What the Midwife Heard

What the Midwife Heard 

by www.themidwifenextdoor.com

I am always saddened when I hear a woman tell me about her birth plans, and then say, “My doctor said he’ll go along with whatever I want as long as it is safe”. Nine times out of ten, that woman is coming back to me later to talk about what went wrong and wonder why her doctor didn’t come through for her.

As someone on the inside of the circle of modern obstetrics, I am privy to a lot of conversation that reveals to me where OB providers are really coming from. Many put on a good face, and reassure their patients that they only have the patient’s best interest at heart and would never do anything that wasn’t necessary for the mother or baby’s safety. I believe that many of the providers sincerely mean what they are saying. The problem is that they do not keep current on the literature, and when evidence is provided that indicates lack of support for a routine intervention, they rely on their personal experience and the fact that they’ve not often seen complications from their interventions, to justify continuing the way they always have. Ladies, it is so important to discuss with your provider his or her c-section rate, definition of normal birth, how often they see a normal birth, and what interventions they do routinely. You cannot count on your provider’s personality, bedside manner, or promises of only intervening when necessary for safety, because they s/he may not know that there are safe alternatives to routine interventions much of the time, and may believe the intervention is being done for your safety. One has only to look at the very high c-section rate in our country to understand this mentality.

With this said, I would like to share some comments overheard in the doctor’s lounge and at the nurse’s station over the last few days. I share these not to disparage physicians and nurses, but to help women understand that what you are hearing from your doctor’s lips very likely is not what he or she is saying behind your back.

Physician: “She’ll never get this baby out vaginally, but she needs to feel like she’s had a fair chance, so let’s ‘pit to distress’. We can get it over with in a couple of hours, and she’ll feel like she had a good shot at it.” (Spoken of a woman with a suspected 9 pound baby, that ended out weighing 7 lbs.)

Nurse (speaking to midwife about a the midwife trying to induce with as little interventions as possible): “I’m not going to turn the pitocin on unless you put in internal monitors. She can just sit here all day, but you can’t make me do it without internals if I don’t feel safe”.

Physician (When nurse pointed out to him that his chosen treatment for the patient was not evidence-based): “Well, that’s why it’s good to be a dinosaur sometimes. You don’t have to worry about what the evidence says!”

Physician: “You need to lie on your back to deliver the baby in case the shoulders get stuck” (evidence shows this is the one position that makes it most likely the shoulders will get stuck).

Physician: “Don’t feel bad about having a c-section. Think of it this way, you’ll be in good company with all the celebrities who have pretty vaginas!”

Physician (one reputed to have a great personality and be willing to accomodate mother’s wishes, spoken to parents when they asked him about second opinion regarding his recommendation for immediate induction): “I am very uncomfortable being questioned like this. If you don’t trust my judgement, you can find yourself another provider–that is, if anyone will take you at 39 weeks!”

Nurse: “We’re admitting another one of those hypnobirthers. Make her stay on the monitor so she can’t get out of bed, and she’ll agree to the epidural by the time she’s three centimeters!”

Physician: “She (the patient) didn’t want to take my advice, so she deserves whatever happens to her.”

Physician (trying to get mother to sign a consent for c-section for failure to progress satisfactorily in two hours): “Sure, we can wait longer if that’s what you want. Personally, I think it would be better to head back to the OR at a leisurely pace rather than waiting until your baby takes a nosedive and we have to run you back there.” Mother then asked him if the baby was having any distress. Physician answered: “No, but do you want to wait until he does? Do you really want to put your baby through that stress? Birth is dangerous and stressful for babies!”

Physician (spoken to patient handing him a written birth plan): “Oh, you don’t really want a birth plan, do you? Every patient I have who writes a birth plan ends up with a c-section. It’s a prescription for trouble. Besides, that’s why you’re paying me to make the decisions. I’ve been to 8 years of school to learn how to safely manage labors. Do you really think you know more than I do just because you’ve read a website on birth plans?”

Physician (to a patient who was expressing discomfort over a vaginal exam): “Come on, now, you’ve had something a lot bigger than my finger in there! How’d you ever manage to get pregnant if you can’t put up with this?”

Birth Sense Tip: Pay attention to your intution. If your physician seems impatient with your questions, patronizing in any way, or unable to describe any of the ways s/he supports normal birth, RUN, don’t walk, for the exit and find another provider. Don’t just hope that things will work out OK, because chances are your physician is saying things like the comments above, about YOU, behind your back.

