Do not read this post, if you are not comfortable with the word, "Vagina." This word will be used in this post. If you are not comfortable WITH vaginas, then this post may or may not help you to become more comfortable with them. We'll see. Personally, I am comfortable with vaginas. I have one; and I have seen and examined thousands of them and even repaired a few. I have taught people about them and have talked about them a LOT with their owners. For me, they are like a mouth to a dentist, just an orifice of the body, like any other; and I am not embarrassed by them, except when it comes to mine. I am pretty particular about who I share mine with. We all should be; and we as midwives, should feel privileged when someone chooses to entrust theirs to us.
Lately, there has been a lot of controversy about vaginas, particularly in the examination there of. Many women are beginning to fear them and made to believe that these exams are an unnecessary expression of practitioner dominance over the female victim. Practitioners, who perform these examinations are being persecuted by the "Trust birth-ers" and their midwives, by being called "Birth rapists" simply for believing that there is a time and a place for vaginal information.
Women who have allowed someone to examine their vaginas are being informed of their "Violated" status in society and referred to therapists to heal from the experience. They are now able to join support groups and receive acceptance into elite groups. And to think of how many of us have been victims of dentists who have place their fingers in our mouths! Where is MY "Oral rape" support group? I am WAY more traumatized by my dentist than by my midwife!
OK, so, I believe that I am a "Vagina expert" and am quite qualified to speak on the subject. I will examine (no pun intended) the physiological and psychological aspects of the vaginal exam - Why we do them, why you might want one, what valuable information there is to be found inside a vagina and when they are necessary or not necessary.
When a pregnant woman comes in to my office for her first prenatal exam, one of the first things I tell her is, "Relax, I won't be doing a vaginal exam today," because sheesh! What's the hurry? Why does a pregnant woman need a PAP smear right now? Why perform pelvimetry when there is still so much "pelvis opening" to take place over the next several months? Why feel the size of the uterus from the inside when you can feel it from the outside? Why look for signs of pregnancy when we have advanced detection kits at Walmart?
There are physical "reasons" why doctors (or midwives) perform vaginal exams during the first prenatal exam, but according to an old 1955 Obstetrical textbook that I have on my shelf, there are also psychological reasons, It reads, "The initial pelvic examination also serves to establish an intimate relationship between patient and physician."
(WHAT!?)
Apparently, physicians have known, for years, the fact that when a women disrobes for him/her (usually him, we'll call him "him") she begins to view him differently than she does any other man, except for her husband, of course. The doctor has now earned her trust, simply by seeing her naked. If you are a woman, then you know what I mean. This is called, "Job security," but I am not going to talk about that right now.
Putting aside the psychology involved: In 30 years of practice, I have not yet seen a "safety" need for routinely subjecting clients to the humiliation of pelvic exams during their first prenatal visit, especially when there is plenty of time for that later; but is there ever a good reason for such an examination during the course of the pregnancy? There is; and here are a few examples:
- When the client requests a vaginal or rectal exam due to physical problem/s she is having in those areas.
- When there is vaginal bleeding or cramping - symptoms of miscarriage. A gentle vagina exam could determine if the cervix is dilating, pointing to a threatening miscarriage. Using a speculum and swab can help the practitioner to determine where the bleeding is coming from. ex: from the cervix or a ruptured vessel in the vagina?
- When there are symptoms of threatened premature labor. A gentle vagina exam can determine if the cervix is dilating, effacing, coming forward or is low in the pelvis or if the water is bulging. Contractions that are affecting the cervix might also be detected during the exam and the strength of those contractions noted. I have had cases where such an exam has alerted us to a real threat and enabled us to prevent a premature delivery. In one such case, I found a 5th time mom, who had no symptoms except for her husband had a "feeling," to be 5 cm dilated, 100 % effaced, head engaged and membranes bulging. She was not having contractions, but the threat was REAL. I alerted the pediatrician and hospital and then had her husband carry her to the car and drive her home. She was put on strict bed rest and given a herbal blend to prevent contractions. I made house calls to visit her. She held the baby in for 5 more weeks and delivered only 3 weeks early, at home, after only 20 minutes of labor. That is a success story that began with a vaginal exam. Without the exam, things would have turned out differently.
- In later pregnancy to confirm the position of the baby or assess the condition of the cervix.
