In which I desire to learn

Being in school as an adult is completely different than when I was a teenager and in my early 20s. While my husband knew what he liked as a kid (science), studied it in college (chemistry and biochemistry), and started an illustrious career in it (he's a chemist), I followed the more "traditional" path of getting a B.A. in a vague liberal-arts type of concentration: psychology, and creative writing. The creative writing has served me -- and you, dear reader(s)! -- well over the years. I write, not as much as I want, but I am satisfied with my style that I hope mixes humorous anecdotes with serious topics. But I've never used the psychology, and a bachelor-level degree in psychology is sort of ambiguous anyway.

My parents paid for my school and I'm grateful. Thank you, parents. However, now that I'm paying for my own school, I feel more INSPIRED than grateful. (Because, honestly, it's hard to feel grateful to yourself, right?) I want to milk this for all its worth. I want to get my money's worth. I want to learn while I have the opportunity and the access to teachers and fellow students.

Yeah, learning never stops, blah blah blah. But I think this a specific time in my life when learning is the FOCUS. Reading, writing papers, attending births, learning. That's going to be it for the next few years. Leigh gets a chance to read for pleasure, to see movies, to watch "The Office" with her husband. I've always got an assignment to do, a birth/midwifery/breastfeeding-related book to read, something to google.



I keep a list of things that I want to learn. It's pretty short right now, but each topic is vast. I update it every few weeks. Here's what I've got:

• Normal physiological birth
• Placentas
• Nutrition during pregnancy
• Hormones during labor and birth and postpartum
• Homeopathic/"Natural" cures for pregnancy-related complaints
• Twins
• Anemia
• Common diagnostic tests during pregnancy, and interpreting their results
• Meconium
• Appropriate weight gain during pregnancy, and its effects.
  

In which I learn why midwives knit

I go to Ancient Art Midwifery Institute, where the unofficial motto is, "An unassisted birth for every woman, unless she really really REALLY thinks she needs a midwife (although she probably doesn't; she has just been convinced by society that she cannot birth alone) in which case you must be the midwife who knows everything -- but does absolutely nothing!"

Seriously, Carla's mottos are "Trust Birth," and "Birth is Safe. Interference is Risky."

But sitting on your hands is difficult. At least for me. Even though I know that doing nothing is important, both for the sake of normal physiological birth and for the woman -- intervening can lead her to believe that her body failed by not doing that thing that we did for her, or that her body is incapable of doing that thing we did for her. My friend Angela, when she was pregnant with her 5th child (who was born unassisted at home), worried about her water breaking. With her first four births, it had always been broken by a doctor or CNM. She worried that her water wouldn't break. She worried that her body didn't know how, or when, would be the right way or time. That baffled me. This from a woman who had had four children without any drugs, and suddenly, with #5, she didn't trust her body to give birth!

So, at a birth recently I sat on my hands (not hard; I don't do much anyway) and I watched Leigh sit on hers, and it was difficult for me. I wanted to move along the labor. I wanted to "help" the mom. I just wanted to DO SOMETHING.

So, next birth I will bring some long-term knitting project. I've known how to knit for 20 years. I've never actually completed a project other than a scarf or two. But now, I'm inspired. I want to make these to help teach breastfeeding!

HIPAA -- I salute you!

Yes, you! I'm talking about you!



Actually, I'm not talking about you. I can't. It would violate HIPAA to blog about you, and it would feel ethically wrong to discuss specifics about a client. I know I don't ever say anything bad about clients, but still, it's just a comfort thing. So I've gone back and edited my old blogs. From now on, I'm going to maintain privacy: change details, times, not use names, etc. I am upfront about working with Leigh, and she is an out-of-hospital midwife, but when the birth center opens she will be doing both homebirths and birth center births. And I'm going to be working with midwives other than Leigh in the future.

So there, HIPAA! Take that!

From the "Marsden Wagner is eating my brain and all I got was this lousy t-shirt" file

What is safe?



We -- I'm talking about doulas and CBEs and even midwives -- teach our clients that if they end up at the hospital, and a doctor or CNM suggests an intervention, to ask, "What are the benefits? What are the risks? Is it safe?"

My boyfriend Marsden writes:

Since every medical procedure or technology has side effects and risks, no technology is 100% "safe." In every case, it is necessary to balance the chance of a good result (efficacy) with the chance of a bad result (risk)... But the decision as to whether the good chance outweighs the bad chance should not be made by the doctor, who is taking no chances, but can only be made the person taking the chance -- the woman. Therefore the doctor can never say that any procedure is "safe" but only tell the woman the chances and let her decide.

I'm going to think about this the next time someone asks me if a particular intervention or procedure is safe. I tend to think of "safe" as interchangable with "risk," but they're completely different. For example, I usually cite the BMJ study and say that homebirth is safe, but the real result is that homebirth outcomes were similar or better than hospital birth outcomes for low-risk women. To me, that means that homebirth is as safe as hospital birth -- which I'm allowed, since it's my opinion -- but that isn't fact.

This really becomes an issue for VBACs, where there are risks for VBAC and risks for a repeat c-section. There are slightly more risks for single-layer incisions, and less risk for double-layer incisions. Is VBAC safe? I think so. In my opinion, the risk of uterine rupture is less than the risk of surgical complications. But many women disagree, and schedule a repeat c-section. I tend to blame the doctors or others for over-emphasizing the risk of uterine rupture, but nevertheless, safety comes down to opinion.



I've seen some homebirths where the baby or mom needed intervention -- actually I've seen more homebirths like that than nice normal easy homebirths -- but I still think that homebirth is safe.

"Hey, aren't you a doula?"

This week I've gone on three interviews with potential doula clients, all first-time parents, all of whom are planning "natural" birth. (I put that in quotes because I do not believe a hospital environment is natural. What I would say is that these couples are planning "medication-free" births. However, they all referred to it as "natural." It is splitting hairs, perhaps, but I put a lot of stock into language -- one day I'll post about how breast isn't best, and my favorite list of condescending obstetric phrases, like "incompetent cervix." Siiiiigh.)

