In which I receive the book

The book! The curriculum! This is IT!


Okay it doesn't really look like that, but you get the idea. I received my curriculum in the mail. It came later than I expected, but that was fine because, like I said, I've been sick and not up to it.

AAMI is awesome because it's a self-paced program; the state of South Carolina, on the other hand, wants me graduated within three years of starting my apprenticeship, which is around May of 2012. On one hand I have this lovely "take all the time you need" thing coming from AAMI (although you have to purchase curriculum extensions), and that makes me feel confident. I want to finish in three years, I can finish in three years, but if Life or something gets in the way, I can take a bit longer. On the other hand, I have the three year handcuffs in my head with South Carolina. However, I can always ask them for an extension. At this point, SC DHEC takes things on a case-by-case basis. AAMI is a difficult program. It's rigorous, it's thorough, it's intense. I plan to graduate in three years, but I can argue that I may need an extra month to finish the program. Christine, my mentor, nearly killed herself finishing on time.

But this is all moot because right now, this minute, my priority is getting started with the curriculum. I'll worry about the months and years later. Right now I'm reading Gentle Birth, Gentle Mothering by Dr. Sarah Buckley, and Misconceptions by Naomi Wolf. I'm thinking about my specialties: EFT will be one, and maybe newborn safety or care for the other one? I'd like to incorporate what I've learned from becoming a CPST, and maybe combine that with other attachment parenting choices.

In which I am forced into hiatus by illness

I've been sick for a few weeks now, and it culminated in 2 days at the hospital for dehydration. Was this caused by my surgery? The GI doctor says "not exactly," as he thinks I have a bacterial infection. However, my surgery does make me prone to bacterial infections. So... maybe?

Fun things I go to do while in the hospital:

• Stay in a 24-hour unit, which for me meant a windowless room on a windowless hall of the hospital, which had a toilet right next to the bed, disguised as a chair. I stared at it, and wondered who came up with such a feat of engineering.
  
• Give three stool samples per day. Three. Every day. In a cup.
  
• Have a colonoscopy.
  
• During the colonoscopy, got Propofol as my anesthetic. Propofol, you may remember, is the Michael Jackson drug! And I have to say: FAIL. First of all, it burned as it went through my IV. Second of all, I didn't even dream! Third, it was over so quickly. I had Dilaudid after my surgery; I'd take that over Propofol any day.
  

I send a big thank you to my friends Leigh, Marianne, and Leslie for visiting me while I was there, and Emily for talking to me on the phone for hours. Leigh brought me food -- and watched my kids on Monday all day long while I was at the doctor and being admitted! Marianne brought me books and let me use her iPhone. Leslie brought me gum (since I was NPO for the colonoscopy by the time she arrived) and took me on a walk outside.

Once again: I have good friends. Actually I have great friends. I appreciate all of them.

Prior to my illness, I spent four days in Child Passenger Safety class, which culminated in the following initials behind my name: CPST. Child Passenger Safety Technician. It was long, somewhat interesting, and I'm glad I can now check car seats for proper install. My friend Joanna told me that I would learn more about seat belts than I ever thought possible.



She was right. I learned about the mechanism behind seat belts; what part of the belt keeps the child safe; how to add or change things to make the seat safest for the child. I'm still a little confused in my head about ALR, ELR, Switchable, and types of locking mechanisms. Luckily, I have a thick CPS book to help me, as well as the seat manufacturers and the car manufacturers to call if I need help. I was in class with six people who worked for Britax, as their company is here in Charlotte. Three engineers and three customer service reps. And several police officers and firemen.

I'm feeling better now, but definitely not back to 100%. I'm glad not to have anyone due as far as doula clients for a few months. Leigh has someone due but if I'm not feeling up to it, she will ask someone else to help. Also, I'm having some babysitter trouble. During the birth in which I wore uncomfortable pants, I had called my kids' typical sitter for help, and she was unavailable. I pay her to be on-call for me. I was not happy with the situation. I have begun looking at other options in case this doesn't work out.

