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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?
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:
Objections to Intact Foreskin:
And Finally, What the Research Says... Circumcision Risk:
Intact Foreskin Risk:
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?
What About Religious Ritual Circumcision?
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:
Choosing Intact Foreskin:
Additional Considerations:
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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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! 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! 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?
The Don'ts of Early Labor:
The Do's of Early Labor:
How Will You Know When You are in Active Labor (aka early labor is over) ?
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. 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. 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:
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:
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.
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:
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 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:
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. An intact perineum is the goal of every birthing woman. We love to have whole, healthy female genitalia. Many people consider the health of the vagina/perineum to be a matter of chance, luck or being at the mercy of the circumstances of the forces that prevail at the time of the birth.
Folklore abounds about doing perineal massage prenatally. No other species of mammal does this. Advising a woman to do perineal massage in pregnancy implies a lack of confidence that her tissues have been designed perfectly to give birth to her infant. The intact perineum begins long before the day of the birth. Sharing what the feeling of a baby’s head stretching the tissues will be like and warning the mother about the pitfalls in pushing will go a long way to having a smooth passage for both baby and mother. The woman will be open and receptive to conversations in prenatal visits about the realities of the birth process. Here, in point form, is the information I convey for the second stage (pushing):
Americans are more familiar with the vital work of nurse midwives than ever before, thanks in part to the PBS show “Call the Midwife.” Yet in the United States, midwifery is often seen as a fringe choice — something strange, or even perceived as “less than” when compared with OB-GYN care.
But in a country dealing with a maternal health crisis, that may all be about to change. An increasing number of U.S. families are turning to midwives for their maternity care despite systemic, social, and cultural barriers. “The midwifery model of care emphasizes normalcy and wellness. It empowers women and gives them greater ownership of their health, their pregnancy, and the outcomes of that pregnancy based on choices that they’re able to make,” explains Dr. Timothy J. Fisher, OB-GYN residency program director at Dartmouth Hitchcock Medical Center and assistant professor of obstetrics at the Geisel School of Medicine at Dartmouth University. “Unfortunately, the medical model of prenatal care can take some of that ownership away, in a way that can ultimately be detrimental for some people,” he says. WHAT’S THE MIDWIFERY MODEL? Midwifery care involves a trusting relationship between the provider and pregnant person, who share decision-making. Midwives also see pregnancy and labor as normal life processes rather than a condition to be managed. Millennials in particular may want something different than the medical model when they decide to have a baby. Saraswathi Vedam, FACNM, a midwife for 35 years, midwifery researcher, and professor at the University of British Columbia, tells Healthline, “We have a generation of consumers now who are socialized that they should have a voice in making decisions about their own healthcare. In previous generations it was more normative to [give] control about healthcare decisions to the provider.” “Another increase [in midwifery services] is in people who’ve had negative experiences in birth — or have been with family or a friend and witnessed something that scared them — and they don’t want the loss of bodily autonomy,” says Colleen Donovan-Batson, CNM, the director of the Midwives Alliance of North America Division of Health Policy and Advocacy. Kendra Smith, an editor in San Francisco, was determined to have a midwife as her care provider for her first pregnancy. Smith drove an hour and a half for every prenatal appointment so she could access her midwifery practice. “I understood that midwives seemed to focus more on care for the whole woman during pregnancy, and felt that there was less likelihood of complications if I had a midwife,” she tells Healthline. “I thought it would be more likely that I’d be given the time to labor naturally, even in the hospital, if midwives and nurses were supporting me.” That’s the level of assistance the midwifery model of care strives for. Midwives see pregnancy and labor as normal life processes rather than conditions fixed solely by medical professionals. That doesn’t mean everyone who uses a midwife has to have a low-intervention birth or go without pain medications. The majority of midwives in the United States practice in hospital settings, accessible to a full range of medications and other options. The 4 types of midwives, at a glance: Certified nurse midwives (CNM)Certified nurse midwives or nurse midwives, have completed both nursing school