I'm not a huge fan of interviews, although the more I do it, the more used to it I become, and I start to feel more comfortable. There are many many many doulas in Charlotte, so it's rare that I meet a couple and we click and that's it. Usually the couple is interviewing at least one other doula. I start out with the usual, Hi, I'm Erika



and ask about the woman's experiences so far, how her pregnancy is going, how she's feeling, what she's planning for this birth, how I can help, and how I can help her partner. Sometimes it's just a natural flow of conversation, sometimes I sort of rely on the checklist in my head (birth plan, location of birth, ob group, newborn plan, postpartum concerns). Once I was genuinely interviewed like, "How are you different from all the other doulas in Charlotte? What do you do if your client wants an epidural?"

Honestly, I'm probably not that different from all the other doulas in Charlotte. I market two things about myself: one is that I've given birth in a hospital with an epidural, in a birth center with a shot of narcotic, and at home with nothing; two, I'm an apprentice midwife and midwifery student.

For the first point, I think it relaxes people to know that I'm just like them, that I traveled on a path to natural birth and didn't just start out knowing that I would do it that way. Because most of the women I meet -- especially first timers planning a hospital birth -- aren't ready for a homebirth with their first baby. And they say that too, "Not with my first baby!" Like the first one is a practice baby. I wish I could go back and have homebirthed all my kids, but with my first three I just wasn't there yet. And I respect their position and I understand where they are coming from, and I want them to know that.

As far as being an apprentice and AAMI student, my leg up is that I know more than the average doula about normal pregnancy and birth. I'm early in the game, but I've learned a lot, and I can't even imagine all the things I will learn in the next three years!

I usually try to work in my favorite doula story, which is that the doula I had for my first birth wasn't a licensed doula, she was just a woman interested in birth who had attended a few births and offered to help me. Her name is Gretchen Humphries and she's very active in ICAN. She was so wonderful, during my pregnancy and my birth. My twins had Twin-to-Twin Transfusion Syndrome; I was induced and I was a first-time mom; my baby B was a foot-first breech; in short, I was a fantastic candidate for a c-section. And yet I had a beautiful vaginal birth. I really credit Gretchen with helping me get there. My doula for my next birth was licensed by several doula organizations, and she was very well-known. I felt lucky to have her. Still, I don't feel we clicked, and for that reason, she wasn't very helpful for me.

The moral of the story is: forget all the labels and the initials behind the name (I am Erika Gebhardt, CD, CCBE, LAMW SC) and go with the person you feel comfortable pooping in front of. Because you will!

And yes, I'm also still a childbirth educator.

(See all my hats?) Tonight I'm teaching part of Leigh's class, on breastfeeding. I've posted before about my experiences with breastfeeding. Leigh and I agree that breastfeeding success is about 95% intention. At the Red Tent I met a woman who had breastfed while having MRSA infection in her breasts! That's pretty incredible. (Although Leigh points out, only HIV/AIDS and Hep B have contraindications for breastfeeding. But still. MRSA! Is there a scarier word? And how the hell did she get rid of it?)

Suturing! Anne Frye! Chickens! Oh My!

In which I pretend this chicken is a perineum


And then I cut an episiotomy on it


And then I put it back together and feed it to the dogs.


I pray that I never have to suture anyone -- at least, not for several years -- because I really had no idea what I was doing. I know I say that frequently on here, but really, this time I meant it! I did note that when we watched a video about repairing tears, Anne Frye (of Holistic Midwifery fame) pronounced ischial the proper way (is-kee-al) rather than the commonly accepted "ish-ee-al." I smirked at Leigh when we saw that, because when I first told her how ischial is supposed to be said, she didn't believe me. (Google it. You'll see.)

I've been out of town for the last week, at Outer Banks with my family and my extended family. It was a beautiful trip except that on the next-to-last day I fell down the stairs and broke two bones in my big toe. That sucks. It hurts, it's hard to walk, and it bled for a long time. I didn't go in the ocean after that happened. Oh, well. We plan to go back next year too, and I will not carry laundry downstairs again on narrow, creaky stairs. These stairs were really narrow and really creaky. I had a feeling someone would get hurt on them, I just didn't imagine it would be me.

While I was gone, one of Leigh's clients had her baby. I'm so bummed I missed it! Unfortunately her birth was not quite what she had planned. I'm still learning about complications, and I'm struck with the unfairness ofl ife. A not-particularly-healthy mom can have an easy birth, and a very healthy mom can end up with a medical condition. But, of course, like Forrest Gump says, "Life is like a box of chocolates. You never know what you're going to get."

This week I have three interviews with potential clients. Two are Wednesday, back-to-back, after a vet appointment for Maizey, and after a prenatal appointment with Leigh and one of her clients. Yeah, it's going to be one of those days. I just had another interview tonight. I can never tell how it goes, except when it goes exceptionally badly. Luckily there's a million women in Charlotte who want to hire doulas; unluckily there are a zillion doulas here who want to get hired. I hate competing against my friends, but at least I feel good knowing that if I don't get hired, it's usually because someone I know and like did get hired.

I did do some studying while I was on vacation; there's actually a picture of me, in a bikini, no less, diligently reading my boyfriend, Marsden Wagner. I will post it when I upload the pics from my computer (which I've been saying I will do since we got home on Saturday). Marsden and I spend a lot of time together lately. I'm reading his books and articles. After him, I'm moving on to a relationship with Jan Tritten, the editor of Midwifery Today. Then Henci Goer, whose book, The Thinking Woman's Guide to a Better Birth, set me on my path toward midwifery. I have three years of midwifery and I don't think I'm going to be monogamous with anyone during that time.

Along with "a housekeeper" "a laundress" and "a mansion on the beach with private surfing lessons given by Laird Hamilton,"...

Recently I've been fantasizing about all the midwifery items I'd purchase if I won the lottery. Most of what I want is books, as midwifery texts cost a freaking fortune. Most of them are in the $50-ish range, which isn't too awful, but some, like "Midwifery: Community Based Healthcare During the Childbearing Year," is $135. Myles Textbook for Midwives is over $70. I'm just thinking about the NARM primary reference list, although I know I'll come across many more books and texts that I want as I progress through AAMI. In my dreams I own most -- if not all -- of them, and have extra copies of books that I think are helpful for clients, like The Nursing Mother's Companion, The Baby Book, The No-Cry Sleep Solution, Attachment Parenting, etc.