In which I learn to trust the process, and wear comfortable pants.

Ohhhhhh mahhhhhhhhhhhh gawwwwwwwwwwwwwwwd, I don't think I could have been wearing less comfortable jeans unless I'd been sweating and they were made of leather. Seriously. It was a pair of jeans that my mom bought me during a super-fast shopping trip while I was in Michigan a few weeks ago -- it was literally hours before the wedding started. I found a really cute pair of jean capris and she went find a second pair just like it, and she couldn't find the exact same ones, so she grabbed a "similar" pair, "similar" in this case meaning "looking somewhat like it except not meant to be worn in any situation where one might have to attempt sleeping in these pants." To give you some idea, dear readers, of the extend of my discomfort, let me say this: there is a belt buckle sewn into the BACK of these jeans. Ugh.

In my defense, I was under the impression that this birth would move quickly. Also, in addition to torturing myself from the waist down, I hadn't washed my hair that day. I think at one point the laboring mom actually looked at me and shuddered at my overall grossness.

After returning home, I immediately got on oldnavy.com and bought two pairs of cotton yoga pants, 2 cotton tshirts, and 2 long-sleeved shirts (I'm skinny now, so I get cold, yo). I'm going to make two birth bags and put one in my car and one in my house, and include the clothes, dental floss, travel toothbrush and toothpaste, travel deodorant, hair ties, and maybe some of those face cleaner wipes. Because I really never want to feel as gross during a birth as I have recently.

What I have learned recently: to trust the process.


There is such a huge difference for the mom and the experience when the provider trusts the process versus a provider who does not believe in what she's doing. I can see that a lot of it is experience -- it takes a lot of birth experiences to believe in birth. Sometimes things go wrong -- without any warning -- and often it doesn't go the way it "should," as prescribed by physicians in the 1950s. Here is Friedman's Curve of expected dilation.


The Friedman Curve -- which is adopted by hospitals and written in the blood of obstetricians -- is kind of a hot mess. Here's a quote from BirthSource about dilation

Current definitions of labor protraction and arrest may be too stringent, Dr. Jun Zhang of the National Institute of Child Health and Human Development, in Bethesda, Maryland said at the 2002 annual meeting of the Society for Maternal-Fetal Medicine. "And the long-accepted Friedman curve may not be an accurate description of normal labor progression, according to a new analysis of data from 1,329 nulliparous women aged 18-34 undergoing singleton, vertex presentation deliveries following spontaneous labor," said Dr. Zhang.

Based on the speed of overall labor progression and current cervical dilation, Dr. Zhang and his colleagues calculated the expected traverse time for the cervix to reach the next centimeter and the expected rate of cervical dilation at each phase of labor. "Our curve is very different," Dr. Zhang said, pointing out that on his curve the average was 5.5 hours for progression from 4 cm to 10 cm, compared with 2.5 hours on the Friedman curve.

"We also didn't see a deceleration phase," he said, noting that in 1978 Friedman modified his curve, but the distinctive sharp upturn remained, as did the deceleration phase. "Our data suggest that most women enter active labor at different times, mostly between 3 cm and 5 cm dilation, and even in the active phase the speed of progression varies from person to person," he further explained. The median time for cervical dilation to progress from 4 cm to 5 cm in the present study is 1.7 hours. And for fetal descent, it could take 3 hours to progress from station +1 to +2, and an additional half hour from station +2 to delivery, he added. "Therefore, the definition of protracted descent or arrested descent appears to be too stringent in current practice," according to Dr. Zhang.

Generally, when there is a plateau (stopping of progress) of two hours in Friedman's curve while in a non-medicated active labor, or of three hours in active labor with an epidural, then "failure to progress" is the diagnosis and C-section is indicated. Of course, evaluation of the "4 Ps" -- Power, Psyche, Passenger, and Passageway (basically this means the force of labor, mental preparedness of the mother, the size and position of the baby, and the size of the birth canal) must be made to see if there is a correctable measure.