and an additional graduate degree in midwifery. They’re qualified to work in all birth settings, including hospitals, homes, and birth centers. They can also write prescriptions in all 50 states. CNMs can also provide other primary and reproductive healthcare. Certified midwives (CM)Certified midwives have the same graduate-level training and education as certified nurse midwives, except they have a background in a health field other than nursing. They take the same exam as nurse midwives through the American College of Nurse Midwives. CMs are currently only licensed to practice in Delaware, Missouri, New Jersey, New York, Maine, and Rhode Island. Certified professional midwives (CPM)Certified professional midwives work exclusively in settings outside of hospitals, such as homes and birth centers. These midwives have completed coursework, an apprenticeship, and a national certifying exam. CPMs are licensed to practice in 33 states, though many of them work in states where they’re not recognized. Traditional/unlicensed midwives These midwives have chosen not to pursue licensure as a midwife in the United States, but who still serve birthing families in home settings. Their training and background varies. Often, traditional/unlicensed midwives serve specific communities, such as indigenous communities or religious populations like the Amish. Benefits of midwives: In areas like the UK and the Netherlands, midwives are the standard providers of care for pregnancy and birth, attending over two-thirds of births. While shows like “Call the Midwife” and documentaries like “The Business of Being Born” have led some Americans to choose midwives as their care providers, they’re still vastly underutilized. Currently, CNMs attend only about 8 percent of births in the United States. The majority of those are in hospital settings. Out-of-hospital births account for about 1.5 percent of all births. About 92 percent of these are attended by CPMs. Midwifery care is safe — some say safer than physician care — for women and families at lower risk. People who use midwives report high levels of satisfaction with their care. A 2018 research found that, in hospital settings, people who have midwives are less likely to have cesarean deliveries, commonly known as C-sections, or episiotomies. Other research has found that people who birth with midwives are more likely to breastfeed and less likely to experience a perineal laceration during birth. Midwives and women of color: Cultural competency, too, is an issue. A profound lack of midwives of color makes it even less likely that women of color will access midwifery care. Currently, black women in the United States are three to four times more likely to die in the perinatal period than white women and, according to the March of Dimes, are 49 percent more likely to give birth prematurely. This disparity may be because providers may underestimate the pain of black patients or dismiss their symptoms. Serena Williams is one example. She had to demand her doctors check for blood clots after the cesarean delivery of her daughter in 2017. Midwifery care could make a difference in birth experiences for black women. Yet it can be next to impossible for black women to find midwifery providers who look like them. Racha Tahani Lawler, a black CPM who’s been practicing for 16 years, estimates that there are less than 100 black CPMs in the entire country. As of 2009, 95.2 percent of CNMs identified as Caucasian. Many of Lawler’s clients aren’t aware of midwifery or home birth options, she says, until they have a bad experience. “The catalyst for most black people is ‘I don’t like the way they’re treating me,’ or ‘I feel like I am being harmed in my appointments,’” she says. Veronica Gipson, a mother in Los Angeles, chose home birth with Lawler after three birth experiences at hospitals that she felt were disappointing, disrespectful, and racialized. Although she came to Lawler with just about a month left in her fourth pregnancy, Lawler worked with her to establish care and a payment plan. Gipson says it was more than worth it, although she was at first intimidated by the cost of home birth midwifery: “It’s so helpful to have someone who looks like you and understands you. It’s a priceless feeling, a bond and relationship. I’m not just room 31 in the hospital — I’m Veronica when I’m with Racha.” Gipson has since had Lawler attend the birth of her fifth child. The future of midwifery in the United States: Maternal health experts say midwifery could be a viable option to help solve a number of ills in the American maternal healthcare system, including:
Vedam believes it’ll take systems-level collaboration before midwifery is both accepted and integrated: “Healthcare administrators, health policy makers, researchers, providers, the public — everyone will need to work together.” But consumers with resources or access to healthcare coverage can still vote by seeking midwifery care and making it known that they want midwives in their communities, adds Vedam. Donovan-Batson of the Midwives Alliance of North America feels that when people better understand the true benefits of midwifery care, they’ll be requesting it. “Research shows us that midwife care is the safest care for a low-risk woman. We’re the experts in normal pregnancy and birth. So, if you want to have that normal experience, seek out a midwife who will work with you to get you the care that you desire.” And if that day of full acceptance ever comes, there’s a good chance American mothers and babies may be in better care. "I’m an Obstetrician. Giving Birth at Home Isn’t Irresponsible. To improve access to safe birth at home, nationwide standards are necessary."
