she took the powerful, primal energy of birth and used every bit of it to make it hers. Watching her, who'd seemed so young and vulnerable and needy, turn instead into someone powerful, and strong, and even commanding was an amazing thing. When she was hurting, she didn't need me to rescue her or feel sympathetic, she just needed me to trust her and give her the space to keep going.

So: What if you attended births, but you never saw a birth like this? What if instead your system encouraged, or even coerced, needy, opinionated teenagers like this into lying in bed, strapped to a monitor, until they were overwhelmed? And then you talked them into an epidural to make them comfortable? What if their birth plan was treated as the hubris of an inexperienced child and laughed at? What if her request for limited exams was seen as childish and responded to with "You were able to open your legs to get this baby in there!" type comments? What if she'd pushed and pushed, but her baby had been wedged posterior by the epidural, and her sacrum couldn't move squashed against the bed and the baby never came out? Or she did come out, but the sticky shoulders in hands and knees was a full blown shoulder dystocia in semi-sitting and she'd had a huge episiotomy and a brachial nerve palsy, or worse brain damage from lack of oxygen? Then you'd say "Those damn teenagers think they know what they're doing. Can you believe she thought she could do this? Thank God we saved her baby!" And knowing you were right about it all, you'd treat the next client just the same. Occasionally, you'd see some quick birth happen before you could intervene much, but those would be chalked up to luck, and the rest would have the full gamut of technology you can provide.

I've seen that alternate birth story during my training. I've heard it told to me by friends and clients who birthed elsewhere. I'm always so grateful when I get to witness a birth like this, a birth that took a woman to the limits of her abilities, but she stretched herself and did it. These are the births that keep me going, that I remember in middle of night awakenings, that remind how strong women are, that I wish every birth attendant would be required to witness.

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A not-so-quiet hospital birth

Another birth story from the family physician who wrote A quiet hospital birth. I gave the woman a pseudonym. Besides showing how a woman can be wonderfully supported through a challenging birth in a hospital setting, it also illustrates how a care provider's individual practice style can determine whether or not a birth concludes with surgery. This particular woman was "stuck" for 6 hours at 8 centimeters--something that many providers would have concluded several hours earlier with a cesarean section for Failure to Progress. But, as this story illustrates, there was no reason to suggest surgery just because a certain amount of time had elapsed.

This story also illustrates the importance of one-on-one nursing care as well as the continuous presence of the birth attendant. Some women are fine doing labor and birth mostly on their own, but others require a lot of physical and emotional support to see them through. Unfortunately, many hospitals do not have enough nurses to care for each laboring woman individually. Often one nurse will be in charge of several laboring women simultaneously, leaving her little time to provide this kind of labor support.

The recent discussion of the Dux article "Homework is the mother of prevention" made me think about where the "blame" for the state of U.S. hospital birth lies. Is it the fault of women for not preparing enough, or the fault of providers and a system that promotes unnecessary intervention? The recent birth story I wrote ("A quiet hospital birth") illustrates a very un-intervened hospital birth with a mother who had done her homework and knew what she wanted out of her birth. I thought it would be interesting to share another story, a story of someone who hadn't "done their homework" but had a vague idea of how they wanted things to go, to illustrate how a birth attendant and birthplace can still support someone who isn't as easy as my quietly birthing client to take care of! This story is nearly as long as this labor seemed, at the bedside providing support for someone working hard.

One of my younger clients Laura had a long and difficult pregnancy. From the very start, she seemed more sensitive to the normal discomforts of pregnancy, and frequently had a list of complaints at every visit. Nausea, breast soreness, and abdominal bloating were just the start and were followed by low back pain, cramping, pelvic pain, pubic bone soreness, vaginal discomfort, and more. She usually seemed satisfied with all the self-help tips I could think of to tell her, but she usually brought a written list of complaints to each visit. In the third trimester, she added frequent Braxton-Hicks contractions, some enough to keep her awake all night, and on several trips to labor and delivery she was indeed having regular contractions, but no significant cervical dilation. By 37 weeks, she was fairly miserable with contracting for weeks and ready to meet her baby.

When we discussed her labor plans, she was certain she did not want an epidural, and planned to be unmedicated. I admit to being fairly surprised by this, given how uncomfortable she'd been throughout the pregnancy, but, since this was her plan, I laid out for her my usual description of what we could do in the hospital to help her. I always try to have this conversation beforehand, and to remind my clients that pain medicine is always available, but I will not be repeatedly offering it in labor as I find repeatedly offering pain meds influences people to accept, maybe when they weren't really wanting it. I also remind them that I will not be trying to argue with them in labor either – a request for pain medication will be honored. I always tell my clients, too, that most women who choose ahead of time to avoid pain medication do so successfully in labor, and that they are likely to be able to do so, if that's what they wish.

In addition, there are lots of non-drug things we can do for pain relief and comfort measures. Specifically, we encourage women to find their own comfortable positions; we monitor intermittently unless there is a need for closer monitoring, in which case we can monitor by telemetry or waterproof telemetry; we have tubs in every labor room; we have birth balls and rocking chairs and squat bars; and nurses willing to provide back counter pressure, or cool wash clothes, or hot packs. We encourage laboring women to drink throughout labor, and to eat as they feel up to it, and we encourage them to have the support people of their choice with them throughout. Laura heard all of this before she arrived in labor.

