MIDWIVES AND THE CARE OF THEIR INSTRUMENTS
Disinfection and sterilization of instruments is a crucial point in any midwifery practice. It is the procedure by which health care professionals ensure that all reusable medical devices do not harbor any biological matter before the next use. Sterilization causes biological entities to be killed, removed or deactivated either by physical or chemical means, where as disinfection causes most but not bacterial spors.
CATEGORIES OF PATIENT CARE ITEMS AND INSTRUMENTS
Critial items deal with a high risk of infections if contaminated with any biological agents. These items may come in contact with internal tissues and the vascular system, so the sterility of these items is prioritized above all. Because any microbial induction could lead to the transmission of disease, surgical instruments, implants, catheters and probes are examples of this category.
2. SEMICRITICAL ITEMS:
These items have contact with mucous membrane and nonintact skin. Items should be free from all microorganisms, but as they are less critical than the above category, a small number of bacterial spores are permissible. A laryngoscope blade is an example in this category.
3. NONCRITICAL ITEMS:
Like semicritical items, these items are in contact with intact skin but not with mucous membrane. As the skin is the most substantial effective barrier to most of the microorganism, so here sterility is not a big issue. Blood pressure cuffs, bedpans, and stethoscopes are some examples of this category.
STEAM STERILIZATION VIA AUTOCLAVE:
For steam sterilization an autoclave is used. An autoclave is an instrument in which saturated steam is applied under pressure. Destruction of microorganisims occurs by the irreversible denaturation of enzymes and structural proteins. Like dry heat sterilization, it can also penetrate through all the surfaces of the instrument but is not time-consuming. This technique provides complete sterilization in a shorter time period.
Ethylene oxide or any other highly volatile substances are the active agents to this technique. Must be mixed with any other inert gas, to reduce highly toxic properties. This technique can only be used when no other method works. The efficiency of this gas depends on the concentration of gas, humidity and time exposure. Because 100% EO is required and it is extremely volatile, this procedure must take place in a vacumn. This is not a viable technique for community-based midwives
A NOTE ON BOILING INSTRUMENTS:
Boiling instruments in 100°C water for at least one minute kills 99% microorganisms, except for a few bacterial spores. Boiling does NOT sterilize equipment. This is a disinfection method and may be deemed to be acceptable for cord clamping and cutting implements, but is not recommended for episiotomy scissors or suturing instruments. Pathogenic organisms begin to die off between 60° C and 70°C. Water must be at a full rolling boil for at least 2 minutes at sea level, 3 min at 6000 ft or above to achieve full disinfection, with instruments submerged the entire time.
There are so many talented midwives, students, and advocates doing so many different things, that some of the alphabet soup of midwifery acronyms gets lost on the profession at large. (I confess to being confused sometimes too.) So to help myself and midwives everywhere, here (in no particular order) is a concise guide to the many organizations that govern, advise, and advocate for midwives in the United States (with quotes and links to their own websites). If I missed any organization that you think should be added to this list, please message me.
And a few more just for good measure...
March of Dimes
The mission of the March of Dimes is to improve the health of babies by preventing birth defects, premature birth and infant mortality.
We work both at home and abroad to tackle the most pressing human rights violations.
Integrative Health Policy Consortium
We envision a world with no barriers to health.
Council on Patient Safety in Women's Health Care
Our mission is to continually improve patient safety in women’s health care through multidisciplinary collaboration that drives culture change
by Augustine Colebrook
Sing your song
Any experienced midwife will tell you she can 'hear' a woman reach 'complete'. The sound of birth is fairly ubiquitous - individual and unique for sure - but there's just this sound. It rattles your jaw and tingles your spine - we midwives just KNOW it's time when we hear it.
Midwives also like to encourage women to be loose and mobile and SING THEIR SONG.
But what does that mean?
What does it mean to sing your song?
This recommendation to pregnant women is akin to telling a nulliparous woman, "you know, how it feels when the baby kicks?"
No, she doesn't know - she can imagine possibilities, but she has no actual reference for that magical feeling. So too is it for primiparous women being told to just let go and make sound authentically. She can imagine various ways that might sound/feel, but she really has no idea until she's in it.
Singing your song is simply telling your truth.
And this is truly the magic of natural birth in this day and age. How often are any of us really in 'beginners mind' anymore? We can google, Wikihow, or YouTube how to do anything. Seriously, ANYTHING. Except Birth.
Birth must be felt and experienced. Birth must be lived.
No one can adequately prepare you to birth - except you, and your own willingness to walk into the unknown; the shadows. For some women the unknown is entering the hospital and pondering the different options of pain medications. For others it's wondering about the pain and how much they can take. For others still, it's about who will be there and how they will help.
As much as we'd like to, we can't plan birth anymore than we can plan life.
"Did you really think you'd be HERE, 5 years ago?"
No matter what we plan, birth demands that we show up and see just what unfolds.
All women need midwives
Women are stronger than they think, but the degree to which they will believe this or not is entirely dependent on the people that they surround themselves with. The music and books and media they consume are more impactful than some might realize. An environment free of toxic exposure is just as important for the mother as it is for the baby.
Here's the real reason all women need midwives - we're literal experts at walking/living without a plan; without a script. We can't do it for them or even adequately communicate what it feels like.
Just try to explain what opening feels like...
But we can demonstrate courage in the face of the unknown in our own lives. We can say, "I too, will walk into the fire."
Courage is an old English word, meaning to speak your whole truth with your whole heart.
We can sit in all the uncomfortable places in life and choose to smile with courage. Midwives, it is we who can model the way. SO midwives, how are you modeling courage in the face of the unknown in your life? How are you stepping into your own shadows/fire/underworld? And who midwifes you?
Are you singing your song?
by Augustine Colebrook
I am a grandmother and recent empty-nester, and it’s given me the time and space to reflect on this gigantic, twenty-year, “Life 101” course from which I just graduated. I read Kahlil Gibran’s masterpiece, “The Prophet’ when I was a teenager, and remembered the swelling feeling of recognition in my chest reading the chapter on children. When I had my children, I knew they did not belong to me. I tried to parent them accordingly, and I think I succeeded mostly.
