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To cut or not to cut- that is the question.

9/6/2024

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​Our clients are faced with a tough decision when it comes to having a baby boy. Should we circumcise our baby? Once in midwifery care, they are used to taking in all the information and making an educated decision. The circumcision decision seems to have good information both for and against its practice and sorting through it can be challenging. There are also societal pressures, family emotions, and anxiety about making the wrong choice for your baby. We are going to sort through as much of that as we can here and leave you with some excellent resources to continue your own research, as well.

What is male circumcision, and how is it viewed in the US?
  • A surgical procedure in which the foreskin of the penis is removed. Circumcision is done as a religious ritual, cultural custom or medical practice. Modern newborn circumcision forcibly separates the foreskin from the glans (head of the penis), clamps it in place with a surgical device and applies pressure and/or a blade to remove the foreskin, leaving the glans completely exposed.
  • Worldwide, about 15-25% of males are circumcised. In the United States about half of newborn boys are circumcised; the huge majority of these procedures are done as a cultural custom and are considered elective, cosmetic procedures. 
  • The rate in the US is on the decline in recent years, from nearly 65% in 1995 to just over 50% in 2010. Less than 25% of Texas newborn males are circumcised. One of the biggest contributors to the decline is both the CDC and AAP (American Academy of Pediatrics) ceasing to recommend circumcision as a routine newborn procedure for males, due to the lack of scientific evidence in support of it. There is, however, according to AAP, enough evidence for potential benefits that the AAP feels it should remain available for families that choose it.

There are many different sources of information to consider when discovering the pros and cons- and we will get to those below I promise. First, let's take a look at some of the common aspects of this topic that come up when we talk with parents in our prenatal visits about circumcision:

Objections to Circumcision:
  • Altering the way baby was created
  • Changing normal penis anatomy
  • Female circumcision is illegal
  • A painful surgical procedure
  • Complications in healing
  • Decreased sexual sensation as an adult
  • A permanent procedure performed on non-consenting babies

Objections to Intact Foreskin:
  • Hygienically superior
  • Religious tradition
  • Genitals that match Dad's
  • Societal pressure
  • Cosmetic ideals
Here are some facts about the foreskin that some families aren't aware of:
  • The foreskin is more than skin- it's a functional fold of smooth muscle tissue, blood vessels, nerves, skin and mucous membrane.
  • The purpose of foreskin is to cover and protect the glans penis (the head of the penis) and the urinary meatus (the opening of the urethra) from contaminants, abrasions and trauma.
  • The foreskin also acts as a natural lubricant and is an anatomical "prepuce" (which includes the clitoral hood in women.) The prepuce for both men and women is meant to keep the glans as an internal organ unless aroused. 

And Finally, What the Research Says... 

Circumcision Risk:
  • Not all babies will be completely protected from a painful experience even with anesthesia. A very small percentage of babies have complications due to the anesthesia and pain medication.
  • 30 in 1000 babies experience mild to moderate surgical complications
  • 3 in 1000 experience severe surgical complications
  • 10 in 1000 will need to undergo a repeat surgery
  • 1 in 1000 will develop a UTI before age 1
  • 1 in 1 million circumcised males develop cancer of the penis annually
  • Circumcision may slightly reduce HIV and STI acquisition 
  • Expert opinions conflict on whether circumcised males experience better sexual performance


Intact Foreskin Risk:
  • 10 in 1000 need a medical circumcision later in life
  • 10 in 1000 will develop a UTI before age 1
  • 3 in 1 million uncircumcised males develop cancer of the penis annually
* There is critique on this research stating it's compiled from data obtained from adult circumcision in sub-Saharan Africa, where hygiene and medical practices, resources and public health education is very different than in US culture. One argument against the foreskin risk is proper penis care and education effectively reduces morbidity in these areas without surgical removal of functional reproductive tissue.


Sooo, If Research Doesn't Support It, Why Do We Still Do It?

As we mentioned at the beginning of this post, sometimes medical research is not the only piece of information being considered. We are complex beings with complex motives and both societal pressure and norms, plus personal beliefs and ideals play a part in the choices we make.


What About Adult Circumcision?
  • There are more reports of adult circumcision complications, but that may be because adults can verbally report if there is excess pain or delayed healing and infants are not self-reporting. There is no evidence that properly performed adult circumcision is actually riskier. 
  • It is more costly, but that has to do with the anesthesia and not the procedure itself. General anesthesia is the most appropriate pain control method for circumcision at any age but is contraindicated for newborns. Adult circumcisions with general anesthesia costs about $3000 out of pocket; insurance coverage varies.

What About Religious Ritual Circumcision?
  • Jewish and Muslim cultures use circumcision as a religious ritual. Traditional Jewish circumcision was done by just removing the tip of the foreskin, by pulling the foreskin up over the glans and making one cut, without forcible retraction or leaving the entire glans exposed after the procedure.
  • Modern Jewish circumcision is done in a variety of ways, many with a mohel (rabbi/physician), liturgy and ceremony on the 8th day of life. 
  • Christians in the US tend to make up a higher percentage of families choosing circumcision for their sons, stating religious tradition as a reason. The bible tells us that because of the life, death and resurrection of Christ we have freedom in the new covenant and no longer have to meet the standard of old testament law. “For in Christ Jesus neither circumcision nor uncircumcision counts for anything, but only faith working through love.” Galatians 5:6 
What About The Look Of The Penis?
  • Many parents choose circumcision because they prefer the look of the circumcised penis or they are worried about what others will think about the look of their child's penis. I don't have an argument for this. You are simply choosing a surgical procedure for your child, in order to alter the appearance of their genitals.
  • Some fathers worry about how their circumcised adult penis might look different to a child who is intact and have a desire for their parts to "match". We would beg to offer that adult genitalia always look different than a child's- consider the appearance of adult female labia compared to a small girl's labia. We recommend using simple and frank ways to describe any difference in any anatomical feature, genitals or otherwise. One of our client's told his son, "Daddy has an old fashioned penis" when asked, and opened the conversation up to physical autonomy and consent.


