PRENATAL CARE or PRENATAL SCARE?



Women in Australia ask each other “Who are you going to for Prenatal Scare?” Sadly, that could be said in North America, too. Stressed practitioners unloading their personal fears on pregnant women is a common scenario all over the world.
A pregnant woman in Australia wrote to me because of these instructions from her midwives: “Lydia, your baby’s head is not engaged in the pelvis and you are close to your due date. We’re concerned that the umbilical cord might prolapse if your membranes release before your contractions are well established. If that happens, call an ambulance to get you to the hospital and get in an all-4’s position on the floor while you wait for the paramedics!”

She wrote to me in Canada to get my opinion on that advice. I told her my favorite theory about low-probability problems in birth work. I wrote: “Yes, Lydia, all that could happen, but it’s highly unlikely. Do you know that you could be walking down the street in your city and a piano could fall on your head? That’s possible, too, but none of us refuse to walk on city sidewalks because of the falling piano danger.” That explanation gave her confidence to continue with her homebirth plans. The midwives attended and everything went well.

Discussing things that are real and present is what pregnant women need from their midwives prenatally. Hallucinations of possible disasters that aren’t happening need to be silenced.
When a woman comes for a prenatal visit (or you attend at her home), she’s excited to be with her midwife and find out how her baby is doing. When a midwife is doing her best work, she will:
Be listening intently to what the client is saying.
Be organized so the client gets the message that the midwife values the client’s time.
Be writing notes of everything the parents say.
Be able to say “I don’t know the answer to that, but I will look it up and send you what I find out.”

The prenatal visits are a “dress rehearsal” for the actual birth. The family is getting an idea about how the midwife will be once the birthing time arrives. Is she punctual? Does she answer her phone promptly? Does she smell nice? Does she answer questions honestly? Do we feel comfortable, relaxed, and included when we’re with her?

I had a young couple come to an introductory appointment with me about 25 years ago. The government of British Columbia had just regulated midwifery and families wishing to have a homebirth with a midwife could get the service on their medical plan. I was not regulated and I charged $2800 to attend a homebirth. I explained that they could get a midwife “under the medical plan” and I also reminded them that I lived a 90-minute drive away from them. There were midwives working very near where they lived who would be paid by the government.
The father responded that “No, they didn’t want the local midwife and, yes, even though they didn’t have a lot of money they wanted someone like me.” He then proceeded to demonstrate what the local midwife did that he couldn’t accept. He started speaking to me while staring at a spot on the wall that was about 18 inches above my head. He didn’t connect with my eyes for the next little while. It was very weird. Then he told me “That’s what the midwife did. She never made eye contact when speaking to me.” He didn’t want long, deep stares, he just wanted a normal conversation with someone who looked him in the eye once in a while. I wondered what kind of fear state that midwife was in during the appointment.

I had a number of different physicians palpate my belly in my second pregnancy. The possibility of a homebirth had not occurred to me and my husband. We kept shopping for a doctor who would promise that 1. I wouldn’t be given an episiotomy, and 2. The baby would stay with me at all times. Those doctors were very clear that they would be in charge and I would get what they ordered and I didn’t get to tell them what to do.
Finally, we found out there were some midwives in Vancouver, BC, who would attend homebirths. We met with one of them, Elly, and for the first time in my pregnancy, someone palpated my belly with soft, warm hands and seemed to realize there was a real little human in my uterus. That experience sold me on her. Luckily, my husband was very impressed with her, too. I am forever grateful that I found the ideal midwife for me who fit with my family perfectly. Warm hands, a quiet confidence, and a willingness to meet my requests—that’s what her prenatal care encompassed.

Gloria Lemay is a childbirth activist living in British Columbia, Canada. She has a passion for VBAC, waterbirth and ending male genital mutilation. She is a blogger at wisewomanwayofbirth.com. Her film “Birth with Gloria Lemay” was produced in 2012 and has been viewed all over the world.

Postpartum Doula Certification(2025)

Featured

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 British Columbia, Canada. She has built her business over the past 20 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 her local birth community. She is the mother of two boys who were both born at home and breastfed into toddlerhood.
Website: https://www.cherishchildbirth.com/
FIRST COURSE IN 2025:

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

First Course in 2025 dates: January 15 to February 19, 2025 from 7:00 to 9:30 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.

SUA Single Umbilical Artery

SINGLE ARTERY UMBILICAL CORD

About 30 years ago, a baby boy was born at home in a town about 90 minutes drive away from where I lived in Vancouver, BC. All was normal with the birth (first baby for the family). The baby was about 8 pounds and he seemed healthy.