One early morning, when Laura was 38 ½ weeks pregnant, labor and delivery called me early in the morning to say she'd arrived having strong contractions. She'd been woken from sleep around 4:45 am, and arrived to the hospital around 7 am, and was contracting every 2-3 minutes. Her water hadn't broken, and the nurse checked her and found her to be 3-4 cms dilated, 80% effaced, and with a bulging bag of water. The nurse told me on the phone that Laura was working pretty hard with contractions already, breathing and moaning, and was pretty irritable. I hoped that all the prodromal labor she'd had would mean a shorter labor, and hoped the irritability was a good sign.

I arrived around 9 am, and Laura 's water had just broken. She asked for another exam, and was 4-5 cms now, and 85% effaced, with the head at -1 station. By the time I arrived, Laura was breathing hard and frequently yelling through contractions, and pounding on the bed railing. Her boyfriend looked pretty uncertain and was keeping his distance. Laura had eaten some toast and fruit just before I arrived, and that would end up being all she ate the whole day. The nurse encouraged Laura to get out of bed (she'd been trying to encourage her out of bed for some time by this point) and Laura agreed to try the tub. She sat on the toilet and rocked and yelled with contractions while we filled the tub. I really like water for labor and find it relieves a lot pressure. Frequently I'll see a laboring client sink into the water and smile for the first time in hours. This was not to be the case with Laura. Shortly after getting in the tub, she felt too hot and nauseated and weak, and wanted out. We helped her out, and she vomited once, cried for a while, and talked about how frustrated she was that she hurt so much and nothing was helping. At this point, the nurse just asked once if she wanted something for pain, and Laura yelled back that she'd already said no (and a few less printable words!)

After drying off, Laura crawled back into bed, lay on her side, and continued to have frequent, strong contractions. With each one, she'd start to breathe hard, then moan a bit, and then work up to yelling "Ow, Ow, Ow, OWWW! Tell me when it's going away!" and the nurse would tell her as soon as the monitor suggested the contraction had peaked. The nurse tried to encourage her to get out of bed, to sit on the ball, or walk, or at least sit up, but Laura didn't want to move. For a while, in between every contraction she told us over and over that nothing was working, that she just didn't think she could do this, and why couldn't we help her? My nurse did a wonderful job of providing support, without giving in to any "oh, you poor thing" thinking. She'd tell Laura: "You ARE doing this – every contraction gets you closer to baby." She calmly let her know when her contractions were peaking, fanned her with a laminated card, gave her sips of water, and encouraged her to at least roll and change sides every so often. During this time, Laura 's boyfriend started to find his groove as a labor support person too. He pulled his chair next to the bed, wrapped his arms around her, wiped her face with a cool cloth, whispered words of encouragement, and ducked when she'd occasionally pound on the bed railing.

Around 11 am, Laura asked for another exam, wanting so much to be close to done. At this point, she was 8 cms, but the head was still -1 station, and not well applied to the cervix. Still, 8 cms was very encouraging news to Laura, and she got a bit of a second wind. She decided to get out of bed at this point and walked for a few minutes in the room, but quickly decided the contractions were just too intense standing up. She sat down in the rocking chair, then, and rocked through contractions. Laura preferred to have the contraction monitor on, and at the start of each contraction she'd yell for the nurse to tell her as soon as the contraction peaked and was starting to go down. The nurse would hold one hand, while her boyfriend held the other, and Laura continued to yell through contractions, usually some variation of "OW!" until the nurse told her it was going down, and then she'd count out loud until the contraction was done. I took a break to eat lunch at this point, and during lunch I could still hear Laura yelling through her contractions, and the calm voice of her nurse telling her she was doing great, the contraction was almost over, just keep breathing and rocking.

After lunch, the nurse and I switched so she could have her lunch. At this point, the nurse had been in the room pretty steadily for several hours, and she needed a break. Laura continued to cope pretty well in the rocking chair. She would get up every so often to go to the bathroom to urinate and would spend a couple contractions rocking on the toilet. By now, Laura was getting pretty tired and discouraged. During and after every contraction she told me repeatedly that she just couldn't do this, she was too tired, it hurt too much, and the baby wasn't coming, and yet, somehow she made it through every contraction.

Around 2 pm (the nurse had long since returned and taken over primary support) Laura wanted to be checked again. Her contractions had spaced out to more like every 4 minutes, but were stronger and longer. She felt like she had a lot of pressure in her bottom, and in fact had taken to running back to the bathroom with almost every contraction, although usually she wasn't able to actually pee and she'd tried for some time to move her bowels without success and we'd told her we thought the pressure was just the baby. I checked her again, and she was still just the same, 8 cms, about 90% effaced, with the head not well applied to the cervix. This was one of those times I was sorry we'd done an exam, as Laura was pretty crushed by this news when she'd hoped she'd be about to have a baby.