A long plateau is when a typical hospital provider generally starts to freak out (about malpractice, perhaps?) and push for interventions like breaking water, giving pitocin, and suggesting that the mom have an epidural so she can rest since she's obviously exhausted -- whether or not the client says she's tired. I've had a lot of overnight labors. I've only ever attended one where the woman has said she's exhausted. (And it was a woman who had not followed my suggestion that if her labor began while she was sleeping and she wasn't have contractions yet, she should try to go back to sleep, or at least rest. That might have made a difference.)

In a different setting, with a different provider, nobody freaks out when the labor doesn't progress as it "should." In fact, there are no "shoulds." As long as everyone is healthy -- baby's heart rate is fine; mom is eating and drinking and peeing and resting when she can -- the labor simply continues. The provider might consider some alternatives that would gently move the labor along -- changing positions frequently, homeopathic remedies, eating and drinking, resting, discussing any psychological issues the mom may have surrounding the labor and birth and impending motherhood -- but she doesn't force.

Trusting the process is somewhat different from sitting on my hands, which I wrote about last month. Sitting on my hands was at a birth where everything was progressing as it "should," but I felt like something needed to be done. See, I'm inexperienced! Trusting the process is about stepping back and looking at the facts and making decisions based on this individual situation, while taking into account the midwife's experiences.

A quick note about midwives who work in hospitals, also known as Certified Nurse Midwives. I believe that many of them trust the process, but the physician who is supervising them does not, and they are at his or her mercy. At a hospital birth recently, a machine kept malfunctioning and recording incorrect information; the baby was fine but it said that the baby was in distress. The CNM would come in and say that they had to get it fixed because if the attending physician saw the records, he would "go through the roof." Did she trust the process? Well, yeah, she knew the baby was fine. But she was under the direction of the physician who clearly did NOT trust it -- or maybe because he was supervising multiple labors simultaneously (without ever seeing anyone face-to-face) so he was unwilling to look at the individual labor.

In which I extol the virtues of the Cochrane Database and evidence-based practice

Of all the websites I use for wasting time, The Cochrane Collaboration is probably the one I should make my homepage. Rather than learning how to make a hula hoop out of pvc-piping and a vice grip, the Cochrane Database has systematic non-biased reviews of health care studies.

About The Cochrane Reviews:

"Based on the best available information about healthcare interventions, Cochrane reviews explore the evidence for and against the effectiveness and appropriateness of treatments (medications, surgery, education, etc) in specific circumstances. Designed to facilitate the choices that doctors, patients, policy makers and others face in health care, the complete reviews are published in The Cochrane Library four times a year. Each issue contains all existing reviews, plus an increasing range of new and updated reviews."

Some things I learned tonight from about 15 minutes spent on the Pregnancy and Childbirth Topics page:

• They spell cesarean, "Caesarean" -- so if that's what you're looking for, there's how to spell it. Otherwise you might not get any hits.
  
• In Amniotomy for Shortening Spontaneous Labour, the results were "The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged."
• In Antibiotics for mastitis in breastfeeding women, "The review included two studies and approximately 125 women. One study compared two different antibiotics, and there were no differences between the two antibiotics for symptom relief. A second study comparing no treatment, breast emptying, and antibiotic therapy, with breast emptying suggested more rapid symptom relief with antibiotics. There is very little evidence on the effectiveness of antibiotic therapy, and more research is needed."
• In Vaginal chlorhexidine during labour to prevent early-onset neonatal group B streptococcal infection, "The review of five trials (including approximately 2190 term and preterm infants) showed that although chlorhexidine reduced the number of bacteria that passed to the babies, the studies were not large enough to say whether it reduced GBS infections or not."
  

I found the GBS study the most interesting, because you would assume that if the number of bacteria passed to the baby is reduced, the GBS infections would be reduced also, and it's not (as far as the review shows. Probably more research is needed. Isn't it always?)