Here are my #parentingwins
1. I was always just honest with my kids.
Speaking the truth to anyone takes courage, but to kids it’s a gift that grounds their developing brains in reality. Also, I always had a reason, and wasn’t just the ‘heavy’ with the rules they had to follow’. Kids really want and need to know “why”. I frankly told them when I didn’t have extra money for going out or buying things. I shared my emotions with them – I believed that it was better to be sad and say so, rather than pretend I was ok (because they would know anyway). And then maybe they would just be sad when they were sad without trying to hide their real emotions.
2. I choose to live in community as much as possible.
Co-housing, community dinners, room-mates, house-mates, live-in nannies, close neighbors, in-laws in the guest room and big family holidays over the years all helped me raise kids in a village and therefore life lessons came repeatedly from many sources.
8. I made a conscious choice not to use violence to teach my children.
I used to hold their little hands in mine when they were being aggressive or hitting their peers or siblings and say earnestly, “these hands are for helping, NOT hurting”. The one time that I involuntarily slapped my rude, disrespectful, teenage daughter’s face, we talked about it for a month. It took a lot to forgive myself for hitting my child.
9. I forgave myself regularly.
I messed up, forgot, lost track of, or downright dropped the ball so many times. I tried and tried and failed again and again. And I learned how to be gentle with myself – I believed that I was a newborn parent and then a toddler parent and then a teenage parent and I was gentle and forgiving to me and to them.
10. I took breaks.
This parenting gig is so much more full time than any other experience in life. It didn’t used to be, however; we used to parent in a tribe with others helping with the daily chores of life. This nuclear, secular family living in a vacuum is unnatural and it’s exhausting. I took personal days and played hooky and I am better for it. I also encouraged my kids to take breaks sometimes, not just sick days, but personal days to stay home and bake cookies or go riding horses on the first snow day, or stay under the covers when they were sad.
11. I got divorced (twice).
When it was clear to me that my household was growing up believing that disrespectful or abusive behavior was the norm, I took a stand. My kids saw me modeling self-respect and radical self-care their whole lives. I think they will be better prepared to live a whole, full, and fulfilling life because I took this stand, rather than sticking with a marriage only so they could grow up in a two-parent household.
12. I fed whole foods at home.
Sure, Halloween candy and chips and cookies crossed the threshold too, but almost all the time, my kids only had access to fruits and vegetables, traditional fats, organic meats, etc. Exposure is ½ the battle with nutrition – they like what they think is normal. Comfort food is simply the food that feels the most like home. For some people that’s TV dinners; for my kids, its homemade chicken broth or pot roast.
13. I took my kids on vacations that had no agendas.
Our lives are scheduled enough – they needed to have days of un-ended time to let ideas and inventions bubble up. They needed to taste freedom and then take a bath in it. No rules is a good way to live sometimes!
16. I kept switching schools till they found something that was both fun and challenging, inspiring and where they felt successful.
If I hadn’t been a working mother, I probably would have homeschooled. But instead I let them switch and switch until they found what they loved and thrived in, including letting one and then another go to live with their dad in another state. I let them be in charge of as much of their own lives as they could handle, because this is the goal, right? With so many parents experiencing the phenomena of ‘failure to launch’, I wanted to ensure their development was always centered around self-determination.
17. I kept the focus of our lives on how we wanted to feel.
If we can define how we want to feel, then choices become a lot easier. Want to feel successful, then get things done. Want to feel joyful, then hang around joyful people and do the things that bring you joy. Want to feel responsible, then be responsible for your own life. This simple exercise will do more to inform their life than anything else – It’s radical and simple.
Ok, some things I wish I had done differently.
5. When looking back I really wish I had more grace when they decided to move out. My kids all at different times launched sooner than I was ready for them to leave. I wish there was a workshop on how to prepare yourself for the end of daily parenting. I knew all along that raising strong, independent people was the goal, but then in the end, I wasn’t ready to not be needed any more.
But, what's the point?
I think that in birth and parenting and life in general, we finally become experts right when that expertise is no longer needed, and it’s said that you ‘master’ a subject after 10,000 hours immersed in study. So here I am, graduated from parenting with an unnecessary master’s degree. Of course, it’s not til they have very little need of you and launch into their own lives, that you officially graduate. And yet, I’ll never parent daily again (in this lifetime) and no, grand-parenting is NOT the same, so what exactly was the point of the last 20 years of my life?
This is the question that keeps me up at night. What was the point of spending all that time and money and energy raising people that don’t even seem to even like me some days and certainly don’t have need of me daily anymore? Most of my elders tell me that they really don’t appreciate you until they’re 30 years old… gee, that’s reassuring.
I have come to believe that parenting is the most extreme personal growth workshop any of us will ever experience. It’s the most magical and diabolical collection of joy and heart-ache. A mystical, shamanic journey into the heart of humanity. Welcoming a tiny, helpless human into your heart and home starts a odyssey of epic proportions, weaving through a ‘candy land’ of hormones and histories, morals and ethics, physical, spiritual, mental and emotional exhaustion. The trials in the show ‘survivor’ have nothing on the lived-experience of surviving parenting. In fact, the challenges little people inflict on their parents, no TV producer could ethically replicate – much of parenting is downright torture.
But we keep doing it, not just in all of humanity, but many of us have more than one child, and although the way babies are made sure does ensure a modicum of success; this still doesn’t explain why many of us have devoted huge portions of our lives to parenting. And I know, we don’t all do it for the personal growth. So why? Why do so many of us not just sign up for a 20+ year odyssey, but in fact give it all our focus and determination?
I believe it’s more than the biological imperative, hormonally driving us to procreate. That may be why some of us GET pregnant, but it doesn’t account for slogging through the next 20 years of painful challenge.
To be stable, to be still, to hold space and be flexible - this is our most precious job. I have been bent mightily – I am a long slender bow made of willow – and I have been bent nearly in half. I have sent my arrow children flying on their own paths of freedom, but when I read and memorized this chapter as a teenager, I didn’t have the foresight to read the chapter on giving, and even if I had, I’m not sure I would have understood its meaning.