Now let's address the late term pregnancy vaginal exam: What are we looking for or hoping to find in those "Dilation checks?" beginning at week 36-37.
- Presentation - do we have a head down (cephalic) presentation or something else? This is very important to know for safety reasons. Although fetal position can be palpated through the abdominal wall, this is not always foolproof. The vaginal exam confirms what we thought we felt or couldn't feel through the abdomen. We can also feel other fetal body parts that might present with the head, or even a cord.
- Cervical station - how low is the baby? In a first time mother, we are not surprised to find the baby engaged in the pelvis two weeks prior to delivery. A multipara might have a "Floating" head that risks a prolapsed cord, should her water break while the head is still floating.
- Effacement - This is even more important than dilation in predicting labor, but most people don't know this. How thin (or short) is the cervical neck? This usually, but not always, is related to how low the head is.
- Cervical consistency - How soft and/or elastic is the cervix? In the last few weeks of pregnancy the tissue of the cervix actually goes through changes in its cellular structure. A practitioner who is very familiar with the "feel" of cervices can detect these changes. When a cervix is not ready for labor, it will not only feel firm, but it will feel like there is a thick, unyielding, rubber band or drawstring inside of it, holding it firmly closed. Just before labor begins, that "rubber band" will release and the cervix will become loose and elastic as if you could easily stretch it in any direction. When I feel this, I know I need to get to bed early that night. If the cervix is very thin, elastic and low, I know I need to instruct the mother to call me with the first contraction and that when she does, I need to hurry, even if the cervix is not very dilated at the time of the exam. This knowledge can help prevent the birth from happening in the car, on the way to the hospital or birth center or unattended at home with a screaming father on the phone and a midwife sitting on the side of the road receiving her speeding ticket. (yes, this has happened)
- Angle and position of the cervix - is the cervix easy to find in the front of the vagina, or is it way behind the baby's head? Is it off to one side or the other? This is a really good clue as to fetal head position. A posterior cervix is common with a posterior baby. With an acynclitic baby the cervix is likely to be to one side or the other. Mother can then use techniques for helping her baby nestle into the pelvis to facilitate an easier delivery. (but NOT the "spinning babies" technique Please! THAT is another blog subject)
Vaginal exams during the last few weeks of pregnancy are performed more to satisfy curiosity than for safety purposes, although it can be quite helpful psychologically for the mother to know how she is progressing toward labor and what she can expect once it happens. There are natural remedies for tough cervices that can help to prevent a long or overdue labor if this condition is learned of soon enough in advance.
Mothers love to be involved with their pregnancies and know what is going on. I even recommend that they learn to examine themselves so they can get to know their cervices. This helps them during labor to focus on where the pain is coming from and what benefit it has for them. If she knows that the pain is opening her cervix, she will welcome it more. A mother might also like to know when to have her mother come to town or when her husband needs to stop leaving town. These are all benefits of a good prenatal "cervical reading," but not always safety necessities.
Now I will address vaginal exams during labor: This type of exam has come under brutal attack lately, but I have not heard a legitimate reason WHY. Women are just being told that it is wrong and that they need to say "No." Practitioners, particularly midwives, are being persecuted if they do them, even when it is at the mother's consent or request. If you want to get everyone's attention at a midwife herbal tea party, just tell someone that you do vaginal exams; and the room will suddenly become quiet and look your way. Not yet, has one of these vagina-phobic midwives given me a good reason WHY vagina exams are wrong, SO how about I give YOU and THEM a good reason WHY I do them and why I recommend them, at least once during each labor?
I have had cases where a vaginal exam, during labor, has been life saving. Yes, literally saved the baby's life. Is THAT a good enough reason? I have had more cases where a vaginal exam during labor has prevented a c-section or hospital transport or other unwanted interventions. I have known of cases where NO vaginal exam has led to a disastrous outcome. How about those for reasons?
