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Rant: Navigating the maze of caregivers and birth choices
Kat's thread on Will's birth story really got me thinking about the past
couple weeks. You see, with my daughter's hospital birth, I did everything "right" that I knew about at the time in order to have a positive birth experience, and to put it bluntly, it sucked. Well, 11 years later, having taken part in other women's births as a doula, going through childbirth education, working at a midwifery magazine for 7 1/2 years, you'd think I'd have it made as to getting things "right", no? Now, from a purely "technical" standpoint, my daughter's birth was an uncomplicated, unmedicated, reasonably short birth for a primip in a hospital with a 90% epidural rate. Pretty damn amazing in some ways. In other ways, it felt like every scrap of accomodation I asked for I had to argue for, and while the "letter" of my birth plan was followed, the spirit of it, and my spirit as well, were violated. Perhaps the unkindest cut of all was that I told everyone I met that I'd have a homebirth if I could, and weeks after the birth the midwife who acted as my labor support said that she had been really prepared to catch my baby at home. If she'd told me that up front, things might, maybe have been different. I don't know. I was very attached at that point to the "high risk" label. Fast forward. After 6 or so years working for a midwifery magazine, reading birth story after birth story, talking to women on the phone, etc. I knew that just because someone wore the title "midwife" did not automatically make her perfect. Even some of the biggest names in the profession, nationally, internationally known midwives were starting to sound medicalized. Like their trust, faith in birth and birthing women had been broken somewhere and they didn't even know it. I knew that in the next few years I would be contemplating another birth, and was surprised by the fact that although I knew many, many midwives, there were very, very few that I would actually trust in the intimate space that is a homebirth. Not because I thought they didn't know enough to be good midwives, but that they knew almost too much to trust me at all. And the one lesson I learned from my birth with my daughter is that where birth is concerned, my body *really* knows how to get moving and do what it has to do. The first time I heard about unassisted birth, I remember thinking, "How crazy! Why wouldn't they want the loving support a midwife can provide?" Then I started reading. And the birth stories told me why.. I told my boss, "You know, this movement is an indictment of the midwifery community. It's born out of the same anger the lay midwifery movement of the 70's was born in, and as long as midwives keep focusing more on 'safety' than sanity, the unassisted birth movement is going to grow." Then I kept reading. I read Michel Odent's work on instinctive birthing. His catch phrase is "do not disturb the mother." But even he has not truly taken this to the logical extreme. I joined the yahoo cbirth list and kept reading. I entered the list from a professional's perspective. But the longer I stayed, the more my perspective shifted to the question, "What is it that I want from my next birth?" And I realized that when I was pregnant, I fantasized about birthing alone. That what Michel was talking about was the fact that a truly undisturbed mother, a woman who is given the space, darkness, quiet, peace and TRUST necessary for a birth, will usually birth more easily than someone who is being closely watched. That women undisturbed will tend to move to birth-as-reflex, which is about as harmful as a sneeze. That what I really, really wanted, was a birth where I did not have to argue with anyone, worry about anything, wonder when I should go or call or do ANYTHING other than what my instincts to me to do. That I did not want to "plan" a birth, because planning a birth is like planning an orgasm or planning a sneeze or planning a hiccup. The more you plan, the more likely it is to surprise you, not happen or go wrong. As I got closer to trying to conceive, it became clear to me that it would be almost impossible with my known risk factors to find an obstetrician who would take me on, especially since I flat out refuse to plan a hospital birth. And I'm way out of the comfort range of most midwives, because I am not technically low risk. Now keep in mind... my risk factors are all tightly controlled. They are not risk factors which affect birth so much as pregnancy. They are risk factors that might mean a smaller baby if I don't control them well, that might mean miscarriage, that might mean stillbirth. But the only medical treatments available for the worst of my risk factors carry with them risks that I'm not willing to take on. I have herbal treatments which, while not as well "measured" in their effects, are a lot less risky in terms of how they will affect the birth process. And there are many, many women out there walking around with very similar problems who don't even know they have those problems. Maybe those women snore, and get bad hay fever or bronchitis a lot, and maybe Aunt Mabel died of a stroke at age 40 and Uncle Jim had a heart attack at age 28. But as far as they know, there's nothing "major" wrong with them, and they're not treating what in me has been diagnosed as apnea, asthma and a blood clotting disorder. I do treat and control those problems very closely, and during pregnancy, my overall risk is not very elevated. And the risk during birth is no more than my risk during pregnancy--if