I was taught to inspect every placenta carefully at some point in the hours after birth. One part of the placenta exam was to look at the cut end of the umbilical cord and make sure there were 3 little openings where the 2 arteries and one vein were. Remember, this was in the days pre-internet. Midwifery training was accessed by reading thick obstetric/midwifery text books in those days. This little boy’s umbilical cord had only 2 vessels. Oh no. Where was that third little opening for the second artery? I re-cut and peered at the end of the cord but, no, only two vessels. The only instructions in any of my textbooks about that possibility were to “call the pediatrician”. So, I did. At that time, we had a kind pediatrician who always took calls from home birth attendants. When I told him the situation, he said “Hmmmmm, I don’t know what that means. Could you go in to Children’s Hospital to the library and look it up?” I didn’t like to leave the family’s home without knowing for sure that the baby would be okay and I had that 90 mins between their home and the hospital library. I decided to call a friend who was a long time hospital nurse. She didn’t know either but thought it might have something to do with the heart. The baby wasn’t showing any signs of blueness around the mouth and was a keen breast feeder so, I didn’t see or hear any heart problem indicators. After a few hours, I headed back to town and went straight to the Hospital Library.

Vein larger than the 2 arteries

In those pre-computer days, the hospital Librarian was a God-send. She was very helpful and looked up a bunch of articles for me but they really didn’t tell me much more than “it could mean a kidney problem”. I was feeling frustrated but, then, got an idea. I could find the pathology department in the hospital and speak to a person who had seen babies with kidney problems and maybe get some useful help.

I was a bit nervous going to Pathology because I was afraid I’d see dead bodies but, no, the place was clean as could be. The Pathologist was glad to see me and have someone to talk to. (I think that’s a lonely job). I told him what was going on and the first question he asked was “How much did the baby weigh?” He then told me that babies with kidney problems tend to be very small so he doubted my finding that there were only two vessels in the umbilical cord of an 8 lb. baby. He suggested that I should bring the placenta in so he could take a look. I wasn’t relishing the 90 minute drive back and forth again but I was more than willing to be wrong about my count of the vessels if it meant I could relax about the baby.

One vein, two arteries

I returned to the family home, got the placenta from the fridge and drove it back to show the pathologist. He cut the end of the cord on his marble slab and peered at it and then said “Well, I see what you mean. There are just two but can you see that the vein, which is usually larger than the arteries, and the one other vessel are both about the same size? I think what happened here is that the two vessels grew together. If the baby is pee-ing normally and eating well, I don’t think you have anything to worry about.” He then proceeded to reach up on to his shelf and bring down a copy of a thick text book entitled “The Human Placenta”. He told me that it was a fascinating book by a pathologist who had been a veterinarian before he pursued pathology. When I expressed amazement that there was enough to say about the placenta that it could fill a whole book of its own, he said that a lot of the information was comparing the human placenta to that of zebras, gorillas, and other wild animals. Somehow, I’ve never been tempted to buy the book. . . I like to keep my placenta knowledge on a “need to know” basis.

That little boy did just fine and he’s a big man now. That’s the only 2 Vessel cord I’ve ever encountered in 1500 plus births, so it’s very rare (and, in this case, not even a real finding).
I hope this story is informative and reassuring to parents/practitioners about SUA (single umbilical artery) diagnoses in babies with normal growth.
Gloria Lemay, Vancouver BC Canada

From www.midwifethinking.com
A great blog

LITTLE THINGS MEAN A LOT

Quote

I wanted to write this story down because it is one I can’t forget.

I was walking back to my car after a late night downtown meeting and I was accompanied by Peter and Molly, old friends. Molly was someone I really admired and she had two young children. As we were walking along together, Molly said: “Gloria, I don’t think I’ve ever told you what an incredible difference you made to me.” My ears perked right up, I love to be acknowledged, but I couldn’t remember anything special that I had done for Molly.

She said, “Remember that day we bumped into each other on the street when I was hugely pregnant with Caroline, my second daughter? We hadn’t seen much of each other during my pregnancy and I was working with two registered midwives and planning a homebirth.End of Pregnancy

My mother had come out from Eastern Canada to help the family at the end of my pregnancy and it seemed to be taking forever for the baby to come. I was worried that my mom might be really scared to see me birthing and I had a feeling she didn’t like the idea that, this time, I would have the baby at home. I didn’t even want to talk to her about the idea I had of having a waterbirth. Everything else about the birth was going smoothly but I had this nagging fear about my mom’s reactions. Well, Gloria, you listened to everything I said and then you said “Oh, do you know what? I have the most amazing video of waterbirth that you just have to watch. Everyone who sees it has a lovely smooth birth, you’re going to love it”. (The video was Barbara Harper’s “Birth Into Being”). You went to your car trunk and presented me with the vhs tape. I took it home and we watched it that evening. My mom watched it with us and said at the end “Why don’t you get one of those water tubs and do it that way, Molly!” All my worries were gone and the next morning my birth process started. The birth was everything we wanted. Afterwards my Mom said “Honey, that is the most beautiful thing that has ever happened in my whole life. I’m so glad I came out to Vancouver and got here on time to be present to the miracle.”
My Mom returned home to Eastern Canada. She was a widow and she liked to live in her own home alone. A few months after Caroline was born, we got the terrible news that my mother had taken a fall down a flight of stairs and she died. The grief was terrible. Amidst all the grieving I had this sense of peace that my Mom had been present to a miracle and that we had shared a profound experience. I don’t know if it would have unfolded that way if you hadn’t run to your car and lent us that video.”