At this point, I offered 2 options. To begin with, Laura and the baby were doing just fine. Although she was tired, and frustrated, and fairly miserable, Laura was coping pretty well, and the baby was tolerating labor perfectly, and I explained there was no real need to do anything. One option was to just carry on with labor, as nobody was in trouble and there was no emergency. The other option was to try adding some Pitocin to see if that would encourage her cervix to dilate. Laura had been 8 cms for at least 3 hours at this point, past the medical definition of failure to progress, although it's been studied that merely waiting 4 hours instead of 2 can reduce the cesarean rate for failure to progress by 50%. Laura was tired, and hurting, and frustrated, and wanted anything that might speed things up. Her choice was to start Pitocin.

The nurse hooked up Pitocin, and we slowly titrated it up over the next hour, and Laura 's contractions got closer together again, coming every 2-3 minutes. For a while, she lay in bed on her side again, and yelled her way through some more contractions. After an hour or so, the nurse checked her again, and found her to still be 8 cms, with the baby's head still not descending well to the cervix. She talked Laura into sitting upright for a while, in a chair position in the bed, hoping that would help the baby descend. Then Laura decided she needed another trip to the bathroom, and since she was more comfortable there, we encouraged her to stay sitting on the toilet for a while. We put a pillow behind her head so she could lean back between contractions, and her boyfriend wiped her face with a cool cloth. During contractions she'd rock and sway and yell, and in between she'd flop back on her pillow and close her eyes. Around 4 pm, Laura informed me she was really done, she just couldn't take it anymore, and she knew she had to be ready to push. She flopped back down on the bed in tears, and demanded to be checked again. You guessed it: still 8 cms. Now, however, more of the cervix seemed to be in the front, the baby was lower, and the cervix was very soft and stretchy. Laura was really disappointed to hear this, but I tried to emphasize the positive changes (softer, stretchier, head lower) and within a few minutes she went from crying hard to asking if there was anything else that might move this along. I suggested she try hands and knees, thinking maybe that might help move the cervix that was mostly in the front.

Within a few minutes, the nurse had helped Laura turn around in bed, so she was kneeling on the bed with her arms draped over the back of the bed that we had cranked all the way up. During a contraction, she'd kneel even more upright and sway back and forth, and she went back to pounding her fists, this time on the back of the bed. At the start of each contraction, she'd sort of wail the nurse's name at the top of her lungs, and then yell "Tell me when it's going down!" In this upright position, we couldn't actually pick up her contractions on the monitor, so we had to go with educated guesses on when the contractions were peaking, leading to a few times the nurse saying "It's going down!" and Laura wailing "Oh no it's not!" In between, she'd sometimes rest, and sometimes repeat over and over "I just can't do this!" Close to 5 pm, Laura said "This is IT!" and flopped her self back over on her back. She grabbed my hand and said "I'm done. I just want a c-section. That's possible, isn't it?" I had noticed that she had grunted a bit with the peak of the last couple contractions, and I hoped that meant she was close to pushing at last. I talked her into an exam instead of an instant cesarean, and was disappointed to find that same 8 cm cervix, although still it was very stretchy and low. At this point, she'd been 8 cms for 6 hours, and the baby was still doing very well, but she was obviously emotionally at the end of her rope. On a gut feeling, I suggested she just try pushing a couple times and see what would happen. Worst case scenario, I figured nothing would change and we'd be right back where we'd been. With Laura 's permission, I did an exam during her next contraction, and encouraged her to push hard. To my surprise, I could feel the cervix just melt away as she pushed, and the baby surged lower. By the end of her second contraction, she was fully dilated. (And then I wondered what would have happened if I'd tried that 4 hours earlier – but it was only in the last few minutes that she'd started having some spontaneous pushing urge, so likely 4 hours earlier it wouldn't have done anything.)

At first, pushing gave Laura a big second wind. Briefly, she became much less irritable, and even talked about how glad she was not to have a c-section after all. She was quite tired, and at this point, she wanted only to try pushing in a semi-sitting position. Over the next half hour, though, she started to get discouraged again, and to tell us again and again that she was sure she just couldn't do it, that the baby wasn't coming, and that it was all just too much. We encouraged her to try a different position, and to see if she could get a little more strength behind her pushes. She agreed to try the squat bar, and she pushed in the full squat for a while. In between, her boyfriend continued to give her drinks, wipe her face, kiss her cheek, her arm, and her knee, and tell her she could do it – and she would tell him no way, she definitely couldn't do it! After a while, she was too tired to stay squatting, and she moved back to semi-sitting. By now, with each push we could see just a tiny sliver of the top of the baby's head. For a few pushes, hearing that we could see the baby's head encouraged Laura, and she pushed hard and merely rested in between, but when the baby still wasn't out, she started to be more discouraged again. The nurse encouraged her to keep going, and helped her up to squat again for a while, then gave her a sheet to tug-of-war with while she pushed. Finally, a little bit more of baby's head appeared with each push, and even Laura could feel that the baby was moving, although as the baby slid back out of sight in between each contraction, she yell and pound the bed "Don't go back IN!!!" and she kept asking us when the baby was ever going to come.