You Wouldn’t Schedule Kisses, Why Schedule Feedings?

Picture this.

A mother leans over and kisses her wiggly baby on the forehead. She kisses each rosy cheek, each tiny hand, and each squirmy foot. She smiles sweetly at her exquisite child, leaving it with a favorite toy, and then moves on to continue her daily activities.

A little while later the baby starts to cry. She goes to see what’s the matter. She changes its diaper, but the baby is still crying. She offers it a pacifier but it spits it out and cries harder. She checks to see if the baby is too hot or too cold, and she checks for anything else that could be causing discomfort, but the baby is beside itself in tears.

Someone suggests she give the baby a snuggle but the mother shakes her head no.

“It’s not time for hugs and kisses. We just did that half an hour ago.”

*********

If this sounds ridiculous, then good. It’s supposed to.

How are kisses and breastfeeding the same you may ask?

“Scheduling nursing, like scheduling kisses, would just make life harder.”

I am currently reading La Leche League’s newest and 8th edition of The Womanly Art of Breastfeeding. On page 12 it touches on the practical reasons for breastfeeding.

Breastfeeding helps mothers with mothering by being a cure-all for “hunger, tiredness, overstimulation, fear and pain.” The more we breastfeed, the more milk our breasts produce. The little nursing sessions we have throughout the day keep our milk supply in tip top shape and our baby growing well.

When we schedule breastfeeding in the early days, every two, three or even four hours as I have read that some doctors recommend, something is almost certainly going to fail. Firstly, most likely our babies won’t be able to wait as long as they’re supposed to; however, we also will be in a position of needing to schedule the other parts of our life around our baby’s schedule. In this situation it is doubtful that our babies will be able to gain weight and keep our milk supply in good shape. Like Womanly Art says, ” Setting up a schedule risks an underfed baby and early weaning – and a more complicated life.”

Breastfeeding needs to be about flexibility. Breastfeeding babies have been around much longer than clocks, when life was truly hard. Nursing had to fit into an unpredictable day of finding food, tending animals, and avoiding sudden dangers. Breastfeeding the way nature intended, is meant to happen when a baby gives us cues that he or she wants to nurse.

Breastfeeding is an intimate dance.

The more time we spend holding our babies close to our bodies, next to our skin and clothes, the better we get at reading their cues. The emotional connection that occurs as a result of breastfeeding is a strong one. Not only does it become hard to leave our babies emotionally, but physically, it can make our breasts go crazy! With pain from plugged milk ducts, and leaks produced just  by hearing a baby cry. This is the way it’s supposed to be. These instinctive cues remind us that we need to be close to our babies to ensure their very survival because our milk supply is based on supply and demand. The more we nurse, the more milk we will have for our babies.

The best thing a mother can do if her milk supply is low or begins to wane is to nurse her baby frequently. If that means every half an hour, 45 minutes or hour for a little while, that’s okay. Your baby will only drink the amount he or she needs to, and your breasts will start producing more milk. It is okay to offer your child the breast. When I’m feeling unsettled, my husband brings me snacks to help make me feel better. If I really don’t want to eat I decline. But usually l accept. Your baby is the same way.

Moral of the story? Breastfeed based on your baby’s cues. Additionally, offer to breastfeed whenever you feel your baby might want to. And kiss, hug and snuggle your baby frequently to help you learn those cues.

Much of the information provided in this post was taken from The Womanly Art of Breastfeeding.

In Defense of the Amniotic Sac

Posted on August 20, 2010 by midwifethinking

Artificial rupture of membranes (ARM) aka ‘breaking the waters’ is a common intervention during birth. However, an ARM should not be carried out without a good understanding of how the amniotic sac and fluid function in labour. Women need to be fully informed of the risks associated this intervention before agreeing to alter their labour in this way. This post will discuss how the ‘waters’ work in labour and the implications of breaking them.

Anatomy and physiology

By the end of pregnancy the baby is surrounded by around 500-1000mls of Fluid. This is mostly made up of amniotic fluid secreted by the amniotic sac (the membranes). The baby also contributes urine and respiratory tract secretions into the fluid. The amniotic fluid is constantly being produced and renewed – Baby swallows the fluid; it is passed through the gut into the baby’s circulation; then sent out through the placenta. This process continues even if the amniotic membranes have broken. So, even when the waters have ‘gone’ there is still some fluid present ie. there is no such thing as a ‘dry labour’.