Decisions, Decisions

You won't have come to a clear choice of if you should circumcise your baby or not by the end of this post necessarily, but when you do, there are some important things to consider with either option that make your decision informed and responsible as a parent:

Choosing Circumcision:
  • Can the desired benefits be obtained if parents wait for an age that the child can reasonably consent to the procedure?
  • Always choose a licensed physician who is well-trained and very experienced with the procedure and addresses your concerns respectfully beforehand. Untrained providers have the highest rate of complications. The most common circumcision providers are pediatricians, OB/GYNs and urologists.
  • Proper analgesia is key. Babies should be given a penile nerve block as the primary source of anesthesia. Adjunct measures like sucrose pacifiers, topical lidocaine and acetaminophen are to be used in addition to a full nerve block.
  • There are 3 common devices used as clamps during circumcision; Gomco, Mogen and Plastibell. They are not created equal, do some research on each and know which options exist with your chosen provider. 
  • Circumcision as a cultural custom is an elective cosmetic procedure. For this reason, many insurance companies do not cover this procedure. Out of pocket cost can be $800+.
  • Some providers won't perform a circumcision without vitamin k injection, knowing this ahead of time can help you make a decision about standard newborn procedures. It should be noted that babies will synthesize their own stores of Vit K by the end of the first week of life. Many providers will perform this procedure without Vit K if baby is at least 8 days old. 
  • Sometimes our clients tell us they don't want to know what the procedure is or to think about it or be present for it with their baby. This is understandable, circumcision can be very traumatic for everyone. We strongly recommend, however, that parents embrace their choice, watch an educational video on the procedure beforehand and advocate for their baby in person during the procedure. 

Choosing Intact Foreskin:
  • Do not retract an intact penis, never push or pull the foreskin back to clean under it- it is harmful and painful. During puberty, the erections that come with normal growth and development gradually loosen the foreskin from the glans.
  • Gently wipe from the base to the tip or rinse with warm water (no soap at the tip).
  • Include the above information in how you educate your son in other hygiene matters (like brushing teeth and toileting) as he grows and learns to take care of his body.

Additional Considerations:
  • It is one of the most common surgical procedures in the country and the complications are fairly low. Of course, so is the cesarean and we learn that common doesn't always equal normal, right or necessary. Questioning, researching and discussing before making a decision is wise.
  • For parents that choose circumcision, there are ways to exercise discernment in procedure timing. We do not advise families leave the house for non-urgent outings or appointments in the first 2 weeks because rest, bonding and nursing are so important. We also advise to wait and see breastfeeding as well-established before a circumcision is done; Another common but often vital surgical procedure for the newborn involves releasing oral restriction to make breastfeeding successful. There is understandably a hesitation for this when a baby is already recovering from a circumcision done within the first week.
  • There are ethical issues to consider from our perspective as midwives who deeply value physical autonomy and consent. You will not hear us give blanket recommendations for a permanent, elective procedure on a brand new baby. 
  • Informed decision-making is supreme here. We support any choice made after gathering all the information and considering multiple perspectives and research sources.

​For Additional Research:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4364150/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2878423/
https://i1.wp.com/thebirthhour.com/wp-content/uploads/2017/03/Circumcision-infographic.png
https://pediatrics.aappublications.org/content/130/3/e756
https://worldpopulationreview.com/state-rankings/circumcision-rates-by-state
http://intactwiki.org/wiki/Jewish_Circumcision
https://health.costhelper.com/circumcision.html
http://www.cirp.org/library/history/
http://www.drmomma.org/2009/09/functions-of-foreskin-purposes-of.html
http://www.thewholenetwork.org/twn-news/proper-care-of-the-intact-penis-from-baby-to-teenager
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Enjoying your Breastfeeding experience

9/6/2024

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​The benefits of breastfeeding abound. There is no shortage of education on why breastfeeding your child is so important and beneficial. It's an easy decision to make- you want to breastfeed your baby- and we want to provide the support, education and inspiration to make it a lasting and fulfilling experience.

Breastfeeding is a beautiful thing: 

- The birth of the placenta initiates milk production
- Your baby's natural instincts to root and suck at your breast bring the precious colostrum into her digestive system and assist in contracting and shrinking your uterus
- Your baby skin-to-skin on your chest helps regulate her temperature, and your hormones facilitate necessary bonding
- Around day 3 your milk comes in, your newborn fills her tummy and your body begins to provide the perfect and ever-changing nutrition to meet your exact baby's needs.

We know enjoying breastfeeding is at the heart of your desires as a new mom. We champion for your breastfeeding experience as fellow moms and as your midwives. Your midwives are passionate about the physiological process of breastfeeding, and protecting and supporting your breastfeeding journey is at the center of our postpartum care. 

What you can expect from midwifery-led breastfeeding support:

1. We believe in preparation. Breastfeeding is discussed in pregnancy together at your appointments. We explain the basics, provide education, answer questions, examine breasts, make recommendations, loan materials, and normalize both the challenges and the joys of breastfeeding a newborn. If you have had trouble nursing an older child, we work preemptively to address your specific concerns. Advocating for your best understanding and knowledge prior to birth is key. Find a tribe of women who have navigated common obstacles and can offer tips and support. A local breastfeeding meet up is ideal, start learning during your pregnancy. Your Midwife can offer resources for local support as well. 

2. We believe YOU are your baby's expert. You are your baby's first home while she grows, and your baby belongs in your arms the second she arrives. We do minimal touching, fussing or handling of your baby- she is yours to expertly catch, to place on your own chest for her smoothest and most peaceful transition. The sequences your baby goes through in those first many minutes are vital to her initiation of breastfeeding and should not be interrupted unless absolutely necessary. You are free to slowly discover your sweet one, tuning in and building bonds that only the two of you can do.

3. We believe in a supportive postpartum. We ensure a good latch and that nursing is underway before we depart after your birth. We visit you again 2-3 days after birth, 2 weeks, and 6 weeks- and anytime needed in between! These 60 minute visits come to you to address engorgement, nipple soreness, baby's weight gain, milk supply and comfortable latching. We encourage resting in bed for at least a week, getting to know your baby, feeding on demand, skin-to-skin as often as possible and asking others to help with unrelated responsibilities around the house.