Other than books I'd love the following:


1. A one-handed bp cuff. Oh, to me, that is the height of luxury. Whenever I take blood pressure, I feel like I have two left arms, I'm craning my neck around to read the sphyg, and all the cords are in the way. This one would be so nice.

2. A Littmann stethoscope. My friend Amy works in a hospital and I'm always asking her to steal me one; it seems like they're everywhere. You can hear so clearly with them. I don't even know why I bought my $20 sphyg/stethoscope set, since it's so quiet that I usually use Leigh's (slightly more expensive) set anyway.

3. A Leff fetoscope. It looks like just a regular fetoscope, but it's actually $300. They have really incredible sound quality, and actually block out other noises. They are supposed to actually rival a doppler, which would be fantastic for clients who want to limit u/s exposure. I'd like to try one before purchasing it, but if I really won the lottery, what's $300?

4. A birth stool. This one just looks so comfy and perfect for giving birth. Much better than a toilet.

5. An iPhone. You're thinking, this has nothing to do with midwifery, right? But you're totally wrong! Just check out these applications for it: iPregnancy, OB Patient Tracker, Due Date Calc, Bishops Score Calculator, and Weight Converter. Not to mention the GPS, huge amount of storage space for all my clients' info, and internet. I WILL HAVE ONE!

6. That tree in our backyard. Except $100s on it, instead of $1s (lame!) Although I'd take a few branches of $1s. Beggars can't be choosers, right?

7. While I'm in fantasy mode, a day with more than 24 hours in it (in which I still need only 8 hours of sleep -- or less!) Sometimes it seems like there's more to do than there is time to do it and still see my family. I am definitely starting to see the push-pull of the working mom. On one hand, sometimes I miss my family. On the other hand, I feel that what I'm doing is so important -- for me, and for the women I help, and even for society -- that I need to do it and I need to do it NOW. I cannot wait or put it off til my children are adults.

La Carpa Roja

I went to a BOLD Red Tent on Saturday, which included a raffle with all the benefits going toward the Birth Center. It was a good time, full of positive energy and healing and woman-empowerment. I think I can say that without sounding all New Age-y. The purpose of a BOLD Red Tent is to have a place where women can come together and celebrate ourselves, through birth or just anything woman-related in general. It was a little different for me this year -- although still just as hot as it was last year, and I don't care what happens next year, I absolutely insist that our next BOLD Red Tent either take place in February, or at another location where we're not on the second floor facing directly west, on a 100-degree afternoon. It was different because last year I hardly knew anyone there, as I was still fairly new to Charlotte and hadn't gotten involved with the local doula group. I had Sydney with me at the time, and I shared an unhappy birth story, and most of the women after me shared sad/angry/traumatic birth stories. It was a very intense night. This year, I know all the doulas, I knew many of the women who were attending, and I didn't feel like going as deep as I did last year. Yes, I've had three births (for four children) and they were not all perfect; in some ways the hospital birth was the best one, which is pretty screwed up. I shared about my twins' birth, and basically talked about the support I had at that birth. My point was that being supported during birth is important, and I appreciated being in a place where I could say that and other women got it and didn't say, "But at least you had a healthy baby!" Ugh, I hate that. I've had four healthy babies, who are now healthy children, but their births did and do matter.

There was a group of girls from a local home for pregnant young women who are at-risk in some way or another. Most of them didn't seem too interested in being there, but one of them shared. I hope the ones who stayed at least got something out of it. I'm really grateful to spend most of my time among women who believe, like I do, that birth matters. At first I thought I was a total weirdo -- and when I lived in Yuma, AZ, I was one of the only two, along with my BFF, Angela -- but here in Charlotte there are enough women who care about birth that I can actually pick and choose to be around them most of the time. It is really liberating to live in a place where I can do that. I can embrace my passion for pregnancy, birth, and postpartum -- as well as babies, of course -- and I actually have people to hang out with!

Today Leigh and I went to our most recent client's house and did the PKU on newborn. The PKU is not a fun test, because it's a heel-prick that will make the baby cry, and then we have to get 5 drops of blood on the card, which involves squeezing blood out. Not fun at all. I thought the client might get upset because the baby was crying during the test, but it's an important test. It detects metabolic disorders. I was glad not to do it, but I'll probably be doing one sooner or later.

I finally figured out what I mean when I refer to myself as a moron when it comes to midwifery; I'm not a moron, but I expected my doula training and experience to help me with midwifery in some way, and... no. Not really. Not very much. The fact that I've seen births prior to entering midwifery training is probably the only advantage I bring to the table. So that's what I mean. I'm not a moron; but neither are my years of experience as a doula all that helpful. I would imagine that I'm pretty much where most women start off.

In which my puppy attends her first homebirth

... not counting her own, of course!



Yes, Maizey attended a homebirth yesterday. I was so focused on finding a sitter for the kids that I didn't even think about Maizey. My older dogs can handle being crated all day -- once in a while -- but Maizey is just barely 12 weeks. Also, I thought the birth would go quickly, so I just dropped the kids at Emily's neighbor's house and drove to the birth. The kids were at Emily's neighbor's house because their usual sitter was at the hospital with her daughter, who was also in labor! Oh life, you are so ironic. Anyway, a few hours after I got there, while the mom was laboring with her husband and I was trying to teach Leigh how to play some card games, I realized that Maizey might be on her own for approximately 8 hours, which is way too long for a puppy. So Maizey came to the birth. She was very good. However, I learned that I need to put a spare key somewhere near my house so a neighbor can let her out. I'm sure not every client will be as cool and dog-loving as this one.

Also, I learned that (1) I'm not much help to Leigh yet, however (2) that's in my job description, so (3) we need to practice. Suffice it to say the birth didn't go as easily as the last one we attended, and the mom needed some assistance. Leigh and I had touched briefly on some procedures, but we hadn't practiced anything. So when push came to shove, I didn't know how to help.

