Tag Archives: childbirth

WISE WOMAN POSTPARTUM DOULA RETREAT 2024

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April 5th, 6th, and 7th 2024
Bowen Island, British Columbia, CANADA

Join us for the 1st Annual Wise Woman Postpartum Doula Retreat. Wise Woman Way of Birth will be at the Xenia Retreat Center on Bowen Island for 3 days and 2 nights, surrounded by beautiful nature, soaking up the palpable spirit of these healing grounds.

A replenishing experience for your body, mind, and spirit.
An immersive training in continued postpartum education.
A connection for the postpartum doula community.

“I have been dreaming of this retreat for almost two years now, since moving to Bowen Island. I want to bring together the community of postpartum doulas that has been building over the last few years to connect deeper in person. There are so many brilliant, fascinating women doing this work, and we can all be supporting each other to better support the families we work with. It started as this zygote of an idea to give doulas some of the skills they have been asking for and has grown into this immersive, healing, cup-filling retreat with a dream team of speakers!” Candice Johnson

Wise Woman Postpartum Doula Retreat

WISE WOMAN WAY OF BIRTH DOULA TRAININGS (2025)

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The Next Scheduled Course begins on
Saturday, January 18, 2025 at 10:00 a.m. (Pacific Time)
Cost: $675 (Canadian)

taught by Gloria Lemay

Jessica Austin, with a Doula client.

Jessica Austin, with a Doula client.

This course will give you the skills to assist women giving birth at home or in hospital. Doula services are in demand. There is a pre-reading requirement. Please email waterbirthinwoman@gmail.com for further information and to register for the course.

The course will be on Zoom and assignments and tests will be on Google Classroom.
12 Classes 2 and a half hours long. .

Course One in 2025: Saturday mornings (Pacific)

Successful students will receive Wise Woman Way of Birth Doula Training certification.

OVERVIEW OF COURSE CONTENT
Class 1: Introductions, birth “politics” and Language
Class 2: Preventing Problems before the Birth: Nutrition. Prenatal Screening
Class 3: Types of “support” in birth: Midwife, Dr, Obstetrician, Doula — what are the differences? Comparison of home and hospital choices. Assisting your client in making a clear Birth Plan for the chosen place of birth.
Class 4: Anatomy and fetal positions, introduce the concept of “pain” and normalizing birth sensations through knowing the anatomy. Introduction to the concept of breech and twins as variations of Fetal positions.
Class 5: Medical Birth Phases and the “real” phases of birth and how to recognize them.
Class 6: Breastfeeding and early days postpartum and newborn care / Doula Role in these.
Class 7: Common Interventions and the Intervention Cascade. (Fetal monitoring, ultrasound, epidurals, Caesarean, vacuum, forceps, etc.)
Class 8: Preventing Birth Derailment in common scenarios and special situations: Induction for Postdates, augmenting a “slow” birth, a diagnosis of Low or High Amniotic Fluid Levels, Meconium, premature release of the membranes, vaginal birth after cesarean (VBAC).
Class 9: “Informed Choice”: what it *really* means and how to use it as a tool for your client vs a tool for enabling the institutional model of birth, more work on creating a Birth Plan with a client
Class 10: Business Basics: Finances, record keeping, professional practices, client confidentiality, and effective advertising. Structuring a plan for working with clients from interview through to completion.
Class 11: Comfort Measures, supporting Long Births, Helpful things to say, Water Birth.
Class 12: Staying calm when the baby comes: Miscarriage, Abortion, and Stillbirth. How to support people through the hard things in birth work.

Added on May 22, 2024 From Gloria, I am training a great group of women to be birth doulas currently. It’s quite amazing to see them creating alliances and support structures from taking an online course. One of them voiced in the classroom that she thought the class would be about rubbing backs and saying comforting words to birthing women. Instead of that, we have to prepare the students for the “sysem” and how to navigate it to protect their clients from harm. This is my response to her: Quote: “Gloria Lemay May 19”
Oh, I wish so much that we could teach a nice course on how you should all be team players, think positive, reframe every terrible experience into a good memory for your client, be liked, be appreciated and live happily within a specific “scope” of practice. There are courses that try to “sell” that model of being a doula. We’re a little different. We name “Obstetric Violence” , “Medical Rape” and “Birth Trauma”. The numbers don’t lie. When 40% of our sisters, cousins, aunts, friends and associates are having their bellies cut open with a knife and their babies being dragged out drugged and dazed, we just can’t “sell” a denial of the facts. Medical birth is assaulting women.
All of your comments above are so important. Thank you for taking the time to read/watch the materials. I know they are disturbing. We need every one of you in the birth advocate business. It is scary and intimidating at times. That’s okay. You’re going to learn and experience things that will help you be better consumers of medical care to protect yourself and your family. You’re going to have moments of such pride and accomplishment when you know you’ve made a difference. You’re going to have times when you want to quit and get a nice job at a supermarket—-don’t do it! The secret agenda I have for each and every one of you is that eventually you’ll all be the woman in your community who is the “Go To, Birth Woman”. People do recognize courage and persistence.”
Contact Gloria Lemay at waterbirthinwoman@gmail.com

Postpartum Doula Certification(2024)

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We have heard such positive feedback about our Postpartum Doula Certification Course. We have put together a great course that will launch participants into action in this career.

