In Celebration of My Uterus - Ann Sexton

Everyone in me is a bird.
I am beating all my wings.
They wanted to cut you out
but they will not.
They said you were immeasurably empty
but you are not.
They said you were sick unto dying
but they were wrong.
You are singing like a school girl. 
You are not torn.


Sweet weight,
in celebration of the woman I am
and of the soul of the woman I am
and of the central creature and its delight
I sing for you. I dare to live.
Hello, spirit. Hello, cup.
Fasten, cover. Cover that does contain. 
Hello to the soil of the fields.
Welcome, roots.  


Each cell has a life.
There is enough here to please a nation.
It is enough that the populace own these goods.
Any person, any commonwealth would say of it,
"It is good this year that we may plant again
and think forward to a harvest.
A blight had been forecast and has been cast out."
Many women are singing together of this:
one is in a shoe factory cursing the machine,
one is at the aquarium tending a seal,
one is dull at the wheel of her Ford,
one is at the toll gate collecting,
one is tying the cord of a calf in Arizona,
one is straddling a cello in Russia,
one is shifting pots on the stove in Egypt,
one is painting her bedroom walls moon color,
one is dying but remembering a breakfast,
one is stretching on her mat in Thailand,
one is wiping the ass of her child,
one is staring out the window of a train
in the middle of Wyoming and one is 
anywhere and some are everywhere and all
seem to be singing, although some can not
sing a note.


Sweet weight,
in celebration of the woman I am
let me carry a ten-foot scarf,
let me drum for the nineteen-year-olds,
let me carry bowls for the offering
(if that is my part).
Let me study the cardiovascular tissue,
let me examine the angular distance of meteors,
let me suck on the stems of flowers
(if that is my part).
Let me make certain tribal figures
(if that is my part).
For this thing the body needs
let me sing 
for the supper,
for the kissing,
for the correct
yes. 


Ann Sexton

life is a highway...highway 104

so much fun. 


christmas has come on gone. lonely this year. but alright. cooked up a bit of tradition and skyped with the family. that was good.


settling in to the new place. being productive.


tending the fire. 


it's a quiet life up here. working. waiting for the babies. meeting new people. 


took my car in for an oil change and they asked me where i'd been. "looks like you've been having fun!"


waiting on babies. babies please please come. but not tomorrow. tomorrow i have a date and i want to enjoy nature for a minute. even tomorrow night would be fine. tonight not so much. i haven't slept. i should be sleeping. but i've been studying like a diligent student midwife. 


still have three multips in dates and i leave in a week. oh how i don't want to miss them! this going away for classes is troublesome. 


six more months. six more months then there won't be anymore distractions. no more pulling me away. 


six more months. 


every birth i attend i'm learning more. growing more. feeling more and more at home. 


six more months and i feel like i can grasp hold of this path. 

best job ever or a week in the life or i want cowboy boots now that i live in the country.

this last month has been filled with ups and downs. 

i lost someone important to me. my sisters father in-law. he was a very special man. he fought a battle with leukemia and past away last month, a month after my sister and her husband got married. it was a beautiful ceremony and a wonderful celebration. i feel honoured to have sat across from him and was fortunate to spend that with him. from the beginning of my sister and her partners relationship our two families worked as one. we spent the holidays together and i was invited over for many a sunday dinners throughout university. 

it was hard not being able to go home for his funeral. on top of this loss a plague fell upon our house. my housemate found a lump in her breast. the dog was diagnosed with malignant cancer. we were left with no option but to leave the house we were in and were all in a position of finding a new place to live. 

in the end it all has worked out. the lump was a cyst, the dog had the cancer removed and although i'm sadly parting ways with a family that i love and kids that i will thoroughly miss living with, we've all found wonderful new accommodations. tom and christine are moving to the island, to a farm, a proper farm owned by a family that wants the farm to come alive again. i wish i could join them. me. i've moved in with melissa, the other student midwife. 

we live in a cabin built in 1900, described as the size of a "postage stamp". it's got a wood stove to heat the house and backs on to port gamble bay. it cute and quaint and the land lady put up plastic on the window today. it's toasty warm. 

so amidst all of this chaos wonderful things have emerged. 

we've had several really lovely births in the last while. the team that we have is working out the kinks of our system. the way to enable both melissa and i told get our numbers.

our numbers. after two and a half years. i'm starting to think about numbers. i'm recognizing my strengths and my weaknesses. i feel stronger since i've moved to the northwest. mental, physically, emotionally. still of course i am the emotional being that i am and i still have a lot to figure out, but i've grown into the persona of a midwife. i feel more secure in this identity, but i still have to learn to give myself enough credit. i know that i can be my own worst enemy. that i will be the one to destroy myself, my relationships, opportunities; if i allow it.

from this day on i need to remind myself to be grateful for what i have, to appreciate myself and what i have been given in this world. to take advantage of it, make the most of it and to see myself as having knowledge, skills and value. 

-----------

a week in review. the life of a student midwife. 

went to clinic monday morning. started with a home visit on the other side of the bridge in this lovely wee village. got to love on two new babies and hang out with a couple mothers-to-be.  as i was getting dropped off i got the call to a birth. turning around i met the other midwife and was part of one of the best labours and births i have ever had the honour to be part of. 

this mother was so into her labour, into the feelings and sensations as the baby descended into her pelvis into the birth canal and emerged into this world. 

i got home at nine the next morning, started a fire and crawled into bed after eating the grilled cheese sandwich i had been craving since lunch the day before. i woke up in the afternoon and heated the house to the point that i could only be in my knickers. it was luscious. cooked good hearty food. yellow split peas and acorn squash. 

wednesday started with a postpartum visit. family settling in beautifully. then chart review. prenatals. manastats. in the evening, i returned to the new families house to encapsulate their placenta. i love this part. 

in the end only about half the placenta was dehydrated. we made the mother a smoothie and then froze small pieces of the raw placenta so that she could continue having her smoothies for the next week or so. home at nine. 

