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ECV - External Cephalic Version

2/16/2021

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Babies sometimes require help to settle head down in the pelvis.
Sometimes just being reminded what we want of them is enough; bodywork on the pregnant body helps to remove barriers, but sometimes as we near the due window, it's smart to help them move head down before they run out of room because of their growing size and the normally decreasing fluid volume.
Here's a great example of the midwifery model of external cephalic version. This mama was almost 37 weeks and her baby was still breech. She had done ‘all the things’ and was beginning to get worried about her birth plans. We discussed her options (planned c-section, planned vaginal breech birth, an ECV with a physician or an ECV with me, her midwife), She researched all her options and decided that she would prefer to try to turn her baby with the care provider she already knew. We talked about risks, benefits and gave her our protocol for the most successful version. 
The night before her appointment, she did a lot of inversions. Then the day of the appointment, she went to her chiropractor for a ‘turn encouraging’ adjustment. When she arrived at the clinic, she spent another 20 min in the ‘knee-chest position’.

Finally, we were ready to ask and encourage baby to move.

For all the providers out there, it's not ‘woooooo’ to involve the baby in the process. Why shouldn’t we treat baby with the same respect we treat our adult friends? Ask, communicate, encourage, speak nicely, listen to them!

When I do a version, I approach both mom and baby and ask them both permission to touch and move their bodies (not in this video), once I receive consent, I tell them what to expect and then move forward knowing that either could change their mind at any moment - consent is a verb y’all.

We physically listen to the baby’s heartbeat throughout so that we can clinically tell if they are tolerating the experience. But we also listen to the energy in the room, to the silent and subtle changes. Midwives develop a skill to ‘read the room’; we calibrate our intuition and learn how to communicate telepathically. If you don't believe this - you don't spend enough time with midwives.

The hardest part of a version is moving through the transverse. Before you push a baby into this space, ask them if it's ok, literally pause and ask the ethers. A NO is clear - they push back against you, their heart rate goes down, or your body gets nauseous or cold sweat or chills - let the higher self guide in these moments. A YES feels easy, like butter, your hands just start moving without your control, baby moves into the space themselves, or your body stands up and leans in. LISTEN to these clues. In 20 years of providing versions to families that request them, I have never experienced a baby in distress because of my hands. I have, however, listened to my ‘holy no’ and stopped, ordered another scan or checked in with mom and discovered a real contraindication to ECV.

This baby turned and the mama was so happy! Such a relief - she did go on to have a beautiful, al be it, long homebirth.

A quick note on pressure - ECV should not hurt. The touch is deep but slow and steady - something you can get used to. The communication flows both ways, I am as responsive as mama and baby, together we make a team.

A note on monitoring - bp;abies should be monitored before and after an ECV to risk assess fetal distress - but this can be done with Doppler, not just ultrasound. In this video, my student was doing her best to follow baby as I moved her. When needed, I was able to give her exact direction, and even though we were hearing echo and cord for much of it, we were assured of baby being happy throughout. We listen again with every maternal position change to determine baseline after the procedure.

A note on risks- the only real risk with ECV is fetal distress. Pressure from outside can compress the cord, placenta, vena cava, or uterine arteries. It is very unlikely for a term baby being touched by a sensitive provider with good FHT monitoring throughout, but it is possible. If baby says no, put them back where you found them, assist the birther to the left lateral position, and depending on the severity, initiate transport and begin the intrauterine resuscitation techniques of oxygen and bolus IV fluid.

A note on ultrasounds - my highest advice is to confirm position of baby BEFOFE attempting an ECV. Diagnostic US also confirms placenta location, amount of amniotic fluid and sometimes cord location as well. This can be very informative and helps the parents make a more informed decision.

A note on post-version protocols - getting up from the table with a baby still high (like in this video) is not recommended. So we bind before we rise. Rolled hand towels splint babies head and then an elastic, Velcro binder is placed around the abdomen for the remainder of the day and mom is instructed not to remove it till she is in bed for the night. This decreases the percentage of babies who flip back to breech and increases the likely hood of engagement after version.

If you would like hands-on training in ECV, consider coming to one of my summer workshops in the US - schedule on our website.
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Asynclitism

1/9/2021

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SO the thing about Asynclitism is that it happens most commonly while the head is negotiating the mid pelvis, so the baby is almost always R or L OT, i.e, facing her side.
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​There are two kinds.

1. Posterior - baby's body is tilted toward the mom's back - baby's head has the forehead/ crown towards her pubic bone.
2. Anterior - babies body is tilted toward her belly - head is prominent in mom's spine.
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These two conditions need opposite treatments, which is why sometimes techniques work and sometimes they don't. An Anterior Asynclitic baby needs to be lifted out of the belly and into the mid-line of the mother’s body, so rebozzo belly techniques and binding work well as well as reclining in the tub (miles circuit because of the reclining bit). These babies usually are born to multips with rectus diastasis. A posterior asynclitic baby needs to be dropped out of the back and into the belly space. Mom needs forward-leaning, belly hanging exercises and frequently disengagement from the pelvis (knee Chest). These babies usually have first-time mamas.

My favorite techniques for a Posterior Asynclitic baby is to spend a contraction or two in knee/chest or couch floor doing an inversion, using the rebozzo over her bottom, with a slight shifting jiggle between contractions and then come up to level for two contractions. After about 2 of these cycles, the progress you’ve been missing will be evident and/or moms pain will be reduced.

My fav for Anterior asynclitic is to have mom do one or two contractions inverted as deep as she can and then come up to a birth ball and then slide back, rolling the ball along her bum and back until she is leaning across it in a back bend for 3 contractions. Then while still in the back bend, we bind her belly with a Velcro belly binder (rebozzo would work but is less comfortable) It is rare to have to do more than one of these circuits, but I have occasionally. Anterior Asynclitism increases the risk for anterior lip too, so belly lifting after this move of baby can be proactively helpful.

Any technique to solve asynclitism ideally will be offered before mom is complete. It should be noted that normally all properly positioned babies enter the mid-pelvis in end of pregnancy or in labor a bit anterior asynclitic and as they rotate anteriorly their head naturally moves to synclitic and well flexed without any outside assistance. So simply lifting the moms belly of an anterior asynclitic presentation can apply the baby to the pelvic tissues and help cause that rotation.

It is much harder to move a baby already impacted from pushing, although not impossible. Frequently, though, midwife will need to add umph from below to help move baby out of pelvis when mom is inverted and then help baby with manual rotation.

If you haven't checked out our upcoming Birth Business Masterclass don't miss it! Starts Feb 1, 2021 and only offered ONCE a year.
Sign up today here:
https://midwifery-wisdom-collective.teachable.com/p/birth-business-club-masterclass
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10 amazing gifts for your favorite midwife or apprentice

11/29/2020

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This holiday season dont forget your favorite midwife. Wondering what would be an appropriate gift? Here are some suggestions.​
1. Informed consent suite  My team and I spent literally 10 months researching, editing, editing, editing, designing, and having our legal counsel review this suite of 14 informed consents. These vital shared decision-making tools give autonomy and sovereignty back to the birthing person AND legally protect the midwife. Give the midwife in your life the gift of time by saving her 10 months of work!!
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2. Birth-wear = every midwife loves to have dedicated birth clothes and what better way to outfit your fav midwife than with a Midwifery Wisdom T-shirt !
3. Handwritten note saying how much you appreciate them - seriously, we midwives save these notes, like forever - they mean the world to us!
4. Starbucks or local coffee shop gift card - what midwife doesn’t need a caffeine fix?!
5. Engraved Stethoscope or Fetoscope (affiliate) - Midwives are proud of what they do, but it helps to have it recognized! What better way that to get one of their most prized tools, personalized! 
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6. Massage gift card - Our bodies literally always hurt, give the gift of relaxation and rejuvenation!!
7. Convert kit subscription (affiliate) Savvy midwives know that developing an email list is the key to an automated marketing system - help your favorite midwife drop the social media time-suck and create ease and automation in her marketing!
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8. Suture Practice Kit (affiliate) - suturing has traditionally been one of the hardest skills to master, because of the complexity of the process and the realities of finding something to practice on (chicken breast just doesn’t cut it) With this kit, you will become a master in no time! 
9. A subscription to UP-TO-DATE (affiliate) - this definitive guide to clinical decision making is a gold mine for the student and midwife alike and lets face it - midwives rarely buy things for themselves. 
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10. Student Handbook Preceptors and students should have agreements before they work together and then clear steps for progress throughout the apprenticeship process, we took the stress and work out of it by creating this 50-page, full-color customizable student handbook.
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Start a Midwifery Business Right

7/29/2020

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Congratulations!!!🍾🩺💞

Did you just graduate midwifery school or pass the EXAM!?!?

