Unassisted Childbirth

Back in the good old days, when I was a subsistence farmer in paradise, I had a friend who told me her birth story. This was before I started working with birth, but not before I had already started studying and learning, and listening to women's stories.

Friends Sharing Birth Stories

 My friend's first baby had been a breech who did not want to get her head down. The policy at that time in Italy, as in many places, was to deliver breech babies by cesarean section, especially if the woman was a primipara.

So, my friend had a c-section, and she did not feel good about that birth at all. She thought that it was probably possible to give birth to a breech baby vaginally, and she felt pushed into making a decision that did not feel right to her. She decided she didn't want to go back to the hospital again to give birth.

She became pregnant again, and decided to stay at home this time and give birth on her own terms. She looked for a homebirth midwife but at that time in Italy they were a rare breed, especially if you were living in the hills as all us organic subsistence farmers did. She prepared by reading about natural birth, and she made sure she had methergine in the house - they always had it on hand for the goats.

Labor started and she sent her husband and child out for the day. She didn't want her daughter present for what she knew was going to be an intense and possibly scary event.
This was before cell phones, and they didn't have a phone, so he planned to come back around suppertime. She labored on her own and late in the afternoon, gave birth to a healthy baby.
"Were you scared?"
"Yes, I really wanted to have someone else around. I remember when I started pushing, and I felt a cervical lip, and I gently pushed it out of the way - I really wanted someone to be there with me. But I knew everything would be okay - I had a feeling. And if it wasn't ok, then it wasn't. I did it my way."

There is a growing movement that promotes unassisted childbirth as a way to regain control over your own birth, and there are many valid reasons for not wanting anyone at all from outside your circle of family and loved ones to be present at the birth of your child. It is, after all, a natural event, more like lovemaking than like a medical procedure. The presence of a stranger, even a well-liked one, can change and disturb the process. Midwives can be regulated by laws that perhaps don't agree with a woman's perception of how she wants her birth to proceed. This site provides some interesting information about unassisted childbirth:UC

I often get calls from women who are planning to give birth without attendants. They want information, or they want to find someone to be a "fly on the wall" - who can be there "just in case". Most of these women are women who have not been able to find a registered midwife - either they didn't call early enough, or they live in the wrong area, or they are considered too high risk for a homebirth. They don't really want an unassisted birth, but they are committed to not wanting to go to the hospital unless they really have to, so they are left with unassisted birth as their only option. Because we Canadians are used to free health care, cost is also a consideration. Unregistered midwives charge around $2000 for prenatal, birth, and postpartum care (that works out to about $10.73 an hour, in case you're wondering). Many women do not feel that this amount is an option, and, again, make the choice to give birth "unassisted".

I firmly believe in a woman's right to choose what's best for her body, and for her life. If a woman chooses to give birth on her own, or just with her partner, or her sister, in her own home, then power to her! She is making an adult choice, and she is accepting responsibility. But I do feel sad when women want to have the care of a midwife and cannot.

No woman should have to give birth on her own if she doesn't want to. Midwifery care should be available, really available, to any woman. Homebirth should be an option for us all. Unassisted homebirth is only one option, but it should be an option that is actively chosen and not decided on for lack of other plans. Equally, hospital birth is only one option. Health women carrying healthy babies should not have to go to the hospital to give birth unless they actively want to. Informed choice should be a reality - it should be informed, that is, women should educate themselves and each other, and they should ask for informtaion from their care providers. And choice should be a real choice with real options - unassisted, home birth, midwifery care, hospital birth.

Let's work together to bring the woman and child back to the center of maternity care!

Ask the Doula: Evidence-Based Care

It's Ask the Doula time again!

Please keep sending in your questions. You can add them as comments below, or send your questions to our Facebook page, or twitter @montrealdoula.

Today I will be looking at the concept of "Evidence-Based Care". What does it mean? How does it work?

Question Number Four

"What is evidenced based maternity care?"

