Thursday, December 27, 2012

Day 2:Haiti

Day 2
I woke up earlier than I would have liked but I heard voices and felt guilty being in bed. It was around 6 am. I must have had a few mosquitoes in my net last night as I woke with a dozen new bites. These ones are mean and the itch was driving me mad. I walked out on the deck to Mary doing her daily devotional. We talked a bit and got ready for the day. I went down to discharge the mom who came in false labor again last night. She headed home. I was not feeling well at all.Some sort of cold probably caught on the plane. Breakfast was scrambled eggs and the most delicious pineapple I have ever tasted. 

Friday is the day MBH teaches Family Planning and Mama Baby classes. We also saw a few kids for a national program called Medika Mamba. Mary went to teach the baby class with an interpreter, and Martha who is a nurse, helped do informed consent and screening for women wanting the Depo-Provera injections for birth control. Two new women came, and six returned who had come before. Of those 6, 2 were risked out due to high BP. It is amazing to me how often high blood pressure is a problem here. It leads me to ponder everything I have studied. Is it nutriton, genetics, stress or a combination?

It got really busy quickly. I helped with the Medika Mamba program. Medika Mamba means "peanut butter medicine" in Haitian Creole. Each child is weighed and measured and then compared to a chart that rates their malnutrition, severe, moderate, or mild. There were 6 children today. Two of them were in the healthy range and sent home. The others were given a certain number of Mamba packets and instructed to mix the peanut, oil, sugar and vitamin formula in clean water and administer several times a day before meals. They are expected to gain a certain amount per week. To learn more about the Medika Mamba program visit


Photo Meds and Foods for Kids
They are also administered amoxicillin and a deworming pill the first visit to eliminate bacterial or parasite issues. I got to snuggle a 10 month old little girl for almost 20 minutes while her mama went to go get some food. She was a doll and after she would fuss and I would get her calmed down she would do that little shutter babies do when they relax. Melted my heart. A very young mom, my guess would be 15 brought in 12 month old twins a boy and girl. 

Severely malnurished little tiffi twin

Moderately malnurished gason twin

The girl was severely malnutritioned and the boy moderate. They were both so cute but their little skinny legs didn't look like they had enough muscle to ever support them.The little girl vomited up the dewormer and I had to go get a syringe and figure out a different way to help her take it.  She was a good attentive mother and still breastfeeding them both. There was a Mama Baby Class taught by Mary after clinic that day with about fiveteen mothers and infants. The other mothers were so impressed when this young mom easily and with little fuss breastfed her two 12 month old twins while listening intently.
After Medico Mamba was done I helped with 2 postpartum visits. A 1 month old had gained a whole kg since birth and mom was so proud. A second mom was having high blood pressure at 1 week post partum and had me check her sutures. She was healing well but we asked her to return next week after cutting MSG from her diet to recheck her blood pressure. 
 I was doing an exam of a 6 month old baby with a cough when they announced a laboring mom came in, Madeline. I admitted her quickly. She had only had one visit and had never returned with hey HIV or syphilis testing so we did a rapid HIV test. We had trouble getting enough blood and the first one was inconclusive, but maybe positive so we did a second that came up negative. I checked her to be 1 cm so I told her and her friends to go walk around the yard. This was her second child. I have been surprised how most of the Haitians I have met only have 2 or maybe 3 children and they are spaced often 4 or more years apart. The average Haitian breast feeds for 18 months. 
I helped with the rest of the sick child visits, gave some opthamalic eye ointment, amoxicillin, and vitamin C. Then ate lunch, rice and beans, and stripped all the beds and changed them. Mary noticed I was still not feeling well despite all of my water and Emergence c packets so she told me to go lay down. I took a nap out the outside deck after covering myself with bug spray. The power has been off since yesterday and that means no fans. It is really hot with no airflow. Medeline was more active after my nap. After she vomited I checked her again, 2 cm. Her friends all left, she had bad back labor and a terrible headache but didn't want me to help. She was much poorer than the other women who have been in. As I wrote earlier most of the women who come in are very clean and although poor their clothes are well kept. Medeline was different. She was very dusty and just looked plain exhausted like she had had a harder than average life, even for a Haitian. She labored mostly naked out in the yard after the sound and smell from the generator pushed her out of the labor room. A few of her very young teen age cousins came for a visit. They laughed a lot and Medeline basically ignored them. They poked fun at her labor noises and nakedness. She had had some mild bloody show that was concerning to her but she labored along.
 I continued to feel worse and worse physically. Dinner was some sort of spicy green soup with fish and crab. Just the smell made me feel nauseous. We all climbed up on top of the roof and spent some time looking at the cities and countryside around us. The houses are all made out of concrete and many of them are huge but almost all of them are unfinished.

Next door neighbors house

 I asked Claudin about it and he said that is the legacy parents leave their children, a huge unfinished house. At around 8 pm a friend of the mamas came and gave her a hard time for just laying in the bed. I checked her again, no change. We told her that she needed to either drink and eat or we would have to start an IV. She drank a little water and Emegcen-c and we put her to bed with Martha checking on her every few hours through the night. The power was still out and the center was hotter than it had been since I had been there with the power out for 36 hours. I made a cup of chicken noodle soup and instant oatmeal, took a bucket shower and headed to bed. It was so miserable. I moved from bed to bed trying to find a cross breeze. Nothing worked. I was probably the most physically miserable I had ever been without pain. I felt like my skin was burning up from the insect repellant I covered myself with. Finally some time after midnight I felt the fan start up and the power was on. With Martha downstairs I moved the fan right next to my head and between the cool  breeze and white noise, I couldn't wear my ear plugs due to my cold, I finally fell asleep

Tuesday, December 18, 2012

Day 1 in Haiti

Day 1 Mamababy Haiti

A 3rd time mom N., and  her husband have arrived with mom in active labor at 7 cm. In my practice in the states women very rarely have internal cervical exams. The clinics policy is a check at arrival and then no sooner than 4-6 hours later if not necessary. They had one midwife who came who was very upset about the frequency of exams so she did a mini class for the staff midwives about other ways to assess dilation. Her main emphasis was the purple line. As the woman dilates and the baby moves down deeper in the pelvis and pushes on the sacrum the tissues spread from the buttox crease revealing a purple line.