Should a complication arise at any point in your breastfeeding relationship, your midwives are still only a call away. We will assess the symptoms, make an extra visit, bring in extra supportive measures, and make referrals to our trusted lactation consultants. As we continue to visit postpartum with you and your baby throughout their first 8 weeks we are able to support the adjustments in store for new nursing phases, changes and challenges. 

We are also there to celebrate your hard work, take joy in your triumphs, admire your selfless effort, and cheer you on wholeheartedly. The story of your family is in these tender nursing moments, and we are here to help make your experience an extraordinary one!
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Prodromal Labor

9/6/2024

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I’ve got a Midwife joke for you.

Braxton and Hicks walk into a bar…
….Nothing happens. 

Funny, I know. I’ll be here all night. Tip your Midwife. 

But really, what is Prodromal labor?
I believe once upon a time this was referred to as “False labor” and I truly despise that term. There is nothing fake or useless about Prodromal labor. It has a job, and we are thankful that the job it is doing isn’t painful. It’s just annoying at times. 

Prodromal labor refers to the (usually) evening time rounds of frequent Braxton Hicks contractions that can mimic labor. Moms will notice these contractions are more frequent than the day to day variety, her uterus is tightening for short spurts (typically 20 seconds or less), and she will wonder if this is labor beginning. She prepares to sleep, eats and drinks something before going to bed, and wakes up the next morning after a fitful night of sleep to find she is still pregnant and not in labor. 
How frustrating! We get it! Let’s try to understand the process, shall we?

Your body is learning to ride a bike!
Braxton Hicks contractions can be thought of as practice contractions, and practice makes perfect. 
Remember when you first learned to ride a bike? You got on, wobble wobble, fell off. Then you got back on. Wobble wobble, fall off. But eventually you got back on, learned to balance, and took off! You still know how to ride a bike today. 
The body is much the same. For any mom having her first baby, or experiencing her first birth without an induction, your body is having to learn to balance the hormones baby is producing coupled with your own hormones and issue that command to your uterus. It’s a lot. The beauty is that once your body has been given the opportunity to learn this on its own, it won’t forget. Subsequent labors usually begin smoothly, without days and days of Prodromal Labor. 

How is Prodromal Labor helpful? What’s the point?
These concentrated rounds of practice contractions work to do the early stuff for your birth. They soften, thin, and shorten your cervix with the help of those hormones. This early work is key to dilation later once you are in Active labor. This is usually referred to as “early EARLY labor”. 

So now back to my terrible Midwife joke….
The difference between Braxton Hicks (and Prodromal labor) vs. Active Labor:
Braxton Hicks WILL NOT change your cervical dilation. (Nothing happens)
Braxton Hicks contractions will not become increasingly
*Longer, Stronger, Closer Together*. 
That is the key to knowing if you are in or approaching Active labor. 
Contractions will over time become longer in duration, stronger in intensity, and closer together. 
Braxton Hicks contractions coming in fast bursts (aka Prodromal labor) will continue to be infrequent, short, mild. 

I’m tired! How do I sleep through this?
Something helpful you can do when you are just over it all and need some rest, and also a handy way to tell if this is going to become labor or not:
Eat a meal with protein and complex carbs
Drink electrolyte rich fluids
Take 50mg Benadryl or 10mg melatonin
Soak in a very warm bath
Go to sleep!
You’ll either wake up well rested and go about your day or you’ll wake up because your Active Labor contractions have woken you. This “Rest protocol” will not stop active labor, but it will stop Prodromal labor. Either way, rest prior to labor is so incredibly important we can’t stress it enough. 

I hope this info dispels any doubt you may feel about your body and ability to labor naturally. As always, when in doubt, contact your Midwife!

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What to do in early labor: Patience, trust and a bit of Midwife dust.

9/6/2024

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If there is any one mistake we try to prevent for first time moms planning a natural birth at home, it is the accidental over-activity during the first phase of labor. It is so common for a couple to get so overjoyed with the labor process finally beginning that they hype themselves into overdrive too early and begin to putter out just as the "real" work of labor is actually beginning. Rookie mistake, you can call it, but it's a very easy one to make without some extra wisdom and guidance.

This scenario plays out all too easily. Picture it with us. You are diligent to follow your midwives advice to have everything ready for baby at 37 weeks in pregnancy. Your due date comes and goes, and although cognitively you know it's normal, you were secretly hoping you'd be the one to go early. You are spending 7-10 days after your due date going back and forth between trusting your body and wondering if you are going to be the first women ever to actually stay pregnant forever. You wait, you cry, you scream at the daily well-meaning "any baby yet?" texts and are vigilant for any sign of labor beginning.

And then, HARK! Was that last Braxton Hick a little stronger than usual? Was that a bit of pink on your toilet paper? Was your bowel movement looser than normal? Yes, these are wave-like surges you realize- and that's the 5th one you have felt in an hour. This must be it, finally your day has come! You call your midwife and she agrees, this may be the very beginning of your true labor. And you find yourself at a fork in the road. Will you let your excitement get away from you and jump into full labor mode yet? Or will you take the advice of your loving care provider and all the many wise women who have traversed this path before you? You want to be the latter, we know this, you just need some encouragement to light the path a bit. 