I was whining to my friend/midwife for Sydney's birth, Charlotte, who told me that it's okay that I'm not much help yet; that I'm not going to be much help for a while, til I have more experience. I am somewhat of a help because I have two hands and I can take bp, pulse, temp, and find fetal heart tones. And I can write! (And I think my writing is beautiful! Leigh totally disagrees!) I can chart. Leigh and I are going to do some drills on procedures so that if she ever comes across a situation like this, I can actually help.

I really look forward to the birth center opening. I think I'm going to get more experience on a regular basis -- before this, Leigh and I hadn't attended a birth together since late March, I think? -- so things will be more cohesive in my mind. Right now it's new AND it's infrequent. Fabulous!

Feeling slightly less totally incompetent

The title is my roundabout way of saying I actually feel slightly MORE competent lately. Which is a relief. I can't point out anything concrete, but I just feel like some clinical things are starting to click in my mind. Maybe it's that checking fundal height is finally getting a little easier -- for some reason, I have a really hard time finding the exact spot on the pubic bone to start measuring. I used to be off by up to five centimeters. Now I'm getting a little more accurate.

I have also long proclaimed that I know nothing about midwifery, but as I'm delving deeper into AAMI, I can say that though I may be an idiot currently, I'm going to be a freaking genius by the time I graduate from AAMI. The coursework is all copyrighted so I can't say much, but suffice it to mention that the sheer volume of readingis enormous. And that's not to mention notes, papers, reviews, commentaries, and critiques.

For those (my three readers!) who are considering midwifery school, I recommend AAMI. Just looking at the small bit of curriculum I have now, I'm going to get a very thorough education. It takes a while to get used to AAMI-isms, but once you start drinking the Kool-Aid, it makes more sense. Plus the other students are very supportive and will share how they are balancing everything -- life, apprenticeship, education. The most difficult part is probably the money, which unfortunately is not something we have a lot of. Just this last week my oldest dog, Deuce, had an emergency vet appointment and treatment (she's fine now), and Dustin accidentally broke one side of the double-paned window next to our front door. Babysitting costs is what really kills me, although I appreciate the situation I have: a woman and her 5 daughters babysit the kids. The daughters were all homeschooled and are all (except one) married with kids and live close by. So I almost always have coverage, and I don't have to drive far, and next year when we're homeschooling, they will understand that and not think it's weird that 6yos are home during the day. It has really worked out nicely. The daughters are all into natural birth, so hopefully one of them will use the birth center in the future!

Last night I went to a Mother's Blessing ceremony for my friend and fellow doula and midwifery student, Brooke. This is her third pregnancy in four years; she is ridiculously fertile and has very fast labors. I didn't know her before her last Mother's Blessing, but apparently everyone gave her candles which she never even had time to light during the labor. It was less than two hours. We all joked that if she doesn't get a chance to use the candles with this labor, she can save it for the next one. HA. Soon she will be tandem nursing three children. Go Brooke!

The Ethics of Formula Companies

Copyright Erika Gebhardt, 2009. May not be reprinted without permission.

In 1981, the United States became the only country to vote against the World Health Organization’s International Code of Marketing Breastmilk Substitutes. Although the United States eventually supported the Code, little has been done in nearly thirty years to enforce it and the United States lags behind many countries who call for more strict regulations on the sale and promotion of formula.

Formula companies market relentlessly without concern for health ramifications, as each pregnant and postpartum woman is a possible consumer who will bring in revenue. Once a mother’s breastmilk dries up, she is dependant upon that substance to nourish her baby for up to a year or longer. Although the Innocenti Declaration of 1990 encouraged all countries to maintain the Code by 1995, in practice, the Code is rarely enforced.

The Code’s main provisions include no free samples to mothers, no advertising, and no gifts or personal samples to health care workers. With regards to the last rule, formula companies circumvent it by donating samples to health care organizations – such as hospitals or medical offices – rather than specifically targeting health care workers. These gifts are not just the formula itself but also helpful parenting tips (including the “breast is best” adage), diaper coupons, and, more often than not, a free diaper bag. These tactics are particularly manipulative with regards to lower income families – especially non-Hispanic black women, who have the lowest breastfeeding rates in the United States – as the free gifts are an important aspect of their birth experience. However, the increased financial cost of uninsured mothers receiving formula from WIC burdens all taxpayers. The gifts may be free, but the long-term ramifications are costly.

Forced not to advertise directly, formula companies came up with a brilliant trick: “follow-up” formula for babies who have been weaned. As follow-up formula targets mothers of babies who have been weaned, its promoters claim freedom from following the Code’s guidelines. Unsurprisingly, manufacturers advertise this formula for babies as young as three months. This type of formula – which has the same name as the infant formula, making it nearly indistinguishable from the infant version – is marketed with pictures of cherubic, smiling babies drinking formula from bottles.

The next marketing ploy used by formula companies is promoting breastfeeding. Since formula companies cannot state that formula is superior to breastmilk, they must concede that breastmilk is best and advertise as such. However, these pamphlets, books, and videos often contain advertisements for the formula company. In addition, many depict breastfeeding mothers as exhausted, nursing in a dark room by themselves. This is a marked contrast to the smiling woman bottle-feeding her chubby baby, surrounded by family and friends.

When trying to market formula that is nearly as good as breastmilk, formula companies have again damaged babies and mothers. Specifically, formula companies have added laboratory-produced oils that contain DHA and ARA in order to compete with breastmilk, which naturally contains both fatty acids. However, the DHA and ARA found in formula are extracted from fermented algae and fungus, via hexane, a solvent known for being neurotoxic. Formulas marketed to contain DHA and ARA only contain 40-50% of each fatty acid, with the rest made of components not found in human breastmilk – resulting in diarrhea in babies who consume this formula.

The most conclusive evidence that formula companies place profit above health comes from the Philippines, where three large United States-based companies – Wyeth, Abbott, and Mead Johnson – attempted to block the introduction of formula marketing regulations similar to the WHO code. In fact, the three companies sued the Philippine Government in order to prevent ethical marketing guidelines for formula. The WHO estimates that 16,000 babies die in the Philippines each year because they are not adequately breastfed, and that 90% of babies under six months who die are bottle-fed and fed foods other than breastmilk.

