Dead woman walking: Obstetric Fistula

“When I reflect back over the years, certain faces come swimming unbidden out of the tide of memory. Even though everyone’s story was amazing, some were even more so. One young woman arrived at the hospital and handed us an envelope with a letter inside that had been written by a missionary doctor down near the Kenyan border. It introduced her and asked us to treat her fistula. There was nothing especially unusual about her. Like so many of our patients, she was dressed in rags and weak from hunger. The sealed envelope was so worn and grubby you could hardly read it, but inside the letter was clear and legible enough. To our surprise it had been dated seven years ago.
“Why has it taken you seven years to get here?” I asked. She told me she had been begging at the bus station for her fare. That was how long it took to raise the money.”

The Hospital by the River—a Story of Hope by Dr. Catherine Hamlin with John Little

I just finished my paper on obstetric fistula. I'm sure it could have been better but I must say I've learned so much along the way about the plight of the poor women afflicted with this devastating condition.  Dr. Catherine and Reginald Hamlin are PIONEERS in fistula repair and opened the greatest fistula hospital in Ethiopia in the late 1950's. To this day Dr. Catherine Hamlin still works there and in 2007 they opened a midwifery school to help train birth attendants to prevent prolonged labor. 

Follow below to read my paper.

(Home) Birth Observe #10

My first placenta print with paint

Thursday I went on prenatal visits with my midwife. One of my favorite mama's was 39 weeks and 5 days and eagerly awaiting the birth of her first baby. She wanted to be checked and was 1cm, 60%, +2. Exciting but nothing to write home about. Later Thursday night the midwife forwarded me a text that she lost a big glob of mucus. Yay, we are getting closer.

Friday morning around 8 am my midwife called me to let me know that our mama had been contracting since about 4 am and that she was going to head over and check her. I went to teach childbirth class and headed to St. Pete around 11am. I arrived at her house at 11:45 am right after she was checked: 80% and 4cm. The mom SROM'd right after the check and was handling her contractions like a CHAMP!

At 1:15 pm she wanted to be checked and was COMPLETE! By the way this mom was handling her contractions you wouldn't in a million years be able to tell she was where she was in her labor. It was AMAZING! First time mom took 10 minutes to push our her baby! It was so beautiful! I am so happy for this young couple and excited grandmother! At 19 years old this mom owned her birth. "I can't believe I just had a baby," was her postpartum catch phrase! Totally awesome! 

Infant formula and divorce attorneys

Exhibit A: Infant formula given to an exclusively breastfeeding mother

(she donated it to the local pregnancy center)

So my newly formed family of three recently got home from the hospital but before they left they got a little parting gift. A bag of infant formula. This is a breastfeeding mother on her way home to nurse for the first time- now with a handy supply of artificial breast milk for when the going gets tough. SERIOUSLY, what is this?

Research shows that the last thing a mom that is nursing needs is free formula as she navigates the ins and outs of breastfeeding. Giving a breastfeeding mom infant formula as she leaves the hospital is like the wedding planner handing the newly married couple business cards to divorce attorneys as they leave the wedding reception. Have we no faith? Not when infant formula is a BILLION dollar a year industry in this country.

Lactation resources need to be made available to newly nursing moms, not the easy solution of formula for when there are issues with breastfeeding. Although breastfeeding is natural it isn't as instinctual as some would think and both mom and baby need to learn this new skill. Practice makes perfect!

It makes me so angry to know that profit is put first over the health and wellness of both mothers and babies. Breastfeeding is the perfect nutrition for baby and it also helps protect the mother from breast and uterine cancer among its running list of other amazing benefits!

There is formula available to every person 24/7. Anyone can go to the store to pick it up in the event of an "emergency"- day or night! Giving breastfeeding moms formula as a "just in case" is helping nobody except the formula companies bottom line. Major THUMBS DOWN to any person and organization that supports this unethical practice!

Something to prove

"We have a secret in our culture, and it's not that birth is painful. It's that women are strong. "
Laura Stavoe Harm

After my hospital birth last Monday, I went downstairs to All Children's to talk to my friend who still works there. While I was sharing a picture of the baby and the details of the birth, a former co-worker questioned why anyone would want an unmedicated birth, "does she have something to prove?" His comments stopped me in my tracks. Was he serious? What does this mom have to prove? What do moms who plan unmedicated birth have to prove? Well, a lot actually. 