Photos credit of

The clinic tried it with the next mom who came into the clinic. The woman ended up delivering alone in the bath room 10 minutes after arrival when the purple line said she was 3 cm.  Needless to say they check everyone now at least once.

She is a very calm birther and smiles when I talk to her in English. I am to only watch and chart for this birth. Her labor progresses slowly and she doesn't end up having her baby until much later. Another woman J, comes in with short spaced contractions. We check blood pressure FIRST THING. This is really different than in the states where I usually listen to baby first before assessing mom. They check blood pressure first thing as high blood pressure and pre-eclampsia is a real problem in Haiti and they send them to the hospital right away if there is a problem before mom starts seizing. Blood pressure is fine. A cervical exam is done by the student and I follow her to double check. She is only 2-3 cm. We tell her she can stay and encourage her to walk to speed up her labor. When I ask her when she ate last she says yesterday at noon. I bring she and her friend a mango and cassava bread with peanut butter. They hang out in my favorite decorated room.

Prenatals start at 9 but the women start arriving as early as 6 but most come at 8. Dressed in their best they sit on the covered porch and talk with each other. They are lovely people. I am so excited to be working with them. They laugh quickly and are so kind to each other as they tease and poke about the different aspects of pregnancy. There are 28 today. A small devotional with a scripture, prayer and song is done at 9 and then prenatals start. The interpreters gather their names and pull their charts as well as do weight and blood pressure. The two native midwives are away for some midwifery training so it is just Mary, Martha (the advanced student), myself and a native student Genni. We do two prenatals at a time with an interpreter by ourside. I watch Mary do one but she gets distracted with Martha and I work through the rest with Genni. It is very different doing prenatals when you do not know the language and culture. Thank heavens pregnancy is universal and most mother love talking about their cute growing bellies. I ask questions and they are repeated by the interpreter.  That takes some getting used to, but the interpreters are kind and very experienced. It makes me smile that they are all male. I asked a mother once if she minded having a male interpreter and she said no most of the doctors are male so she sees the interpreters in the same way.  Most of the moms are happy and healthy. They are all severely anemic. We talk and measure bellies and listen to babies. Every mom is sent home with 10 days of prenatals and iron supplements with a prescription to purchase 30 days worth. Most don't have the money to buy them so they wait until their next appointment a month later to get more. Common complaints were acid reflux and lack up appetite. I only saw one with morning sickness. More common in Haiti is "spitting" during the first trimester. An abundance of saliva causes the women the spit frequently and some of them carry around a cup. A first time mama lay down so I could do fundal height. It was the first time she came to the clinic, she was 29 weeks. When I went to touch her belly, they have the softest skin ever by the way, I palpated belly only to feel fetal head and a tiny ear right under the skin. I pulled back surprised. Sure enough you could palpate every fetal part. It was concerning. Measurement was right on and FHT strong but I called in Merry and we agreed a sonogram (costs $25) would be best. Baby implanted out of uterus? Bicornate uterus? Additional note: baby was indeed implanted out of the uterus. They did a c-section at the hospital and baby did not survive but mother did. After I wrote the prescription for the ultrasound Mary called "Baby is coming!". The mother handled her labor like an expert.  Mary broke her very, very bulging bag of water to avoid a shower and baby boy came easily over intact perineum born on a birth stool. Baby born at 11:49 and while drying baby on mom we heard a plop at 11:50. Placenta had come out in bowl. I had never seen a placenta come out so quickly. One shot of pit was given but there was no bleeding as per their protocolls. The odd thing for me was mother had no desire to touch her baby. Very different than in the states. I have seem women who have had a very undisturbed birth often wait a moment or two to touch their baby. Almost like they are waiting to come out of labor land back into reality. More often is is an ecstatic smile or sound. I wonder how much of that is cultural? We are told over and over and shown in videos that you are supposed to be very happy and reach for your baby. I wonder if that would be the case in the States if there was not that expectation. The baby was very healthy and so beautiful. The family is just beautiful together and very happy. I don't get to observe the post partum procedure because there is other work to do.

 I went back to continue prenatals and did a couple post partum exams. A mom with a 5 mo with a cough. A mom who birthed at the clinic 3 days earlier with foul stitches. In the states many women due to good nutrition do not tear. If they have a slight tear we often encourage natural healing methods such as seaweed and staying in bed for a week. Staying in bed for a week is not an option in Haiti. Women tear more frequently due to poor nutrition so they do more suturing. The Haitian people are very very clean often doing bucket baths several times per day, but even with that being around all of the dust and rural living infection is common. The woman was sent home with antibiotics. Things calmed down.

We ate lunch of corn mush with black beans and a sauce made of okra and crab and beef. It was very good. Breakfast had been pancakes and dinner was spaghetti, only spicy with hot dogs in it. They tend to make everything spicy here.
 Around 6 Claudin, an interpreter who has been giving us Creole lessons in the evenings, asked Martha and I if we wanted to go on a walk around the block. We agreed and it was fun to be out in the community. The women smiled and a few men cat called but everyone was very nice. After our walk we talked about culture, marriage, and homosexuality. There are many different religious views in our little group including.. Mennonite,Mormon, Baptist (preacher in training), ex- Methodist preachers daughter, and vudoo. It was a nice evening but the mosquitoes were out in full swarm so Martha and I hid under a big white mosquito net while sitting on the deck looking ironically like two lesbian brides. We laugh a lot and Claudin likes to poke fun at our names comparing them to Creole words. Mine is similar to diarrhea, Mary means husband and Martha is similar to liar.