In one such case of disaster prevention, labor was progressing quickly. When I arrived and saw her laboring, I figured I hardly had time to set up before the baby would emerge. There was no reason to suspect any kind of problem. It was her 3rd baby and the last one had nearly fallen out without much effort. She was laboring hard on all fours and I sure didn't want to intrude, but thinking of unknown possibilities, I suggested a quick "Safety check" vaginal exam, to which mother agreed. To my surprise, my fingers touched an eyeball and eyebrow with an ear off to one side. The baby was locked down hard in this position being shoved in harder with each powerful contraction. I had just examined this mother earlier that day and found a perfect presentation. It's a good thing I didn't assume everything had stayed the same! I transported her immediately to the hospital. The receiving OB wanted to wait and see if the baby could be born vaginally, face first, but as soon as the mother's body began to push, she pulled back and yelled, "It's hurting him! I need a c-section!" So the doctor agreed to perform one. As they were prepping her for a c-section, the baby suddenly crashed, meaning his heartbeat began to drop rapidly with no recovery or variability. He was dying suddenly and quickly. The baby was barely saved by an emergency c-section. Luckily the only bad outcome was a baby with a very swollen, black eye and brow.
In another case of disastrous outcome: (This story was told to me by the midwife herself and then again later by the father of the baby) The mother labored for several hours and, just like in the last story, it seemed that everything was going along normally. The midwife decided to get some sleep but after it seemed that too much time had gone by without being called in for the birth, she decided to do a vaginal exam to see what the hold up was. She found the baby's arm in front of the head, sticking its elbow into the vagina. The mother was 8 cm. She transported the mother to the hospital but it was too late. The baby had been allowed to descended deep into the vagina elbow first! A c-section was performed at the hospital but the baby sustained irreversible brain damage.
In another case, (twins) the initial exam found a normal head down position, but during another exam, an hour or so later, it was found that an umbilical cord had slipped down beside the head. The membranes were still intact and the babies were not in trouble....YET, but because this potential for disaster was detected, a disaster was prevented.
I have too many more stories to tell to illustrate the importance of vagina exams during labor, for safety reasons. The fact is, no one can know, for sure, what is going on in there, without examining it. Yes, I have heard that you can feel the dilation of the cervix by palpating a mother's foot (heal) or one can tell by other "energy" tests if all is well in there. I love to ask the people who do this sort of thing to tell me a woman's dilation BEFORE I examine her. I've not yet seen one instance where dilation was correctly estimated by palpating a woman's heal, but if no one is doing a vaginal exam to confirm it, they can say whatever they want. I am still open-minded and waiting to be convinced.
What about other benefits of vaginal exams during labor? Are there any?
YES.
-Through a vaginal exam, a midwife can meter the intensity of the contractions in relation to progress that is being made. She can learn how different labor positions or techniques are aiding in the progress of labor. She can identify fetal position and rotation to learn if a certain position is helping the baby to rotate and come down better than another. This can be quite beneficial to a mother who may not want to be in labor longer than she has to. She can also detect cervical abnormalities that may hinder progress, like scar tissue from past medical procedures that can't be identified until labor has had a chance to open it.
-Through a vaginal exam a midwife can help a mother to focus on her cervix, to relax it and allow it to open. This is quite helpful to women who are panicking from the pain of labor. I ask them if I can try something to help them focus and explain what I will be doing. With their permission, (I have to emphasize that because I know someone is going to copy and paste this onto their blog) I simply place a finger on either side of the cervical opening, within the vagina, touching it lightly. With the next contraction, I tell them to focus on where I am touching, to relax it and allow it to open while they mentally "drop" their baby through the opening. In most cases, the mother will ask me to do that with each consecutive contraction until full dilation, because it helped her so much. I have even had them scream at me, "GET YOUR FINGERS IN THERE!"
An added benefit of this technique is the unique understanding of labor that is gained by the midwife who is privileged to feel it happening under her touch. Labor progress is much more than simple dilation and cervices don't just merely "open." They change in other ways too. Did you know that the cervix is actually SUPPOSED to swell just before it slips over the babies head in full dilation? Too often, this swelling is blamed on premature pushing because mothers are simultaneously feeling urges to push at the same time. So, how do those "rule of 10" professionals explain the cervix that swells even though the baby's head is not even applied to it because it hasn't descended yet? With few exceptions, the cervix will swell slightly, then it will pull into a shape that resembles the beading around the neck of a balloon, next it becomes paper thin; and then the head slips through it. This can all happen in one contraction for some lucky ladies but for first time mothers, it can take awhile.
Through a vaginal exam a good midwife can detect CPD (cephalo-pelvic-disproportion). Although this condition is far too often misdiagnosed in hospitals, it can actually happen. In these cases, the baby's head is molding while it is still high in the pelvis because it is TRYING to get in. In other words, it acts as if it is lower in the pelvis when it is not there yet. In a normal female pelvis, the entrance of the pelvis is wider than the outlet, like a funnel, becoming progressively tighter. The baby's head will normally mold (bones overlap) as it descends, not before it descends.