today. back to the farm to collect the last of my things. hugged on the kids. heart melted when little abby reached for me from her mothers back and clung to me and nuzzled into me. loved on me. how these little ones work there way into my heart. back to finish the encapsulation and then off to my midwife's house to "work". really. the intention was there. instead we went grocery shopping. loved that her son grabbed my hand as we walked through the parking lot. seriously. these little ones. got back and then did paperwork. my paperwork. but paperwork none the less. home. dinner. writing. fighting sleep. how i want to sleep. 

not all of it sexy and exciting. but i wouldn't change where i am for anything.  

seriously. best job ever. 

living with you takes the romance out of midwifery

thats what i was told by christine after i was finally home after 3 days of birthing with two strong mothers, and then writing an exam, newborn complications and complications of labour and birth.  

the zombie midwife. the side you never see. go to work monday morning, get home wednesday night.  

put yourself together. go. sleep when and where ever you can. 

i'm craving red meat. i need B vitamins to replenish my stores. 

i wouldn't change a thing. 

from conception to birth. visualized.

procrastination of a student midwife - stories of catching babies

i have periodical exams on tues.. so instead of studying i'm writing. been working since 10am as it is, so what ev's. haven't written in awhile. 


haven't even been back from school for a month. prenatals, births, conferences. it's been a busy month. ahead on school work. moving in a few weeks, moving in with the other student midwife. sickness all around me (seriously universe - fuck off). failing relationships. new relationships. don't even know if i'm coming or going. at least my midwives give me permission for a pint or two and will even join me! 


so yeah. where does one begin. births.


sweet sweet births. one boy. one girl. both born into the water. both with nuchal cords (this is not an emergency!!! just a variation of normal - being in the hospital did not save your baby - sorry. rant. over.). 


last thursday in the wee hours i got the call. had been in bed for an hour or so. my midwife picked me up and we headed to the birth. i was to somewhat manage the birth and catch the baby - four handed. me: i've never done a four handed catch. midwife: me neither. 


sure. why not. 


this mother was so amazing. such a difference from how she was at the end of pregnancy. she absolutely glowed. was totally in control. aware of her body. present.  did what she needed to do. i did a VE (vaginal exam) upon arrival and her cervix was beautiful and open and soft and ready for birth. a few hours later she was complete. 


after a bit in the water, her attitude changed. this is where i need to get with it, be more in touch. change my mindset to midwife, not support.  the midwife was out of the room. me and the birth assistant, the grandma and the sister were in the room. cooing to the mother words of support as the father sat behind his wife. 


there was a shift. she was done. she wanted the baby out. sure, of course she did. it didn't occur to me that baby WAS coming out. of course this is the dilemma of a water birth. dark room. mom on her hands and knees angled so baby will enter the world towards the wall. i had gloves in my pocket. i SWEAR i had gloves in my pocket. water breaks. 


like i said i need to shift my consciousness to midwife not support. i should have had gloves on. plus i should recognize that we had a birth assistant that was available to get the midwife and i should have been more prepared for baby. 


me trying to get my gloves out of my pocket. baby is coming. mind you, even though dad was behind mom, he never even saw his baby coming. midwife: get gloves. me: i'm trying. midwife: or not. me: they're in my pocket!! 


get gloves on finally, baby's head is emerging. i'm not actually used to a very hands on approach to birth and i've never caught a baby in the water. so.. yeah. well maybe i was preventing the baby from extending it's head a bit. gentle and kind words from my midwife, reminding me not to hold the baby in. correcting my hand positions. head is out. i check for nuchal cord (cord around the neck). me: nuchal cord. baby is rotating. born OA, rotates to the left. baby ROA. cardinal movements of birth. i reduce the nuchal cord. it's long enough to pull over baby's head. and in the next contraction the baby lands in my hands. 


the mother turns over and receives her baby. so yeah. it may not have been the most graceful of hand movements that a midwife could have used to facilitate birth. and definite areas of constructive criticism i received. but this is the point of what i'm doing. these mistakes. i have to make. i have to learn. i was trying to support her perineum, not restrict flexion. i could have somersaulted the baby out instead of reducing the cord. most of all. i should have had my GLOVES ON and READY to catch that baby. 


sigh. i did a much better job facilitating the birth of her placenta and i think i did a top notch newborn exam. if i do say so myself. injected the wee babe with vitamin K and she didn't even cry. she was a perfect little specimen that one, weighing in at 7lbs 12 oz.


we packed up everything, ensured all was stable and drove home. i collapsed into bed and awoke a few hours later to the pattering of little feet. not a horrible life. it's good to forget about all the bullshit surrounding you when you are in a mother's birth space. nothing else matters. we may gossip like hens, but the stresses all fall away. it's all external. it's all another world that we are no longer part of. that exists, but is not relevant. the only thing that matters is protecting that mother, that babe. the partner and the birthing unit. that all are safe. 


leaving a birth with a sleeping mother snuggled with her newborn babe is perfection. 


-----


story of baby boy needs to wait. i really should study. 


x

third stage

i managed the third stage at the birth i was at the other night. in other words, i helped to deliver the placenta.

i love the this part. i'm still trying to figure it out mind you.

the whole communicating with people thing.

it's not as easy as you may think.

i need to work on articulating what i want, what i need a mother to do, in a kind loving supportive and informative way.

of course after looking at the photo in william's obstetrics a few days ago, i have trepidation about cord traction and prolapsed uterus. maternal demise. sorry. not on my watch. and definitely not because i pulled it out of her.

i knew the placenta had separated. i knew it was hanging out in her introitus. but she was in that bath tub. awkward space. baby was still attached. she was in a semi-reclining position and i didn't have the gusto to really pull that placenta down and out through the curve of carus (the curve created by the sacrum).

my midwife i think was getting impatient with my efforts. she came back right when i was going to get the woman into a squat. we freed the baby and got the mother squatting. the placenta immediately came out.

golden right.

no. not really. ideally you want to twist the placenta once released if there are trailing membranes.

well like the baby, the placenta pretty much was ejected as soon as she got into an upright position in the bath tub.