The amniotic membrane is adhered to the chorion – another membrane between the amniotic membrane and the uterus. These membranes look like one, but you can tease them apart after birth.

During pregnancy

The amniotic sac protects and prepares baby by:

• Cushioning any bumps to the abdomen.
• Maintaining a constant temperature.
• Allowing movement to aid muscle development.
• Creating space for growth.
• Protecting against infection – the membranes provide a barrier + the fluid contains antimicrobial peptides.
• Assisting lung development – baby breathes fluid in and out of the lungs.
• Taste and smell – the smell of amniotic fluid has been found to have a calming effect on newborns (Varendia et al. 1998).

After 40 weeks gestation around 20% of baby’s will pass meconium into their amniotic fluid as the bowels reach maturity and begin to work.  This is perfectly normal and is not a sign of distress. This meconium is diluted and processed with the amniotic fluid as described above.

During labour

Around 80-90% of women start their labour with their membranes intact. This is probably because the amniotic sac plays an important role in the physiology of a natural birth.

General fluid pressure

During a contraction the pressure is equalised throughout the fluid rather than directly squeezing the baby, placenta and umbilical cord. This protects the baby and his/her oxygen supply from the effects of the powerful uterine contractions. When the membranes have ruptured the placenta and baby get compressed during a contraction. Most babies can cope well with this, but the experience of birth for the baby is probably not as pleasant. When the placenta is compressed blood circulation is interrupted reducing the oxygen supply to baby. In addition, the umbilical cord may be in a position where it gets squashed between baby and uterus with contractions. When this happens the baby’s heart rate will dip during a contraction in response to the reduced blood flow. A healthy baby can cope with this intermittent reduction in oxygen supply for hours (it’s a bit like holding your breath for 30 seconds every few minutes). However, this is probably not so great to do for an extended period of time.

Forewaters

The sac of amniotic fluid is describes as having two sections – the forewaters (in front of baby’s head) and the hind waters (behind baby’s head). A ‘hind water leak’ refers to a tear in the the amniotic membranes behind the baby’s head. Often this is experienced by the woman as an occasional light trickle as the fluid has to run down the outside of the sac and past baby’s head to get out.

During labour forewaters are formed as the lower segment of the uterus stretches and the chorion (the external membrane) detaches from it. The well flexed baby’s head fits into the cervix and cuts off the fluid in front of the head from the fluid behind (hind waters). Pressure from contractions cause the forewaters to bulge downwards into the dilating cervix and eventually through into the vagina. This protects the forewaters from the high  pressure applied to the hind waters during a contraction and keeps the membranes intact. The forewaters transmit pressure evenly over the cervix which aids further dilatation. When the baby is in an OP position the head may not flex as well to block off the hind waters = pressure is able to move into the forewaters and they may rupture. Early rupture of membranes if often a feature of an OP labour.

Lubrication

The forewaters usually break when the cervix is almost fully open and the membranes are bulging so far into the vagina that they burst. This ‘fluid burst’ lubricates the vaginal and perineum to facilitate movement of the baby and stretching of the tissues.

Born in the caul

If is fairly common for a baby to be born in the amniotic sac when labour is left to unfold without interference. I have some beautiful photos of this but don’t have permission from the parents to share them online – so if you want to see them you will have to come and study midwifery at USC. However, I have found: Some photos of a waterbirth in the caulon Pamela Hines blog; photos of a land birth in the caul on Navelgazing Midwife’s blog; and a youtube movie:

Although in the movie the midwife breaks the membranes this is not necessary. Eventually the force of the contraction and the movement of the baby will rupture the sac as the baby’s body is born. This can be rather dramatic and messy and is another good reason for the midwife not to be fiddling about at the perineum during birth. A waterbirth in the caul is possibly one of the most amazing sights in the world (and less messy than on land). Once the baby is born the membranes can be peeled off – see the photo at the top of this post.

Historically being born in the caul was considered good luck for the baby. It was also believed that a baby who was born in the caul would be protected from drowning. Midwives used to dry out amniotic membranes and sell them to sailors as a talisman to protect them from drowning. Very enterprising!