The Wise Woman Way of Birth Postpartum Doula Training will be taught primarily by Candice Johnson. Candice is the owner/operator of Cherish Childbirth in Vancouver, BC. She has built her business over the past 10 years and is the “go to” woman when families are having problems in the early days of parenting. She has a broad education in Massage, Breast Feeding, Childbirth Education and Infant Massage. Candice has trained many postpartum doulas and is active in the Vancouver birth community. She is the mother of two boys who were both born at home and breastfed into toddlerhood.
Website: https://www.cherishchildbirth.com/
FINAL COURSE FOR 2024:

6 live classes on Zoom, 2 and a half hours long.
Cost: $525 (Canadian)

Final Course in 2024 dates:

Course: Saturday September 28 to November 2 10 a.m. to 12:30 p.m. (Pacific)

6 Classes Live on Zoom, assignments and materials on Google Classroom.

Course Description:
This course will prepare you to be with families in the months after welcoming a baby. It includes all the aspects of the “fourth trimester” from practical feeding skills, to understanding the postpartum person’s body and how to support the family as a whole.
Our societal structures provide little care for new families. Having a trained eye and calm presence in a home in the early days is invaluable. Postpartum Doula care is proven to improve breastfeeding success, family bonding, and postpartum dis-ease disorders. Postpartum Doulas are in high demand!
The course will be on Zoom and assignments and tests will be on Google class room.
Successful students will receive Wise Woman Way of Birth Postpartum Doula Training certification.
Please email if you need more information or to register. waterbirthinwoman@gmail.com

Class ONE – The Fourth Trimester and the Role of the Postpartum Doula

Class TWO – Postpartum Healing – Physiology, Nutrition and Traditional Practice

Class THREE – Business for Postpartum Doulas and your Post Birth Bag

Class FOUR – Breastfeeding

Class FIVE – Alternative Feeding Methods, Twins/triplets, Newborn Intensive Care Unit

Class SIX – Newborn Care (including diapering and baby wearing).

Introducing Candice Johnson, the course instructor: Quote:
I have been living and breathing all things birth since I was asked to attend my first birth over 15 years ago. I feel a deep innate knowing of the undisturbed birth process. As an extension of my birth work I organically began supporting breastfeeding. I enjoyed my time with families postpartum but until I had my own babies I didn’t fully understand the importance of supporting someone through the postpartum period. Suddenly what I had always known, respected, and held space for I experienced first hand. This sparked a passion for serving new families. I hope by sharing my knowledge of how to support the “fourth trimester” through doula education, much needed support can be brought to communities everywhere.
Candice Johnson, Birth and Postpartum Doula, Childbirth Educator, Breastfeeding Counsellor
— on Bowen Island, British Columbia.

Is the baby breech?

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The baby can be breech or head down throughout the pregnancy and it’s of no real concern until 34 weeks gestation. At that point, the baby’s head is big enough and firm enough that it can be palpated and a reasonably good assessment can be made by a clinician. This is also the point in the pregnancy where it makes sense to take steps to encourage the breech baby (3% of all pregnancies) to turn to head down through Webster technique (chiropractic), knee/chest position, or external cephalic version by an obstetrician.

For birth workers, these are some of the things I’ve observed about pregnant women carrying the baby in a breech position. They are not 100% diagnostic but can alert you to look closer for breech position. If the only thing that is concerning in the final weeks of pregnancy is “What position is this baby in?”, it’s possible to have a “one swipe” ultrasound. An ultrasound technician can do a very brief scan and see where the baby’s spine, head and bum are. There’s no need to do a time consuming (prolonged ultrasound exposure) scan just for position. If the baby is breech, you’ll want to know where the placenta is located as well. If the baby is head down, the scan can stop and the parents can go celebrate.

These are some signs that the baby could be breech at 34 weeks and beyond:

1 heart tones heard with fetoscope (not doppler) in upper segment (belly button level or higher).
2. Woman has feeling of a hard ball in her ribcage. Woman tends to squirm and press down on the top of her uterus when sitting.
3 head is slightly firmer than the bum on palpation after 35 weeks gestation age.
4. Abdomen has a more tight/taut sausage shape/quality than the usual round/squishy orange shape/quality.
5. Where are the baby hiccups felt? If high (woman’s belly button region), breech is suspected.
6. If the woman has had a previous breech birth, check carefully because a fibroid or a bicornate uterus (or other unusual anatomy) may predispose to carrying all her babies breech. (One woman I have worked with had 7 breech births. She had 2 uterii.)

I must admit that the best breech births that I have attended are the ones that were NOT diagnosed in advance. Women who have a surprise breech are spared all the worry, over-testing, over-lecturing and general misery that diagnosis of breech can bring.