Time flies when you're waiting on a baby

I haven't posted since May 8, which was a client's due date. Today is June 1. I had a ton of stuff going on between then and now, much of which I tried to put off until after the client had her baby. For example, I planned to attend a homeschooling conference but didn't want to make formal plans to go until after my client had her baby. Same with contacting another client who is due in August. Same with planning a party for my birthday, which was May 23.

My client went to 42 weeks 4 days.

What I have learned from this experience is that I need to calm down and not avoid living my life because I'm on-call. They all have babies. I have babysitters set up. Everything works out just fine. (I have never missed a birth except for the sand-road situation with Leigh, which was not my fault.) But not sleeping and stressing out because I'm waiting is not good for me. Or my family. Or my friends, or Leigh, to whom I whined about my dilemma.

However, I did not skip my birthday trip to NY state, where I got a new puppy! Yes, my first puppy. Her name is Maizey and she is a Cardigan Welsh Corgi, with many many champions in her immediate family (in fact, nearly everyone for three generations back). I have always had older dogs from the Humane Society, so I was a little nervous about getting a puppy, but she's doing very well. Along with my AAMI books and literature, I'm reading Dr. Ian Dunbar's book "Before and After You Get a Puppy," and "The Art of Raising a Puppy," by the Monks of New Skete. I'm following all the rules, and in return, she's having very few accidents (none today!) and chewing only appropriate chewtoys, and sleeping in her crate when I can't keep my eye on her and at night. I plan to show her and try to finish her. The breeder, Kate Roberson of Hagaren Cardigans, was very kind and generous, and if I am able to title Maizey, and if she is breedable, I'd like Kate to breed her. If she wants to, of course.

(Aside: my birthday trip was when I was technically off-call, as I'm on-call til 42 weeks, and my birthday was at 42 weeks 1 day. I did set up a back-up doula, just in case.)

Leigh gave me my first bit of constructive criticism, which was a terrifying moment for me. She had said, "I need to talk to you about something," and my first thought was, "Aw fuck, what did I do?" LOL. We have been in the honeymoon phase, as Carla refers to it in "Helping Hands," where it's all sunshine and compliments and she's the best preceptor ever and I'm the best apprentice ever. (I am probably the funniest apprentice ever.) Leigh had some genuine concerns about maintaining my (slow, but steady) progress and not moving too fast in clinical practice before I get there in academic study. Totally valid stuff. The initials "CD" and "CBE" behind my name really mean very little when it comes to midwifery (perhaps I've mentioned this before?) and I am really starting from square one, just like everyone else. She was very kind and I felt like an idiot for being so worried. That's always how I feel when someone says, "I need to talk to you;" I always assume I've done something completely wrong and I rack my brain trying to come up with whatever it is, and then when it turns out that I haven't ruined the world, I think, Oh. Right. Just like stressing about being on-call, I need not to stress when it's time to receive constructive criticism. It's just information really, that can help me to improve. Leigh and I have the same goal, which is to prepare me for being a licensed midwife.

Here is another picture of Maizey. Her AKC registered name is Hagaren's Maizey Rockstar. My kids picked the middle name Rockstar.

"Just enough to hinder..."

I'm one of the rare women who got an apprenticeship before starting midwifery school. I'm totally lucky. Religious folks might call it the hand of God; I call it incredible serendipity and/or fortuitousness. I don't even think there was a formal asking or accepting. Leigh was new to the area and through auditing her childbirth class (which I was doing to fulfill a requirement to become a CBE) I met a few of her clients, and, as she didn't have an apprentice, I offered (or maybe she asked me?) to attend the births with her, and that was that. We attended a birth together and we appeared to drive well together (or at least, we both survived the high-speed race to get there) and so I got my TB test, enrolled in midwifery school, and became licensed in South Carolina as an apprentice. At some point Leigh started referring to me as her apprentice, and I started referring to myself as her apprentice. Voila.

From what I understand, it typically doesn't work that easily. Many women who choose distance midwifery school are students for a long time first, and then have to apply to become an apprentice, and interview and compete against other potential apprentices. Reading on my AAMI group about other students who are doing that -- I'm thrilled that becoming an apprentice and enrolling in school has been so easy for me.

What has been difficult is turning my brain into a midwife brain when I've been a doula for years. Or, I should say, when I've been a non-midwife for my entire life up until now. Even though I saw a CNM for my second pregnancy, and a licensed midwife for my third, my default brain is still amazingly medical. It's insidious; I think it's just from living in this country and talking to pregnant women. I believe 98% of women have hospital births, and so 98% of women are talking about doctors, inductions, pain medication, and other interventions, and they're NOT talking about nutrition during pregnancy, comfort measures for normal pregnancy discomforts, and spontaneous labor and birth. Now, many of my friends and acquaintances are that 2%, but still. It's hard to replace approximately 22 years of mainstream-ness (I would say I've become more crunchy and natural-minded in the last 7 years).

Also, many of the pregnancy and birth related things that I "know" aren't really things that I "know" but are things that I've seen or heard, like anecdotal evidence. I now need to do the research and really learn. For example, the Cochrane Collaboration does not specifically say that Cytotec causes uterine rupture; one study does say, however, that it hyperstimulates the uterus, which can lead to uterine rupture.

There's so much to learn! And I thought that being a doula would be an advantage but if it is, it's a very small advantage. Tiny. I like to talk a lot and recently I've been trying to STFU during prenatals unless I'm either making small talk ("What are you planning to name the baby?") or something that I really really really KNOW for a fact. There are a few things that I know. But there's way more I don't. It's probably like that 98%/2% statistic.

However, AAMI is a long program, and by South Carolina law, I cannot take the NARM until after I graduate (which is different than most other states, where you can take the NARM anytime you have fulfilled the clinical requirement) which will be in 2012. So I have plenty of time to learn. I'm already feeling more comfortable taking vitals on mom and baby, and I'm starting to get better at measuring fundal height. I'll get there.

Birth attendants: worth more than burger-flippers at McD's, I hope.