When women plan an unmedicated birth they are proving that birth is normal. When you are in labor there is not a DAMN thing wrong with you. Why would you want to use drugs during physiologically normal process? The pain of labor is gradual and rhythmic. Non-augmented labor pain will only take you as far as your body can handle and no further. Your body doesn't know that there is an epidural waiting for you at the hospital. There is an end to every contraction.

Moms who are having unmedicated birth are often surprised at how fast it can go. Once a steady rhythm has been established unmedicated birth is often quicker than those with epidurals. The great thing about unmedicated birth is that you can move. You can walk around, get in the shower or tub, do whatever position your body is telling you to do! This is probably one of the reasons why it can go a lot faster than the births where the mom is strapped to the bed.

There is this great myth that epidurals will save you from the pain of labor and birth. I've been to over 15 births where epidurals have been used and I can tell you first hand that that's not always the case.  Some epidurals leave spots of sensation, you still have pressure and sometimes they don't work at all. However, even if your epidural "doesn't work" that doesn't mean that you're again free to move around the room. In fact, once the epidural is placed you are now tied to the bed, almost literally. IV to saline (often Pitocin as well), blood pressure cuff, fetal monitor, contraction monitor and pulse ox are almost routinely required once you get an epidural. Not to mention the joy of the indwelling catheter to collect your urine now that you can't feel your lower half.

Epidurals are a great resource. I'm not anti-epidural. They can truly help preserve vaginal birth, in some rare cases. However, epidurals are often the first step in a cascade of interventions that lead to an operative deliver, either via cesarean or vacuum/forceps. When women are accepting an epidural are they truly doing so under informed consent? Have they weighted ALL the risk (increased risk of invasive interventions like Pitocin, major abdominal surgery, effects to the baby?) When you have a woman who hasn't eaten deli meat, soft cheese, or had any caffeine for the past 8 months but gladly accepts an OPOID epidural, we have a major dichotomy on our hands which leads me to believe they haven't been properly consented. Why would you subject your body and your baby to the increased risk of complications and additional interventions when there is a better way?

Having a doula at your birth has been shown to reduce the incidence of Pitocin, operative deliveries and the mothers request for pain medication. Epidural anesthesia has become the hospitals version of a doula. It offers pain relief while leaving the mother attached to the monitors, which have become the new labor and deliver nurse.  A doula is your labor partner, your coach, your cheerleader, your tour guide as you navigate something you may not have experienced before. "You can do this, you are doing this," is often all a mom needs to hear as she goes through the most intense time of her life. Why would you not want to be completely present at your birth? This is the most powerful day of your life!

The question shouldn't be what do moms who plan an unmedicated birth have to prove, the question should be what do moms who plan a medicated birth have to fear?

Two for Two

Woo Hoo! I'm batting 1,000 for unmedicated, vaginal births. Well, if you count my last two hospital births, anyways!

 This morning I woke up early because I had a potential doula client interview and I was going to have a birth plan meeting with a client who was a couple of days past her due date. Her plan was to stay at home as long as possible but this morning when I looked at my phone I had a text from her from earlier:

Shoot! I hate when my moms run to the hospital as soon as they get a single contraction. I was upset because I know what kind of time restraints people get put on in the hospital but this birth went great. She SROM'd around 6am but was only contracting every 10 minutes when I got there around 9am.

Walking, standing, singing, sitting on the toilet and nipple stimulation got our mama to 7 cm by 5:30pm (with no pain medication or Pitocin). Around 6:30 pm she started feeling pushy so the nurse checked her. She said she was 8-9 but the baby was still "very high." I knew that this mom had hit transition. She was feeling extremely pushy and pushing uncontrollably with every contractions. The nurse reassured me that she still had a while to go and that we could keep walking around and even go sit on the toilet for a while. Seriously? This mom is bearing down! There was no way I was going to have this mom sitting on the toilet because the last thing that I need (as a doula) is to catch a baby in the bathroom of a hospital!