Parenting is giving – giving all of ourselves until we are emptied out - carved and hallowed. Some stay here craving to be filled again or sadly lamenting their emptiness, but I – I am glad for it. I feel completely hollow – ready to be filled with the experiences of the second half of my life. Someday I will be emptied again, but right now I am happily gathering experiences like seashells on the beach. All the sparkly and stripy ones catch my eye. All my years of parenting was an exhale of breath, now, I am inhaling life sharply. The season of giving is over, and it is a celebration not a mourning. Just as each new seasonal shift is welcomed – I feel ready for this winter spiraling into myself and then the spring that will follow.
In the goddess tradition there are 5 life phases – maiden, lover, mother, queen, crone. Using this imagery, I have donned my crown this year. I am happily reigning sovereign over my own life for the first time ever! Were we still living in tribal culture, I would be celebrated and honored for my service.
Danielle LaPorte, a guru of mine shares this story:
"Do you know the story about the two stone cutters? When asked what he’s doing, the first man replies, “I’m cutting this stone into bricks.” When the second laborer is asked what he’s doing, he replies, “I’m building a temple.”
How much do we do in a day with our nose to the grindstone? Myopic, focused, making a list and checking it twice. Done. Done. And done.
But what have we done? Really?
There is a Big Real behind everything we do. Sometimes it’s a negative Big Real. Sometimes it’s a positive Big Real.
I’m not posting to my blog. I’m evoking the truth.
I’m not working on my book proposal to have it to my agent by Sept 1. I’m writing a book that could spark people into true action, and it’s burning inside me, and people want it and they want it bad.
I’m not cleaning my house, I’m making it a Zen temple in which I can hear myself think and we can cozy up. (Okay, I’m just jokin’ with that one. Vacuuming is vacuuming and it sucks hard. Pun. I know, I just caught it.) But you get my point.
What’s became rote or banal for you that is really part of a great dream or vision OR a bad plot that you really don’t want to be participating in?"
So midwives, what is the big real behind your work? Why do you do what you do?
We see clients day in and day out. We get up the second our phone rings - boom - out of bed in a flash at 3 AM. We get up from dinner, a t-ball game, sex to answer the phone.... again... (from the same scared new mama).
But what are we really doing> what's the big real of midwifery?
Try to define the big real of your practice, your work....
I am midwife, I deliver babies.... and mamas, and papas, and siblings and grandmas..... and whole communities.
I am midwife; I wake at the drop of a hat, I'm in ninja training to be responsive to the world's calls.
I am midwife; I hold space for many and I'm demonstrating loving kindness.
If your big real isn't so positive, perhaps you can find a way to shift it, or to midwife the world in other ways.
Danielle says, "Zoom back from the tasks and see the holy weaving of your time and love and action. Make it matter. Because it does."
More wisdom can be found at http://www.daniellelaporte.com/
'Non-Nurse' Midwifery Her-Story in the US
The midwives that practiced during this time, many have affectionately called, 'Granny Midwives'. This could be construed as a derogatory term, but since I live in a mind-set of honoring one's elders, I choose to understand it as a term of endearment and respect.
Granny Midwives 1800s - 1920s
"Home was still the place of birth in the early 19th century, and the average American woman gave birth to six children, not including children lost to miscarriages and stillbirths. Only women midwives attended women during childbirth. (In later years there were male midwives.) These women were skilled in assisting the woman by providing comfort measures, nourishment and nurturing, and by patiently waiting for nature to take its course without undue interference with the normal process of labor and birth.
Midwives were local women, usually with children of their own, who had learned midwifery as apprentices, as did many 19th century physicians. Observing and helping with deliveries honed their skills and exposed them to the variety of problems they would face when working on their own. For their work, midwives might receive modest compensation, however, they might be paid with a chicken or household goods." 
Ghost Midwives 1930s - 1950s
Extensive knowledge of herbal identification, harvest, preparation, dosage and administration was a chief component of the midwives' skill. In the United States this expertise was a backbone of all communities until approximately the 1930's. Although 'barber-surgeons' in New England were the first to displace midwives as the primary healers and birth attendants as in the big cities of New York, Boston, and Philadelphia, laying-in hospitals started offering pain relief in the form of ether or chloroform in the first decade of the 20th century. The appeal for women to be out of pain during labor was enough of an incentive for some to leave their homes and to birth in these hospitals.
"To gain more clinical practice, [doctors] established lying-in hospitals or wards in major hospitals. Asepsis was unknown, so, with unclean hands and tools, physicians examined women and tended to the birth of their babies, leading to epidemics of puerperal fever, which caused thousands of maternal deaths. Fortunately, many individuals contributed to understanding the cause of puerperal fever, including Ignaz Semmelweis, a renowned Hungarian physician; Oliver Wendell Holmes, an American physician; Louis Pasteur, a French scientist; and Joseph Lister, an English surgeon. By the end of the 19th century, germ theory was finally accepted, and the advent of anesthesia made surgery safer and free of pain. Anesthesia administered for pain in childbirth became desirable for many women who chose physicians as their birth attendants.
In the late 19th and early 20th centuries, American obstetricians sought to overtake the entire field of childbirth and declare major war against the traditional midwives in the United States. Midwives wanted an education, but obstetricians fought hard against this idea. "Schools for midwifery education were established in European cities, and European health care created a dual system by which midwives continued to attend normal births while physicians handled complications. This did not happen in the United States. American physicians fought hard against midwifery education, in spite of midwives wanting an education, which public-health reformers supported. In the early 20th century, many midwives still practiced in rural, remote areas of the country and with inner-city, poor populations. The next push by American obstetricians was to move the place of birth from homes to hospitals, where midwives were forbidden to practice."  In an effort to entice women into the hospital, ads at the time promised a 'pain-free' childbirth. Unfortunately, what ensued was tantamount to torture. Two drugs were combined to produce Twilight Sleep: morphine and scopolamine. - See more on this practice here.
Orphan Midwives 1960s - 1970s
In 1960, the world of American women was limited in almost every respect, from family life to the workplace. A woman was expected to follow one path: to marry in her early 20s, start a family quickly, and devote her life to homemaking. As one woman at the time put it, "The female doesn't really expect a lot from life. She's here as someone's keeper — her husband's or her children's." As such, wives bore the full load of housekeeping and child care, spending an average of 55 hours a week on domestic chores. They were legally subject to their husbands via "head and master laws," and they had no legal right to any of their husbands' earnings or property, aside from a limited right to "proper support"; husbands, however, would control their wives' property and earnings. If the marriage deteriorated, divorce was difficult to obtain, as "no-fault" divorce was not an option, forcing women to prove wrongdoing on the part of their husbands in order to get divorced.