It's finally time to start your own practice and start making money in this job instead of constantly paying and sacrificing for the profession. However, if you’re like most new midwives, starting a midwifery business can feel super overwhelming. Let’s face it: midwifery school is nothing like business school.

In fact, many of the principles and hallmarks of good midwifery care are the antithesis to good business practices. Also, sleep deprivation doesn’t lend itself very well to good business management.
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4. Hiring Assistants
Already know that you don't want to go this alone?!? Planning to bring other people to births with you? Please, for the love of all things good, don't do births alone anymore 🥴 You need to probably pay someone something at some time for this. Did you know that evading state employee taxes comes with large fines and potentially a year in jail? Yeah, you need to learn how to file the right forms if you're hiring people, even to assist at births.

5. Um, what about the money?
After all those years as a student, it's time to make some money right?!? But, um, how? Start-up expenses can be large as you invest in equipment and supplies and it can be hard to gain traction in a community as a newcomer. How midwives make real money has been a secret for too long. It's time to end the martyrdom complex - you're worth it - you deserve to be paid what you're worth!
This is just the tip of the iceberg. Want to learn about these topics in-depth to get your midwifery business started right? Be sure to sign up for our course here!
I've spent the last 10 years mentoring new midwives in their transition to independent practice and their top pain points boil down to these 5 issues.

1. Choosing the correct business/practice model
There's a big difference between a group practice model and a business partnership. Additionally, protecting yourself from liability and saving money on your taxes, aren’t skills taught in midwifery school and many many a midwife has suffered the ‘live and learn’ lesson of starting a business off on the wrong foot.

2. Allied Service Professionals
A burned-out midwife is no midwife at all. You want to know the fasted way to burn out? Force yourself to do jobs that you either weren't trained for or hate to do. The ABC’s - Accounting, Billing, Cleaning - being the top contenders. Top reason new midwives call me to consult? They tried to do it all in their first three years.

3. Location, Location, Location
This isn’t just a catchy saying - this is the literal truth of whether your business survives or thrives. And it doesn’t matter whether you're planning to do 24 births a year or open a birth center with a staff attending to 150 families a year - where and how you set up shop really matters.
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Start a Midwifery Business Right
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A New View of Shoulder Dystocia

3/1/2020

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The Questions

Panic and fear arise in the hearts of many midwives and doctors when they think of shoulder dystocia. And many have a strong desire to teach everyone else how best to manage the situation.  Yet for others, the same topic creates a feeling of dismay at the over-diagnosis, and frustration at the needless interventions that are forced on so many normal births.

  • How can competent, informed care providers have such opposite views of seemingly the same complication? 
  • ​Why are there so many reports of seemingly different resolution methods?
  • How is it that a one-minute delay of the shoulders can sometimes be normal and other times result in a severely depressed baby that needs extensive resuscitation? 
  • Is there truth behind stories of babies on the perineum for 5, 10, 15, and even 20 min with no sequala?

Well, for starters there are multiple scenarios that can occur during birth, all labeled the same thing: shoulder dystocia.  And birth itself looks radically different depending on the birth environment. As Ina May Gaskin reminds us, “physiologically, birth doesn’t happen the same way around surgeons, medically trained doctors, as it does around sympathetic women.”  Although less discussed in the main-stream population, the reserves of the baby during birth (and during a dystocia) are directly correlated to the mother’s nutritional history, habits and status – but that’s a topic for another article.

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The Definitions

Dystocia simply means, ‘lack of progress’.  Shoulder dystocia means, ‘lack of progress at the shoulders’.  Each of these situations I’ll describe below needs a skilled provider’s assistance to an increasing degree. In fact, without a skilled provider, babies with true shoulder dystocia will likely experience a grave outcome.

Note: many midwifery circles use the phrase, ‘sticky shoulders’, despite the fact, it’s not really a clinical term. I vaguely define this as something like, ‘it was scary, we almost had to do something’ or ‘we did something and then afterward realized that what we did wasn’t really necessary, so we called it something.’

The Finer Points

I encourage midwives to use the terms below when charting at births and reporting at peer review because it’s more accurate and ultimately helps the woman’s next care provider treat her according to real risk instead of perceived fear.

1.      Normal Spontaneous Vaginal Delivery (NSVD) is any birth that completes on the mother’s own power, or on her own power with midwife’s suggestions, and does NOT result in a depressed baby (even if the baby is on the perineum for quite a while).

2.      NSVD complicated by a shoulder dystocia of ___ minutes, resolved using ________ techniques is any birth that requires midwives’ hand maneuvers and direction to effect delivery. The timing should be assessed from the time the midwife realizes that she needs to physically intervene, NOT necessarily for the whole time the head is out.

Using the above definitions presupposes a few components of a midwife's skill level and ability to risk-assess. First, she must have skilled assistants who record accurate times of all major events. Second, she must know how to assess and interpret fetal status throughout labor to know which babies should be risked-out of homebirth for fetal distress, and how urgently to effect delivery, if imminent.  Third, each midwife must have current, accessible, and practiced skill in resolving dystocia. The fourth and final qualifier is that she must be skilled and able to direct a practiced Neonatal Resuscitation Protocol (NRP) response with enough people to continue the effort until Emergency Medical Service  (EMS) arrives. Sometimes this means continuing NRP all the way to the hospital since  the Emergency Medical Service NRP skill is not uniformly proficient around the country, as many midwives have reported.  Additionally, because of this last definition, it reasons that out-of-hospital birth should not be attempted in areas where the distance to the hospital (EMS to the home) is greater than the time the birth team could sustain effective neonatal resuscitation protocol.

Most importantly, because there suddenly becomes two patients at birth, every resuscitation effort requires every midwife team to simultaneously manage the maternal postpartum.  IT IS ESSENTIAL TO TAKE ENOUGH SKILLED PEOPLE TO EVERY BIRTH, so that every emergency can be handled appropriately.

The History

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There are predictive conditions or risk factors for shoulder dystocia such as:  
  • large baby
  • gestational diabetes
  • history of dystocia 
  • first time mom;
  • narrow pubic arch,
  • history of broken tail bone
  • prominent ischia spines
  • long labor
  • ​fetal distress
  • supine birth position and/or epidural
  • fetal arm behind the back and/or nuchal arm (although you're very unlikely to know this ahead of time)


The incidence of shoulder dystocia is generally reported to be between 0.3 % and 1.5% with scattered reports listing values both higher and lower. The "true" incidence of shoulder dystocia, however, is very much dependent upon how it is defined, how it is reported, and the characteristics of the population being measured. For instance:
  • The Bulletin on Shoulder Dystocia by the American College of Obstetricians and Gynecologists (ACOG) lists the rate of shoulder dystocia as 1.4% of vaginal births;
  • The rate of shoulder dystocia in Great Britain reported by the Royal College of Obstetricians and Gynecologists is 0.6%.
Dr. Henry Lerner, Assistant Clinical Professor, Harvard Medical School writes that 'many obstetricians are reluctant to write down in their delivery notes that a shoulder dystocia has occurred for fear that this will be a red flag attracting a malpractice suit should it later turn out that the baby suffered an injury. Some studies have shown that only 25% to 50% of shoulder dystocias -- as noted by objective observers in a delivery room -- are recorded by the delivering physician."

Lerner goes on to say, 'how one defines shoulder dystocia, of course, affects its reported incidence. Some obstetricians will only report a delivery as involving shoulder dystocia if they had to employ specific maneuvers to deliver the baby's anterior shoulder. Others will record shoulder dystocia if there is ANY delay in the emergence of the shoulder following delivery of the head. In some cases, a physician will only record shoulder dystocia when a fetal injury has occurred.   Finally, the characteristics of the delivery group being measured will affect statistics on shoulder dystocia. A study evaluating the incidence of shoulder dystocia in a population with larger than average babies, or higher incidence of diabetic mothers, will have a much higher reported incidence of shoulder dystocia than if the population were a general one containing a more representational sample of both small and large babies and the normal percentage of mothers with diabetes."  The same variations may change the numbers for the homebirth population vs the obstetric population. The bottom line is, we don’t actually know the rate of incidence. Most homebirth midwives report a higher rate than 1% and so we must be prepared for it at every birth (yes, even at ‘roomy’ multips births with no risk factors).