Like the rest of her active labor, crowning took quite a while. For the last 5 contractions, I was sure each time that this would be the one. But, although the baby didn't slide back any longer, he just moved a millimeter at a time and slowly, slowly, slowly a little bit more and then a little bit more, and then even a little bit more of the head stretched the perineum. Finally, when it seemed there was no way more head could be out and the baby not be born, the baby's forehead, and then eyebrows, and then one eye, then the other, the nose, and baby's mouth slowly slid out. Once the head came, the whole baby tumbled out quickly, wrapped tightly once in the cord around the neck, which I unwrapped as he tumbled out. Laura didn't want the baby immediately on her chest–she somehow managed to gasp out a reminder while the baby crowned that she wanted him dried and cleaned off first. I don't like to cut the cord immediately, so the second nurse brought a couple receiving blankets, and we held the baby level with mom's belly and dried him and wiped off all the blood. Baby was immediately pink and had wonderful tone, and let out a yell. The first nurse (the one who'd been there all day) encouraged Laura to look at her baby, and asked her if she thought he was clean enough to put on her belly, and Laura agreed. We laid the baby on his mother, and she wrapped her arms around him.

After 20 minutes or so, the placenta separated and Laura had more cramping and pushed it out. She had a small 1st degree skin tear, but it was on the outside of the perineum, where they often sting quite a lot without suturing, so I offered sutures and Laura agreed. Fortunately, after all her hard work, she barely felt even the local anesthesia going in, and the sutures were quickly done. This baby turned out to be very calm and alert, and he latched as soon as his mom shifted him near the breast. He was born at 6:43 pm, nearly 8 hours after the first time Laura had been 8 cms. He was 7 lbs and 2 oz, with dark hair, dark grey eyes, and long slender toes. Once the baby arrived, as I'd seen so many times, Laura perked up and all the frustration and discouragement disappeared into the joy of holding her new baby.

The nurse and I, however, were fairly exhausted. Watching someone work that hard and need so much constant encouragement for so long is really draining. The nurse commented that she didn't think she could hear "I can't" one more time and stay sane. But Laura intended to birth her baby without pain meds or an epidural, and with a lot of encouragement (and some questionably useful help of Pitocin augmentation) she did just that. Of course in a home setting, we may well have not known about the long pause at 8 cms, and she may well have started to push spontaneously, and the fact that she dilated from 8 to 10 with her first 2 pushes may well have never been known. But even in a hospital setting, with a more medical approach, a client who hasn't done any research or have any knowledge about how things are supposed to go (and some interventions which may or may not have been helpful) can be supported in her wishes to get through labor without an epidural – even if she herself is sure a lot of the time that she can't do it!

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A quiet hospital birth

Just today a family physician friend emailed me this birth story, and I am reposting it with her permission. I thought this story was pertinent given our current discussion about the book Homebirth in the Hospital. Notice how the nurses and physician pay close attention to the woman's personality and desires and adapt accordingly.

I attended an amazingly beautiful birth last week. This is the second birth for this couple and I attended their first as well. This couple does an amazing job of taking over and creating their own atmosphere in the hospital—to the point that the nurses and I feel almost bad intruding on them, yet they are so sweet and pleasant that you want to be with them. It's hard to describe, but basically there is like a bubble of personal space around them.

Mama was 2 days overdue, and had asked me on the Monday before Thanksgiving to strip her membranes as all her family was coming for Thanksgiving. She was a good 3 cms already, 70% effaced, and it was easy to sweep her membranes for her. She told me later that she started having contractions almost immediately. She was able to sleep off and on during the night for most of the night. She's a teacher, and she debated going to work in the morning, but finally decided to call in, as did her husband. They took their daughter to her day care provider anyway, and spent the day together doing errands and walking and getting a little nap. She called me around 2 pm and let me know her contractions were getting closer and stronger, but she wasn't ready to come in yet. I made sure she'd been eating and drinking, which she had.

Labor and delivery called me around 3:30, to say she'd arrived and was 5-6 cms, but smiling and looking comfortable. I was still seeing patients in the office, and so arrived around 4:45 pm. At that point, the nurse had just checked her again because she wanted to get in the tub, and she was 7 cms. I found her in the tub, wearing a gorgeous black tankini swim suit (top and bottoms!) leaning back with her legs crosses and the jets on, and sipping a drink with a straw. She smiled at me and informed me she was pretending she was on the beach. She stayed in the tub until close to 6 pm, and the nurse just checked heart tones every so often, and otherwise we left her and her husband alone, and they talked and held hands, and really didn't need us. Around 5:45 pm, she called the nurse and said she was getting out as the contractions were too intense for the small tub. The nurse asked if she wanted help, and she smiled and said that her husband would help her. We retreated from the bathroom again, and they shut the door.