Women who became midwives in this era had no real mentoring in their craft - they were orphans. They had to create, invent, imagine, make-up, and discover ways to attend birth on their own or with the council of medical doctors. Almost every midwife in practice today is a descendant of this renaissance. Naturally the age-old tradition of apprenticeship began again and slowly more and more women began to go to each other's homebirths and learned together how best to attend births. Many decades of medicalized birth, however, influenced even these anti-establishmentarianism pioneers, and at homebirths women would lay down to give birth and depend on their providers to guide the process.
Organized Midwives 1980s - 1990s
The students of the 'Orphan Generation' are a very different breed of midwife. In reaction to their laissez faire and largely unorganized learning experience as apprentices, these Midwives became organized. This era could also be called the era of acronyms because the midwifery organizations formed across the country created a kind of alphabet soup. Aside from our nurse-midwifery sister's organization of ACNM, the 'Organized Midwives' created MANA, MEAC, NACPM, CfM and NARM, as well as countless state organizations all including the letter M.
The Midwives Alliance of North America (MANA) was formed in 1982, with the vision and intention to create a national, inclusive, organizing alliance. They created the Certified Professional Midwife (CPM) certification process, and in 1986, launched The North American Registry of Midwives (NARM) to oversee this process. The Midwifery Education Accreditation Council (MEAC) was formed in 1991 by the National Coalition of Midwifery Educators as a not-for-profit organization. Citizens for Midwifery (CfM) is a non-profit, volunteer, grassroots organization. Founded by several mothers in 1996, it is the only national consumer-based group promoting the Midwives Model of Care. And finally, The National Association of Certified Professional Midwives (NACPM) is the membership organization specifically representing Certified Professional Midwives (CPM) in the United States. NACPM, formed in 2000 directs its influence toward promoting, developing and strengthening the profession, improving outcomes for childbearing women and their infants, and informing public policy with the values inherent in CPM care.
These midwives turned away from their grass-roots mentor-midwives, craving structure and systemic steps. They were the originators of the curriculum for all the Direct Entry midwifery training, but found it hard to put all that they learned, often over many, many years into a succinct 3-year process. Consequently, midwives from this generation are aggravated when students anxiously 'count their numbers' like eggs before they hatch.
Ida Darragh, CPM, a midwife in Arkansas and Executive Director of NARM, reiterates, ' A good midwifery education can't just be about the numbers, its about the development of intuition, and intuition takes time. You can catch 10 babies in a week and that doesn't teach you as much as following 10 women through their whole pregnancy and postpartum experience." The challenge, of course, is that we lack enough training sites in our nation. As interest in the field of out-of-hospital midwifery grows we have far more students than we have preceptors. Ida agrees: "One-on-one apprenticeship is a very valued way to learn, but its a very slow way to create more midwives. We need more clinical sites in this country." This generation of midwives and the next have had many conversations over the years about the balance between time and numbers in student training, and, as of yet, there doesn't seem to be an answer to the challenge of making more midwives quickly, while maintaining our standards of education. 'Right now, CNM's aren't required to have any out-of-hospital birth experience before graduating, and wouldn't it be great if they did, but there is no where for them to get it, and precious few for CPM's to get", adds Ida.
The major difference between this generation and the next? "The internet," says Ida "Communication can happen so efficiently now. The are no walls, no boundaries, with email we can literally talk with anyone and everyone in the country and the world. Midwives can Google things at birth. This technological change and many others and more still coming out is the biggest difference between midwives who came up in midwifery in my generation compared to the next. I remember when I would send the hand-written notes from my states meeting to the president of the Missouri group and she would send me her's. Indeed, so much is possible now that wasn't possible in this era.
Modern Midwives 2000s - 2010s
The Modern Midwives who managed to make it through their 'sink or swim' apprenticeship, are a dedicated lot. They have rounded many of the sharp edges of midwifery and awakened to their own needs as well of those of mother and babe.
They have embraced formal education and command an impressive knowledge of anatomy and physiology as well as a strong understanding of all manner of policy and procedures of their obstetric counter-parts. This era of midwife places a strong emphasis on balance (although, we may not feel we have achieved the elusive work/life balance in our own lives yet). When asked to comment, Krista Miracle, DEM, a new midwife serving northern Utah said, "the most challenging piece of midwifery, in my opinion today, is the lack of true leadership and positive role models in midwifery necessary to LEAD women to this profession and mentor them successfully. The midwifery model, one of apprenticeship, has led to abuse of power and lack of accountability. Rather than plant, nurture and grow midwives, we are holding hostage their ability to flourish and in turn decreasing the opportunities for them to serve their communities, and those in need, successfully."
This generation believes in equal access and inclusion, and has been the driving force behind many initiatives to increase access to the under-served and low-income; honor and research multi-cultural traditions and educate the profession on cultural competency; mainstream the profession in all states; legislate mandated Medicaid reimbursement of services; and increase the numbers of midwives who serve people of color. The website, Blackmidwives.org was launched in 2002 from the International Center for Traditional Childbearing (ICTC) and has been instrumental in education and advocacy of this severely under-represented segment of the birthing world.
AS much as this generation of midwives wants to grow the profession, they seem to be caught in a vicious cycle. Experienced midwife, Andi Raine, CPM, LM, IBCLC in NE Wisconsin has this to say about her experience practicing midwifery, "The biggest challenge that I've faced in midwifery is bullying. Midwives of this generation and before so often approach their profession with the energy of scarcity because I think they've had to fight so hard to have it. They've had to fight institutionalized birth, they've had to fight to find an apprenticeship, fight to be legal, fight for a good education, fight for legitimacy, fight for the breath and lives of their clients. And that feeling of lacking abundance, and not having sustainability in this work has caused a wary disposition towards our sisters. Bullying is rampant in midwifery, and it's devastating. There are so few of us that there simply are not alternative peer groups where we can seek support when our local organization is corrupt or disenfranchising. We have been tormented by witch hunts for generations but have also created our own amongst our tribe. Midwifery is a place where you can get shunned just for practicing someone else's area, or not looking the part. I'm a good midwife and I've had a career attending many hundreds of births over 16 years with excellent outcomes. It's everything I wanted to be when I grew up, and when I'm practicing, I'm fully working within all of my gifts. But I'm leaving midwifery because the hatred shown towards me by other midwives has broken my heart."