Less than 30 minutes later I paged for the nurse to come back. A new nurse came in (it was after shift change) and the mom was complete at a +1 station. The doctor came in very shortly after that and he had the nurse push with her. Boom, head crowns. Less than 15 minutes later the baby was gently born.

Soon after the birth the mom was nursing the baby with a great latch. This was such a happy birth. I'm glad that I got to be a part of it! It's amazing how intuitively I'm starting to understand where moms are in their labor. The physiology of normal, unmedicated birth is becoming clearer to me the more births I experience. It still amazes me when hospital nurses (who see THOUSANDS of births) have a hard time 'reading' physiologically normal birth! Truly undistirbed birth is still a hospital rarity. I'm glad that this doctor was hands off and let the mom labor at her own pace, in her own time. It was beautiful!

The thing I lost in the fire.

I'm in the last few weeks of my first year of midwifery school. Only two years more before I graduate and become eligible to become a Florida licensed midwife! Time has flown by.

A lot has changed since I started midwifery school in August. One of the biggest changes came when Mike and I broke up during my first semester. I've been wanting to write about this for a while but how do you sum up two years in one blog post?

There is no blame for how our relationship ended. When I got the calling to become a midwife it was as if a fire consumed me. I was being pulled toward midwifery on an almost cellular level. It takes a lot of compromise and patience to date someone who is in midwifery school (or who is a midwife!). Not only was I spending two days a week in Gainesville, I could get called to a birth at anytime and not know when I'd be home. How would you feel if you had to share your partner with laboring families for hours, or even days, at a time? It's asking a lot.

I don't know if I was just extremely busy with school and clinic this past semester but I've been thinking about us more now than when we first broke up. I miss us. When I look back at the good times it brings a smile to my face because we had a lot of fun together. I miss our dog family, going to his moms to hang out and just spending time together. I don't regret going to midwifery school at all. I know that I'm in the right place. I just wish that we could have figured something out. I suppose everything is exactly how it should be.

I've been carrying around this ache for a couple of weeks. I am grateful for everything that has happened and I can't wait for all the changes that will happen next. When some people break up they see their relationship as a waste of time. I look back at our relationship and see it for all the ways it changed me in a positive way. Moving to Saint Pete, meeting my midwife preceptor, becoming a doula and applying to midwifery school all happened because of my relationship with Mike.

I haven't seen him since February but I wish him love and happiness in whatever he does. He truly helped change my life.

"Love hurts sometimes when you do it right." - John Legend

Pelvis Project

This semester is Reproductive Anatomy and Dr. Scott has gone crazy with the art projects! I'm no artist but here is my Pelvis Project. The female pelvic floor muscles and the female bony pelvis in 2 views. Thanks to my friends suggestion I used tracing paper and the project was 100 times easier than I thought! 

 

 My poster board

I traced those!

100,000

 

Well, it's official. My 2007 Toyota Corolla has over 100,000 miles on it!!! When I got to the hospital last night it registered at 99,999. Too bad I forgot to take a picture of it at exactly 100,000.

Each mile gets me closer to my goal of becoming a midwife.

(I sleep well at night knowing that I'm balancing my carbon emissions by being beef, pork and seafood free for the last ten year.)

"Best Doula Ever"

Today was the day of one of my happiest and most beautiful births (thus far).

The couple hired me late in their pregnancy after they took a childbirth education class at St. Joseph's (43% cesarean rate as of 2008)  and the teacher recommended that they hire a doula if they were wanting an unmedicated birth. I had met the couple a few times and was super excited to work with them. They were incredibly nice and the mom had such a beautiful pregnancy I just knew her birth was going to be amazing! Plus I had never doula'd at St. Josephs and was up for the challenge of preserving a vaginal birth at the hospital tied with Brandon Regional for the highest cesarean rate in the county.

I met the couple at their house around 2:30 pm yesterday after the mom's water started leaking at work around 10:30. After hanging out for a couple of hours (watching a child care video, walking on the elliptical, eating the best grilled cheese sandwich and with nipple stimulation for 20 seconds every 5 minutes) the contractions picked up a regular pattern. Around 8 pm the mom took a shower and the contractions were getting stronger, longer and closer together as time moved on. The dad did an AMAZING job at timing the contractions and keeping a log!

