Part Two - "Hands off"

A woman's body is created to give birth.  If there were no one to help a woman through childbirth, most women would manage adequately on their own and their babies would come out...alive...yes, imagine that!  Midwives and veterinarians (but not all OBs) know that complications can arise any time there is interference with the natural birthing process, whether physical interference or psychological interference.  It would, therefore, make sense that birth attendants would serve the mother better by not interfering.

Many midwives are using this excuse as to why they "Do nothing." while attending births. In fact this is a growing fad in the midwife movement of today. It seems to be "popular" for midwives to boast that they are "Hands off" midwives, who simply "Trust Birth" and to condemn any midwife who performs vaginal exams, offers any kind of suggestions to a laboring woman, encourages a woman to push at any time, carries life saving equipment or even attempts to stop a hemorrhage!  "I just leave it alone," one midwife said, "I have found that they eventually stop bleeding.  They may need a few extra days to recover, but they recover." (WHAT!?)

Many years ago, while in my apprenticeship, I attended a birth, with this midwife.  It was a first time mom, who was having a long, hard labor.  I wanted to help her, but didn't want to overstep my bounds, so I just sat and watched, frustrated, while the attending midwife calmly read her novel and ignored the agonizing mother.  After several hours, the mother, looked up at her midwife, with pleading eyes and desperately asked, "WHAT do I  DO!? TELL me what to DO!"

"Whatever you want to do, sweetie," the midwife replied, and then returned to her book.  With that, I dropped down onto the floor beside the mother and began to rub her back and talk to her.  No sooner did I begin to help, when the midwife also dropped down onto the floor and started doing what I was doing, to which I responded by backing off and returning to my chair.

Another "Hands off" midwife put it this way, "If you need to bring a crossword puzzle or a knitting project or a book to keep your hands busy, do it. But don't interfere with the beautiful dance of hormones just because you feel like you're doing nothing. You should feel like you're doing nothing, because nothing is exactly what's needed in the vast majority of normal births."

Yes, there have been births where I have done nothing but watch the miracle happen.  They didn't need me. It was obvious.  At these births there is usually a super dad, who happens to have a gift for coaching.  A midwife is not there to interfere with the beauty of a couple doing it together.  There is also no need to "help" in the progress of a birth that is happening and progressing normally without any special tricks of the trade, other than to offer comfort.  We should know when to be patient.  We should know when to shut up and be quiet.  We should know when to keep our "Hands off."

There is a fine line between knowing when to drop down on the floor and get busy and when to stay back and be quiet.  These cues will come from the mother herself OR the baby OR even the father.

A mother in early labor should almost always be left alone, preferably with her mate.  A quick safety check and I am out of the room.  I have found that laboring mothers are very territorial and sensitive.  Just a midwife walking into their home can slow down their labor until they get used to her being there.  It's no wonder that labor can completely stop when a mother walks into a hospital full of strangers!  We have all heard stories of mothers being sent home from the hospital only to accidentally have their babies at home or in their cars.  This is why.

As labor progresses and becomes stronger, the physical presence of her midwife will begin to bring her comfort.  The mother lets the midwife know, by her cues, when she needs her help.  The labor partner will also send out his own requests for help, if only with his body language. At first I will go in to her, find which comfort technique works best for her and instruct her mate on how to perform that technique.  I might assess her progress and position to make sure she isn't doing anything to hinder her progress, then I might leave them alone again if it seems they are satisfied with the pep talk and ready to be alone again.  Due to the heavy flow of oxytocin, aka "Love hormone" which is also what stimulates contractions, a mother will bond with her labor coach.  It is good for relationships, to allow this bonding to take place between the couple, rather than with the midwife. Almost inevitably the midwife will have her turn.

My sister, while a labor and delivery nurse said, "More women get epidurals for their husbands than for themselves. Well, it may also be true that the men need the midwife more than their wife does.  Either way, we are there to help both of them.

Yes, I have had mothers, who asked me to do nothing.  I have had them ask me to stay in the other room and only come in when called.  I can do that.  I can, but usually, that mother who thought she wanted to be left alone, will at some point, plead for help.

One such mother was adamant, during her prenatal visits. "I don't even want to know that you are there," she said.  "I don't want you touching me or saying anything or doing anything.  My husband and I are very private and have always done this alone together."  I thought that sounded wonderful and beautiful!

When she went into labor, things took off very quickly.  I doubted if I could get there in time as it was an hour drive for me.  I was on the phone with her that whole hour, while she begged, "I NEED YOU! HURRY!"  When I arrived, she cried for me to help her, so I went in and found her in the bathtub, completely out of control of herself due to the intense pain she was experiencing.  Her husband looked completely helpless and relieved to see me. She landed those pleading eyes right on me, and although I feared she might fault me later, I helped her slow down her breathing and to moan, rather than scream. I noticed that her back was arched and, out of fear, she was pulling away. I explained to her that her baby would come much more quickly and with less pain, if she rounded her back and curled around the baby instead of pulling away.  She desperately followed my suggestion and gasped, "That feels SO much better!"