What is the meaning of life? may be an easier question to answer.

First, I will offer you a collection of attempts to define evidence-based maternity care:

"EBM is about tools, not about rules. Good evidence is likely to come from good systematic reviews of good clinical trials. For many reasons too much of the medical literature can be misleading, or is just plain wrong. We must be able to distinguish good evidence from bad, and to have accurate, reliable knowledge readily available and readily accessible for all. The contrast between the individual and the population as a whole - unique biology, choice and circumstance, often dictates what happens, and evidence is but one part of a complex question."
Bandolier


"Evidence-based care is a type of care in which the medical studies are consulted to help you and your caregiver decide the safety and usefulness of all procedures used. With evidence-based care, only procedures that are proven by research to be safe and beneficial are done routinely. Other procedures which are not supported by the medical evidence are weighed carefully, taking your personal circumstances into account. This is called "informed consent". This may seem obvious, but, for example, routine use of epidurals is not supported by the evidence. 
Birth Matters Virginia


"Evidence based health care takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information." 
Dr Nicholas Hicks

There is a never-never land that people believe we are heading towards, where our huge glut of information and meta-analyses, and  systematic reviews, and technological advances, will somehow be tamed so that we can quickly pick from any number of studies, the answer to a clinical question that is presenting itself. What is wrong with the picture is that we have become wrapped up in the science, or rather, in the scientific methods (or methods), and we have completely misplaced the person at the center: in our case, the pregnant, laboring, or breastfeeding woman.

I have in front of me an example of the type of study that is being used to support and  maintain evidence-based care. It is an "overview". This means that the researchers looked at reviews of trials. The trials are the actual clinical experiments, which are done on real people in real situations. The reviews are done when researchers look at, for example, ten different trials involving 10,000 women, and compare the results and draw conclusions.


This overview examines at several reviews that looked at pain management in labor. The conclusion is that:

"Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence. In many reviews, only one or two trials provided outcome data for analysis and the overall methodological quality of the trials was low. High quality trials are needed.
There is more evidence to support the efficacy of pharmacological methods, but these have more adverse effects. Thus, epidural analgesia provides effective pain relief but at the cost of increased instrumental vaginal birth.
It remains important to tailor methods used to each woman’s wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.
A major challenge in compiling this overview, and the individual systematic reviews on which it is based, has been the variation in use of different process and outcome measures in different trials, particularly assessment of pain and its relief, and effects on the neonate after birth. This made it difficult to pool results from otherwise similar studies, and to derive conclusions from the totality of evidence. Other important outcomes have simply not been assessed in trials; thus, despite concerns for 30 years or more about the effects of maternal opioid administration during labour on subsequent neonatal behaviour and its influence on breastfeeding, only two out of 57 trials of opioids reported breastfeeding as an outcome. We therefore strongly recommend that the outcome measures, agreed through wide consultation for this project, are used in all future trials of methods of pain management." Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

So, what have we here? We have a "world where information is replacing the knowledge that displaced wisdom". (Birth Volume 36, Issue 1). We have a huge amount of man- and woman-hours being spent to gather and examine information.This information is considered to be the evidence, upon which we base our standards of care. The authors of this overview have come up with conclusions about the gathering and about the information. Let's look at the conclusions:
1. That the quality of the evidence-gathering was low, for various reasons.
2. Non-pharmacological methods of pain relief appear to be safe but may not work.
3. The effects of pharmacological pain relief on the baby has not been assessed.

From these conclusions, we can see that the researchers seem to have the best interest of mother and baby at heart. They want more studies on non-pharmacological methods of pain relief, and we get the feeling that they would like those studies to prove that these methods work. They want more studies to be done on the effects of maternal pain medications on the newborn, on breastfeeding and beyond, and we get the feeling that they would like these studies to lead to a decrease in use of pain medication,.