A few minutes later, she emerged from the bathroom, fully dressed again—in a tank top and long work out pants, looking fresh and rested. She walked around the room a bit, then sat on the ball for a bit, and the nurse continued to take heart tones every 15 minutes. The last time the nurse was in the room, my client and her husband were playing cards! A few minutes after that, she called me in the room and said she just wasn't sure how much more she could take. She was still smiling and when I was in the room for a contraction, she just took several deep breaths and focused hard on her husband, and looked like someone in very early labor—but I knew she'd been 7 over an hour before and she was likely close to having the baby. I asked her if she wanted an exam, or if she felt like pushing, and she said she was starting to feel a lot of pressure like she was close to pushing, but not quite yet, and she didn't wanted to be examined. She said she didn't feel like she should push if her water hadn't broken, and I suggested she just wait for a few contractions, maybe push a little or grunt a little at the peak of contractions and see if she felt better. She agreed, and then sort of refocused on her husband, and I again felt like I was intruding, so the nurse and I stepped back in the hall.

A few minutes later, the husband opened the door and said calmly, "her water broke." Conscious of keeping the quiet mood, the nurse and I got up and walked in slowly, and the second nurse went to get warm blankets and snuck in a few minutes later. My client was kneeling on the bed, and she smiled at me and said "NOW, I want to push" They had pushed the cards to the side on the tray table, but she was still fully dressed. I asked her if I could help her with her pants, and she said "sure!" and we helped her get her pants and underwear off (I got a kick out of this as she was wearing thong underwear with a thong pantyliner which I've never seen anyone in labor do!), which were absolutely soaked.

The nurse asked her quietly if she wanted to push kneeling, and she said she'd try semi-sitting first. With the next contraction, she pushed hard, and we could already see some bulging of the perineum, although no baby hair yet. She then said maybe she'd rather kneel, and flipped over to her knees again, and pushed hard with the next contraction. She quickly decided the kneeling was too intense, and flipped back to her back. My nurse asked her if she'd like the squat bar, and she thought maybe she would, so we set it up, but as another contraction started very quickly, she ended up just resting her legs on the squat bar and decided she didn't want to get up. With the next contraction, a little patch of baby became visible. Her husband was holding one of her hands and whispering in her ear, and the rest of us were very quiet. With another contraction, the baby's head slowly emerged, turned to line up with his shoulders, and then fell into my hands. My client reached for him and pulled him up to her chest immediately. When the big sister had been born, she'd been just as quiet as her parents, and didn't cry at all, but this guy was having none of that—he let out a huge yell immediately and let us all know that he wasn't too happy with the cool air and brighter lights! Mama patted him and soothed him, and the placenta delivered spontaneously just a few minutes later, and we clamped the cord and the nurse took pictures of the dad cutting the cord. Mama pulled up her tank top and the baby shifted over an inch or so and immediately latched and nursed like he'd been doing it forever.

Unfortunately, mom started to bleed at this point. Fortunately, my nurses are used to calmly taking care of situations, while trying hard not to disturb the new couple. We gave her IM pitocin, then hooked up some IV pitocin, then some IM methergine, and massaged her belly—all while the baby nursed in his mother's arms. She had a small skin tear that seemed to be bleeding, which I put 2 stitches in, and finally after all that the bleeding slowed and stopped. As soon as we were able to step back from them for a few minutes, the dad wrapped his arms around his wife and son, leaned his forehead to hers, and prayed over them all softly.

After an hour or so, baby was finally weighed and given right back to his mom. 8 lbs 1 oz. Mom got dressed again (she is not like some of my clients who prefer to be naked throughout!) and they all walked up to a postpartum room together. When I talked to the nurse this morning, she said the whole family had spent the night snuggled in bed together.

I love a birth like that—where I am absolutely useless! (Well, at least until the postpartum hemorrhage, and then I'm glad it's me and not some birth attendant who panics and turns the whole thing into a circus as we just very calmly and quietly dealt with it while the new family had their chance to be together.) I wish I had pictures of this mom, 7 cms dilated, in the tub in her gorgeous swim suit, kicking back with a drink in hand! It's amazing to be invited in to something like this, and to be allowed a glimpse of such an intense and private event.

Comments about "quiet" birthers: As a birth attendant, I don't want to give the impression that in labor and birth quiet=good and loud=bad. I think it has a lot to do with the personality of the woman, and the situation of her birth—the support people, the location, the expectations she and her team have. Women who are vocal in regular life tend to be vocal birthers, and quiet women tend to be quiet. I've attended some really lovely births with mom bellowing at the top of her lungs—and I enjoy those just as much as the quiet ones.

I was most impressed with last night's birth by how well this couple created their own world and the environment that was most like them to birth their baby in, if that makes sense. This mama is really quiet in real life, and private, and modest. Instead of letting the hospital environment and staff overwhelm her, she somehow created her own space and did it her way. At her first birth, the nurse who cared for her remembers going into the room to first introduce herself at shift change and finding the mom walking in the room with her husband, wearing sweat pants, a t-shirt, and a sweatshirt zipped up to her chin. The nurse said to me "I took one look at her zipped up to here and thought, aha—it's going to be like that!" (That nurse is a master at assisting women to have the birth they want; she meant by that statement that she just knew that this was not a woman who would welcome a lot of touching or have a lot of need for hands-on support, and who would not want to be messed with much. That nurse, like last night's nurse, simply checked heart tones every so often and said, "let us know when you want to push!" and she eventually did.)