I love being a doula, and helping women give birth, but sometimes being at a hospital can be so disheartening. Hospital protocol often has nothing to do with research. Withholding food and drink in labor to prevent aspiration "just in case" moms need an emergency c-section under general anesthesia is ridiculous -- in a study that included 78,000 laboring women who ate and drank, there was not one case of aspiration (source: The Thinking Woman's Guide to a Better Birth). Continuous fetal monitoring for low-risk pregnant women doesn't improve outcomes any more than intermittent monitoring, and may in fact raise rates of c-sections due to the high false-positive rate (same source). And yet, I see the former at every birth, and the latter pretty frequently. Women who are essentially told to run a marathon are told in the same breath to go the distance without food or water. An IV is not meal replacement -- in fact, they often overload the mom with too much fluid, causing her kidneys to work overtime -- and they are invasive and painful.

Glad the next two births I'm scheduled to attend are not at hospitals.

In which I did something that I honestly didn't remember that midwives do back when I signed up for this!

Guess what I did?

Leigh and I had briefly discussed that I would begin giving injections (using B12 as practice) but I haven't started that yet. Meanwhile, we were with an extremely easygoing client who needed an injection, and she graciously allowed me to shoot her up. Thanks!

Add this to the list of things that I had totally forgotten that midwives do on occasion. People think midwifery is about catching babies but that's just a small part of it. Most of it is about care during pregnancy and postpartum; childbirth is just one day. Although it all seems to come down to that one day!

I'm working on a routine for our days at home so that I can keep my house on the right side of CPS's version of clean, get some school work done (mine), get some school work done (kids), and allow all of us a chance to waste time on the computer enjoy free time. So far it's wake up, brush teeth and get dressed, clean up rooms a little, have breakfast, free time for kids (while I do some school), school time for kids, lunch, quiet time/nap, more learning, clean downstairs, plaaaaaaaaaaaaaay etc dinner husband home. I hope it will work out -- I absolutely need some time during the day for school work; I can't do it all at night. Some nights I have interviews with potential clients, or prenatal visits or postpartum visits.

In which I attend a whole bunch of births

with evidence!


(Yes, I hold every baby in my left arm, and only wear solid-color shirts.)

Here's what I've learned lately: I can't predict anything. I can't assume anything. Even when the evidence is there after hours of labor and I'm thinking that I know -- I know! -- in which direction the labor is heading, I usually don't.

I have learned to turn off that aspect of my brain during labor and just focus on the task at hand, like holding an emesis basin while a mom throws up into it. Otherwise I start thinking, "Wow this really isn't going well, I hope she doesn't end up with a C---" (and baby is born vaginally 20 minutes later.) "Wow, this is going fantastic, this baby is going to be here in an hour--" (and 17 hours later, the baby is born.)

It seems antithetical to the idea of holistic midwifery to put my ideas and my experiences on someone else. Every birth is different. I learn something new at each birth. And what I've learned over the last few years is that I just can't predict anything. Women surprise me. Labors surprise me.

I've progressed a little in my school, I'm now in "Orientation" and have requested my curriculum. My mentor just graduated and took the NARM exam. Recently I talked to another student who told me that I'm making my assignments more difficult than I need to; I'm over-thinking them. Really? Me? The woman who can't order food without having an internal dialogue (complete with debate of the pros and cons) between a grass-fed hamburger that is cooked medium versus medium-well?

I guess it's really not that surprising.

Another example of how I have to be like Nike:


and Just Do It.

In which I write about the first birth-related book I read

Copyright 2009. Please do not copy or repost.

The first book about pregnancy I read was “The Girlfriends Guide to Pregnancy.” As much as I want to denigrate the content of the book, especially from the perspective of a student midwife, I enjoyed it at the time. I recall fondly laughing out loud at some of Vicki Iovine’s descriptions of various complaints of pregnancy, because I could relate!

My first pregnancy was unplanned and unexpected, and initially I did not have the support of my family or my then-boyfriend, so laughter and lightness were hard to come by. Looking back, I cannot completely ignore that positive effect of reading it. I do remember specifically that she’d had two c-sections and two vaginal births, and she rated them about equally. At the time, I thought, “How is that possible? One is surgery!”