Other organizations have also sprung up in support of birthing rights in this era:
Future Midwives 2020s - 2030s
Future midwives are current students. This next generation of midwives express much concern about discrimination and cultural appropriation. In fact, a current National College of Midwifery student, Jessie Rhoads in California, adds that, "We're not just accepting the way things were, we're not doing things just because that's the way its usually done. My generation is asking 'why' a lot and finding that the answers don't always amount to evidence-based practice."
Additionally, many students report significant hardship with apprenticeships citing: lack of access to preceptors of color; restrictive organizational rules that limit and dictate the order and location in which experience must be gained; a culture of abuse with many preceptors, including the hazing by requiring students to do personal errands, childcare, or menial work for their midwives, sometimes for years before being 'allowed' to participate in patient care; and the high cost associated with getting a midwifery education.
Jessie goes on to add, "My generation is a lot less 'woo' than our teachers, we want a more clinically-based education - we want to bridge the gaps between the midwifery and obstetrical models." It seems like this new generation of midwives is ideally poised to tackle the systemic problems in maternity care and co-create a truly integrated health care system. These students are certainly more visible than any previous generation of students and they are asserting their need for respect. So, too, are they being handed a much clearer picture of their career path with many more resources than previous generations.
They have access to 11 MEAC accredited school in as many states, many offering distance education, US Dept of Education title IV funding, and scholarships. They also have many independent schools that help a student complete the PEP process through NARM. Additionally, a joint statement among the seven US MERA organizations in 2015 created support for licensure legislation nationally on the condition that it include a requirement for a graduation from a MEAC accredited program or the Midwifery Bridge Certificate. NARM took up the mantel of creating and certifying already credentialed CPM's in the additional required 50 accredited continuing education hours within the five-year period prior to application. The continuing education hours must be in specific subjects. More information on the approved courses. This additional certification may be necessary as some of the last 17 states without a licensure program develop and legislate one and/or in moving us toward state uniformity allowing midwives to transfer licenses easily between states if they move.
Nikki Helms a southern California student at Nizhoni Institute of Midwifery echo's this enthusiasm about becoming a midwife. "I'm excited to become a midwife because it is part of the extensive legacy of African women brought to this country. I am a Midwife of Color, and that, unfortunately, is a rare thing. I am very proud of returning attention to the work of the hands of my foremothers. I, however have a bit of an anxiety disorder, so all this "being on call" business is for the damned birds."
Lest anyone take offence where it was not meant, let me state that these generational titles were not meant as another way to isolate or separate, but rather as a way to understand the many parts of the whole and give framework to the future generation who enter this profession frequently missing much of the her-story and the nuanced influences in this profession. Additionally, it is my strong belief that, just as in society, each previous generation lives in many of the next generations, I believe this is true of midwifery. We are all in a state of evolution and hopefully all growing toward our best selves in each new era of understanding and professional development.
Midwifery is expanding at an exponential rate. According to the American Association of Birth Centers, a new birth center open in the US almost every month. Homebirth rates have seen as much as a 20% increase in the last decade and for many of the western states the homebirth rate is between 2-6% of the population. But there is so much room for growth as the national homebirth rate sits just at 1.36%. I envision an integrated US maternity system where homebirths are encouraged by all maternity providers for low risk women and a national midwifery usage rate is above 50%. This obviously represents accelerated growth like we've never seen, but luckily we have many successful models of integrated midwifery to learn from in Europe.
In order to meet the consumer demand and offer safe, competent, evidence-based care in every state, we still need to solve many issues as a profession. But I believe it is possible. Please speak up with your solutions and ideas and join me as we live the next era of midwifery!
Oh that chest burn that just wouldn't go away; what a drag for pregnant moms...
I recommend some prevention, a few easy remedies, and an AVOID.
Prevention: First try to avoid getting too full - so snack often, eating 6 meals not 3 every day. If you notice that spicy foods or foods that make you burp increase the heartburn, than obviously avoid them. Try not to eat right before laying down, as the sheer pressure of your growing belly on your squished stomach can increase the leakage of acids into your esophagus. Also see your chiropractor to have your stomach checked for a diaphragmatic hernia because having part of your stomach caught in your diaphragm will definitely cause heartburn.
Remedy: Try having raw almonds in your purse and snacking on them periodically, they contain an enzyme that is somewhat neutralizing to stomach acid, also many people find success with Papaya Enzyme pills or lozenges. Our favorite middle-of-the-night remedy is slippery elm bark powder mixed with a little honey. Mix about about a tablespoon of both in a small bowl until a paste is formed, then gum it down. This is especially helpful for middle of the night heartburn. Some people try a glass of milk, but we have heard that heartburn with acidy-milk burps are almost worse. And the best immediate fix-on-the-go remedy is just chomping on some chia seeds. Yes, thats right, the old cha-cha-chai pets of our youth have been re-purposed to eliminate heartburn (an make you laugh while singing the theme song in your head). Bonus:
A 1 ounce (28 grams) serving of chia seeds contains:
Avoid: Tums or other ant-acids with added calcium. The calcium sounds like a good idea but actually is practically non-absorbable and in large doses (as in popping 2 tums every couple days the entire last trimester) forms calcium deposits in the placenta. These deposits of calcium can cause certain small parts of the placenta to die. The calcium deposits may cause some parts of the placenta to be replaced with fibrous tissue. The calcium deposits can also obstruct parts of the placenta with clots of maternal blood which can harden or block the maternal blood vessels. Calcification can be caused by other factors as well, like just post mature pregnancy, or cigarette smoking. In most cases, placental calcification does not affect the functioning of the placenta, and the fetus is generally not harmed. But I feel it wise to avoid adding that much of a substance that isn't helpful and can be harmful.