Even if we don't know exactly how often it occurs, we can tell when a dystocia is occurring. Let me first say that I am a proponent of the old midwifery adage, "no intervention in the absence of complication'.  A brilliant phrase as long as we truly understand what constitutes a complication.  In a normal second stage labor, baby makes distinct, consistent progress.  Every push moves the baby a measurable amount, although he may normally retrace his steps many times before the head steps out of the perineum. Progress over time, of course, is an individual, subjective assessment.  And interestingly, we aren't great at this assessment while continuously supporting a laboring mum.  One more reason I argue for a robust midwifery team allowing the primary to come and go from the actual delivery room (even at homebirths) so that she maintains the necessary perspective to make these assessments.  Dysfunction as it relates to the birth of the shoulders is when the normal forces applied to birth the head no longer create the same action.   Obviously, a primary midwife should NOT come and go while waiting on the shoulders to deliver.  Instead, we must be familiar with this woman's pushing ability and style (having just witnessed her birth her baby's head) and expect the same amount of force will efficiently deliver the rest of her baby in the next contraction - If it doesn't, then action is needed. The specific action and techniques and what order to apply them in is the topic of many workshops and a topic for another blog post.

​Interestingly, the 'common law' of midwifery, i.e. that birth of the shoulders happens the contraction after the birth of the head, isn't a universal obstetric notion.  Dr. Leslie Iffy, a Maternal/Fetal Medicine specialist in New Jersey and a veritable expert on shoulder dystocia who passed away several years ago, after a 43 year career in obstetrics, wrote an interesting paper in 2015 entitled, "Epidemiologic aspects of shoulder dystocia-related neurological birth injuries".  In this paper he and his co-authors conclude, "Incidents of shoulder dystocia began to escalate in the USA during the 1980s, shortly after the introduction of "active management" of the birthing process. This new technique replaced a conservative philosophy which had recommended abstinence from intervention on the part of the accoucheur. The authors consider the interventionist approach largely responsible for the exponential increase in the rates of shoulder dystocia in the USA. They recommend adherence to the traditional method of delivery on the part of obstetricians in Europe and elsewhere."

Active management of the actual delivery was first proposed in the 1976 edition of Williams Obstetrics, whose major authors were Pritchard and McDonnell. This technique, called by some the “one step” technique, recommends attempting to deliver the infant’s shoulder immediately after the birth of the head.  Prior editions of the Williams textbook (1961), whose major authors were Eastman and Hillman, wrote to expect that the shoulders would emerge in the contraction following delivery of the head—the “two-step” technique.  Iffy's assumption as to not only the reason for the marked increase in brachial plexus injury's, but also the increase in the rate of shoulder dystocias in general.  This may indeed be the result of a nation of obstetricians adopting a technique that, at best rushes the process, and at worst, creates the very complication it's attempting to prevent by impacting the baby's shoulder before its had the time to restitute on his own.  Time seems to be fairly irrelevant in predicting the need for intervention as well as the outcome of babies who do experience dystocia.  Instead, midwives can distinguish between normal and abnormal by lack of normal progress of the birth of the head and/or the first expulsive efforts of the shoulders, abnormal fetal head coloring, gasping or any respiratory effort before birth, and the 'turtle sign'.


As more and more women choose to birth out of the hospital free of the often-arbitrary policies and procedures of the obstetrical model, we midwives are given a broader depth of experience in our practice of the profession, especially those of us who lean towards a woman-centered, hands-off practice-model.  Simply stated, we create opportunities to view physiologic birth and draw conclusions about complications and intervention from as pure a view as possible.   In my experience, there are three distinct types of shoulder dystocia.  I have labeled each based on the increasing speed with which the provider needs to intervene.

The Three Types

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1.      Non-Emergent Shoulder Dystocia
A non-emergent dystocia is the least dangerous for baby.  It occurs because baby is indeed stuck – hung up on the pubic bone, ischial spines, or coccyx -  but he has not been and is not depressed in any way.  This is why we can work hard to get a baby out that is really stuck, but continues to have good color, and either needs no resuscitative efforts, or recovers after just some stimulation and a few breaths. This baby could be stuck because of his own position or because of the shape of mom’s pelvis, but he is NOT compromised. Of course, without effective, timely action, this scenario can change rapidly.  He does need help like all babies in a dystocia, but he doesn’t start out struggling.  I call this non-emergent because it’s truly not an emergency; baby is not struggling, venous return is good, placental function is optimal, and baby is no more stressed with his head out then he was during the whole time his head was in the pelvis.  Many midwives have stories that their colleagues react to with disbelief, of how long it took them to free a baby. They report  6, 8 or 12 minutes on the perineum - ‘who then are totally fine!’   These stories are examples of this first type of dystocia - these babies truly are fine – just stuck.  Take quick action to deliver this baby, but don't be surprised at how well it goes.

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2.      Emergent Shoulder Dystocia
An emergent shoulder dystocia is essentially the birth of a compromised baby who is slow to deliver at the shoulders.  Babies play a huge role in their own births, moving, pushing, and arching themselves out. It's one reason why full-term, healthy, unmedicated births generally go well in any setting.  When a baby has lost reserves (either because of placental insufficiency, cord compression, undiagnosed Intera-Uterine Growth Restriction (IUGR), a deteriorating uterine environment with chorioamnionitis​ or uterine infection, or some other cause of fetal distress) the baby stops fully participating in his own birth. Consequently, descent, rotation, flexion, and synclitisim all become affected by his lack of muscle tone and/or muscle movement.  Expulsion of the head is achieved with maternal power while baby just sits there unable to restitute or push himself down and out.  This type of birth is an emergency before it even starts. This baby needs resuscitative efforts as soon as possible, evidenced by low Apgar scores at birth.  Many of these births are correctly identified before the birth process and transported to a hospital for fetal distress. If not, then these are the babies that are slow deliveries of the head, are frequently tied up in their cords, are relatively 'easy' to deliver once you take action to assist the delivery, but who need a lot of resuscitative efforts.  They aren’t actually stuck, but are frequently descending into the pelvis in funky positions because their muscle tone is flaccid due to being compromised. They are floppy and out-of-fight to get born.  They need help – STAT.

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3.      Catastrophic Shoulder Dystocia
Catastrophic shoulder dystocia has the potential for being exactly that.  These births are the result of a stuck baby who is already compromised.  We midwives want to do everything in our power to identify and risk-out these babies before the birth occurs, but we also need to train for these scenarios religiously. Preventing this type of shoulder dystocia is the motivation behind all of the fear and panic that surrounds shoulder dystocia in our culture.  Watching a baby expire while you’re powerless is a terrifying scenario.  Fear of these births and babies are the reason for C-sections for big babies and dysfunctional labors. It’s also the reason for all manner of interference at normal births.  If you are unlucky enough to be the midwife at a catastrophic shoulder dystocia, please seek support and counseling right away.  We need you - wonderful, hardworking, traumatized midwife - to come back from your harrowing experience ready to teach and counsel others.  These are the babies who potentially spend weeks in the NICU, have broken arms, nerve injury, paralysis, or they simply do not make it.  If you happen to have a long, complicated, difficult dystocia that then needs a long, complicated, difficult resuscitation, AND you have a baby who lives without complication or who you never even had to transport, thank your lucky stars; you just won the midwifery-lottery.

The Answers

Right now, the major flaw with this view of shoulder dystocia is that the only way to categorize these births is after the fact.  We have no way to definitively assess which babies/births are at risk for which type of dystocia beforehand.  But, we do have clues, and we do have an increasingly savvy midwifery skill level nationwide.

So, what’s a midwife to do?

First, become an expert in fetal surveillance assessment.  Like, seriously! Understand how to accurately assess baseline throughout labor, know how to tell if baseline changes, how often to listen, how long to listen, when to listen.  Know how to tell the difference between early, variable and late decelerations. Importantly, transfer all Category II and III babies – believe me, it’s worth it - even if there a few mamas who go on to deliver vaginally without meds in the hospital (like this is a bad thing)– and even if they are miffed that they didn’t get ‘their’ homebirth.  Homebirth midwives only take care of low risk clients, and the only babies you can definitively say are low risk are Category I babies.

Second, practice all the ways - know every possible technique to get a stuck baby out – take all the workshops, practice with your friends, practice with your students, practice in your sleep.  Make up new ways to move stuck babies.  And run role plays with a good mama-actor so that you remember to tell her what you’re doing. So often we practice sticking our hands inside a mannequin forgetting what that would actually feel like and how important it is to communicate with your client so hopefully she doesn’t need therapy to recover from her ‘birth rape’ as well as the emotions of watching her floppy baby be resuscitated.