What is "Early" Labor, Anyway? 
  • Known as the "wait and see" phase, contractions may intensify and progress or dwindle down and start again another day
  • Contractions are usually 5 or more minutes apart lasting less than 60 seconds
  • Your water may have broken but no contractions have begun
  • You can walk and talk easily through contractions
  • Contraction frequency may be inconsistent or start and stop
  • Is normal and fairly common for this phase to last 12-24 hours or more (for the first time mom)


The Don'ts of Early Labor:
  1. Don't get out of bed if it's nighttime: it may seem like it's impossible to sleep and rest, but it's not! Your end-of-labor self will look back on your beginning-of-labor self and say, "you actually could have been sleeping THEN- now it truly is impossible." So do your end-of-labor self a solid and work everything in your power to get back to sleep, or at least doze in-between your surges.
  2. Don't wake up your partner if it's nighttime: you know he will be SO excited with you and for you and it feels almost wrong to keep this little secret, but he needs sleep as badly as you do. 
  3. Don't start timing contractions: you are paying way too much attention to your labor if you are timing contractions already and we guarantee your labor will feel like it's a thousands hours long if you do this. You can notice how far apart they are for a few in a row just to get a gage on the timing and progress, but then you should stop and distract yourself with another activity. 
  4. Don't cancel all your plans and stay home: waiting around for your labor to change will also make it feel unnecessarily long. Keep doing life until your labor takes all your concentration.
  5. Don't group text or post on social media: unless you want to have everyone checking in on you asking why it is taking so long, only tell the essential birth team members that you think your labor has begun. You may not even feel like announcing the birth right after your baby is born, so it is usually best not to let everyone know you are in labor.


The Do's of Early Labor:
  1. Sleep if it is nighttime. Nap if it is daytime: you are going to want as much energy stored up in your labor cup as possible once the big work of active labor shifts into view. A good balance of activity and rest is needed during early labor.
  2. Stretch, walk, do hip circles on the ball, and spend time outdoors: you want to keep your mind and body active and distracted, but you can support the start of labor well with exercises that open, gently shift and balance you physically.
  3. Eat full and nourishing meals: fuel up with calories that can power you through the work of labor. Look at every meal as if it's the last full one you may get before your appetite dwindles. Nausea (and even vomiting) are common in labor and you may struggle to eat for energy later. Choose whole foods that are easy to digest and emphasize protein and complex carbs. Once full meals are not possible, make sure you are snacking every 2 hours, or taking small bites of food every few contractions.
  4. Hydrate: keep hydration at a level that causes urination every 30-60 minutes. Keep a bottle or cup with a straw filled with clear fluids and with you wherever you go. Dehydration can sap energy and make contractions more painful. Give yourself some electrolyte boosts with your fav powders or coconut water. 
  5. Get a massage and visit your chiropractor or acupuncturist: find out ahead of time who on your prenatal team is willing to see you on short notice in labor. This is the perfect time to get one more treatment to relax, align and support a straightforward labor and birth.
  6. Review your birth affirmations: remind yourself what you want and believe to be true about birth and be willing to speak those things over yourself while you embrace the waiting and unknown. 

How Will You Know When You are in Active Labor (aka early labor is over) ?
  • Contractions are usually less than 5 minutes apart lasting 60 seconds or more
  • You can walk and talk easily in between contractions but are starting to need to concentrate and focus during a contraction
  • Contraction frequency is usually forming a predictable pattern
  • It's harder to be distracted and you have a strong sense of wanting to get settled into your birthing space

Now, labor will look different for every women. Each birth for the same mother will be different as well. We have seen first labor that take 3-4 days before the baby is born and first labors that take only 6 hours before the baby is born. We always share with our clients that it is easier to plan for the average 24 hours and adjust to it being shorter, than to plan for it being shorter and have to adjust expectations in the opposite direction. 

Thankfully, you only have to do this first labor once. Your body takes some liberties in slowly opening for the first time. Although the first labor can be particularly long and hard, as midwives, we trust the physiological process and aim to support it unfolding naturally as best we can. Birthing couples can do their part to support the process by taking diligent care during the early phase. ​
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So what happens if there is a complication?

9/6/2024

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​When you are considering and planning a homebirth, many new thoughts and concerns may come to mind. Not only are you taking on the giant responsibility of having a child but there is an added responsibility of doing this in your home and going against mainstream birth culture norms. You wonder, is this a good idea, is this safe, what if something bad happens? And even if you’ve reached a place of confidence with your choice, your friends and family may be very vocal about their own concerns for you.

Homebirth often get portrayed in 2 extremes- a dangerous event that could go wrong at any moment and should always take place in a hospital with standby emergency services; or a peaceful and twinkling family bathtub in your living room with kumbaya playing in the background. There’s room in birth for a vast array of experiences and outcomes, but midwives recognize that a huge majority of women (about 90%) are having a low-risk pregnancy and go on to have a low-risk birth. We proceed to expect and support a physiological process that does best with minimal intervention and interruption. If the majority of what we encounter as midwives is low risk and we plan to be non-intrusive with our care, do we even know how to handle complications and emergencies or are we only equipped to support beautiful and easy births?

Asking these questions is good!! Considering the pros and cons, risks and benefits, is a healthy sign of parenting. We would love to see more consumers prepared to ask about safety and outcomes in all birth settings with all types of care providers. “What if something goes wrong?” Is a common place to start, but it would be even more beneficial to ask questions like, “what are the most common complications, and how do you respond to ______ complication or emergency.” Can you see how you may collect different types of information with the way you ask questions? It’s valuable to know and understand what can actually go “wrong” and what is being done to protect health and safety.

Many people are surprised to learn what training, skills, and equipment midwives have to handle complications. Many families assume that because we are providing care in homes we do not have the resources to handle medical events.
We practice with autonomy and within the scope of a primary caregiver. We carry medical instruments, medications, oxygen, resuscitative equipment, and equipment to monitor vital signs of baby and mother. In fact, we provide every resource that a birth center does, we just bring it with us. What we do not have is an operating room, incubation equipment, or blood products, and will always move to higher level care when these resources are anticipated or needed.


It’s important to note that the primary way we prevent complications to begin with is by taking a holistic approach to care. We believe that birth is a normal event, that usually unfolds best on its own. Midwives have set up prenatal care to spend 12-13 hours of time with each family learning their bodies and babies and establishing individual baselines for them. This allows us to address issues that come up in pregnancy and make preventative adjustments with nutrition, movement, and loads of education. We enter the birth event together, with mutual trust and respect and a common goal.