I feel frustrated when birth work isn't valued, particularly by the women who claim they want it. Most of the time, women who want doulas realize the value of having a doula. But there are some who just don't get it. I think this is more with regards to doula work than midwifery. With midwifery, the care is more tangible. With doula work, it's a little more difficult to see on the surface; we're not always "doing" something.

(I could easily go off on a tangent right now how our entire society and our whole nation doesn't seem to value birth work, versus other countries who subsidize doulas. See "Sicko" and note the part in France with the postpartum doula, who the government provides for free for all women. And I don't want to debate France, since so many people in our country are anti-France; I'm just making the point that the French value birth work. And we don't. Le sigh.)

I'm also thinking about trusting my instincts with regards to the doula clients I take. I've gotten burned over that one. It's just so difficult for me to turn down doula clients. Here's why:

1. I do this because I want to help women have positive birth experiences, and most of the women who hire me choose to birth in a hospital, and they need all the help they can get!

2. There are eleventy-million doulas here, far more doulas than women who want a doula. So getting hired makes me feel good -- I feel validated. I realize that this is my ego talking, and I shouldn't look at it like it's about me, because it's not. When I was pregnant with Allegra, I met several doulas and none of them were the right one. It wasn't anything personal. And when someone I meet with chooses another doula, I feel okay about it because all of the local doulas I know are fantastic, and I usually feel confident that the woman will be in good hands. But it does feel good to get hired.

3. Money. Being a doula is a business, and I deserve compensation for my work.

I spend a lot of time and energy on my clients. Even if I'm not in constant communication with them, I'm thinking about them, I'm googling things and learning things that might help them with their birth, I'm emailing with them or talking on the phone. When I'm on call, my life is on hold. I'm usually sleeping with one ear open, as it were. Going through Helping Hands, my apprentice workbook, most midwives said the most difficult part of being a midwife is that your client owns you, and I'd agree. It can be sucky. Emily once had a client go into labor when we were at a party that was really far away. I've had a birth on Christmas eve and Christmas day. Tomorrow I'm going for an interview with a woman who lives an hour away.

I've attended a birth that started Sunday evening and she didn't give birth til Wednesday evening. Leigh once said that midwives need their faculties about them after the baby is born; but that isn't true for doulas! We work like mules. We can totally deplete ourselves, physically and emotionally, and we often do.

Serendipity: Coming soon to a computer near you!

So, in my last birth-related post I blogged about wanting some more experience breastfeeding, or at least wanting to learn more about breastfeeding, particularly about troubleshooting. I was even thinking about taking the Aviva Institute breastfeeding educator class. Today I was going through my AAMI emails and found that lo and behold, Christine, my AAMI mentor and real-life friend and fellow apprentice, is actually teaching a course on this very subject! Fantastic. It's free for AAMI students -- and only $10 for non-students. I love when life is serendipitous like this. It's an online class, and I think I can attend it, even with my crazy schedule. (Christine, btw, is an IBCLC and a RN, and she's thisclose to being a midwife. And she's also an amazing woman!)

I'm working my way through Helping Hands, the Apprentice Handbook, which was written by Carla, the director and founder of AAMI. It's pretty interesting. It's a workbook, and a chance for me to record my thoughts and experiences with midwifery. It's really good for helping me to answer the questions, Why am I in midwifery school? How am I going to complete midwifery school? What will I do when I complete midwifery school? What are my goals and hopes for being a midwife? How will this affect my life? How will this affect my family?

In between making a prenatal exam cheat sheet for the back of my clipboard

Here is your daily quiche recipe, "Breakfast Quiches to Go" --

But first, let me explain why I love quiche. Mostly it can be summed up in three words: Weight Loss Surgery. I had a biliopancreatic diversion with a duodenal switch (hereby known as a DS or a "switch") in November 2008, when I weighed 262lbs. I currently weight 172lbs, which means I've lost 90lbs in 5 months. It's been fairy easy (I can't drink milk or eat too many carbs, otherwise I feel gross) and although it was excruciatingly painful at first, I feel fantastic now. (But I can't ever forget, it was the most pain I've ever experienced in my life, and I will never have abdominal surgery again if I can help it.)

From allrecipes.com

INGREDIENTS

• 2 (8 ounce) cans Pillsbury® refrigerated garlic butter crescent dinner rolls
• 1 (8 ounce) package cream cheese, softened
• 3 Eggland's Best eggs
• 1 small onion, chopped
• 1 (9 ounce) box Green Giant® frozen chopped spinach, thawed, squeezed to drain
• 1/4 teaspoon salt
• 1/8 teaspoon pepper
• 1 cup shredded mozzarella cheese

DIRECTIONS

1. Heat oven to 350 degrees F. Spray 16 (2 3/4x1 1/4-inch) muffin cups with CRISCO® Original No-Stick Cooking Spray.
2. Separate each can of crescent dough into 8 triangles. Press 1 triangle on bottom and up side of each muffin cup.
3. In large bowl, beat cream cheese with electric mixer on medium speed until smooth. Add eggs, one at a time, beating well after each addition. Stir in onion, spinach, salt and pepper until well mixed. Fold in cheese. Fill each cup to the top with egg mixture (do not overfill).
4. Bake 15 to 20 minutes or until knife inserted in center comes out clean and edges of rolls are golden brown. Remove from pan. Serve warm.

Nutritional Information

Servings Per Recipe: 16

Amount Per Serving

Calories: 197

• Total Fat: 14g
• Cholesterol: 60mg
• Sodium: 429mg
• Total Carbs: 12.6g
• Dietary Fiber: 0.2g
• Protein: 6.3g

Because Boobs are the Best!

One aspect of midwifery education/experience in which I am sorely lacking is breastfeeding. Of my four children, I only breastfed one for longer than a month, and that was Sydney. (I will explain the whys later.) Sydney and I had not a single problem during our breastfeeding relationship, and while I'm really happy that our experience was so positive, I realize that I lack the ability to address problems based on my own experiences! She had num-nums for about a year and we both loved it.