I went to bed when the power was turned off only to be called back by the 2nd mom from earlier who had gone home around dinner when her labor stopped. She was back but after exam was found to be no different. 2cm. She was exhausted. I gave her Benadryl and sent her to bed at the clinic. I took a bucket shower; like it sounds you sit in the shower and poor cup fulls of water from a bucket over you. It was actually very refreshing. They have running water from a well when the power is on. The city doesn't have enough power for everywhere in the city to have it at the same time so they cycle through and randomly turn off the power. You could go weeks with out there being city power. City power is also shockingly expensive even with how rarely it is on it is not uncommon to cost close to $500 a month.  The clinic uses a generator to pump water from the well into the storage containers on the roof to be used for showers and toilets. They also turn on the generator at night once a laboring mother is close to pushing.  A bucket shower is quite nice. Then I crashed and slept hard.

Monday, December 10, 2012

Haiti Travel Day

Haiti by the Numbers:
  •  Less than 45% have clean water
  • 74 babies due per 1000 births
  • 12% of all babies die before their 1st birthday
  • 1/3 of all children die before they reach the age of 5
  • 1 in 71 women will die in pregnancy or childbirth
  • 50% of the population earns less than $60 per year
  • The average life expectancy is 53  
Travel day July 2011

I was so anxious I hardly slept. The kids and I were very emotional when I left. Ben drove me to the airport. It was nice to spend the time with him alone. He was kind enough to help me with the 150 pounds of luggage I had to carry. The first flight from Vegas to Miami was uneventful. I had a window seat over the wing which is my favorite place to sit. I love watching the wing adjust as we fly. The plane had substantial hail damage which was a bit concerning. My two seat mates were two late twenty something brothers from Australia. A third brother sat across the isle.  They reminded me of my boys. There were two that were very similar in height and one suave looking youngest one who was much shorter. They were very nice and we spent a good amount of the time discussing similar places we had traveled over the world. 

 I arrived safely and got my bags only to have several urgent emails from Mamababy Haiti saying my flight must be wrong since the only 1130 flight arriving in cap Haitian was a cargo plane. Of course the ticket office wasn't open so that began the anxious night of attempted sleep. Every 15 minutes a loud speaker would come on and announce the time in both English and Spanish. There were several other repeating announcements in between. I had three sleep options. To try to sleep sitting up in the divided chair, to sleep alone right under a large speaker or to sleep with a bunch of traveling hitch hiker hippie surfing guys. I tried my luck by myself and got a little intermittent sleep. Evidently the Miami airport goes dead at 12 am only to wake up fully at 2 am. So I was up then as well sharing the airport Dunkin doughnuts line with cops and foreign travelers. I woke to these men walking around wearing black jumpsuits with wide green stripes running down the legs.I could not figure out who they were or what they were doing. They started pulling covers off of these contraptions that I assumed were napping pods (yes I think these napping pods to not exist but they seemed like a great idea to my exhausted body at the time.  A little pod you could climb into and nap with a secure place to hold your luggage. Why not?)  Turns out they are baggage wrappers. Wrapping you luggage in green saran wrap to keep it safe from theft. It cracked me up to see every ones luggage a bright green color.

 After walking for over an hour I finally found the tiny ticket counter in what looked like the Miami airport basement. I stood in line with many colorful Haitian people and eves dropped a bit. They were obviously wealthy in order to be able to fly to the states. I got to the ticket counter and everything was explained regarding my ticket. We would be stopping over in a city called Marsh in the Bahamas to drop off some people and refuel. The plane was small and we had to pay a ton for extra baggage and they weighed us before we boarded.  You always know the plane is small when they weigh the passengers this I learned while traveling in Africa. We proceeded to sit and wait. Two  Haitian business men started up conversations with me about what I did and what they did. One in particular worked for the better part of an hour trying to convince me that my time in Haiti would be better spent with him getting the royal tour of the city than at the clinic. I never wear jewelry when I travel internationally but sometimes a wedding ring would be nice. Our conversation ended when I showed him adorable pictures of my family and he commented that I looked too young to have a 9 year old.

The flight was very bumpy and I nearly vomited several times. An extra take off and landing didn't help much with the air sickness. I don't hate flying but I don't love it either especially flying over open ocean. The seats were so small I don't know how anyone larger than me could have folded themselves into them.

I arrived safely greeted by Mary the Mamababy Haiti site director and Martha a student intern and Otair an interpreter. They were lovely and helped me make it through customs easily.  They even got it cleared that customs did not examine by bags which turned out to be a fortunate thing. It trying to save space and weight I had taken all of the probiotics, garlic pills, cranberry pills, and prenatal vitamins out of their original packages and jars and placed them in huge gallon sized bags. I had four gallon sized bags full of questionable material. I had also taken a gallon sized bag of vanilla protein powder. It looked like a bag of cocaine and even felt like it through the bag until you opened it and vanilla filled the air. Do they make vanilla scented cocaine? They would have been confiscated for sure and I would have been detained for who knows how long if they had searched them. The men in the airport were very helpful with luggage and eager for their $1 tips almost ripping the heavy 150 pounds of luggage out of my hands. 


We rode to the clinic in the MBH ambulance, a Tan Landrover, was intense with many near death experiences and gawking people.  We stopped to get native cassava bread which they baked from cassava ground and cooked on large round flat stones. It is delicious and interesting to watch then make. Things are very expensive here. Gas $5 a gallon. I joked with Otair that he liked honking the horn and siren on the ambulance when he smiled and said "We are here and this is how they know to open the gate." Sure enough a compound on my right with bright red doors swung open to welcome me to Mamababy Haiti. 



There was a birth going on when I arrived attended by the two native midwives. I was quickly oriented and unpacked. I share a room with 3 other midwives. It is so hot and humid. I struggle with claustrophobia from the bottom bunk and mosquito net. Dinner of black beans and rice with some sauce was served and it is delicious. I crash early around 8 pm only to wake up delirious several hours later in a hot sweat. The city power had gone off, something that happens nearly every night, and with the lack of power went my fan and my sanity.   I stumbled out to the people talking on the porch and moved my bed to a top bunk in the overflow staff room which is attached to the dinning room and family room and is much more open.  Much less claustrophobic. It slept restlessly until I was woken at 5 am with two moms in labor.

Wednesday, December 5, 2012

Tongue Tie- My Personal Story with Two Different Babies

Tongue and lip ties are present in about 10% of the population and are slightly more common in males. In the 1950's or more years ago in both the US and UK or more it was semi routine to snip a baby's frenulum as part of the post birth care. With the rise in bottle feeding in the 1970's the practice fell out of favor and professionals lost the ability to detect tongue ties.