It’s vital to recognize that birth is not without risk. No one can eliminate risk in any setting with any set of experience and skills. But HOW the risk is recognized and respected matters a lot. Midwifery care is an equal partnership of midwife and client. Your job is to learn the risk, weigh the benefits and make a choice comfortable and supportive for you and your individual family. Our job is to constantly assess the care we provide inside the framework of normal and respond with vigilance to the most common complications in order to restore normalcy to the birth event.
Not everyone is comfortable talking about these things. We recognize that many birthing parents would rather blindly trust, assume competency and hope that nothing goes awry in their positive thoughts birth bubble. We caution strongly against that approach, knowing from experience that unpacking facts and dispelling untruths always takes the charge off these topics. We by no means emphasize an expectation for complications in birth- but truly believe in the benefits of shared responsibility and decision-making.

We endeavor to be transparent about the risks. The 4 most common complications that we experience at homebirth are shoulder dystocia, hemorrhage, neonatal recusitation and maternal exhaustion. These complications rarely come out of nowhere, but more often get revealed inside a bigger story being told, with a few signs that warn us to be alert. Some examples of these signs may be a very long labor, uncoordinated contraction patterns, and a deviation in normal heart tones of the baby, just to name a few. Should we then transfer to higher-level care when we see these signs at birth? The short answer is no. Very often we can bring these items back to normal, they self-correct or ultimately don’t cause any issues at all. Very rarely are a certain combination of these signs a precursor to complication, yet we remain vigilant just in case. Sometimes it does become obvious that higher-level care is best for all, and recognizing these signs before an emergency occurs allows us to make a change in settings safely. As we say, “watch for pink flags, not red flags”. 

1. Shoulder dystocia is when the baby’s shoulders get stuck on some part of the pelvis while it is being born. Most of the head is usually born and then despite maternal pushing effort, the rest of the baby can not be born right away. Again, a huge part of managing shoulder dystocia is avoiding it in the first place. Only about 30% of shoulder dystocia occurs with large babies; the other 70% are due to malposition of the average-sized baby.

The best thing we can do to avoid this complication is leave birth undisturbed whenever possible and set up the support a birthing mother needs to move freely and instinctually throughout her labor. Waiting patiently for babies to come, and leaving hands off during the delivery allows babies to make the full rotation needed for the shoulders to clear the pelvis on its own. Rushing or assisting this process can very well become the cause for babies getting stuck. 

But even the most patient and trusting birth attendants will eventually encounter a shoulder dystocia. We act quickly to first change the position of the mother. A huge majority of the time, this frees the baby instantly. Mom turns over, or lifts a leg to get out of the birth tub and baby comes shooting out. If not, we have several systematic maternal positions to move mom through that all change the diameter of the pelvis in order to shift and make room for baby. When these don’t work, we enter the vagina with our hands to manually reduce the baby’s shoulders and rotate them to fit through the pelvis.

The baby always comes out with the proper use of these methods. Our approach is to recognize and resolve a shoulder dystocia as quickly as possible. It’s not uncommon for a baby to need resuscitation, and a mother to bleed heavier than normal after a shoulder dystocia. We expect and respond quickly to both possibilities.

2. Neonatal resuscitation is a series of actions used to assist a newborn having difficulty making the transition from intrauterine life at the time of birth. Babies go through a major physiological transition to begin breathing air and oxygenating through their lungs instead of their umbilical cords. Some babies, due to various issues, often unknown, need a little extra help initiating this transition. Statistically, 1 in 10 babies will require some level of resuscitative intervention. That may seem like an uncomfortably high rate, however, the first step in resuscitation is 5 breaths to inflate the lungs of the baby, which quickly assists over 90% of babies who need help, in the span of only about 20 seconds. We use positive pressure ventilation with a neonatal bag and mask to force air into the lungs, which pushes the surfactant out of the alveoli and stimulates independent breathing and normal transition.

Many people are surprised to learn that babies are born looking kinda blue or purple. Not all babies begin crying when they are born and crying is not necessary for good transition and oxygenation. At the birth, we wait a full 60 seconds for babies to begin breathing on their own, which oxygenates their blood with air and turns them pink. (With an intact cord, baby is still receiving oxygen through the placenta.) The average adult has a blood oxygen saturation of 98-100%. It takes a normal newborn about 10 minutes to reach 90% saturation, and we are patient with the process.

For babies who need more help than those first few breaths, we continue with resuscitative efforts to breathe for the baby with the bag and mask. Rarely a baby will require chest compressions to stimulate necessary cardiac function but we are trained and prepared to perform a full resuscitation with oxygen while initiating emergency transport for the baby. Less than 1% of babies will require a medical intervention that we can not provide at home. When transport is necessary, we travel with the baby and continue breaths and compressions.

Once again, our goal is to intervene with the intention of restoring the event to normal, while utilizing the advantages of understanding the physiological nature of birth. We never rush the baby off to a station on the other side of the room. We make every effort to resuscitate while the cord is still intact, keeping the baby’s present source of oxygen flowing by allowing the placenta to finish delivering about 1/3 of the baby’s blood volume. We also set up our equipment in a way that allows us to resuscitate while the baby is still being held by the mother, or just next to the mother- often asking the parents to talk and welcome their baby as we work together.

3. Postpartum hemorrhage is often defined as a certain volume of blood loss after the birth. 500 ml is the standard threshold. Midwives are trained to estimate blood loss in order to calculate this number. However, we won’t use the volume as the only rule of thumb for treating excessive bleeding. Many women lose 500 ml and more and tolerate it well, and likewise some women lose less and experience compromise because of it. We assess blood loss along with other signs of low blood volume: primarily evident in vital signs and feedback from the postpartum mother about how she is feeling.

It’s very normal for there to be a lot of blood with birth, 500 ml is 2 full cups. We see average estimated blood loss in the 300-400 range. We have attended births where there was 50 ml of blood loss, and births where there was over 1000 ml of blood loss. There is a huge range of experience here.

When we make the assessment that there needs to be an intervention to stop the bleeding, we first locate the source of the blood. It could be a laceration, a problem with the placenta, blood clotting issues or a lack of tone in the uterus. 70% of all heavy bleeding is caused by the uterus not doing its job to stay firm and contracted after the baby is born.