But it seems to me that here we are running into the late Phil Hall's suggestion that  "after initial gains in evidence-based medicine, we have moved from evidence-based decision-making to decision-based
evidence-making." (Birth Volume 36, Issue 1)
Make the decision that you would like to promote a more humane type of maternity care in your practice. Look at the studies that may support your hunches about how this can be facilitated. Draw your conclusions, make some protocol changes, and bingo!

The problem is thought, that studies can be deeply flawed and they can still be taken seriously. Let's go further with our overview:

It remains important to tailor methods used to each woman’s wishes, needs and circumstances, such as anticipated duration of labour, the infant's condition, and any augmentation or induction of labour.

What is this supposed to mean? I would say it is absolutely important to place the woman at the center of the whole event, where she belongs. Go as far as you can to fulfill her wishes. Cater to every one of her needs. But as soon as we start tailoring methods to a woman's circumstances, we get into trouble. Anticipated duration of labor, we all know, can often be wrong (is there a study?). The infant's condition of course is paramount, but are we then getting into continuous fetal monitoring? And are the authors suggesting that a woman should take an epidural before an oxytocin induction? (I'm not being facetious, it is offered frequently).

What's the biggest problem with this picture?  The whole overview completely missed out on one very important part of the equation. They mentioned massage, aromatherapy, sterile waters injections, TENS, and other methods as non-pharmacological, but nowhere in the overview does anyone mention the benefits of having one continuous presence - a companion, not the partner, but a companion who is trained to accompany women throughout labor and birth.

Let's take a look at the reality. Even during a traumatic, painful labor and an unexpected outcome, women feel better about their birth experience if they have been lucky enough to have had the presence of a doula. And isn't a positive experience for the new family what we are all trying to achieve?

The evidence is right there. You don't need to study or review. Just open your eyes, and then take the giant leap of trying to change practices and protocols.

Wayne Gretzky or PK Subban?

Just a minute to think outside the birth box a little today, bear with me folks.

I was waitressing at the White Spot back in 1979, making money for my trip to Africa. The White Spot was a typical Calgary steak house, just down the road from a popular bar, and it was a busy night. Two couples came in and sat in my section. I served them and catered to their every need, as you do as a waitress. I realized the other waitresses were in a frenzy and I asked what was wrong. See, I was a poet back then, an artist, a revolutionary. I didn't know about normal Canadian stuff like hockey. One of the girls let me know that I was serving Wayne Gretzky! So, whatever. I brought them the bill, Gretzky paid with a Visa (wish I'd kept the receipt - his signature was probably worth a lot for a while), and he tipped me $9.00.

Nine dollars on a $91.00 check ... doesn't even add up to 99! Just under ten percent. I always remembered Wayne Gretzky as a bit of a cheap customer, however well he may have played hockey. The Wayne Gretzky story figures as a small chapter in our family's "Mama's waitressing stories". The guy who lifted up my skirt and got a boiling hot steak in his lap was another story altogether...

I traveled through Africa and Europe on my own for a year after that, and I think there was one moment during that trip when I knew that one day I would be able to provide maternity care for underprivileged women. I was somewhere on the border between Tanzania and Uganda, and a young woman came up to me with her baby, who was clearly dying. She thought I would be able to save him, but I couldn't. She will remember me. Not as the great white hope, but as the useless traveler who was just wandering around her country without a pot to piss in, and couldn't even help save her baby boy.

Move forward thirty-odd years. One of my kids has a job in a cafe. P.K. strolled in and had a little brunch, and left a hefty 20%. It's not that times have changed that much - even thirty years ago the good guys left around 15%, the jerks left nothing, and the nice guys...well... in my books, I will now think of Subban as a better hockey player, just because he is a better tipper, and an all-around nicer guy.

So what does this have to do with birth?

Memories count.

When a woman is giving birth, or when she is expecting, or after birth when she is breastfeeding and finds herself a mother, or a mother with a bigger family, she is incredibly sensitive to what is around her. That is why the best place for a woman to be when she is in labor is at home, surrounded by her own furniture, her own people, and her own germs.