my risk factors alone justify hospitalizaiton for birth, then I ought to be hospitalized for the whole pregnancy--which in itself would increase my risks for clots, infections and poor sleep. Catch 22, that... So I decided that I would go for an unassisted pregnancy and birth. I felt very much at peace with that choice. Then I started to miscarry. Now, keep in mind that I am NOT basically opposed to all technological assistance. I simply refuse to have it "routinely" applied for someone else's liability coverage. I was 7 weeks along, had not even really thought beyond the idea that, oh, Dr. so and so might be a good choice for backup if necessary. As I started to get more and more pain that was typical of blood going where it shouldn't, I realized that I really needed to figure out if the pregnancy was in the uterus or in the tubes. I knew at that point that the technology I was comfortable using would be an ultrasound, a rhogam shot, and possibly a blood test. So I called my regular doc. No joy. They didn't want to touch me with a 10-foot pole. They referred me to Dr. So and So, who yelled at me at a time when I was scared to death and *asking* for help. I tried Urgent Care--they said to go straight to the ER. I gave up and went to the ER. They were willing to do an ultrasound without a pelvic (there was NO useful info to be gained from a pelvic) and I refused a catheter (my bladder was so full when they finally got me up there that I had to actually "go" a little for them to do the test!). I insisted on staying to get the rhogam even though they said I should get it at my doc's the next day, knowing the chances that I would be able to get a rhogam within the 72 hour window from when I started bleeding were slim to nil given I had no OB. Two days later I started calling to see if I could get a follow up blood tests. I didn't want to be examined. I didn't want to be evaluated, I just wanted the damn blood test because I would know what it meant either way. It took at least 4 phone calls at a time when I really didn't want to be on the phone to finally get a doctor's office to agree to do the test--happened to be the place I'd gotten my IUD in that finally said, "Yeah, sure!" The baby came out that night. Complete, no poking, prodding or scraping needed. The bleeding stopped quickly and getting the test results the next morning told me everything was done, as the beta had dropped significantly. When the nurse gave me the results, she asked if I wanted to come in. I said, "I'd like someone to tell me what I'm seeing, because it doesn't make sense." While they could "send the baby to pathology", it wouldn't tell me anything about what I was looking at. Some midwife friends who are coworkers at the magazine came over and did what I asked. We figured out what the placenta was, where the "fetal tissue" was (because it looked nothing like what I thought it would) and when we were done, I buried the baby in my mother's herb garden. Couldn't have done that if we'd sent things to pathology. I realized at that point that I never, ever wanted to have to spend that much time figuring out logistics when I was scared and in pain. Not ever. So I embarked on finding the right midwife, so that if I needed to call someone, I'd know who to call. My coworkers were not an option, because the relationship was already established on a different level and I just don't shift gears that easily. So I called the midwife I'd had with my daughter--she lives 2 hours away. She suggested one midwife in my town. I called her. The interview was long, we dredged up all my old birth trauma, all the anguish of the miscarriage, and then, after all that, she said, "Well, I know that I would insist on measuring to make sure the baby is growing, listening to the baby to make sure things are well, and I need to be there at the birth, even if I don't do anything." Well, the whole issue for me is not that I will "refuse" to let someone measure or listen, but that I want to be the one to decide if it's necessary. If my belly is growing well and I can feel the baby taking up space, I don't feel a need to use a measuring tape. They're wildly inaccurate anyway. If I was worried about growth, I'd eat more and probably measure my belly a few times myself (I know how). But I dont' need someone else to do that. And if baby is kicking persistantly, I don't need fetal monitoring, either. I remember moments of extreme irony where a nurse would be muttering about not getting a good read, and I'd just say, "I know, she just rolled herself away from the transducer. She's kicking my ribs." I might *ask* for a midwife to listen if baby wasn't kicking well, or I might listen myself, but it has to come from me, not someone else's protocols. And I'm not going to promise to call anyone. If I'm right, then most likely I will go into labor one night in the quiet dark, or during the day when no one is home, go into my own little cave and stay there until the baby comes or I feel like I need someone with me. My dreams for years have been of a baby coming quickly, quietly and peacefully into the world, and knowing how fast my daughter's birth went once things were in line (2 1/2 hours from 4 1/2 to complete, 23 minutes pushing, on my back in the worst possible position.), a well-aligned baby could come very, very fast indeed. And if it's not fast, not quick, not easy, then yeah, I might well want to call a midwife in to rub my back just so, give support, monitor if I'm nervous about something, etc... But I can't promise to call and I'm *surely* not going to trust someone in my birth space who won't