As I write, SO many personal experiences come to mind of vaginal exams that have provided valuable information, not only for safety in birth, but for ease of birth.
With so many benefits to vaginal examination, I ask again, WHY would someone refuse to provide this service or advocate against it? Well, I have asked them myself and these are the only responses I have gotten:
Reason #1 - "A pregnant or laboring mother should be thinking "Down and out." When we place fingers "Up and in." it confuses her."
(My answer) "hmmm, Didn't something go "up and in" to get her pregnant in the first place? Isn't this (sex) also happening throughout her pregnancy as well?"
Reason #2 - "Risk of infection."
(My answer) As long as the Amnionic sack is intact, there is no more risk of infection than having sex or taking a bath during pregnancy.
Reason #3 - Most of the time that I ask this question, I just get a, "Because it's wrong. It's birth rape!" answer.
(My answer/question) When did we, as a society, start believing that everyone who touches us is doing it with evil intentions or sexual motivation? I wonder why chiropractors, dentists, massage therapist, hair dressers and ear, nose and throat doctors aren't being socially attacked for the same reasons? After all, aren't they touching us too, maybe even in one of our orifices?
Could it be that vaginal exams went "out" with midwife apprenticeships and the introduction of classroom training, lacking adequate hands on training? Could it be that midwives no longer are being taught HOW to do them and therefore they fear them or simply don't have a clue what they are feeling when they get in there?
I had one such midwife, who had nearly been on as many births as I, call me out to a stalled birth, simply because she needed someone who knew how to "Read" a cervix to figure out what the problem was. I did figure out the problem right away and got her to the hospital, just in time to save the baby's life, via c-section. The cervix was damaged and unable to open; and in the 3 DAYS of hard labor, the uterus had become filled with deadly infection.
I had an apprentice once, who moved away after attending only 7 births with me. There was no apprentice training available where she moved so she attended and graduated from an expensive midwife college instead. After receiving her degree, she practiced for about 5 years before calling me and asking if she could spend a summer with me to get some more "Hands on" training, to which I agreed. During that summer, I was really surprised at how awkward she was with her hands on skills. She had trouble palpating babies, finding their heartbeats and had no clue what she was feeling during vaginal exams, yet she was a practicing midwife!
It probably took me at least 50 vaginal exams before I BEGAN to recognize what I was feeling. Women, who are in their last trimester of pregnancy, have so much vascularity and so many folds in their vaginas that it can feel like nothing but mush in there to a novice. It can be discouraging, embarrassing and scary. I am sure it is much easier to tell your clients that you are being kind by not subjecting them to such an "invasion" rather than to admit that you don't know how to examine them.
Oh, they will tell you that they DO know how, but if they don't do vaginal exams, then I guarantee that they DON'T know how. This is one skill that is learned and refined by DOING it...a LOT. I often tell clients that I have grown eyeballs on the ends of my fingers.
Over the years and spending many cumulative hours with my fingers in vaginas during all stages of labor, has taught me to "see" the cervix in my mind without my fingers in there so much anymore. No one can gain that keen understanding without first getting to know the cervix by physical touch.
All in all, each vagina belongs to it's owner, not the doctor, the nurse or the midwife.
Vagina exams, (Yes? or No?) are ultimately HER choice.
Elizabeth Smith
Licensed, Certified Professional Midwife
435-632-8998
Monday, May 16, 2016
Monday, January 12, 2015
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
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
Monday, April 7, 2014
Choosing your midwife: "Hands on?" or "Hands off?" (part 1)
Part 1 "Hands on"
The very FIRST midwifery learning book I ever read was entitled "Heart and Hands." This was a popular book for aspiring midwives in 1983. Its title alone epitomizes the trend of midwifery care back then. All of the midwives I knew, or had heard of, learned the art of Midwifery through apprenticeship or hands on experience. This was the way it had been done for thousands of years. I likewise was taught by being tucked under the wing of an experienced midwife, shadowing her as her sole apprentice and learning from hands on experience. Of course College coursework and self study was an important part of my education, but it is through the hands on experience that I learned to truly be "with woman" as the word "midwife" is defined. My mentor didn't teach me terminology, anatomy or human physiology. I studied all of that in the years BEFORE becoming her apprentice. She taught me the art. She taught me to FEEL...with my heart...and with my hands.