On the other hand, I've attended plenty of women who NEEDED to be very vocal, and needed a lot of touching, reassurance, even direction some times and that doesn't make their birth any less perfect. Sometimes, for me, it's nice to be needed! The big mistake many hospital providers make is thinking that a noisy client needs to somehow be shut up—medicated or belittled into keeping still usually. I always tell my own clients that being free to make whatever noise and move however you need to have a baby is what helps us humans have babies—we don't birth under a bush with predators lurking, so we can be free to be as loud as we want!

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Upright birth in hospitals

I am taking the liberty of reposting some comments from doctorjen from my earlier post Get Off Your Back--References about how she facilitates upright and active births in a hospital environment, including when women have epidurals. I'd love to hear from other people who attend births in hospitals about how they make this possible.

It seems that there are two major factors important for making this happen in a hospital setting:
1) The hospital staff must have a strong commitment to active, upright labor.
2) The staff must also have first-hand experience facilitating this, especially for moms who have epidurals, IVs, fetal monitors, etc.

Okay, enough of me. Here's doctorjen:

I find that with some help it is possible to get almost all epidural moms upright. Most have enough sensation to support themselves on hands and knees. We put the back of the bed up most of the way so mom can drape her upper body over the top of the bed and then help them get their knees securely under them, and it usually works. They may need assistance to get in this position, but they usually can sustain once we get them up. Also, squatting is not too hard. My labor bed goes into a full chair position with the feet dropped all the way down. We then put the squat bar on the bottom of the bed. Mom can sit at the edge of the top of the bed between contractions and with help when a contraction starts and leaning on the squat bar, they can drop down into a squat to push. Some epidural moms have enough sensation to get themselves up and down and if not, they can use their arms for support and we just help them get up and down. Again, once they are in the squat they usually have enough sensation to support themselves. I have a policy of no operative vaginal delivery without trying a full squat first, and it almost always works. And very importantly, I try to let all epidural moms labor down as much as possible and not do any pushing until they have some urge and sensation. If we get to 2 hours of complete dilation with no sensation yet, we negotiate about turning it off and then most moms eventually get an urge to push.

I find it much harder to move a mom with an epidural around, and they don't tend to be changing positions frequently like a mom laboring spontaneously without anesthesia, but it's both possible to do it and helpful. My nurses were way skeptical at first, but after seeing a few babies come sailing out quickly in a squat they are all big believers now and will be telling me to get mama up if I haven't for some reason thought of it! The hardest part is moving all the wires we have going with an epidural --external fetal monitor, external contraction monitor, urinary catheter, IV, epidural line, and blood pressure cuff. We have it down to a science now, though--we unplug everything that unplugs, pull all wires to one side, flip or move the mama, and replug everything in, passing them under the mama's belly if we've moved to hands and knees. I enforce with my labor clients and my nurses that the mama's comfort is our number one concern and the monitors are our job to keep track of. So mama moves as she needs to, and we chase the cords....

Thought you might like to hear about a nice upright birth I attended an hour and a half ago. Second baby, spontaneous labor at 40 weeks 4 days, no augmentation, no IV, no AROM, just labor. Mama did a lot of laboring in bed because she was tired, but at the very end of labor, she got up. She had been grunting a bit with contractions, but not really pushing, and she thought she needed to pee. We went to the bathroom, but she wasn't able to get comfortable and wasn't able to go. She hopped up and down from the toilet several times, and then squatted on the floor holding on to the sink for a bit. Finally, she said "forget it" and we headed back into the labor room. At this point, she stopped at the end of the bed and squatted down on the floor holding on to the end of the bed. This felt good to her, so we spread some pads on the floor, and over the next few contractions she would go from kneeling to squatting, to kneeling on one knee, to hands and knees. Suddenly, her water broke with a huge gush. Then she decided to try the bathroom again and we went back in the bathroom, but again, a lot of up and down but not able to go. She decided to head back into the labor room, but then she knelt back down on the floor in the door of the bathroom suddenly and pushed all out with a contraction, and gave me that wide eyed "baby's coming" look. I asked her if she was comfortable there in the doorway, and she didn't answer but got up and headed back towards her pile of bed pads on the floor and knelt back down. Over the next 3 contractions she knelt, squatted, leaned back on her hands and feet (like a crab walk position almost!) and then back to squatting, sometimes holding the edge of the bed for support with both hands, sometimes with one hand, sometimes with her hands on the floor.