Maternal presentation is commonly characterized by:

  • Nipple pain and/or erosions that do not improved after the first few minutes of nursing and improve greatly over time
  • A clamped or pinched look to the nipple
  • Painful breasts
  • Persistent Thrush
  • Low milk supply
  • Plugged ducts
  • Mastitis 
  • Frustration, disappointment, and ddiscouragement with breastfeeding
  • Untimely weaning

Infant symptoms and signs include:

  • Poor latch and suck 
  • Inability to latch to a bare breast
  • Inability to stick tongue out past the baby's gums or lips
  • Clicking sound while nursing (poor suction)
  • Ineffective milk transfer
  • Inadequate weight gain or weight loss
  • Irritability or colic
  • Fussiness and frequent arching away from the breast 
  • Acid reflux or excessive gas
  • Fatigue within one to two minutes of beginning to nurse
  • Difficulty establishing suction to maintain a deep grasp on the breast
  • Gradual sliding off the breast
  •  “Chewing” of the nipple
  • Falling asleep at the breast having taken less than an optimal feed, as proven by “test weight” on a digital scale 
  • Weight loss of greater than 10% in a newborn
  • Milk running out of the sides of the mouth when bottle feeding
  • A heart shaped, forked or little butt shaped tongue
What does it look like?

This is my fourth baby, Oliver getting his newborn exam performed and you can really see the lower tongue tie on him.

Here are some other examples

Experience Number One

My third child, Everett, was born with a tongue tie. This was not something that was pointed out during the newborn exam by my midwife. He nursed decently but I attributed that more to me being a third time mom and breastfeeding champ then to him. He made a terrible clicking noise when ever he swallowed and I still had nipple pain and bleeding when he was three weeks old. I started doing some research and a midwife apprentice friend of mine stopped by to visit and picked out the short frenulum right away. She shared that it was much more common in baby boys and tended to be genetic. I called my fraternal grandmother and sure enough my father had been tongue tied, had never nursed successfully and had it clipped when he was about five years old for speech problems. I called around several places and no one seemed to know what to do with me or willing to help me. The hospital IBCLC recommended using nipple shields, which based on my doula experience and problems I had seen them cause I was not willing to do. Because he was a happy baby and gaining weight well I decided to wait it out. I would rub his frenulum between my fingers and have him mirror me often sticking my tongue out as far as it could go. Over the course of the next few months his frenulum eventually stretched and the nipple pain ceased. He is almost six now and has a little bit of trouble saying certain words and definitely has a "butt shaped" tongue, but for our situation I felt like I made the right choice.

Experience Number Two
My fourth child,Oliver, was also born with a tongue tie. We picked it out right away. Having been down that road before it was a problem I wanted to identify early on. He nursed but not very well. He was a very fussy baby and would cry often. He did not gain weight well and seemed generally unhappy all the time. He would only nurse for a minute or two and then would fuss and nurse again twenty minutes later. I assumed that his frenulum would stretch just like his older brother. We did the same massage, tongue exercises, and nursing like before but no change. At about six weeks postpartum with bleeding nipples and a unhappy and underweight baby I took him to see my family doctor. After a short consultation he agreed that the tongue tie was severe enough that it needed to be clipped. As a mother I was very stressed about the surgery but I knew that what we had been doing was not working for either of us. The doctor took a piece of gauze and grasped his tongue and pulled it out and up. Then he took a blunt ended pair of scissors and clipped the tiny piece of tissue that was ruling out lives. There was one spot of blood. Oliver cried when this tongue was held by the gauze but not with the cut. He latched on and nursed perfectly from then on out. What a different experience.

My Role as a Midwife
As a midwife establishing a good breastfeeding experience is imperative to not only mothers emotionally, prolactin hormones make you happy, but also physically as breastfeeding reduces your chances of post partum hemorrhage because it keeps the uterus clamped down. Although my experience's regarding tongue tie were far from fun, I am thankful to have the different experiences to help my clients in assessing and improving their nursing relationship.

What Can Be Done?
Nothing- if you and baby are doing fine nothing needs to be done.
Massage- as I wrote about massage to help the tissue stretch can help some
Breastfeed- the nature of nursing helps to stretch the frenulum and eventually things can improve
Clip the Frenulum- as in the story above this is a simple procedure can can be performed by multiple care providers including a doctor or dentist

Friday, November 30, 2012

4 Types of Midwives that Attend Homebirths in Utah

There are a lot of misconceptions about the types of midwives who attend births in Utah including Southern Utah. Every woman has the right to know the credentials and skills of the midwife who may be attending her birth. Each type has it's positives and negatives.  This video is a basic break down of the 4 different types of midwives to help you make the best choice for your family.

Tuesday, November 27, 2012

A Mothers' Story of a Planned Home Birth Turned Hospital Transport

The number one questions I get asked during a free consultation for my midwifery services is:
What happens if there is an emergency?

How do you get to the hospital?

How do you know you are getting there in time?
I reassure the families that midwives are trained in dealing with normal birth. While we can handle a good majority of unforeseen complications at home we have keen eyes, the benefit of one-on-one individualized care, and intuition telling us when things might be safer in the hospital. 

Most midwives have a 3-10% transport rate. The vast majority of these transports, I would go as far as to say 95% of them are non emergent transports. 