The uterus begins to involute (get smaller) right after the birth, and is responsible for most of the mechanism that causes the placenta to release and be born. The muscles cramp and clamp down to help all the little capillaries at the placenta site to close off and form an internal scab to slow bleeding naturally. When the uterus is soft, the capillaries are open and thus let blood flow through. To get the uterus hard and clamping again we use our hands to stimulate contractions and expel clots or assess for retained tissue. Our first line of treatment are herbs. We carry many different strong and potent herbal tinctures to be used for different bleeding scenarios. If these measures are not stopping the bleeding fast enough we have 3 pharmaceutical medications with us that are anti-hemorrhagic, one of them being the all-familiar pitocin.

If blood loss exceeds what we can reasonable manage at home, we activate EMS and administer IV fluids and oxygen. We continue to provide care through transport, as EMS does not have anti-hemorrhaging medications. 

We are pretty passionate about the physiological process of birth, if you’ve noticed. The best thing we can do to treat a postpartum hemorrhage is to prevent it in the first place. Our clients get nutrition recommendations and a close eye on their lab work during pregnancy. At the birth when it is time for the placenta to be born, we wait patiently for the body to do its job. During this phase of labor we encourage skin to skin, baby bonding and the first latch which all cause the right hormones to be released and contract the uterus on its own.

We do not over-stimulate the uterus with a lot of touching/ checking/ rubbing at this time, we do not pull on the cord to assist with placenta delivery (in the absence of other bleeding signs) and expect mothers to birth the placenta on their own instinct and effort. This is an extremely important part of respecting the design of birth and protective sequences already in place. Again, we are alert and vigilant as we monitor for all the positive signs of normal while remaining prepared to intervene as soon as necessary.

4. Maternal Exhaustion is probably the most common “complication” that we see in our practice. Typically this occurs in first time moms, but can affect anyone for a variety of reasons. You wake in the night to use the restroom, notice you are having contractions that feel different now, alert your Midwife who tells you “Sounds like you are starting to warm up now. Go back to sleep!” But your mind can’t seem to settle. There’s things to do! So mom gets up, moves about the home, preparing this, moving that…. And not sleeping. Hours and hours later, active labor has begun, and mom is tired. Midwives encourage a lot of snacks and fluids all through labor, but exhausted + discomfort tends to make mom less likely to take enough in. This creates a snowball of issues that eventually leads up to a transport to the hospital for pain relief so mom can finally sleep. (We do use several tools to replenish these needs first). 
Exhaustion affects mom first. Ability to focus, to self sooth, to listen to her body, to nourish with food and fluids. Eventually her muscles weaken, creating less effective contractions or a stall in labor and her vital signs start to shift. Baby will feel this through the lack of food, fluids. Eventually babies vital signs begin to shift as well. 
We counsel all moms that regardless of the time of day, when you suspect labor has begun, notify your Midwife and start the “rest protocol” you were given. Adequate rest prior to labor is just as important as nutrition! 

When more is required: At any time (during any birth) that we feel hospital-based care is more appropriate for continued interventions or recovery we transport by car (if the issue is not emergent) or activate EMS. Although these complications can be extremely intense, it’s unusual for there to be a necessity to transport. Midwives are well trained and particularly versed in handling these complications and returning the event back to normal status. We always discuss the possibility, risk factors, protocols and management techniques for complications with every client at their home visit. They see some of the equipment and medications we bring, practice some of the positions we use, and learn what to expect from our care if we need to intervene. We find that educating families, being transparent about our limitations and allowing the normal process of birth to unfold in its own timing all go a long way in approaching complications that can occur at homebirth.

Because we value the relationship aspect of midwifery care, we rely heavily on mutual respect and trust with our clients. Emergencies call for quick action, but preparing for complications can be a conversation. Each family has the opportunity to ask for individualized care and protocol that will make them comfortable. Sometimes this means a request for more frequent testing, monitoring or prevention. (For example, someone with a history of traumatic postpartum hemorrhage may like to have a hep-lock administered in labor.) The bottom-line being we work and collaborate with each birthing mother’s needs and desires to make her birth the best possible one.

This information will stimulate a lot of thought and feeling and we want to hold space for the integration of these ideas. Reach out with any additional questions you have to your Midwife.  There is so much more to share for those that are increasingly interested in this topic.
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Water breaking as the 1st sign of labor- A Midwife’s perspective.

9/6/2024

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Have you thought about (or planned for) how you may respond to the way your labor begins? Do your plans need to change if your water breaks as the first sign of labor? Most moms are preparing for the hard work of coping with labor contractions in the thick of an active labor pattern. That is certainly a valid place for your energy to go, but as homebirth midwives, we notice many birthing couples get surprised by the way labor begins and can feel lost in how to respond to early labor events while they are happening. We aim to shed some light on this topic from a midwifery perspective and provide some helpful information and needed conversation.

We have jam-packed this post with all our best education and planning points for when water breaks as the first sign of labor. If you are here specifically for the worksheet, click ahead to number 8 below. Here's a lineup of what you will enjoy in this article:
  1. What is Premature Rupture of Membranes?
  2. Is PROM Preventable?
  3. Medical Management of PROM
  4. Midwifery Management of PROM
  5. Informed Consent and Shared Decision-Making
  6. What if There is Meconium in the Fluid?
  7. What if Mom is GBS Positive?
  8. How to Plan Ahead for PROM (Worksheet Included!)


What is PROM? (And am I hoping you ask me to it?)
"But what if my water breaks first?" We call this PROM, standing for Premature Rupture of Membranes. It is when the amniotic sac spontaneously breaks open and amniotic fluid begins leaking from the uterus and through the vagina before the uterine contractions begin. About 90% of women have their bag break after contractions have begun, the huge majority of those ruptures happening towards the end of labor. So that means the incidence of PROM is around10%. This surprises a lot of first-time moms who may have picked up in TV or other dramatizations of birth that water gushes everywhere (in public) to signal labor has begun.

Approximately 95% of women with PROM will go into spontaneous labor on their own within 24 hours from the rupture. However, the protocols surrounding the management of PROM vary widely depending on the care community, primary provider, and birth setting. It can be frustrating and confusing for women to navigate what to expect in their own births if PROM happens to them. What do you do when early labor is dreadfully slow? 