Please let me know in the comments if you have any other tips or techniques for spotting those little beings who want to back into life. Thanks Gloria

HOW BIRTH STORIES GET JUMBLED

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I wanted to share this memory with you, Ted. I don’t know if you remember this incident but I’ve told it to so many people and it always makes me laugh so I thought you might enjoy this trip down memory lane.

Many years ago, when we both had young kids and you were married to Karen, I bumped into you in the parking lot of the “7-11” on West Fourth Ave. We exchanged small talk for a while and, all of a sudden, you got a strange look on your face and blurted out the following, unforgettable (to me) sentence: “Gloria, is it true you were a topless dancer in China?” I couldn’t fathom how that thought could ever enter someone’s head. I’ve been accused of many things in my life but that was pretty far-fetched—I had never been to the Orient, I had never been to the local nude beach, none of what you said made any sense at all. But, somewhere in there, I started thinking “How could this husband of another birth attendant have gotten this idea in his head?”

Then, I remembered a birth that I had called Karen out to one evening. It was the second vaginal birth for the woman. When Karen arrived at the home, I went through the woman’s chart with her. The only surgery the birthing woman had ever had was a breast augmentation. She was a Caucasian woman who was married to a Japanese man. I explained to Karen that the couple had met in Japan and the first child had been born in a Japanese hospital, completely natural birth. The woman had been in Japan because she had taken a job as a hostess in a nightclub in Japan. japanese fan

Now, they were living in Vancouver and having their second child. The baby was born just after midnight and I sent Karen home soon after.

I’m guessing that what happened is that she crawled into bed with you, Ted, and you must have asked her “how did the birth go?” There wasn’t much to tell except that bit about her previous breast augmentation surgery so perhaps Karen told you about that. Somehow, in your sleepy state, that got changed into “Gloria Lemay was a topless dancer in China”.

Once I had retraced the strange pathway of that statement, I said to you: “You know, Ted, that’s not true about me BUT it’s way more interesting than my real life. Will you, please, spread that rumour about me!”

Thanks for the special moments and laughs that knowing you has added to my life. I love you and your dear family.

A Doula’s Experience with Breech

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After a birth, it helps to get a perspective on what could have/ should have/ might have been different in order to learn and grow. Every birth story is different. Gloria

A DOULA WRITES:
The family had a super healthy (first) pregnancy, with opportunities
galore; access to acupuncture, chiropractics, yoga, watsu, massage,
walking, biking, good rest and healthy food (they are both vegan and
eat really well). They chose not to have any ultra sounds and had
her first internal exam at 40 weeks, at her request. She was quite
anxious about having internal exams, learned that it is possible to go
through pregnancy and birth without any fingers up her vagina and
decided that would be best for her. She asked for the exam at 40 weeks
because she felt it would be better to have a ‘practice’ exam in a non
labour situation to see what it would be like just in case she wanted
to have one in labour.

Throughout her pregnancy her various health care professionals
palpated her belly and were sure the head was down. I don’t touch
bellies, I just pay attention to how women are carrying and moving and
what they are saying, and it seemed like a vertex presentation to me
as well. At 39 weeks, her chiropractor and her midwives noticed a
difference, but figured maybe the head was engaged. On her due date
she had an appointment with one of her midwives, who is quite new to
midwifery and she basically freaked out from feeling what she thought
were hands presenting and told the family they must go for an ultra
sound the following morning at 8am. The family was left quite worried.
I asked what she felt about the baby’s position. She said she had been
feeling flutters down below, and figured it was simply mild
contractions. I also asked if she was feeling pressure up in her ribs,
or if she was pushing down on her belly in discomfort, and she said
she had been feeling that way all week. I told her not to worry and
offered to join her for the ultra sound in the am.

Later that night I received a call that labour had started, she had
been contracting since her midwife appointment, but thought it was due
to the internal exam. The contractions were building, so she called
the midwives and they told her to go straight to the hospital for an
ultra sound and one of the midwives would meet them there. The ultra
sound indicated baby was breech and the OB on call was one of the only
in the city who was open to vaginal breech births, although he clearly
stated he was not interested in any marathons and she would have 6
hours to labour (no pressure!) The midwife assured them he was good at
what he does, but he was known to have no bedside manner. That was
pretty clear, but they didn’t care.

At this point their midwife said they could go home to grab their
stuff and take a pause. She was well aware that this was a total game
change from their water birth at home plan, so taking a moment at home
seemed an important part of their birth experience. They called to
let me know the baby was in fact in a breech presentation and that
they were heading home to get their stuff. I was pleasantly surprised
they were encouraged to go home, and told them to keep me posted and
take their time. I said I would meet them back at the hospital when
they returned.