in retrospect i should have gotten her out of the tub, onto a chux. yes much more convenient for me. better access, better to estimate blood loss. no funkatated posititioning....but NO! i didn't want to interrupt the third stage. i didn't want to make her to move so much.. i doubt she would have cared. and really i should have just gotten her out of the tub in the first place. she wasn't attached to keeping the baby attached to the placenta before it was delivered...that was something we placed on her in the moment.

so placenta delivers and there are trailing membranes. really. trailing membranes. like the whole amniotic sac was still in there. it was a shultz delivery.. i.e. fetal side first.

but because of positioning when i twisted the placenta it pretty much just tore away from the membranes leaving them inside her introitus/birth canal/uterus....who knows really how far up they went.

she wasn't hemorrhaging. she lost a less than average amount. so no one was immediately concerned.

i told my midwife that there were trailing membranes, but it wasn't until i inspected the placenta and there were really no membranes left that i realized how much were still inside. to be honest. i don't think it did occur to me how much were still inside and the implications. it should have occurred to me.  it wasn't until the exam of her bottom and when my midwife began to remove the trailing membranes, that after a bit of a rub of her fundus and a handful of membranes were released that i knew really how much was still in there.

my midwife asked if i had thought it was that much...i said not until i examined the placenta...but really i don't think i understood.

she said this is information she would have liked to know. i did tell her there were trailing membranes immediately, but like i said there was no immediate concern. i wasn't comfortable leaving it that long. but i'm just learning. i should have maybe expressed my concern more, but it's hard to do that in front of a family. i don't want to put my inexperienced concerns on a new family, when it may be nothing. was there really that much still remaining?

again i need to learn to communicate.

this profession.. it's going to drag it out of me some how.

i am such a recluse and introvert. i find it so hard to verbally communicate and interact with people. funny that i chose to be a midwife.. ha. not really funny like that. ironic.

i'll learn. i'll be challenged. i'll grow. i'll become more experienced, knowledgeable, confident.

this will happen. at least i'm confident in that.

x

complications of labour and birth

study study study

DIC

amniotic fluid embolism

following references into old obstetric textbooks with pictures of prolapsed uterus with placentas still attached.

knowledge is power.

i've heard that this class is what makes many student midwives terrified at everything that can go wrong. it may have even broke a few faint of heart.

i think that this is having a different effect for me.

i'm fascinated by it all. most of this we will never see. maybe if i were to travel overseas.

i'm grateful that we have access to advanced medical services in north america and that there are doctors trained in these obstetric emergencies.

THIS IS WHY WE NEED AND LOVE THEM!!!

i also feel that i may be conservative in my practice - specifically in this moment - retained placenta.

is it prudent to internally explore a uterus to identify if it has accreted when it hasn't detached?

should i attempt a manual removal?
risk haemorrhage? infection?

it's all so interesting.

knowledge truly is power.

i love it.

x

settling in with babies

i'm liking the life that is emerging up here.

there are so many wonderful people that i get to be around.

i've got two new midwives that i've been working with now. i had my first day with peggy the other day. it was fun. figuring each other out.

i have deficits. charting. palpation. physical exam. holding babies. i can be awkward. damn not giving birth can sometimes pose a problem.

tangent #1: i was talking with christine ( friend, house-mate, amazing woman, birther, mother, baker and oh so much more) the other day about choice of birth providers and about the ability of a provider to give care when they have not birthed themselves. christine conceded that giving birth doesn't qualify someone to attend a birth, to be a good midwife, but for her, the way her care provider birthed was important. interesting to think about what women want versus what they need.  


there are other skills i need to focus on. 


working it out with new teachers, mentors, preceptors, mother midwives (whatever you want to call them!) is interesting. 


louisa is great. she gives good feedback. both when i do something right or when i get it wrong. we get on well. sarcastic. dry. i probably bore her with my introvertedness. ahh. probably bore her no more than i do most people that are subjected to my awkward silences. 


i'm encouraged by the confidence that both peggy and louisa have given me. a testament to my former training and to my midwife shell. 


tangent #2: is a student's teacher her midwife? is that a strange or irregular reference? i don't know, but shell will forever be my midwife. 

most of all i'm having a lot of fun. i've been to two births now. the last was real sweet. i was still trying to figure out my place. my role, what is expected, how i can integrate into the practice and the way my new midwives practice.

both are very open to having me practice skills on our clients. i'm not charting directly into the chart as of yet, which is a wee bit strange, but i appreciate it. i knew my charting was lacks, now i'm being directly challenged.

because in washington midwifery is so much more integrated into the mainstream maternity care system, midwives have to practice that way. there are just that many more hoops and standards to abide by. for good or bad.

i don't mind it. much of it appeals to the side of me that needs to make sure all the boxes and checked. that is very important.

i like lists and crossing them off.

----

"Childbirth is PAIN! It canbe the healthy normal pain of labor and birth. Or it can be medically "painless birth" through anesthesia and/or cesarean with subsequent weeks to months of painful recovery while struggling to care for our newborn babies.

There is no escaping the pain. The choice we have is to work with pain and experience the satisfaction of birthing our babies, or to fight the pain."

-  

The healthy pain of labor is natural, and a realization of our own personal power as women and mothers. It should be viewed as a milestone to be embraced, a rite of womanhood. The pain of major abdominal surgery is unnatural pain (a signal from our body that something is seriously wrong), and usurps our own power as women and mothers. It should be viewed as something to be avoided." 