Artificial rupture of membranes (ARM) aka amniotomy

Breaking the membranes with an amni-hook is a common intervention during labour. It is the first step in the induction process (see previous post), and also done in an attempt to speed up spontaneous labour. In an induced labour, intact membranes prevent the artificially created contractions from getting into an effective pattern. There is also the theoretical risk of an induced contraction (that is too strong) forcing amniotic fluid through the membranes/placenta and into the blood system causing an amniotic embolism and maternal death. So an ARM is necessary before a syntocinon/pitocin infusion is started.

In a spontaneous labour the rationale for an ARM is that once the forewaters have gone the hard baby’s head will apply direct pressure to the cervix and open it quicker. However, a cochrane review of the available research states that “the evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”

There are also risks associated with an ARM:

• It may increase contraction intensity and pain which can result in the woman feeling unable to cope and choosing an epidural… intervention rollercoaster begins.
• The baby may become distressed due to compression of the placenta, baby and/or cord (as described above).
• The umbilical cord may be swept down by the waters and either past the baby’s head or wedged next to the baby’s head. This is called a ‘cord prolapse’ and is an emergency situation. The compression of the cord interrupts or stops the supply of oxygen to the baby and the baby must be born asap by c-section. The only cord prolapse I have been involved with happened after an ARM (not done by me  - honest!). The outcome for the woman was a live baby born by emergency c-section. Her previous 2 babies had been vaginal births.
• If there is a blood vessel running through the membranes (see picture below) and the amni-hook ruptures the vessel the baby will lose blood volume fast – another emergency situation.
• There is a slight increase in the risk of infection but mostly for the mother (not baby). This risk is minimal if nothing is put into the vagina during labour (ie. hands, instruments etc.).

Summary

The amniotic sac and fluid play an important role in facilitating birth and protecting the baby. There is no evidence that rupturing this sac will reduce the length of labour. While every intervention has it’s place including ARM, midwives need to carefully consider the risks before offering it to women. Also women must be fully informed of the risks before choosing an ARM during their labour.

Normal Newborn Behavior and Why Breastmilk Isn't Just Food

What is a normal, term human infant supposed to do?

First of all, a human baby is supposed to be born vaginally. Yes, I know that doesn't always happen, but we're just going to talk ideal, normal for now. We are supposed to be born vaginally because we need good bacteria. Human babies are sterile, without bacteria, at birth. It's no accident that we are born near the anus, an area that has lots of bacteria, most of which are good and necessary for normal gut health and development of the immune system. And the bacteria that are there are mom's bacteria, bacteria that she can provide antibodies against if the bacteria there aren't nice.

Then the baby is born and is supposed to go to mom. Right to her chest. The chest, right in between the breasts is the natural habitat of the newborn baby. (Fun factoid: our cardiac output, how much blood we circulate in a given minute, is distributed to places that are important. Lots goes to the kidney every minute, like 10% or so, and 20% goes to your brain. In a new mom, 23% goes to her chest- more than her brain. The body thinks that place is important!)

That chest area gives heat. The baby has been using mom's body for temperature regulation for ages. Why would they stop? With all that blood flow, it's going to be warm. The baby can use mom to get warm. When I was in my residency, we would put a cold baby "under the warmer" which meant a heater thingy next to mom. Now, as I have matured, if a baby is "under the warmer," the kid is under mom. I wouldn't like that. I like the kids on top of mom, snuggled.

Now we have a brand new baby on the warmer. That child is not hungry. Bringing a hungry baby into the world is a bad plan. And really, if they were hungry, can you please explain to me why my kids sucked the life force out of me in those last few weeks of pregnancy? They better have been getting food, or well, that would have been annoying and painful for nothing.

Every species has instinctual behaviors that allow the little ones to grow up to be big ones and keep the species going. Our kids are born into the world needing protection. Protection from disease and from predators. Yes, predators. Our kids don't know they've been born into a loving family in the 21st century- for all they know it's the 2nd century and they are in a cave surrounded by tigers. Our instinctive behaviors as baby humans need to help us stay protected. Babies get both disease protection and tiger protection from being on mom's chest. Presumably, we gave the baby some good bacteria when they arrived through the birth canal. That's the first step in disease protection. The next step is getting colostrum.

A newborn baby on mom's chest will pick their head up, lick their hands, maybe nuzzle mom, lick their hands and start to slide towards the breast. The kids have a preference for contrasts between light and dark, and for circles over other shapes. Think about that...there's a dark circle not too far away.