The first book about birth that I read was “The Thinking Woman’s Guide to a Better Birth,” by Henci Goer. I read it later in the same pregnancy – which turned out to be twins – while on bedrest for Twin-to-Twin Transfusion Syndrome. I was given the book by my doula, Gretchen Humphries, who is a VBACtivist and writer on VBAC-related topics, after she had twins by c-section and two HBACs. I had never read a birth-related book before. It was incredibly eye-opening.

Prior to reading it, I didn’t realize that I had a choice in anything relating to my pregnancy and birth. I just thought the doctor I was seeing – an obstetrician in a high-risk clinic; a maternal-fetal medicine specialist and a twins expert – had my best interest in mind. (In retrospect, I’m not saying he didn’t. But I assumed it because he was my doctor, not because of how he treated me.)

After reading The Thinking Woman’s Guide, I realized that I had to be my own advocate. I specifically remember asking about telemetry monitors, and my doctor gave me a funny look, which I later interpreted – after becoming a doula and seeing that same look exchanged between my clients and their providers – as his realization that I’d become one of “those” types of patients. The annoying type; the type who asks a lot of questions and want a lot of answers, and want to understand the research behind the protocols.

As my pregnancy with my twins progressed, I had a lot of NSTs and BPPs. Baby A, the donor twin, was smaller and seemed growth-restricted. One doctor in the clinic I attended recommended a c-section at 33 weeks, but I refused. I ended up consenting to an induction at 34 weeks due to possible IUGR in baby A. I had cervidil, and did not need pitocin; I had a vaginal birth eight hours after my induction, with a feet-first baby B who was 2lbs bigger than baby A.

I really credit reading “The Thinking Woman’s Guide” to helping empower me. In turn, I wanted to help empower others. Birth is so different when a woman can say, “I chose this,” versus “The doctor did this…” At first I thought that every woman wanted to be empowered during her pregnancy and birth. Later I realized that many don’t. However, those who do need the support of other empowered women, especially those who have had an empowered birth.

In which I write about everything else I do

Today I went to a homeschool conference. I have four children -- monozygotic ("identical") twin boys who are 6 years old, a 4 year old girl who is very sneaky, and a 2 year old girl with ringlets -- and we're going to start homeschooling this year. Or we already are, I guess. Of course the day wouldn't be complete if upon parking at the conference location I hadn't immediately run in one of my sister student midwives and had a quick discussion about recent births we've attended. But mostly my morning focused on learning more about homeschooling.

My biggest concern used to be spending 24/7 with my children; but as I've been doing it all summer and we've all survived, now I'm mostly concerned about finding the time to homeschool, do my own school, attend prenatals and births and postpartums, and keep the house clean enough that CPS isn't called to our house based on reports of squallor. Did I mention we also have three dogs who all shed profusely? Oh, and also keep everyone fed at regular intervals.

I think in my heart, I'm an unschooler. I'm really not looking forward to sitting down with my kids for a specific amount of time and teaching a specific... thing. I'd really rather just kind of let them learn about laundry piles and how to maintain them, and why keeping the door shut to the least insulated room in the house keeps our upstairs somewhat cooler, and how to get dog hair out of the corners where it all seems to converge, daily. I'd rather just let them count their Cheerios and learn the left side of the sink from the right side of the sink for putting their bowls on the proper side, and learn to read by watching TV with Closed Captioning -- because I can't watch TV without using Closed Captioning. I like to see exactly what everyone is saying.

However, that all said, I would like them to read -- at least so they can stop bugging me about "what does this say? what does that say?" -- and write and learn a foreign language and maybe an instrument. Math, I don't really care about, and science is more of Dustin's thing. He's a chemist; I don't even know why the sky is blue.

So, I'm dutifully looking into "curriculum," and have decided that it will consist of Teach Your Child To Read in 100 Easy Lessons, Handwriting Without Tears, and Math-U-See. Also, Sing Song Latin -- one of the only useful lessons from high school was learning Latin and Greek root words and prefixes and suffixes; thank you, Mrs. Taft -- art supplies including Stockmar Crayons, some kids' music, and playing outside.