trust me to tell them when and if I need help. I have this vision of going quietly into my mother's bathroom one evening and coming out with a baby, saying to my family, "Um, oops?" But I also know it could take a lot longer, and I might *want* a whole lot of support. So I politely told the midwife I didn't think it would work, sent her on her way, and started down the list of midwives in the area. The next midwife I talked to mentioned her concerns about liability isues but wanted to meet with me anyway. I should have listened to my gut on that one, because the minute she mentioned her license, I thought, "Uh oh..." But she said she thought we might be able to work together, so I agreed to meet her, but told her that if she wasn't pretty sure it might work that I dind't wnat to bother as I was finding the interview process very stressful. She came over, we talked, though for not as long as I felt from the start of the phone conversation that this was not the right one... and sure enough, after we'd talked for a while and she seemed really positive, she popped out with, "You know, my boundary is that I really need to be at the birth. Because I would have been a perfect candidate for an unassisted birth, but if I'd had a UC, my baby would have died because we had a shoulder dystocia." Oh hell...I've just miscarried and this woman thinks I need to be reminded of all the things that can go wrong? I helped put together a book on shoulder dystocia, darn it. I quit my damn job because I needed to quit look at all the things that can go wrong. I *KNOW* the risks. I know them very well. And the, "My baby would have died if I'd done a UC" argument is as specious as the, "If I had had a homebirth, my baby would have died" argument. You simply cannot generalize that way. Period. The fact of the matter is that she has no idea what the hell might have happened if her midwife had not been there, and in fact, she has no idea if she'd been planning a UC that something wouldn't have prompted her at some point to call in help. People are funny that way. You cannot look at a birth after the fact and say, "If we'd done X, Y would have happened." It just isn't that simple. I've talked to UC moms who've had shoulder dystocias. By and large, so to speak, they get their babies out one way or the other. I've talked to women who've planned UC's, called in help for what seemed like a minor reason at the time, and then had shoulder dystocias which made the help very welcome. Her first birth, it took her an hour to push her baby out, in a homebirth, I assume, in probably a relatively good physiological position. Turns out the first midwife I interviewed was the midwife at her birth... no wonder. My first birth, it took me 23 minutes in a crappy position. You just can't generalize from one to the next, nor from one woman to another. I know there's a risk in having an unassisted birth, but there are risks to hospital birth and assisted birth as well. I need to go for the risks *I* am willing to bear for the benefits *I* want to see. It's not about what ANYONE else feels comfortable with. It's about what my husband and I decide is right for us, the risks we're willing to live with and the risks we're not. I'm *not* willing to accept the risks of lovenox and induction at 39 weeks without being acutely ill. Period. I *am* willing to accept the risks of not doing ultrasound or listening to the baby unless I feel like it's important. We're the ones who have to live with our choices, so we get to make them. Period. I quickly ended that interview, sort of in shock that she'd essentially misled me so that she could come over and tell me how risky unassisted birth is at a time when I was already emotionally raw and vulnerable. This is midwifery? Another call led me to a midwife who'd had several unassisted births of her own. Here's hoping this interview goes better. I explained to her some of the other things that had happened with other interveiws, over the phone, and she said that her boundaries are not about being there, but about having full disclosure (um, if I was willing to lie, I'd have a care provider already...) and a letter on file stating what our expectations and needs were, and that we understood there could be risks with not following standard protocols. That's it. Nothing about "needing" to be there. Nothing about "having" to listen to or measure the baby...she's just asking for honesty and forthrightness. I have no problem with that. My next step is to talk to that doctor's office that actually did the tests. Find out if they can continue to meet me on my terms, as backup. It's possible, but I'm not holding out great hopes. That said, if I already have a midwife, then going to the ER is a little simpler as I can say, "I'm seeing a midwife" and not end up shuffled into the social service's morass that defines anyone who does not have a care provider as a nut case liable to dump her baby in a plastic bag somewhere. This time I just said, it's really early and I hadn't decided on a care provider yet (the truth.) But the thing that keeps coming back up for me is that there is this tremendous lipservice paid to "safety"...yet when someone is willing to take responsibility for their own health and care, then accessing care "for safety" becomes extraordinarily difficult. For an ultrasound and rhogam shot, I should NOT have had to spend 6 hours in the ER. I should not have had to spend 3 hours on the phone to get a simple blood test. This encourages women to seek help when they feel they need it? I think not. The focus is not really on safety, you see... not my