Mom's sweat smells like amniotic fluid, and that smell is on the child's hands (because there's been no bath yet!) and the baby uses that taste on their hand to follow mom's smell. The secretions coming from the glands on the areola (that dark circle) smell familiar too and help the baby get to the breast to get the colostrum which is going to feed the good bacteria and keep them protected from infection. The kids can attach by themselves. Watch for yourself! And if you just need colostrum to feed bacteria and not yourself, well, there doesn't have to be much. And there isn't because the kids aren't hungry and because Breastmilk is not food!

We're talking normal babies. Breastfeeding is normal. It's what babies are hardwired to do. 2009 or 209, the kids would all do the same thing: try to find the breast. Breastfeeding isn't special sauce, a leg up or a magic potion. It's not "best. " It's normal. Just normal. Designed for the needs of a vulnerable human infant. And nothing else designed to replace it is normal.

Colostrum also activates things in the baby's gut that then goes on to make the thymus grow. The thymus is part of the immune system. Growing your thymus is important. Breastmilk= big thymus, good immune system. Colostrum also has a bunch of something called Secretory Immunoglobulin A (SIgA). SIgA is made in the first few days of life and is infection protection specifically from mom. Cells in mom's gut watch what's coming through and if there's an infectious cell, a special cell in mom's gut called a plasma cell heads to the breast and helps the breast make SIgA in the milk to protect the baby. If mom and baby are together, like on mom's chest, then the baby is protected from what the two of them may be exposed to. Babies should be with mom.

And the tigers. What about them? Define "tiger" however you want. But if you are baby with no skills in self-protection, staying with mom, having a grasp reflex, and a startle reflex that helps you grab onto your mom, especially if she's hairy, makes sense. Babies know the difference between a bassinette and a human chest. When infants are separated from their mothers, they have a "despair- withdrawal" response. The despair part comes when they alone, separated. The kids are vocally expressing their desire not to be tiger food. When they are picked up, they stop crying. They are protected, warm and safe. If that despair cry is not answered, they withdraw. They get cold, have massive amounts of stress hormones released, drop their heart rate and get quiet. That's not a good baby. That's one who, well, is beyond despair. Normal babies want to be held, all the time.

And when do tigers hunt? At night. It makes no sense at all for our kids to sleep at night. They may be eaten. There's nothing really all that great about kids sleeping through the night. They should wake up and find their body guard. Daytime, well, not so many threats. They sleep better during the day. (Think about our response to our tigers-- sleep problems are a huge part of stress, depression, anxiety).

And sleep... My guess is everybody sleeps with their kids- whether they choose to or not and whether they admit to it or not. It's silly of us as healthcare providers to say "don't sleep with your baby" because we all do it. Sometimes accidentally. Sometimes intentionally. The kids are snuggly, it feels right and you are tired. So, normal babies breastfeed, stay at the breast, want to be held and sleep better when they are with their parents. Seems normal to me. But there is a difference between a normal baby and one that isn't. Safe sleep means that we are sober, in bed and not a couch or a recliner, breastfeeding, not smoking...being normal. If the circumstances are not normal, then sleeping with the baby is not safe.

That chest -to -chest contact is also brain development. Our kids had as many brain cells as they were ever going to have at 28 weeks of gestation. It's a jungle of waiting -to-be- connected cells. What we do as humans is create too much and then get rid of what we aren't using. We have like 8 nipples, a tail and webbed hands in the womb. If all goes well, we don't have those at birth. Create too much- get rid of what you aren't using. So, as you are snuggling, your child is hooking up happy brain cells and hopefully getting rid of the "eeeek" brain cells. Breastfeeding, skin-to-skin, is brain wiring. Not food.

Why go on and on about this? Because more and more mothers are choosing to breastfeed. But most women don't believe that the body that created that beautiful baby is capable of feeding that same child and we are supplementing more and more with infant formulas designed to be food. Why don't we trust our bodies post-partum? I don't know. But I hear over and over that the formula is because "I am just not satisfying him." Of course you are. Babies don't need to "eat" all the time- they need to be with you all the time- that's the ultimate satisfaction.

A baby at the breast is getting their immune system developed, activating their thymus, staying warm, feeling safe from predators, having normal sleep patterns and wiring their brain, and (oh by the way) getting some food in the process. They are not "hungry" --they are obeying instinct. The instinct that allows us to survive and make more of us.



Dr. Thomas