- Barbara Brown-Hill, VBAC educator and birth assistant (in the vaginal birth after cesarean experience - Ed. Lynn Baptisiti Richards) 

new chapter

no this is not about prenatal vitamins.

i've been up in the pacific northwest now for two weeks.

i'm getting settled in. i finished last school session which was great. IV's, catheters, suturing....

for some reason i think i can manage a shoulder dystocia, assuming i can keep my shit together in that situation. again. growth after coming back from classes. it really is amazing how two weeks intensively spent with a strong group of women and wicked teachers can have that effect. very happy i'm in this program.


i'm in a different land now and attended my first birth.

meeting a woman for the first time in labour is something new to me. being welcomed into another families birth space is an honour. as an individual you can have a lot of influence over outcomes, attitudes and the energetic spirit of the birth room.

i met this family and melted. they were the sweetest couple. a couple in their late thirties having their first baby. a military family. not what i had expected.

i got the message in the afternoon. "want to come to a birth tonight?" me: "yeah"

of course i did!

i hadn't been to a birth in about two months.

i knew this was going to be a difficult birth. or a long one. one where the outcomes were unknown. baby was sitting really high. hadn't engaged. this isn't a normal situation for a first time mom. usually baby drops into the pelvis and gets comfortable at the end of pregnancy.

when i arrived the mother was in great spirits, but was definitely feeling her contractions. she was feeling it in her back. i never had a real good feel for baby, but it didn't seem posterior even though she was having classic signs of labour of posterior baby.

it was late at night, mom and baby were happy so we encouraged rest and privacy. there wasn't any need for monitoring yet. she was just beginning to efface and only slightly dilated.

she laboured over night and in the morning there had been little change.

she was in and out of the tub. she got active. she was a great sport. she walked stairs for 45min two by two. we chatted. she laboured on the toilet without complaint. she went for a half hour walk. no change in baby's position, not much change in her cervix.

both mother and baby were perfectly fine, but little sleep had been gotten, she was labouring hard and her ctx were 2-3 min apart and seemingly strong enough. but why weren't we seeing any change?

so my first birth up on the peninsula ended in a transport.

we needed access to more options. breaking her water wasn't really an option. i've gone from having three or four high level hospitals within 5 minutes of most home births to being out in the middle of no where, with the nearest hospital 45 min away and it doesn't even have a nursery, much less a NICU.

so this is what was amazing. i have never experienced a transport like this before.

the staff. one nurse. one doc. were fantastic. they were kind, welcoming, supportive. there was no sort of power struggle. everyone was sincerely on the mothers team. the staff an extension of the care she had been receiving. we arrived. the nurse got the mother in the tub, monitored the baby with a doppler and she didn't have a vaginal check for over an hour after arriving.

the tubs. the envy of any birth centre overlooked the harbour where there was a wooden boat festival. across the water were the cascade mountains and in the distance, canada.

seriously.

the doctor and nurse treated me with respect. me just a student was consulted with and informed of the status of our client as though i were their peers.

through this birth i was introduced to a new perspective on midwifery care. in this area ~20% of births are attended by midwives at home. some midwives (LM's) have hospital access.

there are open (somewhat) lines of communication.

it's not perfect, but it's a hell of a lot different than arizona.

i'm so excited what the next year will bring.

oh and it can't hurt being back on the farm and being able to watch the sun rise over puget sound from our couch.

x

the last PHX-PMW connection

sitting here at my gate, reflecting on the fact that this will be the last time i make the trip to school from sky harbour.


i'm excited to see my sister students and see where they are all at. 


this is the beginning of our second year. 


all things have changed. i wish we had some documentation to compare where we were this
time last year. a green group of aspiring midwives have learned so much, touched so many lives and our lives enriched by many.


i think this is the first time i've more or less had school in a place where i wasn't freaking out. 


i only have the small task of packing to loom over me. thankfully i have a mother. i don't need her to pack, but she's come to depersonalize? not sure how i feel about that, but my lovely place will have the tracy taken out of it while i'm away at school.


the weather in phx has been absolutely gorgeous these last few days. i've managed a few good monsoon rains this season, and lately the below 100 temps have allowed for a lot of outdoor galavanting.


over the last 6weeks or so, since my last session up in maine, i've driven the coast to the shores of puget sound. i put my feet in the pacific and have dugs my toes into the desert. 


i've had the rain fall from a shining sky and i've seen it unleash a fury of rain,  replenishing the parched earth.


i studied studied studied. 


so much research and online discussions with students from around north america. i think i amused a few people along the way.


i purged some belongings.


i met new friends and am saying good-bye to the ones i love.


so bittersweet. the closer the time comes to leave, the more i am falling in love with this desert wasteland. this sprawl that defines america.


i'm sad. in a confused way. 


this will be my last commute from sky harbour, but this isn't the end of the journey. 

sleep and PROM - prelabour rupture of membranes

Sleep is elusive.


I want it, but it doesn't come. too many thoughts running through my head.


it has been a productive day. a sad day. a day filled with seeing lovely people, a nap and a good amount of school work. i should be sleeping.


i'm thinking a lot about PROM. no. not that american tradition i am still trying to understand (is it only important in  your senior year, or every year?), but premature/prelabour rupture of membranes.


i've been reading the washington state guidelines and i'm exited to see that there are three levels of considerations a midwife has.


1. discussion
2. consultation
3. transport


in regards to PROM, in AZ midwives must have active labour within 24hrs. this is pretty limiting to say the least and is more in line with the obstetric model, though better to an extent than what is offered in hospitals.


i've been reading a lot on PROM and i have no idea where AZ got their information from, but they may want to get with the times. in 1996, 1996 the TermPROM study was published. in this study women were allowed to labour for up to 96 hours. FOUR DAYS!!! in a HOSPITAL. granted all the data comes from outside of the USA, but still. i am simply amazed at this.


they did find there was an increase in neonatal and maternal infection the longer birth occurred after ROM, but this was more a factor of GBS status and the number of vaginal exams that occurred...not ROM itself. also the only significant finding in regards to the latency period after ROM was the frequency of neonatal admittance into the NICU unit...and this was based on hospital protocol, not on an increased occurrence of neonatal sepsis or other infections. 


----


so back to washington, reading their guidelines, midwives must have a "discussion" at 48 hours and transport at 72 hours.


i haven't figured out what "discussion" means, i.e. with the client or physician, but the fact that women are allowed to actually go into labour naturally is fantastic. by 72hours most women will be in labour (i'll write a more detailed post on PROM later). with these guidelines, midwives and mothers don't need to be worried about a clock.


all this though brings up questions.