safety... but on the doctor's liability...the midwife's license... the hospital's policies...routine....Why is it that one practice can order a blood test without a qualm, but another practice requires an office visit? It's not about *my* safety. I refuse to be routine. I refuse to do things just because "that's how they're done." My body has shown through a birth and a miscarriage alike that it is strong and capable of doing whatever it needs to do in order to take care of things as they need to be taken care of. I was thinking about this during the miscarriage--I was not miscarrying because the placenta was separating--my body had to very deliberately contract my uterus in such a way as to sheer a very small placenta off. In a live birth, this happens relatively simply--the uterus has a baby to push against, the baby's head helps open the cervix, etc. The placenta sheers off quickly in most cases because with no baby in the womb, the size changes so radically that it peels off like a postage stamp. In the miscarriage, the gestational sac took up maybe 1/6th of the available room in the uterus and was nowhere near my cervix. Truly there was no weight to pull and no size change to help. My body had to cramp and cramp HARD for about 14 hours to get the placenta loose. It took 10 hours of little contractions to open up my uterus enough to let the baby out, and that was just when I was awake. But my body DID those things, which are, in their own way, more challenging than giving birth, where the baby's size and weight serve to help with the process. And with giving birth, my body contracted to move my daughter into a better position, then just opened up and pushed her out. All I really had to do was stay upright and walk through the contractions. My body took care of the rest very competently. In the ER, they routinely do pelvics for threatened miscarriages. WHY? I can tell them I'm bleeding and cramping. At that point, my cervix was hard and closed, I could tell them that, too. Later it was open and soft--I know the difference! I asked what information the doctor would get out of it, and he sort of blinked and said, "We just always do them. But if you don't want one, we don't have to do it." Then they wanted to do a catheter for the ultrasound. Why? I can fill my bladder in about 15 minutes. They're going to do a catheter on someone threatening a miscarriage? When I get bladder infections easily from catheters? He said, "What they do and what makes sense are two different things." I responded, "And that's why I will never plan another hospital birth." Because I don't want to argue common sense against hospital policies, not ever again. And especially not when I'm in labor. Because in labor, I will eat when I am hungry and drink when I am thirsty. In labor, I will only allow monitoring if *I* have a question about how the baby's doing. In labor, I will not get on the bed just so someone else can stick their fingers in my crotch to check to see if I'm dilating. I had no exams between 4 1/2 cm and complete, and I got there anyway. Vaginal exams don't help get the baby out, they just give a couple trivial pieces of informaiton about something that is dynamic and can change very, very fast. I've seen women go from 3 cm to complete in 10 minutes. I really, really don't need anyone second guessing me in labor, least of all myself when I hear some number that doesn't really mean what I think it means. In labor I heard 4 1/2 and knew it had taken me 6 hours to dilate 1.5 cm. But that didn't tell me that it would only take another 2.5 hours to dilate 5.5 cm! If I can't find my cervix and want to know what it's doing, then I'll ask someone to examine me. But I'm not going to lie on my back just to satisfy someone else's curiousity! I got over that one in college. Birthing my baby, I want not one word from the peanut gallery telling me if I can push, when to push, where to push, or how to push. I'm a damn good pusher and will do it in spite of anyone else. I might, however, strangle the next person I hear start to say, "Hold your breath and count to 10." After my baby is born, no one is going to take that baby out of my arms or touch the baby's cord without my permission. Not for anything. They're not going to wake me up to tell me it's time to nurse, or to take my blood pressure just because it's time according to their schedule. They're not going to poke my baby for information which is meaningless anyway for another 48 hours or so. They're certainly not going to put anything in my baby's mouth. And the last place I want to be is in a damn hospital full of sick people. Are they crazy, putting maternity in the same building as people with horrible infections? Haven't we learned *anything* from Semmelweis? I've worked as a CNA. And the floor of a hospital is a filthy, filthy place. If they drop a pillow, they will pick it up and put it back on the bed. I think my baby and I stand a much better chance in the friendly dirt of our own home, versus the illusion of false sterility a hospital gives... the janitors go everywhere. So do the lab techs. And they carry what was on the dropped pillow on the surgical ward to the floors of maternity. I'm just not going to argue with someone when I've got a precious new baby in my arms. I'm not going to argue while I'm trying to bring that baby into the world. I want to be able to access care if and when I need it, without being yelled at or condescended to. I'm really convinced that while this may be a lot to ask, it really SHOULD NOT be too much to ask. Jenrose |
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