 Only two remain undilated.


Only two remain undilated.

Molly (not her real name) only told me this story when the baby in this story was about 12 years old. You never know what the ripples in the pond of your actions might be. Love Gloria

MIDWIFERY CARE FOR THE VBAC WOMAN

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.

“Birth with Gloria Lemay” the film

This is the kind of delightful feedback I receive about the DVD. Gloria

From Donna Reicks:
“Gloria, I just have to tell you…..I loaned out your DVD “Birth with Gloria Lemay” as I do to any “English” ladies I serve. These are 1st time parents (after 7 years of trying!) and she loved your DVD and commented her favorite part was the extra features on circumcision!! They were on the fence if they had a boy. Now, their decision is made. Thanks Gloria!! Keep up the good work! Much love to you!”

From Gloria Lemay: “When I made the DVD, it was easy to add a few “extras” besides the footage of 9 home water births. One of the “extras” is a Director’s Cut-type film with me explaining what is going on in the film. The strange thing for me is how many women say, “After watching the version with you explaining what’s going on, my husband is now comfortable with the idea of birthing at home and he feels confident.” The conclusion I’ve come to is that I must have been talking to the back of the sound technician (a man) and that’s why the words seem to affect men. Completely inadvertent but I like it.

Then, there were 2 really good videos that really taught me a lot about the importance of the male foreskin so I requested the use of them from the owners. They were both thrilled to give me their material. Again, so much of the feedback that I get is that those two features have such an impact on people. Both of those intact penis features are available for anyone to watch online but, it seems, a couple sitting on their couch watching a DVD will keep going right to the end of the DVD and THAT has put the information in a lot of people’s hands. It’s so gratifying to know that those DVDs are all over the world. If you have one, don’t leave it on your shelf—get it out and show it or lend it to pregnant families!”

“Birth with Gloria Lemay”

To order the film and download to a thumb drive go to this link
https://birthwithglorialemay.vhx.tv/products/birth-with-gloria-lemay

Facebook favourite Updates

I’ve been on Facebook for five years, apparently. These are the most popular updates that I’ve posted there:

They are not “unvaccinated”. . . they have a natural immune system. Women are not “unmastectomized” . . .they have their breasts. Boys are not “uncircumcised”, they are intact. Every word creates a hallucination. When we hallucinate wholeness, wholeness will show up as normal.

Gloria Lemay

October 2013 393 likes

What do I want for my birthday? I want everyone who reads this to take 30 seconds to get up, walk through your place and turn off any lights or appliances that don’t need to be on, OFF. We make the difference in having our Mother Earth work. Thank you.

Gloria Lemay

October 2012 270 likes

If you’re hiring a doula to “enforce your birth plan”, “keep you home as long as possible”, and “protect you”, wake up and plan a home birth with an attendant you trust.

Gloria Lemay

July 2012 359 likes

I don’t know who wrote this but I found it very funny 🙂

If you love something, set it free. If it comes back, it will always be yours. If it doesn’t come back, it was never yours to begin with. But, if it just sits in your living room, messes up your stuff, eats your food, uses your telephone, takes your money, and doesn’t appear to realize that you had set it free……. you either married it or gave birth to it.

July 2011 213 likes

www.pinterest.com

Courage

According to the Merriam-Webster dictionary, courage is a noun meaning ‘ability to overcome fear or despair” The fear has to be present in order for courage to exist. The English word “courage” is derived from the French word for the heart, “cour”. When someone finds the heart to continue on doing the right thing in the face of great fear, everyone around her is inspired to become a nobler human being. This is the source of courage for many midwives. In ourwork, we see women and men facing their fears in birth, we ask them to have faith in the face of no evidence, we demand that they be bigger than the circumstances and, when they conquer, we get a renewed vision of how life can look when our fears don’t stop us.