1. at what point should a midwife start monitoring clients- with ROM or active labour?
2. do we put mothers and babies at risk if left unmonitored (expect for mothers taking their own temperatures) or is it better to leave things alone and wait for active labour?
3. what affect does a midwife and clinical monitoring have on the labour process?
4. at what point should we consider home inductions/augmentations of labour, and what are the best methods?
5. do midwives (CPM) or should they have access to prostaglandin gels to help ripen an unfavaourable cervix?

anyways...it's things like these that keep me awake.

searching through transition

Definition of TRANSITION

a : passage from one state, stage, subject, or place to another : change  

 

b : a movement, development, or evolution from one form, stage, or style to another 

 

------

shift in the balance of energy. i'm searching for a new midwife.

 

three weeks ago i left phoenix for the pacific northwest. 

traveled through joshua tree to the redwoods of california, stumbling through san franscisco into the madness of pride. i met with midwives in oregon. i met maria. i was there when abby turned one. ate decadently with tom and christine. we played backgammon. we built a turkey roost, made cheese and cooked. and baked. i saw a 360 degree fireworks display over puget sound. we milked goats and opened a new garden bed. i met with midwives. listened to a talk on the period of purple crying and went to momma's group. 

i left phoenix with the intent to interview with some midwives in the pnw.  i don't know. i got back from school last session and something had changed. there was a spark within me. i was compelled into forward motion and have found myself in transition. searching for a new teacher.

my life is liminal. i wish i could say i have an answer from my search. i know where i want to go, but my fate is waiting in someone else's hands. i'm torn as to what i should do, but there are other options.  

it's a delicate dance between keeping options open while not burning bridges. 

 

the trip was fruitful and it was sad to leave. however, the trip back was as lovely as the rest. 

 

i stopped through oregon, where maria and her family had rented a cabin on the lake near florence. the evening i arrived i went for a canoe ride through the lily pads and the dunes.

 

it was magical. 

 

i was given the full coastal experience. tide pools. a little late to see the crustaceans, but there were amazing waves crashing against the jagged rocks erupting from the ocean.

that afternoon we went to the sand dunes and there i was introduced to sandboarding. waxed boards on sand dunes. fun. painful.

the next morning i packed my car and started driving. it was a beautiful through the country. crossed through california, nevada and made it all the way to indio. i ate biscuits and gravy and pulled pork. i slept in a rest stop for a few hours and drove towards phoenix as the sun rose over the mountains. 

i'm home now. still in transition. waiting. working away at my classes and connecting with those i love. the prospect of leaving is absolutely terrifying to me. i was enjoying getting settled into a life here. 

 

------

i have worked with amazing women over the past two years. my experience here will last in my heart. it has been imprinted on my soul. 

 

these were my formative years. how i grew here. as a midwife. as a woman. will stay with me.

going home, good-byes and nature vs. nurture.

So two weeks ago, when i arrived at school this session, my mother sent me a message telling me my aunt was in the hospital and that she was flying to toronto and then taking the bus down to see her with my cousin the following week.

Over the last two weeks I found out that it was unlikely my aunt was going to be leaving the hospital. i knew i had to go.

after my classes ended, i flew to new york and then took a bus up into canada where i met up with my mom, my cousin and my uncle and his grand-daughter and we all went to the hospital to see my aunt. to say good-bye.

i never grew up with this family.

from the time i was three, the story goes, i had a bag packed and under my bed ready to go and visit family, my dad's family. the first time i took the greyhound alone i was three. i traveled all around saskatchewan between my ukrainian family, my aunts, and my cousins.

a few years ago at a family reunion, one of my cousins called me the black sheep of the family. i never really fit in and he called me on it. i loved growing up in a family that really did have so much culture to embrace, but most of my dad's side of the family are conservative farmers. home grown, salt of the earth kind of people. they are good people, and it was a good family to grow up in. my cousin's "accusation" though, was so true.

sitting around my aunts hospital bed with family that i've only really come to know in adulthood was a revelation. this is why i am who i am.

dark. sardonic. we joked about my aunts death and who was going to be the next one. there are bets. it was like a black episode of the odd couple. i fit in, without missing a beat. there is no question of nature vs. nurture here. my irish catholic heritage runs strong in my blood.

it was a long journey to get to my aunts side and i am at risk of not being allowed back in the country. my aunt may get out of the hospital. she talks as though she will, but she has congestive heart failure and only has 5% of her lung capacity left and from what i understand, thats the beginning of it.  the hospital isn't doing much for her. her sheets were filthy. so after 16 hours of travel, i changed them so she could lay in a clean bed and i placed the compression socks that she was wearing on her legs the right way. two very small insignificant acts, but if i could do anything for my aunt the last time i was ever going to see her, anything to make her more comfortable. i would.

it wasn't a sad day. there were lots of laughs. lots of stories of their childhood. i'm glad i made it for this. i'm glad the i am meeting the family and getting to know them. understanding where it is i come from.

Birth. A Technology of Gender.

We can easily talk about birth positions in a purely mechanical sense. There are a limited variety of positions in which a woman can physiologically give birth: upright, squatting, hands-and-knees, or lithotomy/semi-recumbent. Throughout time and space, we have seen women give birth in any combination and spectrum of these positions. Each, one can argue, serves a purpose. But to look at birth positions culturally and apply it to how “we,” as women, birth today and how this may affect our daughters and grand-daughters, requires a deeper understanding of why we birth the way we do.

Feminist critiques on the state of modern birth focus on how the transference of birth out of the home and into the hospital has medicalised the event and removed a woman’s agency to direct her birth experience. While being true to an extent, it does not allow for the influence of our social constructs of gender identity and how we, as women, have been ingrained to birth.

Rational, selfless, caring, polite, and kind. 

Or

Screaming, yelling, self-centered, and demanding of pain-relief.

Which is an accurate portrayal of women birthing today in the United States?

The media would lead us to believe that the latter is more common however, Martin (2003) has argued that we have internalized our roles as women to such a degree that even in the throes of childbirth, many women are more concerned about those around them than they are about themselves. We have internalized our gender roles so deeply that we birth in “gendered ways from within” (Martin 2003).

Childbirth classes teach women methods of self-control and relaxation. Martin (2003) argues that the Bradley Method, teaches us that when we get to a point where we cannot take it any longer, our partner, our husband, the father, is our protector and will show us how to birth, and give us the strength to birth.

