Respite

The pauses in labor can be hard to appreciate. After all the waiting for labor to start, the months of anticipation, the anxious texts from loved ones, it’s finally happening, and then… it’s not. 

The art of midwifery is knowing - or guessing - when to resist the troughs of a long labor with the tools in our midwife bag (herbs, breast pump, dance music, lunges, stairs - and yes, pitocin) and knowing when to surrender. To turn off the lights and draw the curtains, arrange the pillow fortress, and allow the body to float among the lapping waves of contractions, languid as they may be. 

Labor can be a marathon, and the turtle can win the race. Trying to rush it can push someone over the edge into true exhaustion. At other times a slowdown represents a normal developmental phase of birth. 

Often people experience a natural pause between the first stage of labor (dilation of the cervix) and the second (pushing). Midwives call it the “rest and be thankful” phase. The intensity of transition has come and gone and the reflexive urge to push hasn’t kicked in yet. The contractions space out and lighten. The birthing person, and their support team, can easily feel anxiety - what is happening? 

Nothing is happening and everything is happening: the cervix is open, the baby is perhaps rotating and preparing for the final descent, the uterus is gathering its reserves for the energy required to push. On the outside it doesn’t look like much. But after a while, the moans transition into grunts, and the grunts produce a head, millimeter by millimeter, or in the singular whoosh of a baby barreling into the world. 

Of course, there are times to step in, times when the clock is ticking and it’s necessary to get that labor rocking and rolling. But just as often it’s our work to give ourselves, as Ellen Bass says, to the stillness.

Respite

By Ellen Bass

And then this morning, on the seventh day of crying,
a calm came over me like the one I remember.

I’d been laboring all night
and into the next afternoon, the white
room filled with doctor, midwife,
photographer, friends. Someone
suggested they all leave us alone.
I lay with my head in my husband’s lap,
and in that quiet, contractions ceased,
pain stopped. A stillness
came over the enclosed world
like the cool emptiness coiled in a basket
of sweetgrass. Like the air
inside a bell. I couldn’t stand it.
I thought I should get going again,
get back to my work.

Many times since, I’ve wished
I’d lain there longer:
a kind of Eden, a bestowed peace.
But today, when the respite came,
I didn’t move. I lay limp as a lizard
on a lizard-colored rock, spent.
I didn’t question it, this hush.
I felt my breath enter
and leave. The small wind of it
in the mesh sacs of my lungs —
like that too brief gap in labor
that I couldn’t give myself to
then, hellbent, ignorant as I was.

How to Talk to Pregnant People: 10 Dos and Don’ts from a Midwife

I often hear stories from clients about how casual remarks from friends, family or strangers have disrupted their day or caused them to doubt themselves or the health of their pregnancy. Exercise discernment, and know that usually less is more.

1. Don’t ask if they are pregnant

Okay, I’ve broken this one with good friends who I know are trying - it’s so exciting! But in general, if you run into someone and they look a little big around the tummy or are declining drinks, sit with your curiosity and wait for them to tell you when they’re ready. There’s many reasons someone might not be ready to share the news - they might be waiting on results of genetic screening, or feel ambivalent about the pregnancy - or maybe just gained some weight! DO exercise patience and wait for their announcement.

2. Don’t comment on their appearance in detail

Saying “You look small”, “You look big”, “You’re starting to show”, “You’ve gained a lot of weight”, “You’re carrying high”, “You look like you’re about to pop” or “Do you have twins” often creates worry for the pregnant person and make them question the normalcy of their pregnancy. These are all unwelcome comments people have said to my clients. DO simply say “You look wonderful”.

3. Don’t give unsolicited advice

What worked for you or someone you know is not the solution for everyone. Also, when someone is really struggling with an ailment or discomfort, physical or otherwise, hearing your advice (that they’ve probably already tried, along with a zillion other things) is usually just frustrating. Remember that you’re not their care provider! DO trust that if someone wants advice, they will ask for it, or ask if they want advice before you give it and be willing to accept a “No”.

4. Don’t tell them your traumatic pregnancy or birth experience

Sharing negative experiences can heighten and compound any fear that may exist for them and is usually harmful. I counsel my clients to respond to the beginning of such stories with “I care about you and I want to hear your story but I need to take a raincheck until after the birth because I’m trying to keep things positive”. Don’t take it personally. DO find support for processing your own trauma with a therapist, others with a similar experience, and/or friends.