If she cannot stay at home, because she can't find a midwife, or doesn't want to, or needs specialized medical care, the doula is there to create an environment in which she will feel safe. Where her memories of that intense time in her life with be bathed in pleasure, even if at the time her physical sensations may be painful and downright unbearable. The doula is there to let a birthing woman know that she is doing exactly the right thing, that her body knows what to do, that she is doing just fine. The particular skill that a doula has is that she manages to translate the woman's reliance upon her, into a memory of self-reliance and self-love. She is so invisible, so subtle, that the woman will remember only "I did it! My body DID know what to do!"

At that moment, a woman is a queen. She should be treated like the royalty she is, like the famous person she will always be remembered as by her children.

So, if you are a doula, remember to give that birthing woman 100%, so that she can remember her birth experience with joy and a sense of accomplishment and peace. What you do doesn't really matter, in the long run. It's how you do it, how much of yourself you give, how big an emotional "tip" you leave that new family with, that really counts in the end.

Life, birth, hockey.

Ask the Doula - the "too-big baby"

A week has gone by already, so quickly. I am involved in many interesting projects, more about them in a few days...
It's Ask the Doula time again!
Please keep sending in your questions. You can add them as comments below, or send your questions to our facebook page, or twitter @montrealdoula.

Today I am going to be looking at the question of cephalo-pelvic disproportion, or the "too-big baby". This mother generously agreed for me to print her question and the response.


Question Number Three 


"I had my first baby three years ago. I am expecting again and I would like to have a doula to accompany me. I am not sure how it will go. My doctor told me that my pelvis is too small to give birth. My first baby was born by cesarean after I was in labor for two days. I had contractions all day on the first day, then by the next morning they were so painful I couldn't even talk. We went to the hospital, where they broke my waters, and then I took an epidural. My baby didn't come out after two hours and they said she was too big. She ended up weighing seven pounds thirteen ounces, and had an Apgar score of 9 and 10. I have a very small pelvis and a narrow pubic arch. Do you think this is a good reason for a cesarean?"

First of all, let's understand how birth stories work. A woman will tell me her story, and it will be just that - her story about what happened to her. It is a story in the first person, about a primal experience she had. I will listen to the details but I will also listen to the tenor, the resonance, of the story.

This story is about a normal labor that somehow went wrong. The first hint is that she labored all day and after 24 hours had contractions "so painful I couldn't even talk." This is normal labor. Mothers will have contractions for a few hours, or a few days, and they will be uncomfortable and even painful. Then the body gets down to work and contractions become so intense that she cannot speak through them. Then she gets to the point where she doesn't even want to speak in between contractions, and this is when the doula knows that the laboring woman is definitely in good labor.

But in this story, the woman was not prepared for the intensity, and she went to the hospital soon after she entered the beginning of active labor. She doesn't say why they broke her waters, but usually it is done because there is a perception that labor isn't moving quickly enough.

In this case, it appears that the breaking of the waters did stimulate labor, and this stimulation increased the intensity of the contractions to the point where the laboring woman decided to take an epidural for pain relief. She was probably quite tired by now, as well, as no one had told her to rest during the night in between the contractions.

The epidural probably helped in terms of her energy, and her body obviously did the work of opening so that she reached the pushing phase. Then what happened? She pushed for two hours. The staff told her the baby was too big and she went to surgery. I cannot extrapolate too much, but here is a possible scenario:

The pelvis is narrow and small. The body made a baby that, in fact, was a perfect size for this pelvis. Her labor was progressing normally and the baby was doing the appropriate moves to navigate through the bones of her mother's body. At a certain point, she had moved her head to a sideways plane so that she could get some leverage to push it down further.

Imagine one of those wooden toys, where the child has to push blocks through different-shaped holes. The child will turn, and turn, and turn the block until it finally pops through. He learned this at birth.