Understanding the way we birth, in the context of a technology of gender,[i] helps us to understand why so many women do not “ask what they need while giving birth, and/or … put themselves at the center of the birth experience” (Martin 2003).  Martin argues that

 “[w]hen these gendered technologies broke down, usually during the most exhausting and painful parts of labor, these women said that they felt bad about their behavior, and they often apologized for it. Furthermore, in the end, some of these women did not value their own lived experiences and found their husbands' or doctors' views of the birth more "real" than their own.”

Robbie Davis-Floyd (1987), in her essays on “The Technological Mode of Birth,” identifies that 54% of women seem happy about their birth experiences in hospitals. They are more comfortable with the interventions and, she argues, American women may even feel slighted out of their birth-right if they were not given access to the technologically prescribed modes of childbirth (see below).

This ideology that birth “happens to us” is prescribed by our embedded, gendered experience of childbirth. We enter the hospital to be sick, to be taken care of. Childbirth has become an illness to be treated.

Cultural Patterns in Childbirth

The above is an introduction to how we, as women, birth in hospitals today. There are, however, some generalizations that can be made around birth itself. The following is an observation made by Simmons (1952) from a cross-cultural comparative study on childbirth:

“1. All peoples everywhere tend to regard birth as a significant biological event and ritualize it somewhat accordingly.

2. All peoples recognize certain critical psychological implications for childbirth. Primitive people tend to stress the psychosocial even more than the physical, while we do the reverse. We moderns are waking up, however, and perhaps we can learn a great deal from our primitive contemporaries.

3. The psychosocial factors of birth are under better-almost automatic- regulation in stable societies with slowly changing cultural patterns.

4. Babies are amazingly malleable and adaptive in almost any set of consistent, stable cultural patterns.”

A woman entering a hospital today undergoes a ritual. Robbie Davis-Floyd (1987), in her definitive essay on “The Technological Model of Birth,” describes this ritual initiation as it occurred in an American hospital in 1987.:

Shortly after entry into the hospital, the laboring woman will be symbolically stripped of her individuality, her autonomy, and her sexuality as she is "prepped"-a multistep procedure in which she is separated from her husband, her clothes are removed, she is dressed in a hospital gown and tagged with an ID bracelet, her pubic hair is shaved or clipped (returning her body to a conceptual state of childishness), and she is ritually cleansed with an enema. Now marked as institutional property, she may be reunited with her husband, if he chooses to be present, and put to bed. Her access to food will be limited or prohibited, and an intravenous needle may be inserted in her hand or arm. Symbolically speaking, the IV constitutes her umbilical cord to the hospital, signifying her now-total dependence on the institution for her life, telling her not that she gives life, but rather that the institution does. The laboring woman's cervix will be checked for degree of dilation, at least once every two hours and sometimes more often. If dilation is not progressing in conformity with standard labor charts, pitocin will be added to the intravenous solution to speed her labor (80% of the women in my study group were given pitocin, or "pitted"). This "labor augmentation" indicates to the woman that her machine is defective, as it is not producing on schedule, in conformity with production timetables (labor time charts). The administration of analgesia and/or anesthesia further demonstrates to her the mechanicity of her labor; epidural anesthesia, which can numb a woman from the chest down, produces an especially clear physiological separation of her mind from the body-machine that produces the baby. This message is intensified by the external electronic fetal monitor, attached to her body by a large belt strapped around her waist to monitor the strength of her contractions and the baby's heartbeat.

As the moment of birth approaches, there is an intensification of actions performed on the woman, as she is transferred to a delivery room, placed in the lithotomy position, covered with sterile sheets and doused with antiseptic, and an episiotomy is cut to widen her vaginal opening. These procedures cumulatively make the birthing woman's body the stage on which the drama of society's production of its new member is played out, with the obstetrician as both the director and the star”

We can be thankful that many of these practices have evolved since then and most women’s experience of birth is much more humane. One thing that hasn’t changed is the focus on the all the machines that monitor our birth and make sure we are OK, even though nurse-midwives are widely available. The bed in a hospital labour and delivery unit stands proudly at its centre. In most hospitals, nurses provide the bulk of labour care mothers receive, the doctor, the hero, steps’ in for the final solo. He is the star of the show as the baby crowns, he catches the baby, thrusts her onto her mothers chest, and leaves the room.

Women today have lost their agency in their childbirth experience. Sargent and Bascope (1996) provide a comparative analysis of birth in the three cultures, two in hospitals (one in Jamaca and one in Texas) and a homebirth practice among the Maya in Yaxuna, Mexico. It is this latter group that draws an interesting comparison to the “ritual” of birth in America as described by Davis-Floyd.

Sargent and Bascope introduce us to a lay midwife (Dona Lila) and give us a very different view of agency and knowledge over birth. Dona Lila is a traditional midwife who is trusted by her community because of her experience through attending births. Her knowledge is observational and every woman in the village, more or less, has control over the same information of how birth happens. Dona Lila is set aside because of her privileged knowledge on cord-cutting and the use of pitocin for labour stimulation.

In this community, knowledge about birth is shared by women through their mutual experiences. A mother who has given birth repeatedly is considered to be as knowledgeable as the midwife and has autonomy over her birth. The midwife is there to perform a few procedures that are considered her domain or require special knowledge. Conversely, a mother who is birthing for the first time receives many more interventions and active management of her labour, including considerable fundal pressure, manual stretching of her cervix, and the use of pitocin to augment her labour (Sargent and Bascope, 1996).

Though both first time and more experienced mothers give birth in a traditional position, seated on a hammock with the midwife in front to receive the baby, mothers birthing for the first time receive many more interventions and active management of her labor than mothers who have birthed repeatedly. We can see how a woman’s knowledge of birth influences how she is treated, even among “traditional” societies[ii].

The comparison between the birth experiences of Mayan mothers and the ritual of American birth, as described by Davis-Floyd is important insomuch as woman in this Mayan village gain agency over future births by being initiated through their first birth. American women tend to have repeat experiences without much differentiation by hospital staff between the number of children the patient has birthed. Each mother’s experiential knowledge of birth is minimized and diminished below that of the physician. Martin (2003) confirms this however, she identifies that working-class women were more likely to make changes in subsequent births how their birth was managed, compared to women of higher social standing.