My third recommendation is to practice NRP often. Don’t just recertify every 2 years; actually know it by heart! Like backwards and forwards – like you can explain it at 3am to your green student until she gets it.  And if the new NRP is throwing you – take a Helping Baby’s Breathe workshop.  Practice – run scenarios in your head – run role plays in your midwifery practice – talk case studies until you can do it in your sleep.  Invest in a good pulse ox monitor (Mossimo Rav 5 is the best). If you have the wherewithal to get the baby out, you must be able to get him breathing! The reality is, if you practice long enough, you are likely to attend a birth or two or three where you really can’t get a baby breathing – but don’t let this be because you don’t know what you’re doing.

And lastly, relax.  You really can take comfort in the fact that you are a homebirth midwife which means you take care of the creme-de-la-creme of birthing mothers.  On the whole, there is no group of pregnant women more motivated to have a healthy, safe, beautiful experience in the whole world.  She will leap when you say leap – she will do all the things you suggest, even eat the gelatinous throw-up that is soaked chia seeds.  Your clients will grow the biggest, healthiest, strongest babies of any in the world.  Those babies really do instinctively know how to get born – they even help.  And because you are a badass midwife who knows her limits, and you listen to your heart - you really will risk-out all the mamas/babies who aren't meant for you.   Relax, because it’s really not solely your job to deliver healthy babies. Delegate a whole lot of the work back to your mamas.  Have a comprehensive prenatal program that helps bring them along the path of health and wellness as far as they can possibly go.  Inspire confidence – exude confidence – model confidence.  We all birth better (or do anything for that matter) when we believe we can.  Belief, most simply, is a combination of thought, feelings and actions. Think about how to resolve dystocias,, feel into all the feelings, and when in doubt - always take action. Believe YOU can handle it, and so will she.
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What’s the ‘big real’ of what you’re doing?

2/15/2020

2 Comments

 
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Danielle LaPorte, a guru of mine shares this story:

"Do you know the story about the two stone cutters? When asked what he’s doing, the first man replies, “I’m cutting this stone into bricks.” When the second laborer is asked what he’s doing, he replies, “I’m building a temple.”

How much do we do in a day with our nose to the grindstone? Myopic, focused, making a list and checking it twice. Done. Done. And done.

But what have we done? Really?

There is a Big Real behind everything we do. Sometimes it’s a negative Big Real. Sometimes it’s a positive Big Real.

  • I’m not posting to my blog. I’m waking the truth in myself and my readers.
  • I’m not working on my book manuscript to have it to my agent by August 1.  I’m writing a book that could spark people into true action, and it’s burning inside me and must be released: just call me PELE the fire goddess!
  • I’m not just hand washing my clothes, I’m practicing being in the present moment and also making it so I walk into the world looking my best. (Okay, okay, so kneeing on concrete with buzzing flies around my head while washing said clothes proves I still need a lot of practice and I'm no Zen master,  but you get my point.

What has become rote or banal for you that is really part of a great dream or vision? 

​So midwives, what is the big real behind your work?  Why do you do what you do?
​We see clients day in and day out.  We get up the second our phone rings - boom - out of bed in a flash at 3 AM.  We get up from dinner, a t-ball game, and sex to answer the phone.... again... (from the same scared new mama). We stay late or get up early to finish charting or review  labs.

​But what are we really doing> what's the big real of midwifery?

Try to define the big real of your practice, your work....
​
​I am midwife, I deliver babies.... and mamas, and papas, and siblings and grandmas..... and whole communities.
​I am midwife; I wake at the drop of a hat, I'm in ninja training to be responsive to the world's calls.
I am midwife; I hold space for many and I'm demonstrating loving kindness.

​If your big real isn't so positive, perhaps you can find a way to shift it, or to midwife the world in other ways.

Danielle says, "Zoom back from the tasks and see the holy weaving of your time and love and action. Make it matter. Because it does."

​More wisdom can be found at http://www.daniellelaporte.com/

2 Comments

Organizations all midwives should know about.

2/8/2020

2 Comments

 
There are so many talented midwives, students, and advocates doing so many different things, that some of the alphabet soup of midwifery acronyms gets lost on the profession at large.  (I confess to being confused sometimes too.) So to help myself and midwives everywhere, here (in no particular order) is a concise guide to the many organizations that govern, advise, and advocate for midwives in the United States (with quotes and links to their own websites).  If I missed any organization that you think should be added to this list, please message me.

Association

MANA
In 1982, the Midwives Alliance of North America was established as a non-profit (501 c 6) professional organization for all midwives. MANA grew out of a grassroots coalition of diverse types of midwives including nurse-midwives, lay midwives, direct-entry midwives, and traditional midwives from across North America. The impetus to create MANA was a desire to establish a professional home for all midwives that would recognize and honor the diversity of educational backgrounds and practice styles within the profession.
ACNM
​The mission of the American College of Nurse-Midwives is to support midwives and advance the practice of midwifery in order to achieve optimal health for women through their lifespan, with expertise in well woman and gynecologic care, promoting optimal pregnancy, physiologic birth, postpartum care, and care of the newborn. ACNM supports the practice of midwives by promoting education, research, and advocacy that advances clinical excellence, expansion of a diverse midwifery workforce, and equitable legislation, regulation, and institutional policies that establish midwifery as the standard of care for women.​
AABC
The American Association of Birth Centers promotes and supports birth centers as a means to uphold the rights of healthy women and their families, in all communities, to birth their children in an environment which is safe, sensitive and cost effective with minimal intervention.
NACPM
The National Association of Certified Professional Midwives implements a variety of initiatives and projects. NACPM recognizes the power of building and participating in coalitions to multiply its influence on policy, practice and outcomes. Today, NACPM partners with midwives, consumers and other stakeholders to unify and strengthen midwifery in the U.S. and to influence state and national policy to improve maternity outcomes throughout the country.
AWHONN
​The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) is a 501(c)3 nonprofit membership organization that promotes the health of women and newborns. Our mission is to improve and promote the health of women and newborns and to strengthen the nursing profession through the delivery of superior advocacy, research, education and other professional and clinical resources to nurses and other health care professionals.
The Home Birth Summits
The Home Birth Summits and Data Taskforce bring a cross-section of the maternity care system into one room to discuss improved integration of services for all women and families in the United States. In 2011, 2013, and 2014 the Home Birth Summits convened a multidisciplinary group of leaders, representing all stakeholder perspectives, to address their shared responsibility for care of women who plan home births in the United States.
US-MERA
The mission of US MERA is to elevate and grow the profession of midwifery in all 50 states, and all territories and commonwealths by applying the ICM Standards to the education and practice of midwifery through collaboration and support of professional associations concerned with these issues in the United States.  ​
ICM
The International Confederation of Midwives envisions a world where every childbearing woman has access to a midwife's care for herself and her newborn.  Our Mission​ is to strengthen Midwives Associations and to advance the profession of midwifery globally by promoting autonomous midwives as the most appropriate caregivers for childbearing women and in keeping birth normal, in order to enhance the reproductive health of women, their newborns and their families.

Education

MEAC
​The Midwives Education Accreditation Council is an independent, nonprofit organization recognized by the U.S. Department of Education as an accrediting agency of direct-entry midwifery institutions and programs.
ACME
The Accreditation Commission for Midwifery Education has been recognized by the U.S. Department of Education (under 'Health Care') as a programmatic accrediting agency for nurse-midwifery education programs since 1982. In 1994, ACME approved criteria to accredit direct-entry midwifery education programs; the first program was preaccredited in April 1996.  ACME currently accredits 39 programs offering nursemidwifery and midwifery programs. ACME is administratively and financially autonomous from the American College of Nurse-Midwives.
AMCB
The American Midwifery Certification Board is the national certifying body for candidates in nurse-midwifery and midwifery who have received their graduate level education in programs accredited by the Accreditation Commission for Midwifery Education (ACME).​ Certification by the AMCB is considered the gold-standard in midwifery certification and is recognized in all 50 states.
NARM
NARM’s mission is to provide and maintain an evaluative process for multiple routes of midwifery education and training; to develop and administer a standardized examination system leading to the credential “Certified Professional Midwife” (CPM); to identify best practices that reflect the excellence and diversity of the independent midwifery community as the basis for setting the standards for the CPM credential; to publish, distribute and/or make available materials that describe the certification and examination process and requirements for application; to maintain a registry of those individuals who have received certification and/or passed the examination; to manage the process of re-certification; and to work in multiple arenas to promote and improve the role of CPMs in the delivery of maternity care to women and their newborns
AME
The Association of Midwifery Educators (AME) is a non-profit organization committed to strengthening midwifery educators, schools, and administrators through connection, collaboration and coordination. All midwifery educators – preceptors, academic faculty, and school administrators – are welcome as members.
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Advocacy