Some examples on non-emergent transports in my practice might be:
Mother has a fever during labor

Mother's blood pressure is rising during labor

Mother is too exhausted to continue with her homebirth plan

There is unusual bleeding during the birth but mom and baby seem to be doing fine

After a long labor mother is not progressing and would like pain medication to see if it makes a difference

After pushing for many hours baby is not descending well into the pelvis

Baby's heart tones are not as reactive as they should be and may be too high or too low at some points

Baby has passed very thick meconium and giving us other warning signs that s/he may be in distress

Baby is born and there are obvious birth defects that many need further examination or baby might be showing signs of infection such as a temperature or fast breathing

Mother tore during the birth to the extent that she needs a surgeon to do extensive repair

In the case of a non-emergent transport in my practice the family and myself talk about all of the options. Based on our discussion and both of our intuitions we may make the choice  that the birth may need to be moved to the hospital as it has become higher risk. I call the hospital and inform them that we are coming. The hospital is wonderful here and myself and my clients have always been treated with respect. They ask for information about the client so they can pull records and contact their OB if they have seen someone during their pregnancy or call the on-call doctor if not. We all load up in the largest vehicle we have and the baby and mother are monitored on the way to the hospital. The nurse copies my charts and the family checks in and the situation is assessed by the medical staff. I remain with the family the entire time they are at the hospital acting as their doula and support person as well as answering any questions the doctors and nurses might have.

The majority of non-emergent transports still end in vaginal and often even unmedicated births. A small minority end up with a cesarean for various reasons.

In the case of emergent transport I would handle the problem as well as possible at home while calling in an ambulance to transport the mother or baby to the hospital. I would still also call the hospital and tell them we were coming and what to expect. This is important! If you know that the mother needs a cesarean quickly it is crucial for your midwife to have a good relationship with the hospital so that their points of view regarding what is occurring is respected. It is not easy to call in a c-section team STAT but if your midwife has shown competence in the past the nurse on call will have no problem doing just that.

Some examples of emergent transport in my practice might be (keep in mind that each of these complications are very rare most with less than a 0.5% chance of happening during a birth with a full term newborn and healthy mother):

Prolapsed cord where the cord comes out before the baby -0.14% of births usually caused by artificially breaking your water or twins

Placenta Separating from the Uterine Wall before birth-01% of pregnancies world wide with poor nutrition and drug abuse the main cause

Uterine Rupture-0.07% of births with most of them being to women with twins, a transverse baby, or a  previous uterine surgery such as a cesarean section

Postpartum Hemorrhage or greater than normal bleeding after birth-1.5% of all births. Using a midwife who is competent in herbal remedies to help stop bleeding as well as licensed so that they can legally provide I.V. therapy and anti-hemorrhagic medications such as pitocin reduces the need for transport for this reason

Fetal concerns such as trouble breathing- 10% of babies needs some assistance to breathe after birth which a qualified midwife is trained to handle at home and the baby breathes and the family stays at home.  1% of babies need extensive breathing support which would require transport

The families feelings about a transport are so important. How you feel about your birth is often more important that what actually happened at the birth. 

I asked a past client of mine if she would be willing to share her story of a planned homebirth that ended in a hospital birth. She very selflessly agreed. Here is her story in her own words.

Midwives notes will be in blue: Look at how relaxed she is here at 9cm dilated
Please tell me about your choice to have a homebirth:
I had been interested in homebirth for a while. A local midwife had given a presentation on homebirth in one of my developmental psychology classes a couple of years before I got pregnant and I really liked what I heard. When I brought up homebirth to my husband after I got pregnant he said absolutely not. So, I started seeing a female OB. I knew I wanted a female doctor because I wanted someone who had experienced what I was going through and could anticipate my questions and calm my fears. After seeing her for almost 20 weeks, I decided that she was not the person I wanted to be with me at my birth. She never took the time to talk to me about any questions I had, nor did she make me feel calm or comfortable. I always felt like she was in a hurry to get somewhere else and I didn’t want to feel hurried during one of the most important events of my life. So I decided to change care providers to a family doctor. I chose this particular doctor because I had heard really great things about him from friends and family. My first visit was great. He was supportive of my desire to have a natural birth and he spent time with my husband and I never once making us feel like he was in a rush to get to his next patient. I was excited to have a doctor that I felt would be supportive of my decisions.  
A few weeks after I switched doctors, my husband and I started taking DyAnna’s childbirth classes. One of my good friends had hired DyAnna  to be her doula for her hospital birth and told me how amazing DyAnna was and that I should take her childbirth classes. During the six week course of classes, I realized again how much I wanted a homebirth. I decided that if I couldn’t have a homebirth I at least wanted DyAnna to be with me as my doula at the hospital. 
When I was somewhere around thirty weeks, I was in for my doctors visit and he told me that was probably going to have to have a c-section because I was showing signs of pre-eclampsia. The “signs” he was referring to was that I had one episode of high blood pressure. Subsequent visits with him continuously got more negative. He never even pretended to remember me from visit to visit, he always asked if I was a new patient. He also made negative comments about my body while checking my baby’s heart tones. I left many appointments feeling embarrassed and ashamed. Since I was in my last trimester by then, I felt like it was too late to change care providers again. Then, at my last visit with him I gave him my birth plan. He read it and then told me that he was unwilling to follow it and that the things I wanted were unreasonable and crazy. The “crazy” and “unreasonable” things that I wanted were things like no deep suction, no vitamin k, no eye drops, and to delay clamping and cutting the cord. After telling me I was crazy, he again told me that I was borderline pre-eclamptic and that I was going to have to have a c-section. I was really upset after that visit and I immediately called DyAnna because I knew I could trust her to tell me what was really going on. She invited my husband and me to go visit with her and another midwife. We discussed the things that my doctor had said and they took my blood pressure and checked my urine. All of which were fine. There were no signs of pre-eclampsia. Then they asked if I would like to have a homebirth. I was ecstatic! It wasn’t too late to change care providers again and have a homebirth like I had originally wanted. This time my husband agreed since he had become much more educated about the safety of homebirth and we both knew we wanted these to amazing women to attend the birth of our child. We trusted them to tell us the truth at all times and I felt safe and comfortable with them.

What were some of your concerns going into your birth?
I was most concerned with the pain of labor. I had confidence that my midwives would take care of everything else. I knew they would be monitoring the baby and me so I wasn't concerned that anything bad would happen to us. I was only afraid of the unknown pain. Everyone told me that it was pain with a purpose and that made it easier to handle but that made no sense to me. Pain was pain right? Nope. Now, having gone through the pain of labor, I understand what pain with a purpose means and that makes it much more manageable.