Positions in Childbirth

So how have women given birth historically and in different cultures?

A question arises regarding whether women birth the same today as their sisters of the past, and around the world. We all our influenced by our culture, but did ancient societies protect the culture of birth? Were their technologies of gender different than ours?

In 1884, George J. Engelmann published Labor Among Primitive Peoples. This is a thorough account of all the knowledge that we, as a modern society, had learned, culminating in the current obstetric practices of Engelmann’s time. It contains all the previously catalogued birthways of indigenous cultures or “primitive peoples”.

Engelmann documents the parturition, birth, and management of the third stage as observed in cultures from all around the world.

“…I had entered upon the study of the posture occupied during labor by the women of other people, I found a great variety in their customs; but it soon became evident, and impressed itself forcibly upon my mind, that the recumbent position in labor is rarely assumed among those people who live naturally and are, as yet, governed by their instincts and have escaped the influence of civilization and of modern obstetrics. It certainly appeared as if the ordinary obstetric position of to-day must be an unnatural one…”

He classified the birth positions he observed into the following:

A. Perpendicular:	1. Standing 2. Partially suspended. 3. Suspended.
B. Inclined:	1. Sitting erect on stool, cushion, or stone. 2. Squatting, as in defecation. 3. Kneeling. (a.) With the body inclined forward, and resting on a chair or staff. (b.) Knee-elbow position, knee-breast, or knees and hands. (c.) With the body erect or inclined backwards. (d.) Not definitely described. 4. Semi-recumbent. (a.) Sitting semi-recumbent on the ground, a stone, or stool.  (b.) On the lap or between the thighs of an assistant who is seated on a chair or on the floor. (c.) The obstetric chair. (d.) Semi-recumbent positions, strictly speaking.
C. Horizontal or recumbent:	(a.) On the back. (b.) On the side (c.) On the chest and stomach.

In 1966, the British Medical Journal documented at least forty different postures women have adopted to give birth across various cultures. The author gives us points of considerations for optimal positions in labour which include: comfort of the mother, a position that does not impair the dilation of the cervix or expulsion of the baby, reduction to minimize harm to baby and mother, and lastly, ease of access by birth attendants.

PERPENDICULAR OR UPRIGHT POSTURE

Standing - common in Eastern, in India and parts of Africa.

Brulé Sioux.
Standing

The standing posture may increase the risk of hemorrhage, prolapse of the uterus, and rupture of the perineum.

Most often a strong person supports a mother from behind and holds their arms, while others hold the separated legs, and the midwife can sit comfortably in front.

A variation seen amongst the groups along the eastern coast of India and in the vicinity of Madras, are delivered in an erect, standing posture, supported by an assistant under each shoulder. 

Partially suspended

This can be seen to occur in a variety of ways, including the woman hangs on the neck of a husband or friend, swing themselves by a rope from the branch of a tree, or are tied up until the act is over, as if undergoing “punishment”.

Suspended

Engelmann provides several examples, including hanging on to the limb of a tree (Africa), hanging to a cross-bar (Finland), in Brazil, the parturient woman occasionally has her arms tied to a tree while she is waited on by some “old hags” until the delivery is completed.

INCLINED POSITIONS

Engelmann (1884) notes that this position for birthing is the most common among “civilized and savage” people, in both ancient and modern times.

The erect, sitting posture.

The pelvic axis is more inclined than in the standing posture. Englemann notes that women in this position make use of cushions, stones, stools, or “mother earth herself”; but the temptation to assume a somewhat reclining position, leaning against the assistant or some other support, that quite often women assume a somewhat reclining position. 


The squatting position

Squatting

Posture 

of the 

Tonkawas.

Though apparently inconvenient, and repugnant to the refined woman, this position is certainly the most natural one for expulsion from the abdominal or pelvic viscera, and will certainly, in many cases, facilitate labor.

The Irish were identified as also using this natural position, although the knee-elbow position is more common among them. Englemann notes a story where a poor Irish woman was found in a vacant lot in New York city, squatting on the ground, birthing her placenta, having already been delivered her baby in the same position.

Variations:

“during the first stages of labor the woman is in a stooping posture, with the buttocks resting on the heels. An assistant places herself back of the patient, clasping her body with her arms, letting the fingers reach below the ribs over the base of the uterus, making steady pressure backwards and outwards during the pains. During the third stage, or expulsion of the child, the patient, however, lies down indifferently on either side or on the back, while the pressure by the hands of the assistant is kept up continuously, if on the side; if on the back, the assistant remains by the side of the patient and keeps up the pressure in the before-mentioned directions.” In Mexico, they “sometimes suspend a cord from the ceiling, with a stick attached, so that the women can seize it in a half-upright, squatting position” The Zuñi women of New Mexico are delivered in this same position, which we may call a squatting one, and which is described to me as “half standing and half sitting;'' an attendant supports the patient, and facilitates expulsion by pressing the abdomen from above downward.

The kneeling posture and its modifications

Southern Negress.

·  Hands and Knees.
· The body inclined forward.
· This position overdone; that is, with the body thrown completely forward, the patient resting on the  hands and knees, or knees and elbows.

Position for 

Delivery 

of very Fat 

Women

· The body is erect or inclined backward, sometimes clinging to a rope.
· Kneeling postures, where precise descriptions are lacking.

Kneeling has been referred to in the Bible as well as by the Roman poets. Englemann notes that kneeling was taught in ancient Rome, among the Arabs, and in Germany during the Middle Ages, and that there were definitive rules for the circumstances under which kneeling should be resorted to, suggesting that it was reserved for complications of birth, not normal birth. However, Englemann remarks that it is one of the most universal positions among Native Americans.

There are advantages and disadvantages to this position in that it is physiologically correct, and “appears most practically to favor the expulsion of the child”, however, it may increase the risk of hemorrhage.

Semi-Recumbent

Favorite Posture of the French Canadian  

The semi-recumbent positions are by far the most frequent among ancient cultures, especially among what Englemann calls “the more civilized people” of olden times. However, it is also a documented position used among many indigenous cultures of the present day.