FAM
The Foundation for the Advancement of Midwifery (FAM) is a 501(c)(3) non-profit organization seeking to improve maternal and child health by funding projects that advance midwifery as the gold standard for North American maternity care through research, public education, advocacy, and health equity initiatives.
ICTC
The International Center for Traditional Childbearing, Inc. is a non-profit infant mortality prevention, breastfeeding support, and midwife training organization, comprised of women and men who want to improve birth outcomes and provide training opportunities in their communities.
NLIRH
The National Latina Institute for Reproductive Health (NLIRH) builds Latina power to guarantee the fundamental human right to reproductive health, dignity and justice. We elevate Latina leaders, mobilize our families and communities, transform the cultural narrative and catalyze policy change.
APIAHF
The Asian & Pacific Islander American Health Forum works with communities to mobilize in order to influence policy and to strengthen their community-based organizations to achieve health equity for AAs and NHPIs across the country.
Changing Woman Initiative
The Changing Woman Initiative is a developing non-profit organization with the mission to renew cultural birth knowledge to empower and reclaim indigenous sovereignty of women's medicine and life way teachings to promote reproductive wellness, healing through holistic approaches and to strengthen women's bonds to family and community. We are focused on developing a culturally centered reproductive wellness and birth center.
Uzazi Village
Uzazi Village has been established to decrease the maternal and infant health disparities found in the urban core, particularly among African-American women, but also other at-risk populations residing there.
The Elephant Circle
Elephant Circle brings the strength of advocacy, scientific inquiry, information, and education to issues of
birth and reproductive justice, protecting mothers, their children, families, and health providers. Elephant Circle was founded in 2009 with fiscal sponsorship from the Colorado Organization for Latina Opportunity and Reproductive Rights. 
Human Rights in Childbirth
Every woman has the right to access the healthcare support that she, personally, needs for a healthy birth.Every woman has the right to be respected as the decision-maker about her own care and her baby’s care.  Every healthcare system should be equipped to meet women’s individual needs and personal decisions around childbirth.  HRiC is committed to supporting the efforts of individuals and organizations working all over the world to promote the fundamental human rights of pregnant people.
The Big Push for Midwives
​The mission of the Big Push for Midwives is to provide strategic planning and message development for state consumer and midwife groups that are actively working on legislation to license Certified Professional Midwives (CPMs), envisioning the day when CPMs are licensed in all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, and Guam.
Childbirth Connections
​For nearly 100 years, Childbirth Connections has helped develop and advance many forms of care that are now critical components of the nation’s maternity care system. More recently, we launched a long-term program to promote evidence-based maternity care through policy and quality initiatives. We will continue working to improve and transform the nation’s maternity care system so that childbearing women and babies consistently receive high-quality, woman- and family-centered care.

And a few more just for good measure...

March of Dimes                                         
The mission of the March of Dimes is to improve the health of babies by preventing birth defects, premature birth and infant mortality.
Amnesty International                             
We work both at home and abroad to tackle the most pressing human rights violations.
Integrative Health Policy Consortium                         
We envision a world with no barriers to health.
Council on Patient Safety in Women's Health Care
​Our mission is to continually improve patient safety in women’s health care through multidisciplinary collaboration that drives culture change
2 Comments

17 parenting wins and the stuff I wish I'd done

1/18/2020

8 Comments

 
by Augustine Colebrook
This article first appeared in the Elephant Journal on January 31, 2018. Read that version here
I am a grandmother and recent empty-nester, and it’s given me the time and space to reflect on this gigantic, twenty-year, “Life 101” course from which I just graduated. I read Kahlil Gibran’s masterpiece, “The Prophet’ when I was a teenager, and remembered the swelling feeling of recognition in my chest reading the chapter on children. When I had my children, I knew they did not belong to me.  I tried to parent them accordingly, and I think I succeeded mostly. ​
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“They come through you but not from you,
And though they are with you, yet they belong not to you.
You may give them your love but not your thoughts.
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow,
which you cannot visit, not even in your dreams.
You may strive to be like them, but seek not to make them like you.
For life goes not backward nor tarries with yesterday.
You are the bows from which your children as living arrows are sent forth.
The archer sees the mark upon the path of the infinite,
and He bends you with His might that His arrows may go swift and far.”​

 Here are my #parentingwins 

1.      I was always just honest with my kids. 
Speaking the truth to anyone takes courage, but to kids it’s a gift that grounds their developing brains in reality.  Also, I always had a reason, and wasn’t just the ‘heavy’ with the rules they had to follow’.  Kids really want and need to know “why”.  I frankly told them when I didn’t have extra money for going out or buying things.  I shared my emotions with them – I believed that it was better to be sad and say so, rather than pretend I was ok (because they would know anyway).  And then maybe they would just be sad when they were sad without trying to hide their real emotions.

2.      I choose to live in community as much as possible. 
Co-housing, community dinners, room-mates, house-mates, live-in nannies, close neighbors, in-laws in the guest room and big family holidays over the years all helped me raise kids in a village and therefore life lessons came repeatedly from many sources.
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3.      I let natural and logical consequences be my secret parenting partner. 
Right from the beginning when they were very little I allowed them to learn from their own choices.  Choose not to wear a coat when it’s cold: you learn that being cold at the playground is no fun, and next time you bring your coat. Throw a fit and refuse to eat dinner: then you go to bed hungry.  Now obviously, compassion also teaches, so I was also the mama that had a blanket to share when they were cold and a bowl of soup at bedtime when they were hungry.  But I tried to always find the balance between compassion and enabling.
4.      I made forward going motion the law of the land.
Playing was more important than work.  A clean floor was good enough in the playroom, organization of toys can be a part of the playtime tomorrow.  The point was to get out the door to the park not dress to impress.  I refused to tarry with shoulda, woulda, coulda language.

​​5.       By de-emphasizing the little things, we had a lot less fights than our peers. 
That old saying, “shoveling snow while it’s still snowing, is like cleaning your house while your kids are young” is true. Day to day, the mess will continue, you can either spend a lot of time clearing sidewalks, or you can just get out and play in the snow!  We played a lot!​
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​6. I never put my babies in baby-jail and never let them ‘cry it out’.
My infants had unrestricted access to me – their first and only home. I tried to meet their needs as soon as they had them because I believed that I was teaching them to trust the world. Slowly, and at their own pace, they transitioned from sleeping on me, to sleeping near me, to in-the-next-bed, to in-the-next-room. Slowly they found their own way confidently in the world. This patient way of introducing the big bad world to my little innocents created a deep well of self-confidence and self-love. I believed that my children’s relationship with me would set the precedent for all future relationships and I wanted it to be loving, mutually respectful, and honoring of each other’s needs. In other words, I treated them how I would have wanted to be treated right from the beginning.  It was exhausting, but worth it.
​7. Horses… just horses.
My kids all suffered various stresses, challenges and bouts of depression navigating adolescence. Horses solved so many of these issues. As a single mother I didn’t have much money to spare – so this access didn’t look like the hunt club scene, but I did find ways to make it a daily part of our lives at one point or another. From volunteering at the local ‘horse therapy group’ to just getting the local show barn head groom’s permission to walk down isles and feed carrots. Where there is a will there is a way. Horse people love to share their knowledge and love of horses and pre-teens are usually willing workers. Also, once some skill has been developed, a partial lease is a real possibility. 
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This means going barn to barn until you find some unused or barely used horse and proposition his owner for you to pay ½ his expenses. This can be as little as $50 a month up to $150, in exchange your kiddo gets access to a horse to brush and clean-up after and ride and love 3 days a week! Even though only one of my daughters got totally bitten by the horse-love bug, we all benefited. Horses (and the work they create) is the ultimate in teaching accountability, patience, and a good work-ethic.

​4-H, pony clubs, and school equestrian teams exist in most parts of the country and can be a great place to start. Bottom line, if you can create regular access to any animal or any daily or weekly outside pursuit - you're #winning!
8.      I made a conscious choice not to use violence to teach my children. 
I used to hold their little hands in mine when they were being aggressive or hitting their peers or siblings and say earnestly, “these hands are for helping, NOT hurting”.   The one time that I involuntarily slapped my rude, disrespectful, screaming, teenage daughter’s face, we talked about it for a month.  It took a lot to forgive myself for hitting my child.
 