Hey birthy-people –
Brrrrr - its chilly, and I don’t mean the nights as the weather grows cooler. The national midwifery vibe is chilly as more and more situations of preceptor abuse and discrimination of midwives of color are brought to light.
Unity is what we preach; but rarely what we practice. As the polarization of factions within the midwifery community grows wider – we have an even bigger job ahead of us - bridging the gap in our words and actions.
Our struggle in midwifery is not unique, in fact, it’s just a microcosm of the challenges we face as a nation politically- albeit with less violence. My friend and community elder, Asha, an ally to the disenfranchised and a friend to midwives, an entrepreneur and philanthropist – owner of Pacific Domes, recently lost her son to racial violence in Portland, Oregon. In witnessing her grief, I am reminded of our shared grief at the shocking injustice in our world. She has been a model on how to love in the face of devastating violence and loss. Her grace and her son’s brave actions have inspired me to persevere in finding the illuminated path through to a peaceful place in myself, in my community and in the world.
As a community Midwives have been victim to ‘moral exclusion’. We modern midwives exist with the genetic and soul wounds of generational abuse, marginalization, and delegitimization by our obstetric sisters and brothers and the medical establishment in general. We all have been and/or are currently being excluded from our sovereign rights to be part of the fundamental solution to women’s health care. With so much subtle and not so subtle violence directed at women and midwives (both now and in the recent and distant past), it's no wonder we fight with tooth and nail to establish our ‘place’ within our society. The challenge, of course, is that some of us have forgotten what we’re fighting and speaking for.
“Opting out of speaking out because we may get criticized is the definition of privilege” – Brene Brown
Let us all denounce our privilege and speak out for what is right both in our nation and in our profession.Inclusion and tolerance are needed in all areas of our life. Two of my mentors recently had a conversation about this very topic – Marie Forleo interviewed and discussed the profound content of the new book, “Braving the Wilderness” with Brene Brown. So much of this book and video can be applied to midwifery:
Stay tuned for a public announcement from Wise Women Consulting this winter – we have some amazing women working on an exciting national project to address racial disparities, practice inequities, and the general sense of ‘LACK’ experienced across much of this country in the profession of midwifery.
Love & light,
Augustine + wise women
Have you heard about our new Wise Women round-table discussions?
Peer-to-peer education, called 'Rounds', has long been a preferred way of staying current in health care practice. Because of the unique way midwives practice (in the communities and homes of their patients - not inside big facilities), they rarely get these opportunities.
Wise Women Rounds is engaging the midwifery community in discussing the current issues of our profession. Affordable online peer-education enables connection of the disparate geographic areas of this country and abroad, as well as furthering equal access to the development of the profession of out-of-hospital midwifery as a whole - contact us for a scholarship application. Please join us for these live quarterly presentations and suggest our next topic here.
Our next topic of discussion being held this Wednesday, September 27, is Stillbirth and the Midwife.
The purpose of this part of the program is to really HEAR and LEARN wisdom shared by mama and midwife experts. The title uses the word stillbirth; but we will be discussing the ordeal and return journey from all forms of perinatal loss. This conversation is designed to feel safe and real for all of us to sit with the pain and heartache without flinching or holding back - as our society so often teaches/models. We mamas, midwives and audience members choose to walk into the fire of remembrance with our panel so that we can learn more about fire - NOT get comfortable putting fires out.
We start from the understanding that ‘even when you do everything right' sometimes (given our resources and information at the time) we can’t prevent death. From this starting point, we are able to break the silence and dig deep into our collective resources for ourselves, our sisters, our mamas, papas, families, and communities. Simply put - this workshop is designed to be a think-tank of healing.
Join three courageous mamas and five fearless midwives who have experienced perinatal loss, along with your co-hosts, Krista Miracle and yours truly. To reserve your spot click here.
Upcoming Advanced Practice Clinical and Business Workshops:
Our flights are booked, our mannequin pelvises are packed, and we’re ready for the slew of workshops coming up! Where will we see you?:
San Diego, CA - 11/1- 11/3
Dallas, TX – 11/6- 11/7
Orange County, CA – 11/10- 11/13
Los Angeles, CA – 11/17- 11/19
Santa Cruz, CA – 11/24- 11/26
Ukaih, CA - 11/29 - 12/1
For more information and to register click here.
Are you interested in bringing Wise Women Education to your community and hosting a workshop? Let us know here!
Lastly, check out my newest blog post on shoulder dystocia here
Panic and fear arise in the hearts of many midwives and doctors when they think of shoulder dystocia. And many have a strong desire to teach everyone else how best to manage the situation. Yet for others, the same topic creates a feeling of dismay at the over-diagnosis, and frustration at the needless interventions that are forced on so many normal births.
Well, for starters there are multiple scenarios that can occur during birth, all labeled the same thing: shoulder dystocia. And birth itself looks radically different depending on the birth environment. As Ina May Gaskin reminds us, “physiologically, birth doesn’t happen the same way around surgeons, medically trained doctors, as it does around sympathetic women.” Although less discussed in the main-stream population, the reserves of the baby during birth (and during a dystocia) are directly correlated to the mother’s nutritional history, habits and status – but that’s a topic for another article.
The Finer Points
I encourage midwives to use the terms below when charting at births and reporting at peer review because it’s more accurate and ultimately helps the woman’s next care provider treat her according to real risk instead of perceived fear.
1. Normal Spontaneous Vaginal Delivery (NSVD) is any birth that completes on the mother’s own power, or on her own power with midwife’s suggestions, and does NOT result in a depressed baby (even if the baby is on the perineum for quite a while).
2. NSVD complicated by a shoulder dystocia of ___ minutes, resolved using ________ techniques is any birth that requires midwives’ hand maneuvers and direction to effect delivery. The timing should be assessed from the time the midwife realizes that she needs to physically intervene, NOT necessarily for the whole time the head is out.