How did your family react to your choice?
My family thought I was crazy. I’m sure they thought I was going to die. I come from a very medically oriented family. If you sneeze you take cold or allergy medicine. You have a sore throat you take antibiotics and go to the doctor and get tested for strep. They had a really hard time thinking that I wasn’t going to go to a doctor and that my baby wasn’t going to be born in a hospital. Some members of my family refused to talk to me about my plans for childbirth. Also it was suggested that I was letting others (meaning my midwives) make my decisions for me. It was really hard not to have the support I so desperately wanted from my family. But I was unwilling to sacrifice what I believed was best for me and my baby just to make my family happy. After my son was born, they still didn't want to have anything to do with homebirth or midwives. All I wanted to do was tell them how amazing my midwives were and what great support they had been and still were being but they wouldn't listen or let me talk to them about it. Now, over a year later they are fully supportive and have become more educated themselves about midwifery and homebirth.
How did your labor begin?
I was ten or twelve days over my estimated due date and I was miserable! I was huge and uncomfortable. Walking hurt, sitting hurt, standing hurt, and laying down hurt. My husband and I thought it would be a good idea to try to shake the baby out by taking our Jeep off-roading. Every bump would bring on a contraction and it would eventually get so painful that I would have to ask my husband to stop the Jeep so I could catch my breath. The bumps also made me have to pee so we were stopping the Jeep every five minutes so I could either climb out to take care of business or just catch my breath. My contractions would stop when the Jeep stopped so after an hour or so we gave up and went home. There were no more contractions. Since I was going to be pregnant forever I thought that there was no need to go to bed at a reasonable hour and I stayed up until 2:00 am watching old episodes of Lost. I finally decided to go to bed and just as my eyes started to close I felt a gush of fluid and my first real labor contraction began immediately after. So, I rolled out of bed, cleaned myself up and tried to not be excited because I knew I needed to sleep. Sleep turned out to be impossible because my contractions were coming every 3-5 minutes and they were hard. So we called our midwives and they headed over to our house. That was it! I was officially a woman in labor.

Was the beginning of your labor what you expected?
It was not. I didn’t expect my water to break before I had any real contractions. I also didn’t expect my contractions to be so hard and close together at the very beginning. I had no idea what to expect. I guess I sort of expected to never go in to labor! It was so exciting though. I was finally going to have my baby. It was an exciting and happy time. I wanted to call everyone that I knew and tell them that I was in labor and I was finally going to have my baby!

How were you treated by your birth team in early/active labor?
They were all wonderful! My husband was incredible. He was my rock throughout it all. My midwives were excited for me and were helping make me comfortable in any way that they could. I decided that I needed some things from the store and they were more than happy to run out and get whatever I needed. They were patient and loving and made me feel totally at ease.

What are some of your favorite memories about that time?
My favorite memory of early labor is everyone sitting together watching The Best of SNL Commercials. In particular I remember “I’m not a woman anymore, I’m a mom”. That was a lot of fun. My midwives were great. They were there for me when I needed them and they faded into the background when I didn’t. I wanted my husband to be near me at all times. I had thought that I wouldn’t want him touching me but it turned out that I wanted him next to me holding my hand or something the whole time. He was wonderful. He got in the birth tub with me even when he didn’t want to and was an active participant throughout my whole labor. He was there giving me sips of water and bites of food and helping me position myself to ease the pains of labor. I felt closer to him at that time than I ever had before. It was a time full of love and tenderness.

What tools did you use to cope with your labor pains?
Counter pressure on my lower back was a life-saver. At times it seemed to almost take the pain completely away. Water also helped. Being in the birth tub took all the pressure off my body and helped me to relax which, in turn, reduced the pain. I don’t remember doing much of anything else to help with pain. The counter pressure and the water were the two big ones. I suppose deep breathing and keeping my body relaxed helped also. Oh, I would also grab a body part of whoever was closest to me when a contraction started and squeeze as hard as I could until the contraction was over. 

Tell me about when things changed in your labor and why you decided it would be better for your baby to be born at the hospital?
I’m not really sure. I guess I started to question whether or not my baby would be born at home when my midwives took turns checking my cervix and said that I just wasn’t dilating fully. They asked if they could try to help my cervix out and told me exactly what they would be doing and I agreed, but when they started it was just too painful and I asked them to stop. Of course, they immediately stopped but my concentration had been broken and I was no longer relaxed and the pain seemed to overwhelm me.  I tried to tough it out for what seemed like hours but was probably not a very long time. I was determined to not wimp out though. I wanted a homebirth more than anything. I did not want to end up at the hospital because in my mind bad things happened had the hospital. I was technically fine and there was nothing wrong with my baby and I felt like I had no reason to go to the hospital. I think it was around 5:00 pm (my husband says it was only 3:00 pm) when my midwives said something like “It is okay to go to the hospital if you feel like you need to. No judgments.” I had known that all along, but having them say it out loud gave me the courage I needed to make the decision to go to the hospital. I don’t know that I ever thought it would be better for my baby to be born at the hospital but I felt like he just wasn’t going to come out at home. On top of that, I was in excruciating pain and there was no break between contractions. It was one on top of the other each one more painful than the last. And I still wasn’t fully dilated. So I asked to be taken to the hospital. Midwives Note used with permission: She had followed a wonderful labor pattern up to 9 cm but then had no change for over 4 hours with extensive non-typical pain and baby not engaging deeper into the pelvis.

How was the transport handled?
My midwives were amazing. The instant I said I wanted to go to the hospital they were making preparations. They called the hospital to let them know we were coming, they found me stuff to wear and helped get me presentable, and they got their van ready to go so all I had to do was be half carried to the car. I didn’t have to worry about anything and neither did my husband. They took care of everything. 

Were you scared? What were you thinking of while going to the hospital?
No, I was in too much pain to be scared. All I could think about was the pain. There was no room for any other thoughts in my brain other than “It hurts! It hurts!” 
How were you treated when you arrived at the hospital?
The hospital staff seemed to not know how to deal with a woman coming in who was in full blown labor. They tried to stick me in a wheelchair, which I know is protocol, but what woman who is dilated to a 9+ and having never ending contractions is going to be okay with sitting in a wheelchair? The poor girl with the wheelchair seemed to not know what to do when I refused to sit. I don’t remember much about what happened after we got to the room because of the pain, but I do remember that they were asking me endless questions that I didn’t know the answer to, nor did I care to answer them. It was really irritating to be asked stupid questions when I was clearly not in a state of mind to be answering them.