5. Don’t touch their belly without permission

I am shocked by the number of stories I still hear from my clients about people (and strangers!) feeling entitled to touch their pregnant bellies without even asking. Be judicious with who you ask - a stranger probably doesn’t want your hands on them and may feel obligated to say yes out of social nicety. DO express your appreciative joy at the new life they are bringing into the world.

6. Don’t ask if they’ve had the baby or are in labor yet

You can ask if they want to go see a movie, or if there’s anything they need, but the constant checking in only adds to any anxiety they might have about when the baby will come. The number one complaint I hear from clients who go past their due date is how much they are pestered by family and friends. They will tell you if they’ve had the baby when they are ready! DO give them space at the end of their pregnancy, except invitations for fun or offers of help.

7. Don’t comment on their eating or other prenatal choices

Again, you’re not their care provider, and it’s not your job to monitor or even note their food, beverage, or other life choices. Pregnant people are often judged for what they put into their bodies and how they exercise, sleep, etc. You can’t possibly know what is healthiest or best for them and their baby. DO approach their choices with curiosity and a willingness to learn if invited to listen.

8. Don’t assume that someone isn’t pregnant or is in good health

In the Bay, I have clients who have to take the subway regularly in early pregnancy and need a seat at that stage more than in mid-pregnancy when they may be feeling great. If someone asks for your seat on public transportation, unless you need it yourself, give it to them. There are also many auto-immune and other conditions that could cause someone to feel unwell even though they look healthy. DO act generously towards everyone, and keep in mind that someone could be pregnant even if you can’t see a baby bump.

9. Don’t ask if it’s a boy or a girl

If they have found out the sex of the baby, they will usually share it happily on their own if it is not a secret. If they haven’t found out, or don’t want to gender their baby, that question can be annoying. If you want to get them baby gear, buy something gender neutral. DO act excited to love on their baby no matter what.

10. Don’t ask closed questions that make assumptions

If you’re trying to connect, asking, “Are you excited for the birth” or “Are you scared” closes off avenues for them to share the full complexity and nuance of their emotional world. They may feel both excited and scared (and many other things as well) but you’re less likely to find out when you ask a leading question. DO ask open ended questions like “how are you feeling about the birth?” and genuinely be interested in hearing their answers.

Home Birth: Just as Safe as Birth Centers

View fullsize

We bring equipment too! Note the oxygen tank in the background.

Open letter to The New York Times

Re “Should You Give Birth at a Birth Center” (Family, nytimes.com, Sept. 25):

Thank you for the recent spotlight on birth centers - I wholeheartedly agree that they are an appropriate option for many families.

I’ve worked in both birth centers and home birth and I take issue with only one line in the article.

The author, Alice Callahan, implies that birth centers differ from home birth in that birth centers have “basic equipment on-site and a plan to transfer to the hospital if necessary”. Home birth midwives carry identical equipment and similarly transport when needed. The safety of both has been well established.

In fact, almost every I midwife I know working in a birth center has also done home birth. Most, like me, go back and forth between the two environments over the course of their careers.

There is no need to denigrate home birth to promote birth centers - they are both necessary components of any comprehensive maternity care system.

A quiet, gentle birth

Ana's Birth Story

Around 5pm, I started contracting. Around six my water broke and by eight I was ready to push. The midwives came shortly after and guided me through a beautiful, gentle birth. The three of them surrounded me, but kept so quiet that sometimes I didn’t feel their presence at all.

The lights were low and the atmosphere intimate. I remember wishing to relieve the pressure I was feeling. I was so focused on the task that I hardly gave thought to the baby’s arrival. In fact whenever the midwives tried to bring my attention to the baby, I focused back on the pressure. The midwives were giving me verbal cues that reminded me of my body’s capabilities. They reassured me that what I was going through was natural and expected.

After 3.5 hours of pushing hard and strong, out came a whole human—a jiggly baby that super-manned into my arms. How magical and surreal! I saw it was a little baby girl, which was a surprise. My husband had such deep conviction that it was going to be a boy that he had persuaded me.