9.      I forgave myself regularly.
 I messed up, forgot, lost track of, or downright dropped the ball so many times.  I tried and tried and failed again and again.  And I learned how to be gentle with myself – I believed that I was a newborn parent and then a toddler parent and then a teenage parent and I was gentle and forgiving to me and to them.
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10.      I took breaks. 
This parenting gig is so much more full time than any other experience in life. It didn’t used to be, however; we used to parent in community with others helping with the daily chores of life.  This nuclear, secular family living in a vacuum is unnatural and it’s exhausting.  I took personal days and played hooky and I am better for it.  I also encouraged my kids to take breaks sometimes, not just sick days, but personal days to stay home and bake cookies or go riding horses on the first snow day, or stay under the covers when they were sad.
 
11.      I got divorced (twice). 
When it was clear to me that my household was growing up believing that disrespectful or abusive behavior was the norm, I took a stand.  My kids saw me modeling self-respect and radical self-care their whole lives.  I think they will be better prepared to live a whole, full, and fulfilling life because I took this stand, rather than sticking with a marriage only so they could grow up in a two-parent household.
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​12.  I fed whole foods at home. 
Sure, Halloween candy and chips and cookies crossed the threshold occationally, but almost all the time, my kids only had access to fruits and vegetables, traditional fats, organic meats, etc.  Exposure is ½ the battle with nutrition – they like what they think is normal.  Comfort food is simply the food that feels the most like home.  For some people that’s microwave TV dinners; for my kids, its homemade chicken broth or pot roast.

​13.  I took my kids on vacations that had no agendas. 
Our lives are scheduled enough – they needed to have days of un-ended time to let ideas and inventions bubble up.  They needed to taste freedom and then take a bath in it.  No rules is a good way to live sometimes!

​14.  My kids’ rooms were their private space. 
I decided early on that I didn’t want to be in a battle with house cleaning or doing it for them– so the only rule was; 'keep your stuff in your room'.  Sometimes they decorated and organized and cleaned, and sometimes you couldn’t see their beds or floors for months at a time. I’m pretty sure that this is how the hamster died – again refer to #3.  By allowing them this total sovereignty they quite literally lived with the consequences of their actions or lack of action – and developed personal responsibility and accountability all on their own.
15.  They had the same chore for 6 months at a time. 
Every family comes up with their own method for teaching participation in house maintenance. My method was to assign each kid a job that was theirs for 6 months at a time.  It allowed there to never be a shirking of responsibility or blaming it on the person before, and encouraged development of total responsibility – ownership if you will.
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16.  I kept switching schools till they found something that was both fun and challenging, inspiring and where they felt successful. 
If I hadn’t been a working mother, I probably would have homeschooled.  But instead I let them switch and switch until they found what they loved and thrived in, including letting one and then another go to live with their dad in another state.  I let them be in charge of as much of their own lives as they could handle, because this is the goal, right?  With so many parents experiencing the phenomena of ‘failure to launch’, I wanted to ensure their development was always centered around self-determination.
 
17.  I kept the focus of our lives on how we wanted to feel. 
If we can define how we want to feel, then choices become a lot easier.  Want to feel successful, then get things done.  Want to feel joyful, then hang around joyful people and do the things that bring you joy.  Want to feel responsible, then be responsible for your own life.  This simple exercise will do more to inform their life than anything else – It’s radical and simple.

Ok, some things I wish I had done differently.

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1.      I wish I had set better boundaries around money.  I never set up an allowance or a schedule for when money was available to them, so consequently, I was always being shamed, blamed, or guilted by my teenagers.  Because there was no established limit, they wanted money all the time and it was a struggle frequently

2.      I wish that I had moved overseas with my teenagers.  Teenagers will get into trouble anywhere they are and their very point of living is to experiment and push boundaries, but I really wish that they had also had a giant dose of non-America in their developing perspective. Time overseas at any time in anyone’s life is probably valuable, but for American teenagers prone to entitlement and classism, It just might be life-changing!  Plus it changes the dynamic of rebelling against parents to parents being the only ‘known’ or constant and that shift of focus would have been welcome.

 ​3.      I limited my kids screen time a lot more than the mainstream, but I still wish I had limited it more.  There was no screen time at all until my youngest was 5, but then (partly because of a new husband’s habits) TV, video games, and cell phones moved into their lives.  It is the single most destructive force in America today, if you ask me, and I wish that I had really understood the challenges it would bring.

4.      I talked about sex and birth control often (I work in women’s health care), but I didn’t encourage decisive action until after my 15 yr old daughter got pregnant.  I wish that I had taken my girls for birth control as soon as they hinted at being sexually active and I wish that little bowl of condoms in the front hall was there for all their teenage years.  My granddaughter is a blessing beyond measure and we all love her very much.  I think my daughter feels differently, but I know we would have loved her just as much were she to have arrived 5 years later.  I will always wonder what would have been different for my daughter who didn’t go to college.

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5.      When looking back I really wish I had more grace when they decided to move out.  My kids all at different times launched sooner than I was ready for them to leave.  I wish there was a workshop on how to prepare yourself for the end of daily parenting.  I knew all along that raising strong, independent people was the goal, but then in the end, I wasn’t ready to not be needed any more.

But, what's the point?

​In birth and parenting and life in general, we finally become experts right when that expertise is no longer needed; it’s said that you ‘master’ a subject after 10,000 hours immersed in study. So here I am, graduated from parenting with an unnecessary master’s degree.  I’ll never parent daily again (in this lifetime) and no, grand-parenting is NOT the same, so what exactly was the point of the last 20 years of my life?

This is the question that keeps me up at night.  What was the point of spending all that time and money and energy raising people that don’t even seem to even like me some days and certainly don’t have need of me daily anymore?  Most of my elders tell me that they really don’t appreciate you until they’re 30 years old… gee, that’s reassuring.

I have come to believe that parenting is the most extreme personal growth workshop any of us will ever experience.  It’s the most magical and diabolical collection of joy and heart-ache.  A mystical, shamanic journey into the heart of humanity.  Welcoming a tiny, helpless human into your heart and home starts a odyssey of epic proportions, weaving through a ‘candy land’ of hormones and histories, morals and ethics, physical, spiritual, mental and emotional exhaustion.  The trials in the show ‘survivor’ have nothing on the lived-experience of surviving parenting.  In fact, the challenges little people inflict on their parents, no TV producer could ethically replicate – much of parenting is downright torture. 

But we keep doing it, not just in all of humanity, but many of us have more than one child, and although the way babies are made does ensure a modicum of success; this still doesn’t explain why many of us have devoted huge portions of our lives to parenting.  I know, we don’t all do it for the personal growth.  So why?  Why do so many of us not just sign up for a 20+ year odyssey, but in fact give it all our focus and determination?
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I believe it’s more than the biological imperative, hormonally driving us to procreate. That may be why some of us GET pregnant, but it doesn’t account for slogging through the next 20 years of painful challenge. 
​Although, Kahil Gibran’s essay on children prepared me to let them go, I failed to fully comprehend the last line of the poem.

 
“Let your bending in the archer's hand be for gladness;
For even as He loves the arrow that flies,
so He loves also the bow that is stable.”​
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To be stable, to be still, to hold space and be flexible -  this is our most precious job.  I have been bent mightily – I am a long slender bow made of willow – and I have been bent nearly in half.  I have sent my arrow children flying on their own paths of freedom, but when I read and memorized this chapter as a teenager, I didn’t have the foresight to read the chapter on giving, and even if I had, I’m not sure I would have understood its meaning.
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"And to the open-handed, the search for one who shall receive is joy greater than giving
And is there aught you would withhold?
All you have shall some day be given;
Therefore give now,
​that the season of giving may be yours and not your inheritors'.”
​Parenting is giving – giving all of ourselves until we are emptied out - carved and hallowed. Some stay here sadly lamenting their emptiness for a life-time, but I – I am glad for it.  I feel completely hollow – ready to be filled with the experiences of the second half of my life. 

Someday I will be emptied again, but right now I am happily gathering experiences like seashells on the beach.  All the sparkly and stripy ones catch my eye. 