By Kate A. McLean *Dr. McLean is a board-certified obstetrician-gynecologist at the University of Washington in Seattle.* Earlier this month, a Nebraska midwife, Angela Hock, was charged with negligent child abuse when a newborn died after complications from a breech birth at home. It’s worth noting that before this delivery, Ms. Hock, the proprietor of a business called Nebraska Birth Keeper, had performed 50 births at home without incident. Nonetheless, Ms. Hock was not certified to practice as a midwife. It’s unfortunate that these are the stories about home birth that make headlines, because they give the practice a bad name, and contribute to a sense that home births are irresponsible, a danger to the mother and baby. Home births can be safe — as long as they occur within a system of standards and regulations of the very sort that were missing in Nebraska. When home birth is practiced in the shadows because of fear of recrimination, patients are worse off. We can change this by acknowledging that home birth is a reasonable medical choice, and by licensing midwives for home birth in all 50 states. I have practiced as an obstetrician in Washington State since 2006. I attend births only in the hospital, but I frequently take care of patients who intended to give birth at home and ended up transferring to me when their labor didn’t progress normally. The American College of Obstetricians and Gynecologists (ACOG) had long opposed home birth, but in 2017 issued a committee opinion acknowledging that while “hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery.” By contrast, the Royal College of Obstetricians and Gynecologists in the United Kingdom encourages home birth for women with uncomplicated pregnancies. The source of this discrepancy, as well as a great deal of controversy, is that studies on newborn outcomes have come to conflicting conclusions. Data collected by researchers in California and Oregon suggest there may be an increased risk of death in babies born at home, while research in the Netherlands found no significant difference between the risks associated with planned home and planned hospital births. There is no high-quality data from randomized controlled trials because none have been conducted. This is in part because of ethical challenges and because very large numbers of patients would be needed to definitively detect differences. A meta-analysis of more than 24,000 births in multiple countries found lower rates of severe laceration, episiotomy and cesarean section with planned home births compared to planned hospital births. Maternal outcomes are likely better at home. What does seem clear, however, is that women undergo fewer interventions when delivering at home because the possibility of unnecessary interventions is removed, although those interventions can still be obtained efficiently through transfer to a hospital. There is also evidence from Britain that there are fewer maternal complications, like postpartum hemorrhage, when women give birth at home. Cochrane, a trusted global network of health researchers, distilled these factors to what is most important: the overall safety of home birth is comparable to that of hospital birth for healthy patients assisted by experienced midwives. Unfortunately, giving birth at a hospital isn’t universally safe. NPR reported that the United States is the only developed nation with an increasing rate of maternal death, which has more than doubled from 1987 to 2015. According to the Institute for Health Metrics and Evaluation, it is now nearly twice as dangerous to give birth here as it is in Britain, France or Germany, despite the fact that the United States spends more on health care per capita than these countries. ACOG notes that the statistics are even more dire among minorities, with black women being three to four times more likely to die than white women. No one is immune to this risk. In 2017, Serena Williams almost died of a pulmonary embolism after delivering her daughter when her complaints of shortness of breath weren’t taken seriously at a Florida hospital. Researchers in Alabama and Georgia found that half of maternal deaths are caused by medically preventable complications like embolism, while the other half, including those linked to rising obesity rates and poor access to health care, cannot be blamed entirely on hospitals. Nevertheless, it remains understandable that pregnant women have started to lose trust in the medical establishment. Marginalizing home birth only endangers patients. There is a better way to handle this, starting with formal accreditation. According to ACOG, approximately 35,000 births occur at home in the United States each year. State governments regulate the education and experience needed to qualify as a birth professional through licensure. Certified Professional Midwives are the only providers required to have training in home birth, but just 33 states license CPMs to practice. Thankfully, Texas is a state very supportive of Midwives. |
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