A semi-recumbent position can be achieved in very different ways, and while there may be almost no resemblance in the method of delivery, the position of the body, the inclination of the trunk and the pelvic axis, together with the relaxed position of the thighs, are nearly identical. 

Kaffir Woman in Labor 

In the position seen among the Kaffir a woman has full power to bear down and assist her pains. However, in this position, no support can be given to the perineum, Englemann suggests that there must be some “support given to the perineum from its resting on the firm floor of the hut, and the sudden passage of the child's head is thereby prevented.''

The simplest of the semi-recumbent positions may be where a mother is sitting on the ground, on a stone or cushion, with her body inclined backward, leaning against an assistant, a tree, or some other object.

Oronoko Indian. 

Seated semi-recumbent 

in hammock.

Alternatively, a woman may be seated in the lap of an assistant reclining against their chest. Englemann argues that the position reaches its greatest perfection in the obstetric chair. 

HORIZONTAL OR RECUMBENT

Typical obstetrical position. Engelmann admits:

“not until I had undertaken this work, and had begun to study the positions assumed by savage and civilized people during labor, that I began to understand that there was a method in the instinctive movements of women in the last stage of labor. I had seen them toss about, and sought to quiet them; I bade them have patience, and lie still upon their backs; but, since entering upon this study, I have learned to look upon their movements in a very different light. I have watched them with interest and profit, and believe that I have learned to understand them. It has often appeared to me, as I sat watching a tedious labor case, how unnatural was the ordinary obstetric position for one parturient woman; the child is forced, I may say, upwards through the pelvic canal in the face of gravity, which acts in the intervals between the pains, and permits the presenting part of the child to sink back again, down the inclined canal. If we look upon the structure of the pelvis, more especially the direction of the pelvic canal and its axis, if we take into consideration the assistance which may be rendered by gravity, and, above all, by the abdominal muscles, the present obstetric position seems indeed a peculiar one.”

Where are we going?

Engelmann’s observation reflects the nature of a woman unencumbered by our technologies of gender that prevents us from trusting our instincts and birthing in the positions, moving the way, and making the sounds that aid in the birth our children.

Above is only a brief synopsis of the more than 62 positions that have been described throughout history and throughout the various regions, cultures and groups of people that have inhabited earth. We, as midwives, need not learn all these positions, but be aware of the breadth that exists. Not inhibit a woman’s movements in labour and instead be there for her, ready to receive or aid in her or her partner receiving their baby for the first time.

As early as the 19^th Century, Engelmann identifies the unnatural state of the obstetric mode of delivery. That it’s only purpose is to facilitate the comfort of those attending a birthing woman, to the detriment of the process. He repeatedly highlights the practicality of traditional birthing positions, despite their crude or primitive nature, over the modern obstetric lithotomy position. Engelmann, in 1884 recognized that women in civilized society were bound by their technologies of birth that were engrained in them to be refined and proper. He saw not only the futility of this, but how these restrictions on women actually impeded the birth process, making it more difficult. He offers antidotes of how lay midwives have measures to aid women in emergencies, that it wasn’t always safe and prolapse of the uterus, for example, was common, yet manageable. The practices of these women, birthing with freedom, prevented many hemorrhages, because within themselves knew if a position was not working, when to change. They worked within themselves, within their environment to birth.   

Engelmann’s ethnography of birth is worth reading. He is eloquent in his humble regard for ‘primitive’ woman and their strength compared to the ‘weak civilized’ women who have become reliant on, as Robbie Davis-Floyd puts it, the technological mode of birth, 19^th C style.

We, as midwives, should aid women to break free of our technology of gender, which may be repressing our abilities as woman to birth without the aid of obstetric interventions and inventions.

This is not to be a judgment on women and families who give birth in hospitals. Hospitals serve a purpose and have become normalized within Western society. What we can, and should, do is challenge our community’s reliance, dependence and execution of birth in these facilities in hopes of making them a space that can facilitate birth in a way that empowers women. A space that makes the woman the centre of attention and aids them in finding within themselves what they need to birth their child, rather than looking to others, wanting to please others, fearing that she did not do her job as well as everyone expected. This should be our goal within our own practices, even within a woman’s home.

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[i]“Internalized technologies of gender discipline us from the inside out. They produce who we are, even during seemingly natural experiences like birth. Foucault's notion of technologies of the self allows us a sharper understanding of these gendered ways of being by showing us how they discipline and control from the inside, how they compel us to act in gendered ways from within” (Martin, 2003).

[ii]

We may question the use of the term “traditional society” here. Dona Lila had exposure to a pharmaceutical salesman who touted the effectiveness of pitocin, which the community readily accepted as it fit within their pre-existing understanding of birth, that the quicker it was over, the safer it was.


* Images are from Engelmann's 19th C ethnography and were reprinted here from the University of Virgina, with many thanks. 

References Cited

Author Unknown. Position in Childbirth. 1966. The British Medical Journal, Vol. 1, No. 5479, pp. 62-63.

Davis-Floyd, Robbie E. 1987. The Technological Model of Birth.

The Journal of American Folklore, Vol. 100, No. 398, Folklore and Feminism (Oct. -Dec.), pp. 479-495
Dunes, Lauren, MHS. 1987. Public Health Then and Now. The Evolution of Maternal Birthing Position. AJPH May 1987, Vol. 77, No. 5.
Engelmann, George J. 1884. Labor Among Primitive Peoples. J.H. Chambers & Co. St. Louis  
http://etext.virginia.edu/etcbin/toccer-new2?id=EngLabo.sgm&images=images/modeng&data=/texts/english/modeng/parsed&tag=public&part=all
Marten, Karina. 2003. Giving Birth Like a Girl. Gender and Society, Vol. 17, No. 1 (Feb.), pp. 54-72
Sargent, Carolyn and  Grace Bascope. 1996. Ways of Knowing about Birth in Three Cultures.
Medical Anthropology Quarterly, New Series, Vol. 10, No. 2, The Social Production of Authoritative Knowledge in Pregnancy and Childbirth (Jun.), pp. 213-236.