All my years of parenting was an exhale of breath, now, I am inhaling life sharply.  The season of giving is over, and it is a celebration not a mourning.  Just as each new seasonal shift is welcomed – I feel ready for this winter spiraling into myself and then the spring that will follow. 
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In the goddess tradition there are 5 life phases – maiden, lover, mother, queen, crone.  Using this imagery, I have donned my crown this year.  I am happily reigning sovereign over my own life for the first time ever!  Were we still living in tribal culture, I would be celebrated and honored for my service. 
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​So, what’s the point of parenting?
To raise strong, confident, independent, conscious individuals – and then to take up your crown and rule as queen. 

We need more queens in this world - powerful women who have suffered and know battle, but who remember to walk with a strong back and soft open heart. Love Warriors who are experts at giving and holding space, but who have the courage to strike out on their own.
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8 Comments

Midwives and the Care of Their Instruments

1/4/2020

1 Comment

 
Disinfection and sterilization of instruments is a crucial point in any midwifery practice. It is the procedure by which health care professionals ensure that all reusable medical devices do not harbor any biological matter before the next use. Sterilization causes biological entities to be killed, removed or deactivated either by physical or chemical means, where as disinfection causes most but not bacterial spors.

DEFINITIONS

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Cleaning:
is the removal of foreign material (e.g., organic material) from objects and is normally accomplished using water with detergents or enzymatic products. If soiled materials dry or bake onto the instruments, the removal process becomes more difficult and the disinfection or sterilization process can become ineffective. Surgical instruments should be presoaked or rinsed to prevent drying of blood and to soften or remove blood from the instruments.
For instrument cleaning, a neutral or near-neutral pH detergent solution is commonly used because such solutions generally provide the best material compatibility profile in addition to good soil removal. If your instruments are not rinsed properly, low pH detergents may break down the protective surface of stainless steel instruments and cause black staining. Likewise, alkaline detergents may leave surface deposits that cause a brown stain and interfere with the smooth operation of the instrument. Rinse your instruments in cool water. Hot water can cause proteinous substances to coagulate. If desired, soak your surgical instruments in cool water with an enzymatic detergent. The detergent helps to dissolve the proteins and break down oils. Then, the instruments may be cleaned by hand or mechanically in a washer or ultrasonic bath
Disinfection:
Disinfection describes a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. In health-care settings, objects usually are disinfected by liquid chemicals.
Factors that affect the efficacy of both disinfection and sterilization include prior cleaning of the object; organic and inorganic load present; type and level of microbial contamination; concentration of and exposure time to the germicide; physical nature of the object (e.g., crevices, hinges, and lumens); presence of biofilms; temperature and pH of the disinfection process; and in some cases, relative humidity of the sterilization process (e.g., ethylene oxide).
Unlike sterilization, disinfection is not sporicidal. A few disinfectants will kill spores with prolonged exposure times (3–12 hours); these are called chemical sterilants. At similar concentrations but with shorter exposure periods (e.g., 20 minutes for 2% glutaraldehyde), these same disinfectants will kill all microorganisms except large numbers of bacterial spores; they are called high-level disinfectants. Low-level disinfectants can kill most vegetative bacteria, some fungi, and some viruses in a practical period of time (≤10 minutes). Intermediate-level disinfectants might kill mycobacteria, vegetative bacteria, most viruses, and most fungi but do not necessarily kill bacterial spores.
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Sterilization:
Sterilization describes a process that destroys or eliminates all forms of microbial life and is carried out in health-care facilities or home-health providers by physical or chemical methods. Steam under pressure, dry heat, EtO gas, and liquid chemicals are the principal sterilizing agents used. 
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Media of Disinfection
Alcohol
Chlorine and chlorine compounds
Formaldehyde
Glutaraldehyde
Hydrogen peroxide
Iodophors
Ortho-phthalaldehyde (OPA)
Peracetic acid
Phenolics
​Quaternary ammonium compounds

​CATEGORIES OF PATIENT CARE ITEMS AND INSTRUMENTS

1.CRITICAL ITEMS:
Critial items deal with a high risk of infections if contaminated with any biological agents. These items may come in contact with internal tissues and the vascular system, so the sterility of these items is prioritized above all. Because any microbial induction could lead to the transmission of disease, surgical instruments, implants, catheters and probes are examples of this category.

2. SEMICRITICAL ITEMS:
These items have contact with mucous membrane and nonintact skin. Items should be free from all microorganisms, but as they are less critical than the above category, a small number of bacterial spores are permissible. A laryngoscope blade is an example in this category.
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3. NONCRITICAL ITEMS:
Like semicritical items,  these items are in contact with intact skin but not with mucous membrane. As the skin is the most substantial effective barrier to most of the microorganism, so here sterility is not a big issue. Blood pressure cuffs, bedpans, and stethoscopes are some examples of this category.

STERILIZATION TECHNIQUES

DRY HEAT STERILIZATION:
​This technique is best suited for sterilization of surgical, suture and birth instruments. It uses thermal conduction for sterilization.
METHOD:
In this technique, heat is absorbed and passed through layers. First, it is incorporated in the outer layer and then transferred to the next layer. When the temperature reaches its maximum, the particular item is said to be sterilized. Dry heat destroys proteins. Proteins are the essential component of a microorganism’s cell wall, and hence their death occurs after the removal of proteins. It usually takes a longer time than steam sterilization, because moisture penetrates faster than dry heat and causes the death of microorganisms
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​PROCEEDURE:
  • Preheat oven (with internal oven thermometer to verify correct temp)
  • 320’ F for 2 hours OR 340’ F for 1 hour
  • Clean, dry and package metal instruments
  • Place instruments plastic side up, on a towel or paper bag on a cookie sheet or bake stone
  • Set timer for appropriate time based on temp
DISADVANTAGES:
  • High temperature i.e. 160-170 degree Celsius is required.
  • Items such as plastic and rubber cannot be sterilized because of increased temperature requirements.
  • Slow heat penetration- an hour or two of heat- plus cool down time is required.
  • Requires oven and a constant source of electricity.

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STEAM STERILIZATION VIA AUTOCLAVE:
For steam sterilization an autoclave is used. An autoclave is an instrument in which saturated steam is applied under pressure. Destruction of microorganisims occurs by the irreversible denaturation of enzymes and structural proteins. Like dry heat sterilization, it can also penetrate through all the surfaces of the instrument but is not time-consuming. This technique provides complete sterilization in a shorter time period.
PROCEDURE:
  • Fill autoclave with distilled water according to package instructions
  • Clean, dry and package metal instruments
  • Place instruments plastic side up on rack
  • Secure autoclave door according to package instructions
  • Set timer or turn on self-timed autoclave to the appropriate time
  • Be sure to properly vent autoclave before opening
DISADVANTAGES:
  • Moisture retention in package is possible.
  • Only stainless steel and plastic items can be used for this technique.
  • Danger exists when not following autoclave instructions.​​

STEAM STERILIZATION VIA PRESSURE COOKER:
​Pressure Cookers, or pressure canners, are often referred to as portable autoclaves. While this is not entirely true, the pressure cooker can be used to create much of the same effect. Using an immersion only method, pressure cookers are ideal for sturdier instruments and most substrates. While they cannot reach quite the level of pressure and heat that an autoclave can, pressure cookers have proven themselves time and time again as an effective means of sterilization. 
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Because it is not designed to create a vacuum as its first priority, however, it is recommended that you let it vent and build pressure for a bit before starting your timer in order to create complete sterilization.
For more in-depth explanation of the comparisons of different brands please see this thorough study.
PROCEEDURE:
  • Read your pressure cookers instructions
  • Add clean instruments to the proper amount of waterbath
  • Close lid and turn on burner
  • Process instruments  at 15 psi for at least 15 min. This means the temp will be about 121 °C within the cooker.
DISSADVANTAGES:
  • Sterilization time required can vary depending on the amount of liquid the size of the pressure cooker and the altitude 
  • It can be messy and time consumin
  • Danger exists if not following instructions
  • Moisture retention in package is possible.
  • Only stainless steel and plastic items can be used for this technique.

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CHEMICAL STERILIZATION:
If as a result of dry heat or steam heat sterilization the instruments are at risk of being damaged or if the autoclave or oven eclectic source is not available, then the best technique to sterilize the instrument is chemical sterilization. Most commonly formaldehyde and glutaraldehyde are used as disinfectants. By using high-level disinfectants, bacterial endospores can be killed if exposed for 10-24 hours. Sterilization usually takes place when you soak the item in 2-4% glutaraldehydes, for at least 24 hours and in 8% formaldehyde for at least 24 hours. Both disinfectants require special handling because the residue may leave after the complete procedure; rinsing with sterile water is essential. 
PROCEEDURE:
  • Purchase chemical items, read package insert carefully to avoid injury or exposure
  • Clean, and dry instruments
  • Place instruments and chemical liquid into container that completely covers all instruments
  • Leave for 24 hours in a safe and secure location
  • Remove just before use using sterile technique
DISADVANTAGES:
  • Skin irritation is possible.
  • Chances of leftover residues.
  • Rinsing with sterile water after soaking requires heat to create sterile water.
  • Glutaraldehyde is expensive.