When I had my first two children, in the hospital, only my young husband tried to help me do what we had learned in Lamaze class. The doctor showed up just in time to cut an episiotomy, catch the baby, stitch me up and then disappear.
My third was my first born at home. My midwife (and her apprentice) labored beside me from the time I needed her, helping with tried and true techniques to reduce the pain and encourage steady progress. She talked to me, touched me, soothed me and kept a protective vigilant watch over me and my baby. I felt so safe and so loved. She seemed to read my mind and say the exact thing I needed to hear at the exact time I needed to hear it. It was amazing. I recall one scene: Squatting on the floor, between my husband's knees as my midwife got into this funny, twisted position on the floor in order to hold hot towels on my perineum, check progress in that position and listen to the heartbeat. I recall smiling and thinking, "What doctor would do this for me?"
Without difficulty or delay in progress, I delivered my 10 lb 4 oz son into three sets of waiting hands; mine, my husband's and my midwife's. The skills and Spirit that she brought into our home, were truly a blessing. I cannot describe how happy I was with my birth! I seemed to walk on air for days after that and soon knew that I needed to be a part of this great work. In my mind, she was the best; and I wanted to be just like her, so I set out to do just that.
Now it is the year 2014 and I regret to report that the trends in midwifery have changed. One on one apprenticeships are becoming scarce. More midwives are learning in classrooms and group observation. They are doing very well on written exams, but we are losing the use of our heart and hands. Because of this, some say that to use your hands is wrong.
I have been midwife to 1,330 babies. Every baby has been delivered safely. My mentor has attended over 2,600 births, with the same safety record. Back in the 80's, one never heard of bad home birth outcomes. My own birth was part of a county-wide study of 1000 home vs 1000 low risk hospital births. In this study, not one baby was lost or damaged in the home birth group however one baby was lost and 16 sustained injuries in the hospital group. Midwives were attentive and involved then. Their skills were experienced and keen. They could "read" a cervix and gain invaluable information to benefit the mother. They could easily find a heartbeat and palpate a baby. Their mentors taught them to pray and trust in God. If progress was stalled, they figured out why and suggested solutions. This is "Hands on" midwifery. This is "Women helping women" with women's most difficult, yet joyful work. Side by side we strengthen one another through words and touch - those who have gone before, helping to calm the fears of the new mother, giving her confidence and drawing out her pain through the transfer of energy one to another. How insane to believe that all mothers should conquer and "rise above" birth...alone! Humans are not natural loners. We are social beings. We need each other!
"Hands on" midwifery is also the understanding that we live in a mortal world where death and injury are constant threats. Although we view birth as a natural and safe process, we are not oblivious to reality. We "trust God," rather than "trust birth." We trust that birth is HIS design; and when mortality causes problems, He will inspire us how to keep safe, those in our care.
(to be continued in part 2 "Hands off")
The very FIRST midwifery learning book I ever read was entitled "Heart and Hands." This was a popular book for aspiring midwives in 1983. Its title alone epitomizes the trend of midwifery care back then. All of the midwives I knew, or had heard of, learned the art of Midwifery through apprenticeship or hands on experience. This was the way it had been done for thousands of years. I likewise was taught by being tucked under the wing of an experienced midwife, shadowing her as her sole apprentice and learning from hands on experience. Of course College coursework and self study was an important part of my education, but it is through the hands on experience that I learned to truly be "with woman" as the word "midwife" is defined. My mentor didn't teach me terminology, anatomy or human physiology. I studied all of that in the years BEFORE becoming her apprentice. She taught me the art. She taught me to FEEL...with my heart...and with my hands.
When I had my first two children, in the hospital, only my young husband tried to help me do what we had learned in Lamaze class. The doctor showed up just in time to cut an episiotomy, catch the baby, stitch me up and then disappear.
My third was my first born at home. My midwife (and her apprentice) labored beside me from the time I needed her, helping with tried and true techniques to reduce the pain and encourage steady progress. She talked to me, touched me, soothed me and kept a protective vigilant watch over me and my baby. I felt so safe and so loved. She seemed to read my mind and say the exact thing I needed to hear at the exact time I needed to hear it. It was amazing. I recall one scene: Squatting on the floor, between my husband's knees as my midwife got into this funny, twisted position on the floor in order to hold hot towels on my perineum, check progress in that position and listen to the heartbeat. I recall smiling and thinking, "What doctor would do this for me?"