The paths of parenting and midwifery push me up against my fears and despairing attitude on a daily basis. Luckily, I have found teachers and teachings that have inspired me to keep going despite a rapidly beating hummingbird heart. When my daughters were very young and I was juggling my heart’s desire to be a good parent and make a difference in childbirth, one of my friends told me to use the affirmation “My vulnerability is my strength.” I thought she was insane and argued that if I lived by that slogan my children would surely perish. I was pretty sure that my strength was my strength—and by strength I meant my ability to force and push life to suit my will. I now know that true strength is an elusive quality of being able to strengthen others. At that time, I trusted my friend and, on faith in her alone, began toying with sharing my vulnerability. I tiptoed into revealing my fears and apprehensions to a few “safe” people and slowly began to realize that what my friend had given me as an affirmation worked a lot better than my stoic, stubborn, brave warrior act.

After a few harsh lessons, I began to realize that it wasn’t up to me to conceal information that was worrying me at a birth from the parents. In fact, if I am afraid at a birth, the best thing I can do is name the fear boldly and even ask everyone else present to say what his or her fears are. One of my dear clients released her membranes at 36 weeks in her second pregnancy. Her first birth had been a beautiful, straightforward home birth and I was deeply invested in her second birth being just as great. After four days of leaking, she began having regular, intense birthing sensations and we drove to the hospital for the birth. I drove and the parents were in the back seat of my car. As we approached the hospital, my hands on the wheel were clutched into white knuckles and a ball of fear formed in my gut. I started picturing the cord being whacked off immediately and the baby being taken away from Mom. I looked in the rear view mirror and saw the father with his eyes looking terrified. I said to him “What’s your biggest fear right now, Brian?” He replied, “I am afraid we’re going to have a Cesarean.” I never imagined this would be his fear. A cesarean was not even a possibility, I explained, “Your wife is in strong birthing, she has already had one vaginal birth, the baby is small—for sure it will be born vaginally”. He asked me, then, “What are you afraid of?” I told him honestly “ I’m afraid that the baby’s cord will be cut too quickly and the baby will be taken away from Karen.” This had not occurred to him but he knew that my experience was a better barometer of things to come. He asked me what we could do to prevent this. I was able to tell him that it was very important to take the doctor aside out in the hall and tell him “It means everything to my wife and I that the cord be left to pulse and that the baby be placed on her skin until the placenta comes out.” We did a couple of “dress rehearsals” of what had to be said and then went in. The staff at the hospital respected the parents’ wishes to have the cord left intact. The birth went beautifully. I would have wished that the baby didn’t have as heavy doses of antibiotics as he was given (with resulting colic for months) but having a birth that involved no induction or anesthetics was a big accomplishment in these circumstances.

Nancy Wainer, author, midwife

Nancy Wainer, author, midwife


There was a period in my career when I was unable to divest myself of fear and dread. I wanted to have a breakthrough and so I decided to “import” some courage into my city. I thought about my heroes in the midwifery movement and asked myself “Whose the bravest person I know?” The answer was, of course, Nancy Wainer Cohen. Her book “Silent Knife” had kept my feet in the room at VBAC births where every cell in my body had been screaming “What the h— are you doing here?!!” I was pretty sure that if Nancy came and lived at my house for a few days, I could get some courage. My husband picked Nancy up at the airport and she came into my house and hugged me wracking with sobs. She cried her way through several boxes of Kleenex at the workshop she taught for my students. Her visit was four days of snot, tears and intense passion for healing birth. I learned so much about the vulnerability and strength connection. Nancy is still my hero in the courage department and she continues to live her life with her heart pinned right on her sleeve.

The sharing other midwives have done about their fears has strengthened me to face my fears of birth One midwife wrote in Midwifery Today that “the drive to the birth with all the “what ifs” running through my head is the hard part, when I walk through the door and see the woman, all that disappears”. Another midwife told me “The scariest thing for me is the first prenatal class of a series. Meeting new people who have so much riding on my teaching is enough to give me an ulcer.” An acronym for fear is:

F= false
E= evidence
A= appearing
R= real

When I am most afraid, it is because I have forgotten the truth about how loved and blessed I am. The fear can dominate and stop me or it can be used to alert me to something to which I am deeply committed. Using a journal to write out fears in the morning helps to clear the mind. Once the fears are on paper, somehow they seem less foreboding. Being in action is another antidote to the paralysis that accompanies fear. Any action—cleaning your desk, organizing a drawer, making a phone call—will bring a new perspective and lessen the dread.

My favorite philosopher about fear and courage is the Wizard of Oz speaking to the cowardly lion “Courage is doing what’s right even though you’re afraid.” I have learned courage from birthing women and other midwives. We are there to inspire and raise the bar for each other on what’s possible in the domain of courageous action.
This article by Gloria Lemay was written in 2003 and first published in Midwifery Today, Issue 67, Autumn 2003

A Proven Method for Lowering the Cesarean Rate

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