But suddenly, the amniotic fluid drained, and she found her head stuck upon the bone in a awkward position. She still instinctively pushes her head to the other side, to straighten it in order to descend further. As she is doing this difficult work, she feels her mother's helpful body go limp. She has no more help from the outside, just uterine contractions that are pushing her more and more into a position that will be very difficult for her to move from.

The cervix becomes fully dilated, because the body is doing what it should. But the combination of the narrow pelvis, the crooked head, the epidural, and the impatient staff adds up to an unfortunate turn of events.

If she had decided to stay at home longer, until labor was more active, she may have avoided getting her membranes ruptured. If she had a wider pelvis, the baby may not have gotten stuck. If she had a doula by her side, she may have managed to avoid or at least postpone the epidural. If she had not taken the epidural, vertical or forward-leaning positions could have helped the baby come down. If the staff had patiently waited another hour, she may have pushed the baby out.

But we do not know. We really can never know what could have happened, had things been otherwise. But if we agree that we could never know what might have happened, then we have to also admit that we do not know if another baby, perhaps with a slightly smaller head, in a better position, without an epidural, with a doula assisting the mother, could successfully navigate through the birth tunnel and be born vaginally.

My answer? I do not know the reason for your first cesarean. But I do know that you do not have any conditions that definitely preclude your giving birth vaginally. There is a saying: "labour is the best pelvimeter". In layperson's terms, this means that the best way to measure your pelvis is with a baby's head, when you are in labor.

My advice? Hire a doula. Make sure you have a good relationship with your doctor or midwife.Stay positive and open. I wish you the best of luck!

Radical Birth Film?

Montreal Birth Companions has been providing volunteer doula services for almost ten years, and we are beginning a fundraising campaign so that we can keep our doors open for the rest of 2012.

One of our plans is to have a film screening. We have chosen one film already, and we are looking for a RADICAL film that shows life and birth as it is.

Can anyone suggest a film that is possibly about doulas working with the type of clientele MBC serves? Refugees, immigrants, young mothers, ... women in prisons...

Please leave your comments here. The screening will take place in September, so if you are in the final stages of film creation ... let us know!
 

Ask the Doula - doula training

It's Ask the Doula time again!
Please keep sending in your questions. You can add them as comments below, or send your questions to our facebook page, or twitter @montrealdoula.

This week I want to tackle another interesting question. I am always getting calls from women who feel a calling to midwifery. They often ask if they can take my doula courses, or if I would allow them to observe me at work or take them on as apprentices. This week, I am going to explore a question from an aspiring midwife.


Question Number Two

"I am 24 years old, single, without children (yet!). I have been interested in birth from a very young age - I was born at home but my older brother was a c-section baby, and my mother always told me about my wonderful birth day. I am applying to several midwifery schools and I am hoping to start my studies in the fall. Do you have any suggestions for me? How can  I increase my chances of getting accepted? Should I train to be a doula first?"

This is a lovely question. It's so interesting that many of the younger women I see moving into the birth "scene" are women whose mothers had wonderful birth experiences. In my generation, many of us went into birth work because of less-than optimum experiences.
First, I would like to wish this young woman all the luck in the world. It is very challenging to send in applications, to receive rejection letters, and to wonder what went wrong. Remember, there are many more women who want to become midwives than places in midwifery programs, and this is especially true in Canada.

I think the most important thing to remember, as an aspiring midwife, is that the road is long, and that the main goal is not just the diploma, the job, or the number of births you end up attending. The journey to becoming a midwife is full of twists and turns, and may take you to some unexpected places.

Of course, you do need to understand some basic principles, and you need a lot of theoretical and clinical 
preparation, and this is why you have to go to school. And here in Canada you cannot become a registered midwife just by apprenticing with an experienced midwife. So, what to do?

There are several important tasks you can take on that will not only increase your chances of getting accepted, but will also give you a good background for the important work of being a midwife.