Using the above definitions presupposes a few components of a midwife's skill level and ability to risk-assess. First, she must have skilled assistants who record accurate times of all major events. Second, she must know how to assess and interpret fetal status throughout labor to know which babies should be risked-out of homebirth for fetal distress, and how urgently to effect delivery, if imminent. Third, each midwife must have current, accessible, and practiced skill in resolving dystocia. The fourth and final qualifier is that she must be skilled and able to direct a practiced Neonatal Resuscitation Protocol (NRP) response with enough people to continue the effort until Emergency Medical Service (EMS) arrives. Sometimes this means continuing NRP all the way to the hospital since the Emergency Medical Service NRP skill is not uniformly proficient around the country, as many midwives have reported. Additionally, because of this last definition, it reasons that out-of-hospital birth should not be attempted in areas where the distance to the hospital (EMS to the home) is greater than the time the birth team could sustain effective neonatal resuscitation protocol.
Most importantly, because there suddenly becomes two patients at birth, every resuscitation effort requires every midwife team to simultaneously manage the maternal postpartum. IT IS ESSENTIAL TO TAKE ENOUGH SKILLED PEOPLE TO EVERY BIRTH, so that every emergency can be handled appropriately.
There are predictive conditions or risk factors for shoulder dystocia such as:
The incidence of shoulder dystocia is generally reported to be between 0.3 % and 1.5% with scattered reports listing values both higher and lower. The "true" incidence of shoulder dystocia, however, is very much dependent upon how it is defined, how it is reported, and the characteristics of the population being measured. For instance:
Lerner goes on to say, 'how one defines shoulder dystocia, of course, affects its reported incidence. Some obstetricians will only report a delivery as involving shoulder dystocia if they had to employ specific maneuvers to deliver the baby's anterior shoulder. Others will record shoulder dystocia if there is ANY delay in the emergence of the shoulder following delivery of the head. In some cases, a physician will only record shoulder dystocia when a fetal injury has occurred. Finally, the characteristics of the delivery group being measured will affect statistics on shoulder dystocia. A study evaluating the incidence of shoulder dystocia in a population with larger than average babies, or higher incidence of diabetic mothers, will have a much higher reported incidence of shoulder dystocia than if the population were a general one containing a more representational sample of both small and large babies and the normal percentage of mothers with diabetes." The same variations may change the numbers for the homebirth population vs the obstetric population. The bottom line is, we don’t actually know the rate of incidence. Most homebirth midwives report a higher rate than 1% and so we must be prepared for it at every birth (yes, even at ‘roomy’ multips births with no risk factors).
Even if we don't know exactly how often it occurs, we can tell when a dystocia is occurring. Let me first say that I am a proponent of the old midwifery adage, "no intervention in the absence of complication'. A brilliant phrase as long as we truly understand what constitutes a complication. In a normal second stage labor, baby makes distinct, consistent progress. Every push moves the baby a measurable amount, although he may normally retrace his steps many times before the head steps out of the perineum. Progress over time, of course, is an individual, subjective assessment. And interestingly, we aren't great at this assessment while continuously supporting a laboring mum. One more reason I argue for a robust midwifery team allowing the primary to come and go from the actual delivery room (even at homebirths) so that she maintains the necessary perspective to make these assessments. Dysfunction as it relates to the birth of the shoulders is when the normal forces applied to birth the head no longer create the same action. Obviously, a primary midwife should NOT come and go while waiting on the shoulders to deliver. Instead, we must be familiar with this woman's pushing ability and style (having just witnessed her birth her baby's head) and expect the same amount of force will efficiently deliver the rest of her baby in the next contraction - If it doesn't, then action is needed. The specific action and techniques and what order to apply them in is the topic of many workshops and a topic for another blog post.
Interestingly, the 'common law' of midwifery, i.e. that birth of the shoulders happens the contraction after the birth of the head, isn't a universal obstetric notion. Dr. Leslie Iffy, a Maternal/Fetal Medicine specialist in New Jersey and a veritable expert on shoulder dystocia who passed away last year after a 43 year career in obstetrics, wrote an interesting paper in 2015 entitled, "Epidemiologic aspects of shoulder dystocia-related neurological birth injuries". In this paper he and his co-authors conclude, "Incidents of shoulder dystocia began to escalate in the USA during the 1980s, shortly after the introduction of "active management" of the birthing process. This new technique replaced a conservative philosophy which had recommended abstinence from intervention on the part of the accoucheur. The authors consider the interventionist approach largely responsible for the exponential increase in the rates of shoulder dystocia in the USA. They recommend adherence to the traditional method of delivery on the part of obstetricians in Europe and elsewhere."
Active management of the actual delivery was first proposed in the 1976 edition of Williams Obstetrics, whose major authors were Pritchard and McDonnell. This technique, called by some the “one step” technique, recommends attempting to deliver the infant’s shoulder immediately after the birth of the head. Prior editions of the Williams textbook (1961), whose major authors were Eastman and Hillman, wrote to expect that the shoulders would emerge in the contraction following delivery of the head—the “two-step” technique. Iffy's assumption as to not only the reason for the marked increase in brachial plexus injury's, but also the increase in the rate of shoulder dystocias in general. This may indeed be the result of a nation of obstetricians adopting a technique that, at best rushes the process, and at worst, creates the very complication it's attempting to prevent by impacting the baby's shoulder before its had the time to restitute on his own. Time seems to be fairly irrelevant in predicting the need for intervention as well as the outcome of babies who do experience dystocia. Instead, midwives can distinguish between normal and abnormal by lack of normal progress of the birth of the head and/or the first expulsive efforts of the shoulders, abnormal fetal head coloring, gasping or any respiratory effort before birth, and the 'turtle sign'.
As more and more women choose to birth out of the hospital free of the often-arbitrary policies and procedures of the obstetrical model, we midwives are given a broader depth of experience in our practice of the profession, especially those of us who lean towards a woman-centered, hands-off practice-model. Simply stated, we create opportunities to view physiologic birth and draw conclusions about complications and intervention from as pure a view as possible. In my experience, there are three distinct types of shoulder dystocia. I have labeled each based on the increasing speed with which the provider needs to intervene.