Let's TACO 'bout It
If you have been around here for any length of time with us you know we are all about informed consent and giving clients the options to make the best decision for them. You'll have the benefit today of reading how we counsel our own clients in PROM management. We'll start with the instructions we give to each mama on how to report water breaking to their midwives. Our clients are asked to record 4 things if they notice any vaginal leaking:
  • Time
  • Amount
  • Color
  • Odor
It just so happens to be an acronym that spells TACO so it's easy to remember. We ask our clients to call us if this happens during the day, or first thing in the morning if it happens overnight. (Of course, they should always call us at night if something is abnormal or concerning- but clear water noted with spontaneous rupture of fluids and the absence of contractions is a variation of normal.)

We want to know what time the water broke, about how much fluid was noted, if it's continuing to leak and how much, what color the fluid is, and if there is any odor. If there is a brownish or green color to the fluid we will want to do some more investigating, as we would suspect the cause to likely be meconium, the baby's first bowel movement. If there is an odor, we may need to do some more investigating for possible infection. Most of the time, all fluid is normal and we chat about next steps for managing labor expectantly.

Is It Amniotic Fluid?
Every once in a while it's not super clear what the leaking fluid is or where it came from. We start to wonder this exact thing if something seems a little off in how the TACO items are reported. It's fairly common, although sometimes embarrassing, to leak urine at the very end of pregnancy. It's also possible that the fluid noted is simply a big increase in vaginal discharge, or sometimes semen after intercourse. One of the tests we do with our clients to figure this out a bit is to have them lay down flat on their side with a pad on for 20-30 minutes. The amniotic fluid should pool in the vagina during this time and come out in a gush when the mama rises from her rest. If we are very uncertain, we can use pH paper or other screening tools to test the fluid. We usually take a wait-and-see approach to this as we expect a true PROM to reveal itself eventually.

What's The Big Deal?
So far all we are talking about is a lot of detective work on stuff coming out of a vagina- why does this matter? The primary concern across all care models is that once the amniotic sac has broken, the protective barrier that keeps pathogens from the outside world away from the baby and her environment is now open. This increases the risk of infection quite a bit, which can be a danger to both mother and baby. However, I am excited to share with you a lot of ways we can decrease this risk by applying some midwifery model thinking.


Is PROM Preventable? There are risk factors associated with the incidence of PROM, including a lack of prenatal care, mothers who are smokers, have untreated sexually transmitted infections or other brewing infections (like UTI or uterine infection) or a history of preterm labor/birth. Besides underlying, unknown infection, some other theories as to why some women are at a higher risk for PROM include a malpositioned baby (like posterior/sunny side up) and poor nutrition in pregnancy. You can keep your amniotic sac strong and healthy by eating plenty of foods high in protein, vitamin c, calcium, probiotics, and iron.

There is some evidence that a daily low dose of supplemental vitamin c with bioflavinoids in the second and third trimester can also help strengthen the amniotic sac. This is good news for the mom who finds her multiple labors repeatedly beginning with PROM. It's important to note that too much supplemental vitamin c actually has the opposite effect and can weaken the integrity of the sac. Whole food nutritional choices are a great way to let your body regulate the right dose- choose vitamin c food with the pith (spongy white membrane just inside the skin) attached like citrus and bell peppers.


Medical Management of PROM Before we move through to how midwives handle PROM, one of the most important aspects of appreciating midwifery care for this is in comparing it to the way it's handled in the medical model. All providers and settings are going to differ in protocols but in our area of North Texas it’s not uncommon for hospital-based providers to require parents to come in and begin receiving antibiotics right away. These antibiotics are administered through an IV port every 4 hours until the time of delivery. While antibiotics are quite effective at reducing infection risk, there are a few important things to consider when evaluating the risk.
  1. Infection risk is generally higher all-around in a hospital setting because of routine vaginal exams given in an environment with many potentially hazardous and unfamiliar pathogens (germs). It makes sense there would need to be more precautions for infection with these conditions.
  2. Antibiotics are not benign. There are risks, often long-term and compounding for years when gut health is disturbed. Antibiotics can be life-saving and we love them when they are truly needed, however, prophylactic use needs to be weighed carefully.
  3. Having an IV in labor is an intervention that will impact how free you are to move and behave in an intuitive way. 
Outside of questioning antibiotic use in labor, there are a couple more important things to understand about medical management for PROM in the first 24-hours. The first is coming into a high-intervention setting before your contractions have even begun. Many care providers will recommend induction before the 24 hour mark. This protocol is potentially setting a woman up for a cascade of interventions she planned to strictly avoid. Second, because of the care attitude around this normal variation of labor, the patient is put into a higher risk category that will likely decrease the already-limited options of experiencing a relaxed and supportive natural birth. The attitude of the birth setting and care provider alone on this issue can certainly seem to be a self-fulfilling prophecy in complicating the birth process.


Midwifery Management of PROM Pulling way back from the snowballing scenario indicated above, we introduce the midwifery perspective. All midwives are going to have a different set of protocols, experiences, and comfortability. We are sharing our practice's stance for low-risk moms and low-risk pregnancies to offer a management outlook that relies heavily on trusting and supporting physiological birth. In most cases, we get to follow and honor this belief when it aligns with our clients as well- stay tuned through the next section on informed consent for the specifics around shared decision-making.

Once we have determined that we do in fact suspect PROM with one of our clients, we advise her to watchfully resume her normal life as much as possible. She will want to wear a pad or disposable underwear or keep a chux pad under her to help contain the fluid, and she will want to continue to monitor a few important items while she waits for contractions to begin. We advise women to work towards a balance of restfulness and distraction to pass the time and intentionally nourish their bodies. We expect roughly 95% of our clients to be in the researched category of women who begin having contractions within the first 24 hours and if they are comfortable with waiting, we certainly are too.