Finally, she pushed out the baby's head in a squat but almost sitting over one leg, so that leg was flexed and the other one a little extended, and then for baby's big, tight-fitting shoulders, she first knelt, then leaned back on her hands and lifted her hips in the air and the little linebacker finally slid out. The dad then sat down on the floor behind the mom and we slid a dry bit of pad under her and she sat down on the floor, leaned back into her partner's lap, and snuggled her baby on her tummy. The thing that always impresses me about a spontaneous second stage in an upright mother is that it's not a matter of getting in one position and pushing the baby out, but most mamas move frequently including during contractions. In the 3 long pushing contractions she had, she probably changed position 15 times--and with that baby's kind of sticky shoulders, I'm glad she was freely mobile and able to wiggle all over and push him out! That, in my experience, is what a true upright birth looks like! Most docs, though, would be driven nuts by having the baby be such a moving target (of course he was never more than a couple inches from the floor and could have easily just slid onto the pads on the floor) and having to get on the floor themselves. Luckily, I'm young and healthy and can kneel or squat myself pretty well, and fortunately tonight I didn't have one of the 2 currently 3rd trimester pregnant nurses trying to get down there with me.

Anyway, that's what an upright birth can look like in the hospital - even with a doctor.

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Permission to Mother

Dr. Denise Punger, a family physician and IBCLC in Florida, recently published a book called Permission to Mother. She and her husband, an osteopathic physician, work together in a private practice. Her book is available on Amazon and Barnes & Noble, as well as an e-book (only $5!) on her publisher's website. This is definitely going on my wish list!

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Evidence-based medicine

A family practice physician I am acquainted with wrote the following about evidence based medicine. Reposted with her permission.

I am young enough to have trained in the era of "evidence based medicine" (EBM) where we attempt to only do those things that have evidence to back them up. In EBM, the gold standard is the randomized controlled double blinded study (RCT) Study subjects are assigned to one group or another randomly, the groups are monitored "controlled" so that you get a relatively similar type of people in both groups, and the results are interpreted by a researcher who doesn't know what group your were in, and the study subjects themselves don't know what group they are in.

This works great for a new medicine, for example, where you can make up 2 identical white pills to give someone, but not so well for behaviors. How on earth would you randomize someone to UC, and expect them not to know it? With the lack of RCTs to use, we are left with case studies, population studies, and case control studies, all of which have inherent flaws. This doesn't mean they don't provide useful information, but since they aren't randomized, you never know if there isn't something special about the group that made them choose the behavior you are studying. (For example, if only well-educated women breastfeed, and then their babies have higher IQs, it's hard to know if it's from the breastmilk, or from having better educated parents.)

The other thing that I feel is absolutely vital to remember about evidence, is that just being scientific doesn't mean there aren't belief systems attached to that evidence. Why do things get studied in the first place? Who pays for it? Who benefits or is harmed by results? There is no "evidence" that is completely objective. It isn't "science" vs. "belief"; science is just another type of belief.

I do not suggest that we need to ignore what evidence we have, but an individual will always need to make his/her own decision also taking into account their beliefs, values, background, relationships, fears, etc. Just because someone does something that seems to go against "evidence" doesn't automatically mean they are making a bad decision. I encounter this every day in my family practice. Sometimes, I have great evidence based reasons for wanting to offer a certain treatment, but my patient has even better life based reasons for declining it, or doing something else.

Even if the evidence were ever to come to light that intentional UC isn't as "safe" as another type of birth, there may well be highly intelligent people who continue to choose that type of birth for their own reasons. Having no such evidence at this point (or in all likelihood, such evidence may never be available) women will continue to make their decisions based on evaluating what evidence there is and taking into account the many other areas of their lives that are impacted by birthing choice...

And a clarification of some of the earlier points she made:

[It is important] to consider how evidence is collected, whether it has relevance to the situation you yourself are considering, and whether it is accurate. Also, it is vitally important to remember that although in the age of evidence based medicine, we purport that "evidence" is somehow completely objective, in reality it is not, nor can it ever fully be disconnected from the social constructs from which it arises. Science and even "evidence based medicine" are themselves belief systems. I happen to live in the world where evidence is very important, and I try very hard to stay on top of the latest and greatest, and I very freely share every bit of evidence I'm using in making a recommendation with my own clients. But I also recognize that evidence will never be the sole factor in any decision made by a real person, nor should it be, nor should I feel any personal discomfort if someone receives my knowledge of the evidence, and chooses to do something other than what I recommend.

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A family doctor's perspective on BOBB

Among members of the audience for The Business of Being Born was a family physician who attends births and her youngest daughter. She emailed me some of her thoughts about the documentary and gave me permission to repost them here. I highly admire her dedication; she works hard to give women hands-off, physiological births in a hospital setting.

Overall, I was impressed with the movie. I tried to look at it with two viewpoints in mind. One, my own sort of "birth junkie" self. Two, I tried to see it as my mostly mainstream clients and acquaintances would.

I was pleased overall with the births they showed, and I loved many of the commentators. I loved that the births were shown to unfold in their own time and that the mamas looked free to move on their own and birthed upright. I love that upright birth center birth where the mama is so joyous right after. I thought Michel Odent was absolutely great. I liked the juxtaposition of the "woman on the street" type comments in between, too--sadly, all those women ready to sign up for their epidural are what I deal with a lot of the time and are very realistic.

It was funny, because looking at the births, I actually thought some were a bit hands-on for my taste. (Why does the midwife have her hands around that woman in the water? What was she trying to do?) On the other hand, I think a mainstream viewer might think they were too "non-medical" especially since Cara can't seem to get gloves on in time ever.

