after birth pains, part 2

If you are on MDC in the birth professionals forum, this will sound very familiar. It isn't plagiarism, it's me thinking out loud on Mothering. I felt like part 1 was not quite finished, that I hadn't completely thought through what bothers me about these situations. So, for me, here is the rest of the story:


I know it's a passing feeling of "what else could I have done?" However, I have thought quite a bit since my OP about why this bothers me and here's the crux of the matter.

I don't want to be the midwife who blames her clients for how the birth turns out. But, I need to back up a step further. I don't want to not have the skills or knowledge to give her the best possible chance at the birth she wants.
It is so easy after a birth that went poorly to say, "I did everything I could", but I always wonder if that's true. Was there some physical or psychological or emotional thing that I missed that would have made a difference? Have I just not investigated or studied enough to be sure that I know everything that would have made a difference?
Like Shelly (reikitiki) posted, I call her when I think the mom needs mothering during labor. Hand holding is not always my strong suit. I just think that although women need emotional support during labor and birth, it is still a path they must travel alone. Only they know how best to give birth.
The problem is that I know midwives who have, what in my opinion, are limited skills for dealing with difficult situations. They have a few things they will do and if that doesn't work it becomes the mom's fault when the labor doesn't progress. She is blamed for emotional blockages related to prior sexual abuse, ambivalence about motherhood, problems with her partner, not wanting the birth badly enough, and probably a whole host of other things.
When I am really tired and frustrated by my own lack of being able to change the physical situation, I have found myself wondering if there isn't something of that nature going on. What I have found every time I begin to think that way is that there was a very good reason why the birth wasn't straightforward and it usually had something to do with what the baby was doing. Things like being asynclitic or posterior, sucking on fingers, being really long bodied in a short waisted mom (think accordion fold rather than curled up).
The baby is the one person we can't do much about. I'm not positive that the mom's emotional state has all that much to do with the baby's positioning. I am sure that baby position has everything to do with how mom labors. It just doesn't seem fair to blame mom when she doesn't have any more control over the baby than we do, yet that is what sometimes happens.

I always regret afterward when I forget that point and have found myself thinking that mom's intentions for the birth were not what she told me they were. Yet, I can't think of a birth that ended as a transport where there wasn't truly some baby position thing or cord wrap thing that was actually the problem. And, I absolutely hate the idea that I may have doubted the mom's intentions and she feels blamed (like being broken) for something she had so little control over.

Like I said above, I don't want to be the midwife who blames her client for how the birth went. I may not be the most touchy-feely midwife, but I want women to know that I believed in them and their ability no matter what happens.

There's a book in there

There is a subject that needs to have a book written about it.

I read messages from the ICAN board about back labor and asynclitic heads and just know that we are missing something of the puzzle here. Babies who are positioned before birth looking up rather than down, or better yet sideways, can cause some hellacious back labor and then they get stuck coming through the birth canal. I think most moms could handle the long, slow labor, but it's the back pain that just wears them out.
Babies whose heads are crooked (asynclitic) coming through the pelvis also take longer, cause back pain, and frequently get stuck (AKA failure to descend). Both of these problems frequently result in a Cesarean delivery.

Most midwives seem to have at least some idea of how to help the mom, as do doulas. However, from comments I have read from other midwives, and mostly from the women who have had Cesareans, the knowledge and skills are far from comprehensive. Everyone seems to have a trick or two that they have some luck with, or a technique that they have heard works really well. I just think that it would be most helpful if all these things were put into a book so there was a reference guide with all the techniques in it.

What I'd really like to see happen is for that book to be widely distributed in hospital labor and delivery units and become required reading. If hospitals are truly concerned about reducing their Cesarean rates and providing quality care, then wouldn't you think that they would want to be sure their staff knows these things. Like having the nursing staff well versed in breastfeeding techniques and lactation management.

I suppose if I were feeling really cynical, I would mention the high induction rates, the "big baby" card, and the effect that hospital economics has on the quality of maternity care. I am just not feeling that cynical tonight.

I am more puzzled by the problems caused by malpositioned babies and am asking how do we solve them.

after birth pains

There are a few other titles I could choose from for this piece.

• Was it the mom? (too judgmental)

• The meaning of birth? (too esoteric)
• There are no guarantees! (borders on discouraging)

The truth is that something, probably the recovering perfectionist in me, compels me to analyze what happens at any given labor and birth. I have postings on Mothering that discuss ethics and competence. One research study I read said that most incompetent people don't realize they are incompetent. The same skills required to develop mastery of a subject or skill set are the same ones it takes to recognize competency. I would think that a willingness to examine shortcomings is probably one of the subsets to recognizing competence.

In a long winded way that brings me back to what I started out wanting to write about: when things don't go as planned is anyone at fault? I have heard other midwives, nurses and physicians blame the mom. I am sure that there may be a few cases where the mom has serious issues that she can't deal with that effect the labor, but we have no control over the baby and it certainly doesn't come with emotional baggage. I think it is too easy to assume that the mom has issues she doesn't wish to deal with and that that is slowing labor. I've heard it in such phrases as:

• She couldn't let go.
• She didn't want the birth bad enough.
• The baby is probably feeling her anger/ambivalence and that's why it turned breech.
• She's just immature and won't listen to me.

As a nurse I cared for a teenager who had a long history of sexual abuse. The doctor wanted to induce her and the poor girl couldn't tolerate even the mild cramping caused by the lowest dose of Pitocin. She was frantic about the pain it caused. I remember hearing another nurse and the anesthesiologist talking about her acting like a typical teenager- turning away from the nurse when she tried explaining things, spending time on the phone when they tried to talk with her, or watching television incessantly, etc. I finally asked if they were aware of her history of abuse and that her behavior was actually dissociative in nature and a coping mechanism for dealing with the past abuse. (Insert light bulb here)

I think that often this judgmental attitude is a coping mechanism for us as birth workers. We don't have any control over the mom or baby and, as a friend wrote, have no idea what karmic forces are at work in the woman's life. When we run out of ideas for helping her get the birth she wants, it is much easier to blame the mom than to admit that no matter how good we are we can't fix everything.

• We can't untangle a cord before the birth
• We can't make the cord grow longer
• We can't fix every malpositioned head
• We can't make a baby smaller
• We can't fix a heart defect
• We can't reseal the bag of waters once it breaks
• We can't always turn a breech
• We can't make mom labor only during the day after a good night's sleep.
• We can't make it happen by wishing and hoping when our skills fail us
• 
  

Our failure to help a woman meet her goal is not a reflection on us as providers although most midwives, at some point, think it is. In most cases the fault lies in circumstances beyond anyone's control.

But our frustration needs an outlet and it is so hard to admit we don't know everything, so we turn to the next best thing. This happened to a laboring woman I know. She had a baby that was poorly lined up in the pelvis and causing extreme back pain. The midwife didn't appear to have the skills needed to adjust the baby's position or to admit that what she did do wasn't helping. Rather than admitting these things (even to herself) she blamed the mom for not cooperating in what she wanted to do. The midwife went so far as to set up the story on a midwives' board to make herself look like the rescuer, but that mom didn't want to take responsibility for her part in what happened. The midwife then shared their "blame the victim" comments with the mom to prove her point.

When I talk with women who are considering becoming a midwife, I ask whether they are strong enough. Maybe what I should be asking is if they are mature enough to understand the concepts of the Serenity Prayer without blaming anyone.

God grant me the serenity

To accept the things I cannot change;

Courage to change the things I can;

And wisdom to know the difference.