Dad's contraction log

Around 10:30 pm we decided to go to the hospital because I suspected the mom was in transition (good moaning sounds during the contractions, hot flashes, shaking). At 11:10 pm we were in our cars and on our way to the hospital (honorable mention: we made it to the hospital in 30 minutes when it usually takes 45)

Hospital art in the lobby

When the nurse checked her in triage she was 9.5 centimeters dilated! Family soon arrived and the baby was born gently, completely unmedicated and natural around 2:30 am. 

Beautiful baby boy

Today when I went to the bank to deposit the check that the dad had written for the birth in the 'for' line it read: "best doula ever." That just made me smile. While I am honored at the title, that birth would not have happened the way it did without the incredible way they worked together and their faith in her ability to birth their baby. It was an amazing experience to be a part of. I am so proud of them, it was beautiful.

Lunch with the ladies.

I just got home from a really nice get-together with the other student midwives in Pinellas county. It was so fun! One of the girls couldn't make it but me and the other two sat around and talked about birth for over 2 hours! It's so awesome to share the experience with wonderful people like my sister-midwives!

Hopefully we can keep it up and meet more often. It's always nice to share time with like minded people with similar interests!

Your placenta IS an organ

SO, I was at this (typical) hospital birth ALL day yesterday. After the birth the mom wanted nothing more than to be "unplugged" from all of the machines that were tying her to the bed. Joking with the mom I said, "you're already down one organ what more do you want?" The nurse, rudely snapped, "the placenta is not an organ it's the inside of an organ."

Ok, I'm not one to argue or bet but this woman is out of her mind. The placenta IS an endocrine organ. The first sentence of Wikipedia (which the entire world can access) begins, "The placenta is an organ..." The placenta is the only temporary organ. It's the baby's little apartment. It keeps the baby warm, safe and fed along with other magical things.

I really shouldn't be in shock. This woman was the nurse at my first birth that ended in a cesarean last January. She was rude to me then and was no better this time around, she wouldn't even sign my silent birth observe form!

Sometimes I wonder how and why some people became nurses! I don't even mean that in a bad way because I love nurses. My best friend is a nurse. My favorite teacher is a nurse. I respect and admire nurses. I wouldn't even mind being a nurse. They are typically full of amazing information, however, last night the nurse was way off base because: The placenta IS an ORGAN! (I promise)

I just don't understand how someone could complete something as difficult as nursing school, work in labor and delivery (for at least a year) and not know that the placenta is an organ. People with the "I don't know I just work here"- attitude really shouldn't be nurses and the nurse last night was one of those people!

ROM

ROM- rupture of (amniotic) membranes
SROM- spontaneous rupture of membranes, happens naturally during labor, pushing or at birth
PROM- premature rupture of membranes, happens at least an hour before the onset of labor
PPROM- preterm premature rupture of membranes, happens before the onset of labor before 37 weeks gestation
AROM- artificial rupture of membranes, happens when a physician or midwife purposefully rupture the amniotic sac releasing amniotic fluid

Before you arrive at your due date it is important that you research the rationale, benefits, risks and alternatives (including doing nothing) of AROM. It is one of the most commonly performed procedures in hospital birth. It has pros and cons and proponents on both sides of the coin.

Pro's
-May speed up labor by an hour
-Allows for the placement of internal fetal and contraction monitors
-Allows for the examination of amniotic fluid for the presence of meconium
-Used for labor induction (ALSO, understand the rationale, benefits risks and alternatives of induction before consenting to an induction)

Con's
-Opens the mother and baby to infection
-Places the laboring mother on a "time-clock" for delivery which may lead to other interventions (ie, Pitocin)
-Lack of mobility (must now stay on monitors)
-Umbilical cord prolapse
-May make contractions more painful

If you are declining AROM be sure that your provider is aware of your refusal of AROM before they perform each vaginal exam. If you are consenting to AROM it may behoove you to delay AROM until you have established a consistent contraction pattern in active labor, this way allowing for shorter time between rupture and birth. A shorter time frame between ROM and birth may help lower your risk of infection because of fewer vaginal exams.

Please, research your options. It is your right as a health care consumer!