Without difficulty or delay in progress, I delivered my 10 lb 4 oz son into three sets of waiting hands; mine, my husband's and my midwife's. The skills and Spirit that she brought into our home, were truly a blessing. I cannot describe how happy I was with my birth! I seemed to walk on air for days after that and soon knew that I needed to be a part of this great work. In my mind, she was the best; and I wanted to be just like her, so I set out to do just that.
Now it is the year 2014 and I regret to report that the trends in midwifery have changed. One on one apprenticeships are becoming scarce. More midwives are learning in classrooms and group observation. They are doing very well on written exams, but we are losing the use of our heart and hands. Because of this, some say that to use your hands is wrong.
I have been midwife to 1,330 babies. Every baby has been delivered safely. My mentor has attended over 2,600 births, with the same safety record. Back in the 80's, one never heard of bad home birth outcomes. My own birth was part of a county-wide study of 1000 home vs 1000 low risk hospital births. In this study, not one baby was lost or damaged in the home birth group however one baby was lost and 16 sustained injuries in the hospital group. Midwives were attentive and involved then. Their skills were experienced and keen. They could "read" a cervix and gain invaluable information to benefit the mother. They could easily find a heartbeat and palpate a baby. Their mentors taught them to pray and trust in God. If progress was stalled, they figured out why and suggested solutions. This is "Hands on" midwifery. This is "Women helping women" with women's most difficult, yet joyful work. Side by side we strengthen one another through words and touch - those who have gone before, helping to calm the fears of the new mother, giving her confidence and drawing out her pain through the transfer of energy one to another. How insane to believe that all mothers should conquer and "rise above" birth...alone! Humans are not natural loners. We are social beings. We need each other!
"Hands on" midwifery is also the understanding that we live in a mortal world where death and injury are constant threats. Although we view birth as a natural and safe process, we are not oblivious to reality. We "trust God," rather than "trust birth." We trust that birth is HIS design; and when mortality causes problems, He will inspire us how to keep safe, those in our care.
(to be continued in part 2 "Hands off")
Friday, February 1, 2013
My best advice for pregnancy and childbirth
Last week a family came to my home for a consultation. They are expecting their 6th child and their oldest is only 8 years old. As I admired their beautiful family and congratulated them on their pregnancy, I got the idea that maybe they could help me with an assignment I was working on. I had been invited to speak in church on the subject of "Teaching Children," so I asked them if they had any suggestions for my talk.
Elizabeth Smith, CPM, LDEM
Licensed and Certified Professional Midwife
In St. George, Utah
The father replied with a chuckle, "Don't ask me. Ask an expert on the subject. Ask someone who doesn't have any children yet."
Isn't it true and ironic that often times those who think themselves the "experts" are usually the ones who have the least experience?
I have been attending out of hospital birth since 1985 and will, most likely, attend my 1,250th birth tonight. One may think, with all that experience, that I have earned "expert" status in the midwife world. However, it seems the more experienced I get, the more I realize how much I still need to learn AND the more criticism I get from the young "experts" in my field.
The most important truth I have learned over all these years is that there IS indeed, a Father in Heaven who loves us. He is the ultimate expert; and we can never become so "expert" at anything, that we cease to need Him.
I am humbled by and grateful for all the wisdom that the Lord has blessed me with and look forward to more learning. I am grateful to all the babies who have taught me, to all my clients (my best friends) who have trusted me, to my husband and children (also my best friends) who have supported me. I am grateful to the Lord for blessing me with 1,249 successful births. It is truly a miracle which defies the odds.
This blogspot is for the purpose of sharing the wisdom of the Granny midwives, those who have been delivering babies for many years, have given their lives to those whom they serve, have weathered persecutions, experienced great rewards as well as heartbreaks, have felt the presence of angels and experienced the miracle of prayer!
The greatest wisdom and advice that I can give the reader is this: Invite the Lord to be part of your pregnancy and to be present at your birth. Ask Him to help you choose your midwife. Listen to His inspirations and trust them. Acknowledging His hand in all things will keep you safer, more comfortable and give you more joy in your experience than ANY other factor.
Elizabeth Smith, CPM, LDEM
Licensed and Certified Professional Midwife
In St. George, Utah
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