We met at the hospital at 9:45. The midwife did a very gentle and slow
internal exam and found her cervix was 4 cm and stretchy. They had her
on the monitors after that. I asked if she could be on hands and
knees, but they couldn’t get the heart rate as clear, so that was
ruled out. She was laying on her side and after 10 minutes on the
monitor we heard major dips in the heart rate over and over, tried
getting her on her other side and baby was still dipping quite a bit.
The midwife was concerned of a cord prolapse, so the nurse came in and
did a very different internal exam, got right in there fast and
vigorously and felt bulging membranes and what she thought was a cord.
Suddenly two nurses had their hands inside of her, it was terrible.
They said they were trying to push the baby up off of the cord.
breech presentations

You can imagine how intense this was for the mother to be. The room
filled with nurses and it was announced that she would have an
emergency cesarean birth. They wouldn’t let her partner go with her,
this was also terrible. The midwife wouldn’t take no for an answer and
got her scrubs on to accompany her. I stayed with her partner. He was
a mess. We found the only nurse on the floor and asked if she could
keep us updated and I asked if there was any way her partner could go
in. They were waiting for the doctor to come (this whole time with the
nurses hands inside of her…) the doctor would do one more check to
make sure the cesarean was necessary. The nurse grabbed scrubs for the father
and he got changed, but just as he was going to go in the doctor
arrived.

I later found out instead of determining whether a cesarean was
necessary, he yelled at the midwife for having let them go home. One
of the nurses spoke up and suggested they instead focus on the task
at hand and he determined the cord was not presenting, but a foot was,
and her cervix was 8cm dilated. They went ahead and gave her general
and she heard the OB yelling at her midwife as she went under. Her
partner and I waited in the hallway, he made a comment that being the
dad waiting in the hallway while his baby was born felt like we time
warped to the 1950’s.

Baby was born at 10:45pm and dad held him for the first time in the
hallway at 11:10 pm. Apgars 8 & 9, and he was 5lbs 11 oz.

Mom and baby were moved to the recovery room and dad right away took
off his shirt and gave baby skin to skin cuddles until mom was ready.
At 12:45am the nurse said baby’s sugar was low and suggested formula
or glucose water. I asked mom if she was ready to try breastfeeding or
if she wanted me to get on the phone and call her friend who had
offered expressed breast milk if they needed. The nurses were outraged at this
suggestion, said they couldn’t allow it and so she did her best to
try breastfeeding. An hour later they did the sugar test again and it
was way up. The midwife and nurse were both in disbelief (the sugar
level raised from 1.9 to 3.7 in one hour!) The midwife commented how
interesting it was that they had no trouble believing the low number.
I told them it must have been the skin to skin contact with mom and
some colostrum that did the trick. Once they were settled and resting, I
drove home with their placenta and made them some quick prints and a
smoothie. They were happy to have had some of their birth wishes
granted.

Today the family is doing quite well. They are breastfeeding, resting,
eating well, have lots of support and are processing their unexpected birth
experience a little bit each day.

QUESTIONS:
– Could we have avoided those low decels if she could have been up on
her hands and knees?
– What happened when that nurse felt bulging membranes? Did she cause the membranes to release?
Or is it possible to feel a prolapsed cord through the bag?
– Could a baby with apgars 8 & 9 have been in such distress moments
before? (or was it that they were worried baby couldn’t handle two
more centimeters as well as pushing?)
– Was this the only way it could have happened? In general it felt to
me like everything happened as it had to, except those few questions
above that leave me feeling a bit curious.

I have never attended a cesarean birth (I have been a doula for four years).

Any way in which we can learn together from this story would be great.
Comments and feedback are very welcome.

Ruby

Gloria’s thoughts

    Dear Ruby, It’s getting to be hopeless to have a primip give birth vaginally to a breech.
    You must be traumatized/grieving about all this. Thank goodness you were able to give them some measure of getting their wishes met.:

    When the adrenalin gets going at a breech birth, they basically find reasons to head to the surgical setting. The cord wasn’t causing problems so, in hindsight, the heart tones were fine.

    Don’t know what the nurse doing the exam was intending but I would hope she was being careful NOT to rupture that membrane with a breech. Did she break the water bag? You would have seen amniotic fluid with clear poop coming out of the woman’s vulva after that exam if the membranes released.FOOTLING BREECH

    As far as diagnosing a prolapsed cord through the membranes with a footling breech, it might be possible because the bag is thin but it’s highly unlikely and, we know in this case (again, good hindsight), it wasn’t there.

    Apgars of 8 and 9 indicate a healthy, well grown term baby (again, golden hindsight). We do know that monitoring increases the risk of cesareans without any evidence that it is helpful in improving health.