What did the doctor say about your reasons for going to the hospital and what course of action was taken?
I don’t remember what he said about my reasons for going. I just remember him giving me pitocin to try to make me fully dilate. I finally got an epidural and I have to say it was nice to be pain free. I think it was about an hour after being on pitocin that the doctor came back in and said that there had been no change. I told him that I wanted to continue to wait and see what would happen.  Three hours later, after no changes with my cervix he came back in and told me I had two options. I could have a non-emergent c-section immediately or I could keep waiting until it became an emergency c-section. I was devastated. My beautiful, spiritual, and sweet homebirth had turned into a major abdominal surgery. After many tears, I decided to have the c-section sooner rather than later. I was terrified. I knew I needed to have my husband in with me during the surgery and I really wanted my midwives to be there with me also. I needed their support. They understood things better than I did and I wanted them to stay with me. I wanted my husband to be with our baby at all times and I knew that he would be leaving when they took our baby out while the doctor put me back together. I needed my midwives there with me to support me when my baby was taken away and my husband was gone. We were told that they would not be allowed in to surgery with me. I was really upset that they wouldn’t be able to come. My nurse who had barely spoken to me other than to ask me the stupid intake questions said “Don’t worry. I will be in there with you.” It was not comforting. I remember laughing to myself when my midwives responded to her statement with something like “She doesn’t know you so that’s not helpful.” It was nice to have them there to stand up for me.

When you went in for your cesarean what were you feeling?
I had a lot of emotions. I was scared and really really sad that I didn’t get to have the birth that I had been hoping for.  I was also happy that I would get to see my baby soon. I was worried about being alone during the surgery since I had told my husband that he needed to be with our baby at all times. 

Are there any details you would like to share about the surgery?
I remember that the nurse who told me she would be in there with me spent the whole time flirting with the doctor who was performing the c-section. She never said one word to me and the doctor only said things like “Tell me if you can feel this.” They were flirting and giggling the whole time! It was not how I imagined childbirth at all. The only person who actually spoke to me was my anesthesiologist. He was really nice. He asked me if I was nervous and explained what was going on and asked me questions about myself to help me relax. Midwives note: The official diagnosis was cord entanglement  Cord was around the neck twice (which is not usually a problem) then around the chest and shoulder and around the abdomen and each leg preventing further descent into her pelvis.

When did you get to see your baby?
I saw him for about 10 seconds as they carried him out of the room. They didn’t show him to me or let me touch him though. I finally got to see him around thirty minutes after he was born and my surgery was finished and I was back in my room. But I was shaking so bad from the epidural that I couldn’t hold him. 

Did you still feel supported by your midwives at the hospital?
Yes! They were incredible!  Every time the doctor or a nurse said that I had to do something or they had to do something to me look for them to shake their heads no or nod yes. I had taken DyAnna’s childbirth classes and I had felt informed and knowledgeable about things that they hospital might want to do that are unnecessary but in the moment, I couldn’t remember anything so I needed them to help support me in my choices that I had already made but couldn't remember at the time especially when they went against the hospitals routine. They kept me entertained and did their best to keep me positive about the experience. They were also a huge support to my husband. After we got to the hospital he was able to shower and take a nap for a few hours. He told me he wouldn’t have felt safe or comfortable doing that without our midwives there to be with me. They stayed with me until after my baby was nursing and I felt comfortable enough for them to leave. They came back to the hospital to check on us the next day also.

How was your nursing experience at the hospital?
That first night it was fine. My midwives were there and helped me get everything figured out. My baby had no latching problems and everything was going well. The next day, a lactation consultant showed up and asked how things were going. I said we were fine and didn’t need any help. She insisted that we did, then she reached out and grabbed my breast and started squeezing it. Then, she began smashing my baby’s face into it. I am a very private person and she was up in my very personal space doing things that I didn’t want done after I had told her I didn’t want help. It was a horrible experience. I was used to my midwives gentle touch and they always asked and waited for permission before they touched me anywhere. On top of the awful lactation consultant I had hospital staff coming in and out of the room messing with my IV and trying to talk to me and whatever else they do while I was trying to nurse. All I wanted was to nurse my baby in peace without being exposed to everyone under the sun. Overall I hated trying to nurse my baby at the hospital.

When did you go home?
I went home two days after the c-section. It was a horrible transition from the hospital to home. First off, could barely stand upright and walk much less do anything else like carry my baby. After spending the first couple days of my baby’s life in the hospital it seemed unnatural to be caring for him at home. I sort of felt like “What do I do now?” While the transition to motherhood can be strange for homebirthing women as well, I am positive it is a much more strange experience for women who have to bring their babies home from the hospital. Birthing at home naturally leads into motherhood. Bringing a baby home from the hospital is not.

Did your midwives clean up the homebirth supplies before you got home?
Of course they did! They even fed our cat since we were in such a hurry to get to the hospital we hadn’t even thought about it. When I got home from the hospital there was no sign that they had even been there. Our house was spotless.

How was your experience physically once you got home?
It was really hard to do anything. I couldn’t lay flat so sleeping was difficult, I couldn’t bathe myself or do any other basic self-care. I could barely dress myself. It is impossible to recover from a major surgery and care for a newborn at the same time. My poor husband had to do everything for us. I was so tired because I wasn’t sleeping well and I thought I was going to go crazy not being able to do anything for myself.
Did you feel supported by your midwives postpartum?
Again, they were amazing! I saw them many times after my baby was born. Our first visits were in the hospital and in my home then, when I was more mobile, our visits were in one of their homes. I saw them at least ten times the first six weeks of my baby’s life. They cared about how I was doing physically, spiritually and psychologically. In contrast, I saw the Obstetrician who did the c-section two times in the same six week period and he only cared about how my incision was healing not about how I was doing psychologically.
At one point, I started having panic attacks from lack of sleep and some other things. My midwives came over immediately and offered their support. They talked to me about my concerns and shared their own experiences and offered to help in any way they could. They even offered to come stay with my baby so I could get some much needed sleep. I wouldn’t have trusted him to anyone else during that period. I also called and texted them many times throughout the first few months of my son’s life. They were always happy to answer any questions or concerns that I had. I have no words to express how grateful I am to them for being so supportive and loving during that time. They are wonderful women. And I love them!