The Three Types
1. Non-Emergent Shoulder Dystocia
A non-emergent dystocia is the least dangerous for baby. It occurs because baby is indeed stuck – hung up on the pubic bone, ischial spines, or coccyx - but he has not been and is not depressed in any way. This is why we can work hard to get a baby out that is really stuck, but continues to have good color, and either needs no resuscitative efforts, or recovers after just some stimulation and a few breaths. This baby could be stuck because of his own position or because of the shape of mom’s pelvis, but he is NOT compromised. Of course, without effective, timely action, this scenario can change rapidly. He does need help like all babies in a dystocia, but he doesn’t start out struggling. I call this non-emergent because it’s truly not an emergency; baby is not struggling, venous return is good, placental function is optimal, and baby is no more stressed with his head out then he was during the whole time his head was in the pelvis. Many midwives have stories that their colleagues react to with disbelief, of how long it took them to free a baby. They report 6, 8 or 12 minutes on the perineum - ‘who then are totally fine!’ These stories are examples of this first type of dystocia - these babies truly are fine – just stuck. Take quick action to deliver this baby, but don't be surprised at how well it goes.
2. Emergent Shoulder Dystocia
An emergent shoulder dystocia is essentially the birth of a compromised baby who is slow to deliver at the shoulders. Babies play a huge role in their own births, moving, pushing, and arching themselves out. It's one reason why full-term, healthy, unmedicated births generally go well in any setting. When a baby has lost reserves (either because of placental insufficiency, cord compression, undiagnosed Intera-Uterine Growth Restriction (IUGR), a deteriorating uterine environment with chorioamnionitis or uterine infection, or some other cause of fetal distress) the baby stops fully participating in his own birth. Consequently, descent, rotation, flexion, and synclitisim all become affected by his lack of muscle tone and/or muscle movement. Expulsion of the head is achieved with maternal power while baby just sits there unable to restitute or push himself down and out. This type of birth is an emergency before it even starts. This baby needs resuscitative efforts as soon as possible, evidenced by low Apgar scores at birth. Many of these births are correctly identified before the birth process and transported to a hospital for fetal distress. If not, then these are the babies that are slow deliveries of the head, are frequently tied up in their cords, are relatively 'easy' to deliver once you take action to assist the delivery, but who need a lot of resuscitative efforts. They aren’t actually stuck, but are frequently descending into the pelvis in funky positions because their muscle tone is flaccid due to being compromised. They are floppy and out-of-fight to get born. They need help – STAT.
3. Catastrophic Shoulder Dystocia
Catastrophic shoulder dystocia has the potential for being exactly that. These births are the result of a stuck baby who is already compromised. We midwives want to do everything in our power to identify and risk-out these babies before the birth occurs, but we also need to train for these scenarios religiously. Preventing this type of shoulder dystocia is the motivation behind all of the fear and panic that surrounds shoulder dystocia in our culture. Watching a baby expire while you’re powerless is a terrifying scenario. Fear of these births and babies are the reason for C-sections for big babies and dysfunctional labors. It’s also the reason for all manner of interference at normal births. If you are unlucky enough to be the midwife at a catastrophic shoulder dystocia, please seek support and counseling right away. We need you - wonderful, hardworking, traumatized midwife - to come back from your harrowing experience ready to teach and counsel others. These are the babies who potentially spend weeks in the NICU, have broken arms, nerve injury, paralysis, or they simply do not make it. If you happen to have a long, complicated, difficult dystocia that then needs a long, complicated, difficult resuscitation, AND you have a baby who lives without complication or who you never even had to transport, thank your lucky stars; you just won the midwifery-lottery.
Right now, the major flaw with this view of shoulder dystocia is that the only way to categorize these births is after the fact. We have no way to definitively assess which babies/births are at risk for which type of dystocia beforehand. But, we do have clues, and we do have an increasingly savvy midwifery skill level nationwide.
So, what’s a midwife to do?
First, become an expert in fetal surveillance assessment. Like, seriously! Understand how to accurately assess baseline throughout labor, know how to tell if baseline changes, how often to listen, how long to listen, when to listen. Know how to tell the difference between early, variable and late decelerations. Importantly, transfer all Category II and III babies – believe me, it’s worth it - even if there a few mamas who go on to deliver vaginally without meds in the hospital (like this is a bad thing)– and even if they are miffed that they didn’t get ‘their’ homebirth. Homebirth midwives only take care of low risk clients, and the only babies you can definitively say are low risk are Category I babies.
Second, practice all the ways - know every possible technique to get a stuck baby out – take all the workshops, practice with your friends, practice with your students, practice in your sleep. Make up new ways to move stuck babies. And run role plays with a good mama-actor so that you remember to tell her what you’re doing. So often we practice sticking our hands inside a mannequin forgetting what that would actually feel like and how important it is to communicate with your client so hopefully she doesn’t need therapy to recover from her ‘birth rape’ as well as the emotions of watching her floppy baby be resuscitated.
My third recommendation is to practice NRP often. Don’t just recertify every 2 years; actually know it by heart! Like backwards and forwards – like you can explain it at 3am to your green student until she gets it. And if the new NRP is throwing you – take a Helping Baby’s Breathe workshop. Practice – run scenarios in your head – run role plays in your midwifery practice – talk case studies until you can do it in your sleep. Invest in a good pulse ox monitor (Mossimo Rav 5 is the best). If you have the wherewithal to get the baby out, you must be able to get him breathing! The reality is, if you practice long enough, you are likely to attend a birth or two or three where you really can’t get a baby breathing – but don’t let this be because you don’t know what you’re doing.
And lastly, relax. You really can take comfort in the fact that you are a homebirth midwife which means you take care of the creme-de-la-creme of birthing mothers. On the whole, there is no group of pregnant women more motivated to have a healthy, safe, beautiful experience in the whole world. She will leap when you say leap – she will do all the things you suggest, even eat the gelatinous throw-up that is soaked chia seeds. Your clients will grow the biggest, healthiest, strongest babies of any in the world. Those babies really do instinctively know how to get born – they even help. And because you are a badass midwife who knows her limits, and you listen to your heart - you really will risk-out all the mamas/babies who aren't meant for you. Relax, because it’s really not solely your job to deliver healthy babies. Delegate a whole lot of the work back to your mamas. Have a comprehensive prenatal program that helps bring them along the path of health and wellness as far as they can possibly go. Inspire confidence – exude confidence – model confidence. We all birth better (or do anything for that matter) when we believe we can. Belief, most simply, is a combination of thought, feelings and actions. Think about how to resolve dystocias,, feel into all the feelings, and when in doubt - always take action. Believe YOU can handle it, and so will she.