    From what that dr with no bedside manner said, the woman wasn’t going to be given much of a chance to give birth vaginally. Since she hadn’t had previous uterine surgery, it would have been nice if someone with the skill to do a cephalic version had been there when she was first at the hospital. The baby presenting by the feet is the easiest to turn, especially if the baby is small and it’s early in the birth process. To be fair, a first birth with feet presenting is not a good vaginal birth risk to take. Luckily it is a rare situation to have so the numbers should be very low.
    footbreech

    If the caregiver is palpating bellies and listening with a fetoscope (instead of doppler) in the prenatal period, the caregiver should be picking up when it’s breech at 36 weeks gestation (if in doubt, the woman can have a one-swipe quickie ultrasound to double-check). At that point, if it’s discovered, there’s time/space to get baby turned to head down. As I said, a footling breech is easiest to get turned. Frank breech is a more optimal position for safe vaginal birth of breech but not for turning baby to cephalic. Querying rib pain, listening in the 4 quadrants with a regular fetoscope (and finding the true fetal heartbeat low in the pregnant belly) and observing the shape of the pregnant belly are your best tools for early diagnosis.
    Thanks for being there for this family. Gloria

MIDWIFERY CARE FOR THE VBAC WOMAN

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Midwifery Care for the VBAC Woman
by Gloria Lemay
© 2001 Midwifery Today, Inc. All rights reserved.
[This article first appeared in Midwifery Today Issue 57, Spring 2001.]

Someone asked me recently what things are done differently with vaginal births after cesarean (VBAC) as opposed to a first baby. Midwives usually reply to this question with a reassuring, “Oh, we treat you normally,” but there are differences in the two situations that can be distinguished in midwifery practice.

Prenatal Preparation

The full history of the events leading to the cesarean is very important. With a VBAC client, ask her to get her operative record, nurse’s notes, anesthetist’s report, pediatric report—get all the records and go over them thoroughly. Often the couple did not get full or accurate information about what was going on. Sometimes there’s a little “clue” as to what went wrong that could help to prevent a cesarean from recurring. Sometimes there is a big chunk of information that didn’t get communicated. I saw one set of records where the only indication for the cesarean was the note from the obstetrician that “this woman is a natural childbirth fanatic.” Another set of cesarean records had no indicator whatsoever of why the woman received abdominal surgery when she had given birth at l9 years old. When she told her parents that the midwife was perplexed and could see no reason for the surgery, her father admitted to her that he had stayed in the visitor’s lounge all day and had been verbally threatening to the doctor: “If anything happens to my daughter, I’ll sue you!” This helped the daughter to understand what had happened to her and also helped her to be firm with her father that he was to be nowhere near her VBAC birth.

With VBAC births it is important for the midwife to work with the dad prenatally. A VBAC father is in a horrible position because, despite the fact that his wife had an operation and a long recovery, he still got a live wife and baby at the end of it all. VBAC dads are often “fantasy bonded” to the medical system and terrified of childbirth in general.

The good thing is that they listen very carefully and really know when the care is better and more thorough and when the practitioner is authentically on their team. I find that if the midwife talks to them very honestly, they can trust and be fully supportive when the birth time arrives.

If the woman has dilated past five centimeters in the first birth, I plan for it to be fairly fast—like any second baby. If the woman has not gone into the birth process or not dilated past five the first time, that’s all right, she’ll still give birth vaginally, but we have extra midwives on call to bring fresh energy if the others get discouraged or tired. We plan for it to be like going to two births in a row. The point that the woman reached in her first birth is often a psychological hurdle for her. If she dilated to six centimeters the first time, the news that she is seven or eight will be a relief and a breakthrough. One of our clients, a minister’s wife, said over and over again in her pregnancy: “I just want to feel what pushing is. If I only get to push, I’ll be happy. I just want to know what other women mean when they say they had to push.” She’d had a Bandl’s ring in the first birth process and the cesarean was done at five centimeters. We were praying that the complication wouldn’t repeat. She dilated smoothly and began to push. With each push she would exclaim “Thank you Jesus, thank you Jesus!” What a wonder it was to watch her push out the baby, a girl whom she named Faith.

All humans have a certain propensity to self-sabotage, and the VBAC woman must be on guard against her own defeating patterns. The midwife must be bold in pointing out ways that the woman is repeating dumb moves—there’s no place for us being “nice” if it will mean another cesarean. An example of this: If the woman had a cesarean with five support people, she will be cautioned to keep her VBAC private.
Privacy and quiet are a must, and we will be very forceful about setting up logistics before the birth so that the woman can birth in peace. In short, the VBAC is high priority because this woman’s whole obstetrical future rides on its success.

Keeping a VBAC normal

Keeping a VBAC normal

We show the couple lots of videos of beautiful VBAC births because one video is worth a thousand words. If you don’t have your own, purchase a copy of my dvd “Birth with Gloria Lemay” which shows a beautiful VBAC waterbirth. Art therapy is helpful in creating the environment before the birth day. I place a big sheet of drawing paper in front of the father and mother with lots of colored pencils and instruct them to, “Draw your birth cave” or, “Color your birth.” When they are finished, I write the date on the two drawings and put them away in my files. After the birth, we take them out and are amazed at the details that were drawn weeks before and later manifested in the actual birth.