I'm tired just thinking about it. And this does not even account for time to do laundry!

Seriously, we might be living in squallor! I cannot procrastinate my own school work, I cannot skip prenatals or births or postpartums; something's gotta give. And it will probably be the house.

I'm wildly lucky to be married to Dustin, who is totally impervious to filth. Totally impervious. He has many good qualities, but that may be his best. Of course, when I'm actually ready to strap on my shoulder-length rubber gloves and tackle the bathrooms, he seems totally miffed, but I'd rather have someone who doesn't mind the mess than someone anal-retentive. Or COD, as my bff Emily calls it. That's OCD properly alphabetized, of course.

I have hobbies other than laundry and wasting time online. I love to read. I love to write. I want to show Maizey and get her titled so that she can be bred in a few years. I want to get back into running -- I ran two 5K races several years ago and I felt like a rockstar although at the time I looked more like a Clydesdale.

You know, those giant horses that clop-clop-clop really loudly? That's how people on the coolrunning.com website describe overweight runners. There's even a group called Lady Clydes. Lovely. I have tons of extra skin since my surgery, and my sister swears that running will help. However, my broken toe still hurts, so the treadmill will probably maintain it's usefulness as a towel-holder for another month til I feel 100%.

Sleeping in my bed is another hobby. I miss sleeping late, and I miss my bed. I used to get into bed on Saturday nights and read People magazine; now I leave it in the bathroom and thanks to my weight-loss surgery and its effect on my intestines, I usually get it all read within a week.

In which my ideals conflict with reality

I have this thing. I'll call it a thing. It's like my achilles heel. It's a thing I see at births that drives me a little crazy, that I vow I will absolutely never do.



I know how silly that sounds. It actually sounds like I'm a total birth newbie -- if I weren't, I'd realize that nothing about birth is absolute, and it's stupid to take such a hard line, especially when I haven't seen that many births. Birth is not black and white, and midwives -- midwives! -- value autonomy and individual decision-making over generalizations like "I NEVER do XYZ to clients," or "I ALWAYS do ABC to clients."

In fact, when I was pregnant with my last child, and looking for a homebirth midwife, I interviewed someone over the phone who had a blanket policy for all clients -- when labor started, the client had to take an enema. This midwife insisted on it, in all circumstances. Immediately a giant red flag went up, and I did not hire that midwife.

So why do I feel so strongly about my thing?

In my idealized version of reality, I'm a midwife who sits on my hands and simply watches a woman birth her baby with no assistance from me. (See my post about knitting during births.) In my idealized version of reality, I'm Ina May Gaskin, with silver Princess Leia hair and no make-up and long patchwork denim skirts.



In reality, sitting on my hands is uncomfortable for me, and I can only assume I will continue feeling that way. I don't want to do every intervention, but I definitely have a hard time just watching and waiting.

I think my strong feelings come from my own experiences, and that of a close lovely friend who has had 5 babies. The truth is, I have always messed with my body during labor in some way. I've taken castor oil, an enema, I've had my membranes stripped, I've done the breast pump, I've had sex solely for the purpose of getting the baby out, I've taken black and blue cohosh. I've tried it all, everything you can do at home that toes the line of "natural" induction methods. And I regret it.

And so, as I become a midwife, I guess I want to save my clients -- from MY bad experiences.

But, the rub is, maybe those same things aren't bad experiences for others; maybe they will do them and not regret them; maybe they will do them and feel grateful. I always have to remember that these are not my births. I have to remind myself, my births are over, done. And I can't undo them, or redo them, no matter how many births I attend. Honestly I don't want to, not consciously. (All that pain... throwing up... no thanks.)

So, among all the things I'm learning -- Braxton hicks contractions start at six WEEKS! Engagement is the point when the widest diameter of the presenting part has passed through the inlet of the true pelvis! PROM occurs in 10% of all pregnancies, PPROM occurs in 2% of pregnancies! -- I'm learning about myself also, and how I can be the most effective midwife for my clients. For them. Not for me.

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.