The baby didn't come immediately.  He was larger than the rest of her children and a little posterior.  I helped her assume a series of positions and to breathe in such a way to helped her baby make the rotation so he could slip through the pelvis more easily.  It was a beautiful birth and rarely have I received so much gratitude from a client!  She continued to thank me for months afterward and often repeated, "It was SO much easier for me than with my other births, because I had you there.  My other midwife didn't do those things for me."

I can't understand how or why a midwife would deny a pleading woman, but there are also safety factors involved and problems that can occur when the midwife doesn't do her job.

I have learned that there is a "Critical period" during labor when the majority of the progress should occur or the opportunity will pass.  This period is typically called, "Transition."  During transition, the cervix should be dilating very quickly, the baby should be dropping down into the birth canal, molding and and rotating.  The contractions are intense at this time.  They are lengthy, which is reason for the rapid progress.  When contractions are short, they seem to only bring the cervix back to where it ended up with at the end of the last contraction, not lasting long enough to dilate it any further past that.  The real progress occurs in the second minute of the contraction, IF it lasts that long.  IF the mother is in a position that hinders progress or the dropping of the baby, she may go through painful contracts in vain.  It is the midwife's job to help the mother to not expend useless energy, endure useless pain; and to make sure the baby is not tiring.

I was asked to come to the hospital one night because one of my client's sisters had been in hard labor with no progress past 6 cm for 5 hours.  She had decided to try a drug free birth but was becoming discouraged.  They wanted to see if I could help.  When I arrived at the hospital, this woman said, "Oh Liz, Don't you think I should just get an epidural?!"  The nurses had dropped the foot of the bed and had her sitting in an upright chair position, slightly reclined.  I knew immediately what was wrong.

"Let me just check you and see what is going on.  I came all the way over here tonight.  Could you please just give me 10 minutes?  If I can't help you in 10 minutes, then I will leave and you can get the epidural, okay?"  She eagerly agreed.

A vaginal exam confirmed my suspicion.  The position she was in was closing off the pelvis by positioning the pubic bone right in front of the descending head.  The head was high in the pelvis, on top of the pubic bone; and the very soft cervix was just hanging there, like a wet sock with nothing coming through it.  The hard contractions were just forcing the baby against the unyielding pubic bone, thus no progress.

I had her sisters recline the bed and raise the foot of the bed back to a level position.  I put the mother flat on her back, yes, that is what I said, "flat on her back."  With the next contraction, I had her sisters bring her knees up so that her bottom was barely touching the bed.  This lifts the pubic bone out of the way while gravity drops the head to the back of the pelvis so it can come under the P-bone.  I had her bring her chin forward, onto her chest to further round the spine and to breathe her baby down, allowing it to drop deeper into the pelvis with each wave of the contraction.  With the cervix as elastic as it was, there was nothing to stop it from yielding to the descending head.  In one contraction she went to 9 cm as the head dropped right into the vagina.  I sent someone to alert the nurse.  Yes, I had my hand in there, feeling the whole miracle happen, to be sure that this position was going to work.  Some would call that "birth rape."  This mother called it, "mercy." Baby was born with the second contraction after I got there.

"Hands off" was not helping this mother, in fact, it nearly cost her an unnecessary epidural.  Eventually, with no progress, this woman's labor would have shut down.  This is the body's safety mechanism to prevent women's uteruses from exploding, although some of them still do if allowed to labor for too long.  It's called a "Bandl's Ring" that precedes the rupture.  Of course most of the time, the uterus just gets too tired to contract anymore.  This is why it is so important to make sure that nothing is hindering the progress and that hard contractions are taken full advantage of.

There are SO many stories of women, who labored for hours and hours, even days with no progress.  All the while, the "Hands off" midwife is telling them to be patient, that the baby will come when it is ready.   To do what they "feel like doing," while the midwife reads a book, does a crossword puzzle or knits. Too often these women end up with a stalled labor and a trip to the hospital for an epidural and some pitocin augmentation.  How is THAT better than some "Hands on" techniques at home?  In extreme cases the uterus is so tired that even pitocin can't help and those women end up getting c-sections.  How is that better?

Yes, there are times that "Hands off" is appropriate, but there also comes a time to help.  Knowing how to help comes with experience in helping.  Helping also takes courage.  It is much easier and risks less criticism to sit and read a book  Most babies will eventually come, but at what price?

The risk of hemorrhage is greater with prolonged labors, fetal distress and post partum depression is more likely, plus they just aren't fun!  Prolonged second stage labor can cause damage to the pelvic floor as well as damage or death to the baby.  No mother should be instructed to resist her urges to push, no matter what her dilation is.  Pushing is very satisfying and natural.  To resist is an interference with the natural process.

While choosing your midwife, remember this:  A good midwife will be skilled in both "Hands off" and "Hands on" midwifery and will know when the time is right for each, but here is the bottom line: A "hands on" midwife can always be "Hands off," but a "Hands off" midwife doesn't always know HOW to be "Hands on," because "Hands on" takes lots of experience in being "hands on."

Elizabeth Smith
Licensed, Certified Professional Midwife
435-632-8998