I schedule longer appointments with VBAC women because they seem to need to obsess. I don’t have solutions to many of their fears but it seems to help to just be able to talk to someone who cares and understands. I usually also ask them to, “Tell me how you know that this time you’re going to have a vaginal birth?” The answers always amaze me. One woman said, “Because this time I’m not depending on my doctor or my midwives—me and my husband are going to have this baby.” I suggested that she give up depending on her husband, too. She looked terrified at that idea but I could see that she understood; she looked me in the eye and said, “Right!” That was the moment I knew she would do it. She’s had three water homebirth VBACs since then, and after each birth her first words were, “I did it.”

VBAC women are so grateful for the opportunity to birth normally that they are often shy to ask for the extra things that make a birth beautiful, such as a Blessingway ceremony or a waterbirth. The midwife must remember to offer and encourage the mother to think “really beautiful birth” rather than “bare minimum birth.” I find it helpful to ask, “This is the only second baby you will ever have—what would make it really special?”

The Day of the Birth

In my practice, no one gets induced in any way or gets pain medication. This policy is very important for all women but especially for VBAC women. If there is a small chance of uterine rupture, we must have everything on our side to prevent it (the rate of VBAC uterine rupture without induction is 0.4 percent or less than one in 200*). It is beyond my comprehension how anyone could give a VBAC woman misoprostol (Cytotec), oxytocin or castor oil or strip the membranes or use any other form of induction when that would triple her chance of having a uterine rupture.

I believe that VBAC women have longer, gentler births because Nature is compensating for the scar. There is no hurrying. I would be terrified to induce a VBAC woman but feel safe to attend her at home if her body is pacing itself naturally. We keep it in the back of our heads that the signs of rupture are stabbing pain, unusual bleeding, decels of the baby’s heart, or a peculiar shape of the abdomen but we don’t look for problems if they don’t exist.

We are especially careful with the birth of the placenta in a VBAC because there is a slightly increased chance that the placenta might be adhered to the scar, and we do not want to have a uterine prolapse caused by pulling.

Postpartum Differences

After the birth, VBAC women need to be told that they can walk upright. They can’t believe that they can straighten at the waist right after giving birth. Then, they can’t believe it when we ask them to do sit-ups and leg raises on day one. Usually by day three when we go to visit, their husbands say, “Oh, she’s gone to the gym.” With VBAC women, the complaints are very few in the postpartum period because they are comparing to post-surgery pain and any minor scrapes and bruises seem like nothing.

In the years following the birth, these women and men send us more clients than anyone else, and if we’re in legal trouble, they’ll be at all the rallies, raise money, stamp the envelopes, write letters to legislators, and be our true friends for life. A VBAC is an amazing experience for the birth attendants as well as the family. Very Beautiful And Courageous (VBAC).

    Q & A: VBAC

Two Types of Pelvises
by Gloria Lemay

Q: From a midwife: A great many Asian women are very small and small-footed, yet I hear that many of them birth vaginally. Would you comment on pelvic size?

A: When I get a VBAC client and she is endlessly self-psychoanalyzing and beating herself up for having a c-section, I usually say, “Look you made two big mistakes! First you were born in the wrong country, and second you were born in the wrong century—if you’d been born and raised l00 years ago in France, for instance, you would have given birth vaginally.” When I teach my workshops, I tell the students there are two types of pelvises in allopathic medicine: l) contracted, and 2) adequate. In midwifery, there are two types of pelvises as well: l) roomy, ample, and 2) you could get a pony through there!

Gloria Lemay is a Private Birth Attendant in Vancouver, British Columbia, Canada and a frequent contributor to Midwifery Today and The Birthkit.

The "Slow Birth" Movement

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Somehow, we all got hooked into thinking that “quick was better” when it came to birth. When women tell their birth stories, it seems to be a point of pride to be able to say “I gave birth in 5 hours”, “I barely made it to the hospital”, “even with my first, it was so fast”. We hear these stories and may envy the women thinking that they performed in a fast, efficient manner and we view them as having a coveted talent.

I’ve been observing women giving birth for thirty years and I have given birth three times. From my experience, I don’t think that quick is necessarily a good thing when having a baby. Often fast births afford the woman no time to get her breath and regain her strength. Some women describe their fast births as feeling like they have been whipped around in a blender. In a rapid birth, the woman’s body sometimes displays the symptoms of transition after the birth of the baby (shaking, feeling hot/cold, vomiting). When a baby comes slower, there’s a building up of the intensity of the sensations so that the woman can adjust herself to the process that’s happening and, even though most women would like to shave a few hours off the whole thing, nevertheless, they know they can cope and that they will get to the finish line of birth. When the baby comes slower, the woman often dozes between her pushing sensations and seems to derive a great deal of energy from those short snatches of sleep even though they are interrupted often. The hormones of birth seem to allow the woman to operate in a different domain of sleep, energy and strength. I’m fond of telling women who are tired and discouraged at transition “You’re going to get a big burst of energy when you get the reflex to push” or “you’ll get an energy rush when you feel the baby’s head at your perineum”.