I think that my best personal characteristic for being a childbirth educator and doula and midwife-to-be is my vast array of birth experiences. I've given birth in a hospital -- in an O.R. -- in a birth center and at home. I've given birth with an epidural, a shot of narcotic, and medication-free. I've experienced labor starting with contractions that got longer, stronger and closer together, and labor that started with my water breaking. I've experienced a labor that didn't start for nearly 2 days after my water had broken, which really tested my patience and my faith in my body! I've had one baby born with a cord around her neck. I've had to change my birth plans based on needed medical care. I've had a great birth experience and not-so-great birth experiences. I think those experiences are my greatest personal assets to a client.

But not so much with breastfeeding.

First, a confession: I had a breast reduction when I was 16, not thinking about ever breastfeeding in the future, or how having a reduction would affect it. Then, when I was around 20, I had a boyfriend who had a baby that was 100% formula fed in bottles. She was a sweet happy baby, and that was my first experience with seeing a baby eat. Later I had a friend who had a baby (my first doula client) and she breastfed for a year, but she experienced overwhelming feelings of sadness when she first breastfed -- there's a word for it, but I can't remember it.

So, when I was a single mom-to-be of twins, my focus was mainly on having a vaginal birth, and not so much on breastfeeding. I went to a La Leche League meeting, but I just didn't give breastfeeding a lot of thought. I had been told by my doc that my babies would likely be in the NICU, and they'd be tube-fed high-calorie formula if they were preemies. (This was all determined by the fact that they had Twin-to-Twin Transfusion Syndrome and would likely be born prematurely.) I could breastfeed if I wanted, and I could pump and store milk, but they would be tube-fed and then bottle-fed before they could go home from the NICU. And I just didn't really think about the transition and how difficult it would be, and whether or not I even believed I could get them 100% breastfed because of my reduction. So, I pumped and bottle-fed them for about three weeks, at which point my level of exhaustion was so great that I made the informed (or so I thought, but looking back I was woefully uneducated) decision to formula feed. Pumping and feeding IS exhausting; someone on motheringdotcommune once calculated that she spent an extra 40 hours per week on pumping and feeding -- 40 hours that she didn't spend with her baby or family.

With Allegra, I had much better intentions. I dutifully breastfed. It was painful and I didn't give my breasts much time to heal. I didn't give myself much time to bond with Allegra either -- I was hell-bent on not taking any time away from Rory and Tiger, and it was to my own detriment and to the detriment of my relationship with Allegra. (In retrospect, I wish I'd done a "babymoon" or a "laying-in" period with Allegra, which I did do with Sydney. It's basically a time just to focus on breastfeeding and bonding with your newborn. It's lovely.)

At three weeks after Allegra's birth, I developed this terrible pain in my stomach, and I went to the ER and had emergency gallbladder removal. I came home the next day and we went back to breastfeeding. But after that, I developed a post-op infection and spent the next week in the hospital, without Allegra. The hospital told me I couldn't have Allegra with me because hospitals are full of sick people (aside: if it's so full of sick people, why is it okay for babies to be BORN there?!?!?!) and my doctor suggested I dry up and stop breastfeeding her.

I was devastated, and I followed his advice, but I was so incredibly sad. Later I tried to re-lactate, but it was just too difficult. I really tremendously regret following that advice, and saying okay to Allegra not being with me in the hospital. It was such wrong advice on so many levels. I wish so much that I'd had some of the friends I have now -- friends who would have provided me with a pump and support in continuing to breastfeed, friends who might have even nursed Allegra themselves so she didn't forget how to breastfeed!

But Sydney was my baby where I really tried to do everything "right," and that included breastfeeding. I did a laying in with her for two weeks, during which we cuddled and breastfed and I caught up on "One Tree Hill," that terrible show on CW. By the time Dustin went back to work, I felt comfortable with my new baby and with breastfeeding her. I felt more than comfortable -- I felt bonded and attached. It was a fantastic feeling. I can't even really describe it. She looked at me, drunk on milk, and I look back at her, drunk on oxytocin. We were a pair.

I would have liked to breastfeed her longer than a year, but I desperately needed to have weight-loss surgery. I was morbidly obese and was starting to experience some common comorbidities with morbid obesity. I didn't want to put it off for another year.

So that's my story on my breastfeeding experiences: three kids for about three weeks, and one kid for a year with no problems. I never had any mastitis, let-down problems, engorgement, over-supply, infection, thrush or any other types of problems. I can spot and possibly correct a bad latch, but I don't have the personal experience with breastfeeding issues that other CBEs and doulas and midwives have. And I'd like that experience.

I know there are some doulas and CBEs and midwives who don't even have children, who have never been pregnant or breastfed. I also know that anecdotal experience is not the entire picture. There are tons of aspects of midwifery that I've never seen, things that are probably even considered common. I haven't had a c-section and I don't particularly want that experience! But this is something I can learn about.

Aviva Institute, where I took my CBE class, offers a three-week Breastfeeding Educator course, and I'd really like to take it.

A glimpse of the future

Starting in June I will be homeschooling and apprenticing and in midwifery school. This week the kids are all on spring break and I'm planning to enjoy it and catch a glimpse of what our life will be like when the kids are done with school this year. (So far, that glimpse involves going to the library, coming home and having quiet/nap time, and then the kids running off to their friends' houses, not to be seen since. Homeschooling is great!)

I feel very confident about the decision to homeschool. I have given school a fair shot -- I dutifully get the boys out the door at 8am every morning M-F and pick them up at 2:30pm. I have only pulled them out of school once for a midwife-related endeavor, and that was to play with the other midwives' kids at a monthly meeting. I've done homework and sent in snack and paid for all the extracurriculars and attended Spirit Nights. I'm still not sold on school. I'm not anti-school, I just hate the bureaucracy and the rules and the general institution-ness of school. I don't like a schedule. This is yet another reason midwifery appeals to me; it's not going to be a 9-5 thing. I know that prenatals will be during business hours, but I also enjoy Leigh's late night prenatals.