I cried at every one of those births. Don't know what was up with that! My little dd even kept asking me if I was okay. (I cry a fair amount of the time at actual births, though, too--you'd think I'd get over it.) I think if people watched this movie and the only thing they took away was visions of women pushing their babies out standing, squatting, in the water, whatever, that would at least be a start. I find that I have to talk quite a bit during prenatal care about how women should try out different positions ahead of time and see what feels comfortable to them, and how we will be encouraging them to move any way they feel comfortable during labor and pushing. Sometimes family members especially are just shocked when the birthing woman ends up standing or squatting or kneeling. Sometimes I think they then think I'm a little nutty or not very professional, because I "let" this go on. Fortunately, usually the birthing woman herself can verbalize how being free to choose her position made her feel better, or that it was more effective for pushing, or whatever.

I was disappointed in the ending. I don't think they explained enough what was happening, and I was disappointed that the final interview blew off any benefits of homebirth and implied that it's all nice if you can have it, but thank God we had this cesarean and saved my baby. I actually think in her particular case transferring for a breech, growth-restricted baby was probably a good idea--but there had to have been a better way to wrap up that movie than Abby saying "Oh well, at least I got a healthy baby" you know?

I wish they'd wrapped up with some kind of activism information--like talking about CIMS, or ICAN. Here's where you can start to change the world kind of info.

The discussion after was really something. It was interesting to hear people's stories and encouraging to hear so many women who think this stuff matters. It was also discouraging, though, to hear how people struggle to get the birth they want. I am pretty disappointed in this whole VBAC thing, and disappointed especially that so many "low-risk" providers are just giving up VBACs and verbalizing that it's just too bad, so sad for the women involved, but nothing we can do. The midwife who talked expressed similar feelings to what I've been hearing from other family docs: "Oh well, we just can't because of these rules." I feel like so many birthing women basically can only have midwifery, or at least woman-centered physician care, if they are low risk, don't have any problems or inconvenient history, and do what the low-risk provider wants. Otherwise, you are stuck in the OB system and have to take the full court press. It's just not fair and I can't figure out how to fight it. Especially in this stupid state. I wish women like that woman who had an episiotomy against her will would make complaints--take it to the hospital administration, the chief of medical staff, and the medical board for failure to get informed consent. I know one complaint is not likely to do anything, but if there were more and more, I think hospitals and regulatory boards would have to listen. It is not okay that thousands of women are treated as if their wishes don't matter one bit routinely in the name of "standard of care."

I actually think all of medicine needs to be reworked. Something I was trying to say, and may not have got it out coherently at the panel discusson, is that having doctors in charge of medical care and responsible for the outcomes doesn't benefit anybody. If birthing women were in charge, in power, and responsible for decision making (not really so much the outcome, because there is so much that is up to chance), I think they would be more satisfied--AND doctors maybe could relax some. Because I think if we stopped this patriarchal, authoritarian way of practicing medicine there would be far fewer lawsuits. If every woman got actual informed consent AND had the opportunity to make her own decisions and then got supportive care when they needed/wanted it, they would be far less likely to sue. (I just went through a long involved discussion with a new client about VBAC and feel I gave her a good understanding of the risks either way, but she is really stuck in that no one in driving distance who takes her insurance does VBACs anymore--doesn't matter how informed you are if your options are so limited.) As a profession, though, we docs don't want to give up the power. We want to be in charge, want to be seen as demi-gods often, and don't want to present our selves as fallible humans doing the best we can with the knowledge we have and freely sharing that knowledge with our clients.

I'm not sure how to make a change in modern obstetrics, but I think one factor is that women have to refuse to accept paternalistic, condescending care. I don't care what kind of choices women make, but they need to insist on accurate information and fully informed decision making.

OBs need to get out of the business of normal maternity care. We have put normal care into the hands of folks trained in the abnormal. You know the saying, “if the only tool you have is a hammer, everything looks like a nail?” If you are looking for trouble, you generally find it one way or the other. Somehow, we have to get in through our heads that women's bodies have not changed that much in the last 30 years, so if the cesarean rate has sextuptled (and it has!), something must have changed in doctors. I'd like to see more consumer-driven organizations getting more and more active and making more of a mainstream presence. I mean, how many women even know there is something like ICAN or CIMS?

The problem, too, is that it seems that as a whole group, women may not care that much about birth. I wish this was more of a feminist issue--I don't understand why women are willing to be condescended to in this area and have choices taken from them. Have you ever read Barbara Katz Rothman? She is a feminist writer who has done a lot of work on birth politics and talks about how she talked an OB into attending her first home birth by basically appealing to the female OB on a feminist basis. (The book is In Labor: Women and Power in the Birthplace.) I just don't see that happening any more. I went into medicine out of a desire to provide woman-centered care from a background of feminist ethics. I feel more and more out of place in modern medicine every year--my colleagues think I'm sort of nuts, my family suffers from me not being there, and even many of my clients don't seem to care much about having the chance to direct their own care.

I wish I could have come to the rest of the discussion. Did you all come up with any way to change the world?

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