This trust in the process and knowledge that energy can ebb but then be regained in the birth process seems to be greatly lacking in today’s Western obstetrics. Slowing down or taking a long time to dilate is simply viewed as a problem and it’s a problem to be fixed by hurrying the woman’s body along. There’s no such thing as a resting phase, going in and out of the process, or simply a looooonnnnngggggg, slow birth process. This is not allowed and it’s viewed as pathological.
It hasn’t always been that way.

Waiting for the baby

Waiting for the baby

In his book “The Farmer and the Obstetrician”, Michel Odent does a comparison of big agri-business to modern hospital obstetrics. When we see the environmental disaster that large scale agri-corporations have produced and we know that the hospital obstetric system has produced a North America wide cesarean rate of 30% and rising, it’s clear there’s been a severe skewing of priorities and principles. We have to re-order our thinking about farming in order to survive: local organic farms, 100 mile diet, moratoriums on genetically modified crops, co-op gardens, raw diets—all these things have grown in the past few years as the few who knew they were important have held onto the knowledge (and the seeds) for the ones of us who were slow to catch on to the urgency.

Instead of talking about “fast food” that seemed so sensible a while back, we’re talking about slow food. Food that takes time, patience, work and integrity to grow, sow and cook. Some are even talking about “slow money” to fund “slow food”, the kind of financing that doesn’t look for a quick return and a scheme but rather looks to the quality of neighborhoods, children, the air we breathe and the long term future.

For those of us who know there’s something terribly wrong with the state of obstetrics in North America, we must call for a return to SLOW BIRTHING. Birth which understands that some women will wait for several days after releasing their membranes and have no pathology. Slow birth means returning to a time when induction of birth was reserved for very seriously ill women and undertaken with great trepidation. Midwifery would be patient beyond all known limits . . . practitioners only steering the birth process in the most rare cases. We would return to a time when practitioners used to say such expressions as:

“Every birth is different, every woman is different and every baby is different.”
“Don’t let the sun set twice on a woman who is in active labor (past 4 centimeters dilation).”
“Don’t practice “meddlesome midwifery”.”
“A good obstetrician does not pick unripe fruit.”
“A good practitioner has two good hands and knows how to sit on them.”

These are all things I heard when I first started attending births 30 years ago and, now, I never hear them. We must get back to those times when the cesarean rate was below 15% or we will perish. As a society, we cannot withstand the damage that is being done to large numbers of women, babies and their extended families. The idea that we can “turn hospital beds” in order to make maximum use of the dollar cost of that bed is insane when it comes to giving birth.
The notion that a woman can be induced with all the pursuant cascade of interventions simply for the convenience of scheduling staff or room availability is a crime. We must wake up and recognize that giving birth to a baby is one of the most powerful transformative events in a woman’s life. This process is so important to the family and the rest of society that all efforts must be made to have it flow normally. Our priority must be the well being of the newborn baby and the conditions that are favorable to a long, satisfying breastfeeding experience. What we are doing right now with inductions, surgeries and the mass use of narcotics in childbirth is as harmful to the planet as fish farms and DDT. The small band of people who have kept the notion of SLOW BIRTH alive so that society at large can get back to what we know is the holistic way to treat new mothers and babies must be listened to and appropriate action taken. Childbirth is not a frill, it’s not an expendable experience, it’s a fundamental lynch pin in forming the family and, without it, we are doomed to being a sick society.

A Proven Method for Lowering the Cesarean Rate

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Another article in my local newspaper last week bemoaned the fact that the cesarean rate keeps rising and physicians are concerned not only about the high rate of surgery but also the future complications that increase after cesarean surgery.  It’s a well-documented fact that a cesarean can adversely affect a woman’s health for the rest of her life and can lead to catastrophic complications in future births.  That’s one reason why, 40 years ago, doctors did everything in their power to prevent that first cesarean from being done.

What if there was a tried method of reducing the cesarean rate within hospitals?  What if it involved some truly innovative thinking?  What if it had a proven track record and had resulted in a significant drop in the rate of surgeries for first-time mothers?  What if it saved money, recovery time for the patient, and better health for the babies?  Would you think that method would be adopted all over North America right away?  Yes, that would be a reasonable assumption.  Unfortunately, this project was undertaken at B.C. Women’s Hospital, it was a success, and it was dropped once the project was complete with a resulting re-increase of the cesarean rate.  No reason for discontinuing the project has ever been given but i will speculate at the end of this post.

A cesarean is major abdominal surgery

A cesarean is major abdominal surgery

The results were published: Grzybowski S, Harris S, Buchinski B, Pope S, Swenerton J, Peter E, et al. First Births Project manual: a continuous quality improvement project. Vol 1. Vancouver: British Columbia’s Women’s Hospital and Health Centre; 1998.

It was the first phase of a Continuous Quality Improvement project with the aim of “Lowering the Caesarean Section Rate“. Start date was January of 1996. The target objective was to lower the caesarean section rate by 25% for nulliparous women, while maintaining maternal and infant outcomes, within 6 months of implementing solutions. 

Staff from all departments of the hospital were brought together in a brainstorming session to share hypotheses on what was causing the high rate of cesareans.  Many of the ideas thrown out were not under the control of the hospital but, in the end, four practices were identified as possibly contributing to the high rate of surgical births.