I'm trying to find someone I can pay to be on-call for me for babysitting. I have two friends, Leslie and Ana, who are willing to watch the kids, but I don't want to burn through the friendships with unreturned favors, and I want someone who has a real incentive to babysit anytime I need a sitter, even if it's early in the morning or late at night. I met one woman who lives very close to where the birth center will likely be located, but if the birth center ends up not being at that location, she's far out of the way. And I'm just not 100% certain about her. I'm supposed to meet another woman this week; she lives very close to me but her email address includes the phrase Jesus Loves You so I'm not sure that will work out either (aside: I've been studying Paganism, upon recommendation from an administrative person at AAMI who I told me sad plight of being currently religion-less. Paganism very interesting, but I'm also not sold on it because it's all about nature and earth, and I'm a bug-killer and always will be.)

Today I requested my AAMI prepak, which is... okay I'm a little confused about the way AAMI works, but everyone says just to do it and I'll catch on as I'm going... I think it's like my orientation paperwork and assignments. It should take a few months to do. When I've finished that, I can request my actual curriculum, but not until I've paid AAMI $750 toward my tuition, which means it will be several months, and I'll need to make an extra payment or two. But I'm progressing along on time. I had to complete 15 assignments before requesting my prepak, which I've done. They included things like getting CPR certified, writing a few papers on what kind of midwife I plan to be, writing a summary of a Midwifery Today article, interviewing my mom and Oma about their births, and starting lists of midwifery-related topics I want to learn about/learn more about.

I'm trying to get more and more into the midwife frame of mind. The other afternoon, when I was picking the boys up from school, we stopped at the park on the way home and stayed for an hour or so. Meanwhile, I missed a bunch of calls from a midwife who plans to work at the birth center, and also from Leigh (when the midwife couldn't get me, she called Leigh. Leigh in turn called Emily, my bff, and then Dustin). Finally I got home and straightened everything out but I told everyone, "I don't keep my cell phone on me when I'm not on call, and I don't have anyone due until mid-May." (And that's as a doula; currently Leigh doesn't have anyone due til early July.) But Leigh told me I was thinking like a doula; a midwife is always on call. A client can always call with prenatal support issues, and I have to answer. So now I'm going to get a holder to clip my cell phone to me so that I'm always near a phone!

From Carla, to the South Carolina Department of Health

in response to an email asking for confirmation of my enrollment as a student with AAMI (in order to license me as a South Carolina apprentice midwife)

Yes Erika is student #2012. We are quite excited to have another South
Carolina enrollee. I have quite a soft spot for South Carolinians. You may
not be aware, but Robert Lawyer was, that we offered the first comprehensive
academic program in the country for non-nurse midwives and have just
celebrated our 28th anniversary. Mr. Lawyer was the first state official to
give us approved status and wrote me a letter I still have to this day about
how thorough our program is.

I know that students there have many choices and I am all for that; I hope
you continue to allow students to choose their own education. However, I
want you to know that our students are not like any other midwifery
students. They know that there are far shorter and eaiser courses out
there, but those chose the most difficult and comprehensive, on purpose.
They will serve the women and families of South Carolina well long after
they have assisted with their births.

We not only offer the most advanced midwifery education but we place a
strong emphasize on parent education. Our approach helps parents realize
their own authority, which means that we help them accept their
responsibility for parenting and birth and health, which can only be a great
thing for your state's future.

You can expect Erika to be an asset to South Carolina and your birthing
families and we know that she will be an asset to our program. Please do
not ever hesitate to contact me with any issue relating to midwifery or our
students. We would love to be of service to you.

Thanks, Carla Hartley
Founder, Director
Ancient Art Midwifery Institute

Nice, right? I thought that was such a nice email. Carla bcc'ed me on it. And then I fwded it to Leigh.

It feels really good that someone I don't even know personally has such confidence in me. Okay, so it's probably really just confidence in her midwifery program, but still, the outcome is the same: I will be awesome in a few years. Even awesomer than I already am!

I'm very excited about AAMI. As I'm reading and printing and 3-hole-punching and filing, I'm very excited. I'm thinking about my future: I will have to pick two specialties of focus, one that is pregnancy and birth related and one that is related to holistic medicine. I'm thinking about twins for the pregnancy and birth related specialty. Obviously I know a little more about twins than the average lay person. I really have no idea about the holistic medicine one. I mean, everything sounds interesting, but nothing in particular sticks out. I would love to go to the Farm though, and do a workshop on herbs.

Off to eat dinner.

Where are we going, and why am I in this handbasket?

One of my AAMI assignments and suggestions for Phase 1 is starting a journal of my birth-related experiences (check) to chronicle my growth as a midwife (check). What brought me to this point (check) and where am I going (uncheck).

So, where am I going.

I sincerely hope that I'm going to a place where I can practice midwifery legally, and that the restrictions placed on my license are appropriate within the scope of the midwifery model of care, and not difficult for either me or my clients to follow. I would like practice somewhere where I can legally do VBACs, twins and breeches.

This location may not actually exist. (It might be Texas or Oregon.)

I realize that I'm answering the question very literally, like what specific place do I want to go and practice as a midwife. What I really want is to be able to follow the midwifery model of care. I'm not sure that a place where I can't handle breech (which is a normal variation) is really a place that supports the midwifery model of care. Same with VBAC. Twins, well, maybe. I realize that some twins can be more risky, like MZ mono/di twins. But DZ twins usually aren't very risky. I wonder what the Cochrane Database says about DZ twins and midwifery.

To answer where I want to go: I want to be a midwife. I want to understand normal physiological birth. I want to know enough about complications to be able to handle them calmly, or know when and how to transfer to the appropriate medical facility. I want to be able to help clients prevent complications to the best of their ability (whether they choose to do so or not) and treat pregnancy-related issues in a holistic way. I want to know. I want midwifery-related concepts and ideas and physiology to be second nature for me.

In order to do this I'm going to have study and learn learn learn. Despite being a doula, it really amazes me how little I know about midwifery. I (happily) turned off my brain when it came to midwifery (or obstetrics) because it was outside of my scope as a doula. Now my scope is changing and I feel like a total moron! I have absorbed practically nothing in years of being around pregnant women!

I feel like such a beginner that I kind of disbelieve that I'll be able to license as a midwife in three years. It doesn't seem like enough time to get me from here to there. (Seriously, did I mention I'm a moron?!?!) Maybe in some ways I know more than I think, but I don't ever want to be cocky about what I know anecdotally to be true, that might not be backed up by science.