How did you feel about the transport?
While It wasn’t my dream childbirth experience, I was mostly just happy that my baby was safe and healthy and so was I. I wished I hadn’t had to go to the hospital, but I couldn’t see how anything could have been different. We tried our best to have a homebirth and it just didn’t work out. I was disappointed, but that didn’t outweigh the joy of having a beautiful healthy baby.

How do you feel about your overall experience 18 months later?
A few months ago I went through a period where I was really angry that I had to go to the hospital. I felt like there was something wrong with me and I was feeling down in the dumps spiritually. I was feeling like if I had been more righteous, prayed harder, and had more faith then I wouldn’t have had to go to the hospital. I talked to my husband about my feelings and he helped me understand again that we actually were blessed during that time. Our son had been born and he was perfect. He was always fine and so was I. We don’t always get what we want and we need to be thankful for the blessings we have been given. Now, looking back at all that we went through it was such a good bonding experience for my husband and me. We are closer than we were before all this happened and I still feel like I had a homebirth. 

How do you feel about homebirth after your experience?
I am passionate about homebirth. It is such an empowering experience. It is also beautiful, spiritual, and gentle which are things that I don’t associate with hospital birth. I hope to have my future children at home.  While I admit that the hospital can provide necessary life-saving options, I don’t believe that all women need the hospital for childbirth. I love the experience I had at home with my midwives. And I wish that all women could have that same experience.

Midwife Note: I just love his little squished and off center nose that was caused by him hanging out in the birth canal for so long

Monday, November 26, 2012

I Had a Baby and Things are Different "Down There"

You had a beautiful vaginal birth the way that babies were made to be born but now it is a few months later and you noticed things "down there" do not seem quite the way they used to. 

Following, you will see an explanation of what might be going on that is different and what if anything you need to do. Keep in mind most change is normal and requires nothing different.

Scar Tissue

What it looks like-There is a line from between your vagina to your rectum. 

Where it came from-If you had an episiotomy or tore significantly and needed stitches you may have a line of scar tissue on your perineum. Usually this is painless and does not cause any problems. 

What you can do to help- If it is painful or in preparation for subsequent births where hopefully you will not tear you may want to apply some evening primrose and coconut oil daily and rub it into the scar tissue.

Extra Flaps of Labial Skin

What it looks like- The folds in your labia (the lips) look different and may have extra folds or flaps.

Where it came from- As the skin stretches it usually goes back to its original shape but not always and occasionally there may be slight tears which cause extra pieces of skin.

What you can do to help- Most of these are not painful and are cosmetic only. You may be surprised that intercourse after a baby feels better because of this extra skin. If that is not the case and it is painful talk to a gynecologist about having them surgically removed.


What it looks like- A ball like lump of tissue on the top part of your vaginal canal.

Where it came from- A cystocele  is a medical condition that occurs when the tough fibrous wall between a woman's bladder and her vagina (the pubovesical fascia) is torn by childbirth, allowing the bladder to poke down into the vagina. Even if you have a c-section you can still get a cystocele just by being pregnant.

What you can do to help- For most women a cystocele causes no problems. In some cases the woman may need to urinate more frequently  Occasionally it may cause problems with retaining or leaking urine or pain during intercourse. Some things you can do to help your cystocele heal are: maintain a healthy weight, avoid lifting things that are very heavy, urinate frequently to keep your bladder empty, space your pregnancies to allow healing time between each child, avoid strenuous running that puts pressure on the bladder. If it is very severe there is a surgical procedure that can be performed by and gynecologist. 


What it looks like- A ball like lump of tissue on the bottom part of your vaginal canal.

Where it came from- A rectocele results from a tear in the rectovaginal septum (which is normally a tough, fibrous, sheet-like divider between the rectum and vagina). Rectal tissue bulges through this tear and into the vagina as a hernia. There are two main causes of this tear: childbirth, and hysterectomy. Women who have birthed a posterior baby, face up, are more likely to have a rectocele,

What you can do to help- For most women a rectocele causes no problem. In some cases a woman may have a "full" feeling in their vagina, have trouble having a bowel movement or have discomfort during intercourse. Eating a high fiber diet and encouraging regular bowel movements is the best treatment. Using a stool to place your feet on and avoid bearing down while passing stool helps a lot. If you are having major pain or problems a gynecologist can perform a surgery to repair things.

Vaginal Prolapse

What it looks like- Extra tissue in your vagina, a feeling of "falling out", feeling your cervix (entrance to your uterus that feels like the tip of your nose) just inside your vagina, vaginal wall hanging out of your vagina.

Where it came from-Vaginal prolapse is characterized by a portion of the vaginal canal protruding (prolapsing) from the opening of the vagina. The condition usually occurs when the pelvic floor collapses as a result of childbirth. Childbirth with an epidural, a very large baby or pushing for a very long time increases your chances of prolapse.

What you can do to help- Give yourself time as things tend to heal by themselves. Avoid lifting heavy object or running and jumping. If it is problematic a gynecologist can prescribe a pessary, which is a plastic rod that you wear internally to hold everything in, or perform surgery to repair things.

What about Kegel exercises?
Kegel exercises can help to strengthen the pelvic floor muscles and for years they were thought to be the cure all for all pelvic floor issues.
 All about Kegel Exercises

New studies have shown that doing sets of squats several times per day are actually far superior to Kegel Exercises.
 All about squats for pelvic floor health

In the end remember that "down there" is beautiful no mater what has changed since you gave birth to your baby. If it is just cosmetic think of it as ever evolving if it is painful or problematic consider some of the above options to improve your quality of life.