1. Women were being admitted to hospital too early (before reaching 4 cms dilation, active labour).

2. fetal surveillance by electronic fetal monitoring (continuous electronic fetal monitoring has been proven to increase the cesarean rate with no improvement to the health of the baby)

3. too early use of epidurals (women who get an epidural before 8 cms dilation are at increased risk of surgery)

4. inappropriate induction (inducing birth before 41 weeks gestational age with no medical indication).

Teams of nurses were assigned to do an audit of hospital records to see if these hypothetical practices were, in fact, as widespread as some of the staff thought.  The audit confirmed that these 4 areas were ones that needed attention.  Task forces were created in each area to use the best evidence and existing guidelines, as well as solutions from other hospitals to improve care at BC Women’s Hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.
 

WHAT HAPPENED?
 
According to published results from the hospital:
After six periods, BC Women’s had admitted and delivered 1369 nulliparous women (first time mothers) with singleton, cephalic, term presentations. The Cesarean section
rate was reduced by 21% compared to the 12 periods prior to implementation. The number of epidurals initiated at 3 3 cms was 64% lower, continuous fetal monitoring was used 14% less, the induction rate had dropped 22% and admission at less than 3 cms cervical dilation had dropped 21%. All changes were statistically significant. Newborn outcomes were unchanged post implementation.”

WHAT’S HAPPENING TODAY (2009)?

It’s back to business as usual at this hospital.  Women are induced, monitored, epidural’ed, and admitted early.  The cesarean rate is 30% and the head of obstetrics is concerned but has no action plan.  Why on earth would this be?  I assert that it is because it is an “up at dawn” battle with the physicians to change their ways.  The gossip that I hear from nurses is that the doctors did everything they could to undermine this project.  For example, a doctor would examine his patient and state “She’s 8 cms dilated, get the anaesthetist.”  Then, later, when the woman had her epidural, someone else would examine the same woman and find her to be only 6 cms.  The doctor would smile and shrug his shoulders, “whoops”.  The same thing happened around the issue of monitoring, induction and admitting. . . trickery to subvert the project and return to their old ways of doing things.

It’s a low tech, novel, innovative approach that had excellent results.  I’d love to see it copied everywhere in North America but it’s a bit like dieting. . . everyone knows how to lose weight (eat less, exercise more) but only a few get into action.  We DO know how to lower the cesarean rate, committed action is needed.

UPDATE: Oct 2023

A hospital in the USA brings their cesarean rate way down: Link to St Mary’s Medical Center
https://www.stmarysmc.com/news/newsroom/st-mary-s-medical-center-achieves-healthgrades-5-star-rating-for-vaginal-delivery-and-c-section-delivery-for-the-8th-consecutive-year
UPDATE: MAY 2024
This information is on a Canadian Government Website.
First Births: Lowering the Caesarean Section Rate
Children’s & Women’s Health Centre
of British Columbia
Vancouver, British Columbia
The First Births Project evolved as the first phase of a Continuous Quality Improvement project aimed at “Lowering the Caesarean Section Rate at British Columbia Women’s Hospital and Health Centre,” began in January of 1996. The target objective was to lower the caesarean section rate by 25% for nulliparous women, while maintaining maternal and infant outcomes, within 6 months of implementing solutions.
After mapping the process of care and brainstorming hypotheses that might contribute to the high caesarean section rate, the group selected four areas as the vital few. These were too early admission; fetal surveillance by electronic fetal monitoring; too early use of epidurals; and inappropriate induction. A chart audit supported the group’s choices. Task forces were created in each area to use the best evidence and existing guidelines, as well as solutions from other hospitals to improve care at BC Women’s Hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.
The project has been about working together to accomplish change in an environment of mutual respect. The process has been data driven as, without measurement, the effectiveness of any change is left to opinion. Hospital policies were created which were consistent with these changes. The project has also been about maintaining and consolidating the gains. This has been achieved through:
• an open and public evaluative process
• enrolment on a voluntary basis of nulliparous low-risk patients
• Nursing Team Leader confidential feedback
• monitoring newborn outcomes
The spirit of this initiative is Continuous Quality Improvement. It is about making gains in the quality of care and then holding them. In the first six months of implementation the process of continuous quality improvement has worked to create statistically significant change in all the target areas addressed. In this six-month period there were 50-60 nulliparous women who did not have a Caesarean Section, as compared with the previous year. This number is projected to 100 nulliparous women for the entire year. If these women choose to have another pregnancy, their chances of having a caesarean section in the next pregnancy will have been reduced from about 60% to about 5%.
The teams are continuing to meet and deal with other issues identified as potential opportunities for improvement. We expect that the First Births strategy will serve as an ongoing vehicle for introducing change concepts into the process of care at BC Women’s and might be a template for the province.
See Appendix C for contact information Source: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/quality-care/quest-quality-canadian-health-care-continuous-quality-improvement.html