First - go to births! You will learn from every single birth you attend. Take a doula training, and start volunteering with your local volunteer doula organization. If there isn't one, start one. Do not expect practicing doulas or midwives to welcome your presence at births. Their priority is the care of the women they are attending. So you need to get out there, get some doula education, find a partner, and volunteer. Some people suggest you go to the births of friends and family, but I think it is easier and "cleaner" if you do not.

Second - Read and keep reading. Read books for pregnant women; read scholarly journals; read blogs and e-zines. Make notes. Try to discover what you really believe about birth. You have an opinion, and it is valid. Don't go along with the crowd without really thinking about what the crowd is saying.

Third - Learn from others. If a doula or midwife allows you to observe a prenatal, birth, or a postpartum visit or group, by all means go and observe. But observe. Don't participate actively unless you are invited to. Take notes. Ask questions, afterwards when you feel it is appropriate. Learn from the medical staff when you are attending a hospital birth. You may ask questions, again, if it is appropriate. Do not try to be their equal. You are not. Be humble.

Fourth - Learn different skills. Take a yoga class. Take a knitting class. Start practicing staying up all night and remaining alert. Do a CPR class. Learn about your own body and how it works under stress and without sleep. Test your patience. Sometimes babies take a long, long time to come. If you have learned the art of sitting on your hands, you won't be imagining non-existent dangers that will lead to to wrong decisions.

I have been on this road for ... since I was thirteen. It is long, interesting, sometimes painful. Open your heart, and know that wherever it takes you, there you should be.

Montreal Doula Training revised schedule

I have been getting lots of positive response about the course, so I have decided to give you all some more details - here below is an outline ... remembering that the best class plans are never followed to the letter!

 Birth Companions Doula Course

a knowledge-based, hands-off approach

Introduction

This course is the first of three levels of the Birth Companions doula program. It includes 24 hours of class time.

When you have completed this level, you will be eligible to accompany clients from the Montreal Birth Companions volunteer doula program, under my mentorship and with a partner doula. Once you have completed three volunteer births, you will be able to proceed to Level Two, after which you will be able to work as a private practice doula.

The course will integrate theory and practice. Shadowing and mentoring may take place throughout.

The only prerequisite is enthusiasm and availability.

Materials

Bring your own experiences, a notebook, your hands and an open heart. We will utilize The Birth Conspiracyas our main reference. The book will be available on or before the first class. The cost is $24.95.

Requirements

To fulfill requirements for Level One, you need to attend all of the classes, if possible. I may ask you to present or prepare assignments, but these will be done within class time. If you are interested in doing an independent project, please speak to me and I will be available for mentorship.

Cost

We are pricing this course to be accessible for as many women as possible. The cost for Level One is $400.00.

Please see the outline below, for the class program. This course will take place at Studio Vie, 5175C, Sherbrooke West, Montreal, H4A 1T5

Class One April 15, 2012, 10am to 1pm

Introductions

“What is a Doula?”

Class Project

Nutrition assignment

Class Two April 22, 2012, 1pm to 4pm

Bare Bones – anatomy

The birth process, cardinal movements

Class Three April 29, 2012, 1pm to 4pm

Questions and Review

The Childbearing Year

Centering Exercise

Class Four May 6, 2012, 10am to 1pm

Nutrition

Breastfeeding

Role playing

Class Five May 13, 2012, 1pm to 5pm*** note this class is a four hour class

Doula Care A to Z, the process, the doula bag

Doula Techniques – alternative ways for coping with the pain of childbirth

Role playing

Class Six May 20, 2012, 1pm to 5pm *** note this class is a four hour class

Common Interventions – Induction, Epidural, C-Section, Episiotomy, Instruments, Exams

Role playing

No class May 27

Class Seven June 3, 2012, 1pm to 5pm *** note this class is a four hour class

Presentations – Nutrition Guides

Review