Here are some ideas for waiting for contractions to begin:
  1. Sleep if it is nighttime. Nap if it is daytime.
  2. Stretch, walk, do hip circles on the ball, and spend time outdoors.
  3. Eat full and nourishing meals, and keep hydration at a level that causes urination every 30-60 minutes.
  4. Get a massage and visit your chiropractor or acupuncturist.
  5. Spend time leisurely going through The Miles Circuit or Spinning Babies balancing activities.
  6. Take your temperature every 4 hours and monitor baby's movements closely.
  7. Begin an immune boosting protocol. (You can find our favorite one right HERE.)
  8. Practice strict vaginal hygiene; changing pads often, nothing into the vagina, and wiping front to back.
We have the benefit of providing highly individualized care to our clients and getting to check in with them often and giving personalized recommendations as they wait. We may visit our client and check on mom and baby while offering encouraging words and activities. For the client whose contractions do not begin around the 24-hour mark from PROM, we get to take their lead in preferences for welcoming contractions. If they want to continue to wait for their bodies to initiate surges and all is well with them and baby physically, we are happy to support that desire. If they prefer nudging their bodies into action instead, we are happy to offer guidance on a natural home-induction protocol we have prepared. If at any point there are signs of infection, illness, or compromised wellbeing of either mom or baby, the safest decision is to transport to higher-level care.

Ongoing management of Rupture of Membranes (ROM), even once contractions have begun, includes extremely minimal vaginal exams, regular vital assessments, and immune boosting practices. We know that the vagina is a self-cleansing organ and we believe when left as an "exit only" orifice during birth we can drastically reduce infection rates. We are especially vigilant for signs of infection in mom and baby into the postpartum time and have the great benefit of returning to the home after the birth for skilled postpartum care to provide ongoing monitoring. 


Informed Consent and Shared Decision-Making It's understandable (to us) how a hospital-based provider would react to a client who has PROM. The care provider has many patients to manage, in a higher-risk setting, with limited relationship and communication, and protocols to adhere to that increase risk for both mom and baby. When I was a doula many years ago I would describe this basic truth with, "if you buy the hospital ticket, you will get the hospital ride", although the ride itself is not always transparent until you are already on it. (Cue "Crazy Train" by Ozzy playing in the background of that ride.)

This is where consumers (in every single care setting) can advocate for better and individualized care. Sometimes the next steps in the labor process are shared in an authoritarian way that leaves very little else to be done but follow the professional's advice. We believe it is every provider's duty to take the time to explain the options and leave the decision in the hands of the woman herself. She is right and good to ask for expertise and information, but true informed consent is shared in the following way:
  • What are the benefits of the proposed treatment/intervention?
  • What are the risks?
  • What are the alternatives?
  • What is the provider's direct experience with outcomes that follow this proposed treatment?
  • When does a decision need to be made?
  • How can a second opinion be obtained?
  • Can we change our minds later?
Barring true emergencies, the birthing family should be given: this information, space made for asking questions, time given for discussing in private, and respect and support given for the final decision. True informed consent is sharing information in a way that empowers the patient/client to make a confident decision of their own. This is sadly not how care decisions are made in every setting, but this is the standard that we aim for in everything we do in our practice.


What if There is Meconium in The Fluid? Mec, or the baby's first poop, will usually turn the watery amniotic discharge yellow, green or brown looking. Although a release of this first bowel movement can be a sign of distress in the unborn baby, it is almost always a sign of normal development and gastrointestinal maturity instead of something to treat as an emergency. We may monitor the baby more closely in labor, assuring that other signs of distress are not present. We will monitor the color and consistency of the fluid as labor progresses to determine if there have been multiple or recent bowel movements (and possible correlating distress).

We certainly will pay close attention to baby's transition at birth and consider the baby at a higher risk for Meconium Aspiration Syndrome (MAS)- a very serious breathing issue necessitating transport and higher-level care.  Meconium staining of the amniotic fluid is noted in about 16% of all births, while MAS occurs in about 2% of all births where meconium is present.

Thankfully, in the absence of additional clinical concerns, midwives have the benefit of continuing to support a low intervention process, even when mec is present. A physiological vaginal birth does a pretty excellent job at squeezing most of the fluid out of baby's lungs, clearing the way for a normal initiation of oxygenating by air, without the use of routine or deep suctioning. Not surprisingly, we apply informed consent and shared decision-making when meconium is noted in the amniotic fluid and keep communication open with our clients as labor unfolds.


What if Mom is GBS Positive? A mom who tested positive during her GBS screen in pregnancy will be at an increased risk for GBS infection with PROM- especially with clinical practices that include vaginal exams, an unfamiliar pathogen environment, and no guidance on immune support. Here are some of the considerations we share when we practice informed consent with our clients on this:
  • About 30% of women have an overgrowth of GBS at the end of pregnancy.
  • GBS is a transient bacteria which means it can come and go from one day to another. Testing positive once doesn't mean there is an overgrowth at the time of birth (or PROM).
  • Having an overgrowth of GBS does not mean that your baby will automatically become inoculated with it. If your baby is inoculated with GBS it doesn't mean an infection will automatically develop.
  • There are other dangerous strains of bacteria that we do not routinely screen for in the US. Not all first-world countries screen for GBS in pregnancy.
  • We are actively preventing and watching for all possible infections, regardless of GBS status.
One important tidbit about preventing GBS in the first place includes using feminine health probiotic in the last trimester of pregnancy, which can cut GBS overgrowth risk in half. So, moms on probiotics carry GBS about 15% of the time instead of 30%- yay for the preventative medicine approach of midwifery care. Lastly, and certainly not surprisingly at this point, we apply informed consent and shared decision-making when PROM occurs with a GBS positive mama, and keep communication open with our clients as labor unfolds.


How to Plan Ahead for PROM (or some other unexpected labor event) Like so many things in birth, PROM can be a part of your labor story that throws you off a bit from what you were expecting and imagining. Staying flexible on expectations around your labor, while having some kind of plan in place to respond to the unknown can be a huge challenge to anticipate. We like to say all of this is *the* master prep for the real work of parenting- there are no wasted opportunities for growth through birth!

Communication is the real MVP when dealing with unknowns. Use some of the topics in this post to form some of your own questions to ask your care provider about this type of scenario taking place in your labor. 
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