The feeling of her passing through my belly and coming into my arms was the most satisfying, fulfilling physical sensation of my life. I wasn’t instantly in love as I have heard some women describe their reaction to seeing the baby for the first time. I was in awe. My love grew with time.

In the first 3 days I couldn’t get enough of her. I kept her jiggly little body in my arms and on my breasts and tummy as long as I possibly could. I didn’t want to miss a thing. I lamented each passing minute because I was in bliss and I wanted it to last. At 6 days, I already missed those first few moments. I just wanted to stay suspended in time.

I’m grateful to my mom who gave me the opportunity to enjoy my baby girl without any household responsibilities. She allowed Eric and me to bond with our new baby. I also feel grateful to the midwives and Eric who did a wonderful job supporting me through the birth and first few days of Maritza’s life.

Selling cord blood is not the answer

The recent Guardian and Medium article by Matilda Battersby on cord blood, placenta and amniotic membrane donation is premised on inaccurate medical information and troubling assumptions about how to fix inequities in our healthcare system.

Although the article is titled “Should US mothers be paid to donate placentas?”, Battersby focuses on cord blood, as the more valuable “byproduct” of birth.

Battersby argues that selling cord blood could provide a source of revenue to offset costs of prenatal care for uninsured or underinsured parents. She cites the high costs of maternity care in the United States and the seemingly untapped reservoir of cord blood that could be sold to research or other medical uses.

Battersby quotes a parent promoting cord blood donation because it's "really of little to no consequence for the donor". She earlier writes that “collection is painless, and there’s no risk to either mother or baby”.

Unfortunately for researchers who would benefit from access to it, cord blood already has a natural home - in the baby that it came from. The donor is in fact the baby, not the person who gave birth, because it is the baby’s blood circulating in the cord and the placenta.

When the baby is born, a third or more of its blood volume is circulating in the cord and the placenta, where it goes to oxygenate and receive the nutrients that grow the baby. If you clamp and cut the cord right away, the baby loses that blood, rich in oxygen, stem cells, immunoglobulins, and iron. If you wait, much or all of it will end up in the baby.

Early cord clamping robs babies of blood that they need to optimally perfuse their lungs and other organs, bank iron stores, and build their immune system.

Battersby is right that the vast majority of cord blood in the United States is currently wasted, as physicians increasingly took over and medicalized birth over the course of the 20th century and early cord clamping became the norm. However, the tide is shifting.

Delayed cord clamping is like climate change: there's a mountain of scientific evidence and consensus among the research community for decades, and a stalwart bunch of non-believers. Or at least non-practicers. Most babies around the world also have their cord clamped immediately, thanks to our global exporting of the medical-industrial model of childbirth.

Thankfully, recommendations are slowly starting to catch up with this research, and in 2017 the American College of Obstetricians and Gynecologists (ACOG) released a committee opinion recommending delayed cord clamping.

The World Health Organization has also recommended delayed cord clamping since 2012 "for improved maternal and infant health and nutrition outcomes”.

This cord still connects the placenta to the baby and the cord is visibly drained of blood

Battersby fails to acknowledge any of this information, and only tosses out a one sentence nod to the disturbing aspects of her proposal: “Naturally, there are considerable ethical ramifications, and nobody wants to start a baby farm where placentas are manufactured and women are treated like chattel”.

The ethics are clear when it comes to the idea that cord blood could be a band-aid fix for the gaping wound of our healthcare system. As more and more parents educate themselves and request delayed cord clamping, how could it possibly be ethical to pay some parents to deny their babies cord blood in order to pay their bill?

There are a few relatively simple interventions that could cut the exorbitant maternity care costs that Battersby cites. First, a universal, single payer healthcare system would eliminate most of the insurance company overhead.

Second, the United States could also follow the model of most of Europe, where midwives are the first line providers for normal birth and costly obstetricians are reserved for high-risk situations that demand their level of specialized expertise. In many countries, home birth is actively encouraged by the government for low-risk pregnancies as a safe and cheaper option.

Selling cord blood is not the answer. It’s an either/or: either that blood is harvested in an interruption of the normal physiologic process for all mammals or the baby receives its full placental transfusion that is every child’s birthright.