GAS STERILIZATION:
Ethylene oxide or any other highly volatile substances are the active agents to this technique. Must be mixed with any other inert gas, to reduce highly toxic properties. This technique can only be used when no other method works. The efficiency of this gas depends on the concentration of gas, humidity and time exposure. Because 100% EO is required and it is extremely volatile, this procedure must take place in a vacumn. This is not a viable technique for community-based midwives
DISADVANTAGES:
  • Time-consuming (24-72 hour process).
  • Difficult to control.
  • Highly skilled staff supervision is necessary throughout.
  • Maintaining sufficient humidity during procedures is essential.
  • Expensive equipment necessary
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A NOTE ON BOILING INSTRUMENTS:
Boiling instruments in 100°C water for at least one minute kills 99% microorganisms, except for a few bacterial spores. Boiling does NOT sterilize equipment. This is a disinfection method and may be deemed to be acceptable for cord clamping and cutting implements, but is not recommended for episiotomy scissors or suturing instruments. Pathogenic organisms begin to die off between 60° C and 70°C. To fully disinfect, water must be at a full rolling boil for at least 2 minutes at sea level, 3 min at 6000 ft or above to achieve full disinfection, with instruments submerged the entire time.
1 Comment

Our Midwifery Legacy

12/21/2019

9 Comments

 

'Non-Nurse' Midwifery Her-Story in the US 

By; Augustine Colebrook, MA- MCHS
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As a modern midwife, an anthropology major in college and with a masters degree in maternal child health systems, I find it particularly interesting to examine the legacy of my profession from a sociological perspective. Sociology, most simply is the study of the social behavior or society, including its origins, development, organization, networks, and institutions. It is social science that uses various methods of empirical investigation and critical analysis to develop a body of knowledge about social order, disorder, and change.
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American pioneer birth scene, Gustave Joseph Witkowski, 1887​ Unmedicated women naturally choose upright positions.
Note to the reader: The following encompasses the paths to midwifery recognized by U.S. national midwifery organizations that adhere to formal accreditation and certification processes. This article and this literature review do not intend to devalue or delegitimize any of the indigenous and various heritages of midwifery traditions in America’s past, present, or future.


Midwifery as a body of knowledge and a physical practice has been in existence since the beginning of time. And traditionally, midwives had a much broader scope of practice than we know today. They were not just birth attendants, but also family/community healers for almost all aliments - this continued from antiquity to the end of the 19th century. ​The midwives that practiced during this time, had a much broader scope than is currently practiced. Midwives practicing in the south were affectionately called, 'Granny Midwives' and indeed, midwifery, much like priesthood was not a profession you retired from.
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Granny Midwives 1800s - 1920s 

Yet midwifery in the U.S. has a complicated history, convoluted educational paths, and varied legal status state to state. In short, the consumer is often confused about training, scope, and legal status nationwide. Traditionally, midwives had a much broader scope of practice than we know today (Davis-Floyd, 2006). They were not just birth attendants, but also family and community healers for almost all ailments until the end of the 19th century. The description below, from an early Euro-American context, summarizes midwifery practice well.

“Home was still the place of birth in the early 19th century, and the average American woman gave birth to six children, not including children lost to miscarriages and stillbirths. Only women midwives attended women during childbirth. (In later years there were male midwives.) These women were skilled in assisting the woman by providing comfort measures, nourishment and nurturing, and by patiently waiting for nature to take its course without undue interference with the normal process of labor and birth. ... Midwives were local women, usually with children of their own, who had learned midwifery as apprentices, as did many 19th century physicians. Observing and helping with deliveries honed their skills and exposed them to the variety of problems they would face when working on their own. For their work, midwives might receive modest compensation, however, they might be paid with a chicken or household goods” (History of American Women, 2018, para.07).


Extensive knowledge of herbal identification, harvest, preparation, dosage and administration was a chief component of the midwives' skill set. In the United States this expertise was a backbone of all communities until approximately the 1930s (Wertz & Wertz, 1989). Although 'barber-surgeons' in New England were the first to displace midwives as the primary healers and birth attendants as in the big cities of New York, Boston, and Philadelphia, laying-in hospitals started offering pain relief in the form of ether or chloroform in the first decade of the 20th century (Wertz & Wertz, 1989). The appeal for women to be out of pain during labor, as well as the public relations campaign of ‘birth cleanliness’ in an institution was enough of an incentive for some to leave their homes and to birth in these hospitals (Ehrenreich & English, 2010; Scott, 2013; Wertz & Wertz, 1989).
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A midwifery training program in Alabama teaching how to weigh a baby.  In 1912 there were 9,500 midwives in Virginia; in 1950 only 1,500 had permits. By the end of the 1950s, African American midwives had nearly disappeared throughout most of the south. 
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"As one resident of Taney County, Missouri, remembered:
The nearest doctor was 20 miles away and there was no way to travel only horseback and no money to pay with if he did come. . . . Mother watched over us carefully. There wasn’t money to buy medicine. In the spring she would make sassafras and sage tea to condition our blood. In the summer and autumn we would eat . . . anything we found growing wild, without washing it. Naturally, we would get “wormy.” [Mother] knew the symptoms. Some morning before breakfast she would stir up a mixture of wormfuge [vermifuge] in a skillet of molasses. . . . Before night we were rid of our worms. If one of us needed a tonic Mother went to the woods, peeled some bark from a wild cherry tree, dug some sarsaparilla, some blackroot, and other herbs (I have forgotten), boiled a brew out of it and gave it in regulated doses. . . . She made tea of pennyroyal, mullein, and tansy for our stomach cramps; slippery elm she made poultices of and applied to boils. . . . I have often heard Mother wish she would have studied medicine and have been a doctor. She would have made a good one." [1]
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Traveling Arkansas midwives and their van and driver, 1920's

Ghost Midwives 1930s - 1950s

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 "To gain more clinical practice, [doctors] established lying-in hospitals or wards in major hospitals. Asepsis was unknown, so, with unclean hands and tools, physicians examined women and tended to the birth of their babies, leading to epidemics of puerperal fever, which caused thousands of maternal deaths. Fortunately, many individuals contributed to understanding the cause of puerperal fever, including Ignaz Semmelweis, a renowned Hungarian physician; Oliver Wendell Holmes, an American physician; Louis Pasteur, a French scientist; and Joseph Lister, an English surgeon. By the end of the 19th century, germ theory was finally accepted, and the advent of anesthesia made surgery safer and free of pain. Anesthesia administered for pain in childbirth became desirable for many women who chose physicians as their birth attendants.
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Babies born severly effected by the medications given to their mothers, created confirmation-bias by reinforcing the doctors belief that these babies and mothers were in grave 'need of their help".
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Women were often restrained in lithotomy position,  drugged and semi-conscious, and their infants were pulled out of them with forceps.
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The result of women being unconscious and highly medicated was the development of a whole separate profession to take care of infants.
In the late 19th and early 20th centuries, American obstetricians sought to overtake the entire field of childbirth and declare major war against the traditional midwives in the United States. Midwives wanted an education, but obstetricians fought hard against this idea. "Schools for midwifery education were established in European cities, and European health care created a dual system by which midwives continued to attend normal births while physicians handled complications. This did not happen in the United States. American physicians fought hard against midwifery education, in spite of midwives wanting an education, which public-health reformers supported. In the early 20th century, many midwives still practiced in rural, remote areas of the country and with inner-city, poor populations. The next push by American obstetricians was to move the place of birth from homes to hospitals, where midwives were forbidden to practice." [2]  In an effort to entice women into the hospital, ads at the time promised a 'pain-free' childbirth.  Unfortunately, what ensued was tantamount to torture.   Two drugs were combined to produce Twilight Sleep: morphine and scopolamine. - See more on this practice here.
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The midwives that practiced during this time in American her-story are what I call 'Ghost Midwives', because they entirely disappeared or practiced in secret.  The few midwives who did practice in these decades almost never took any students and so it is almost impossible to find a midwife alive today who apprenticed earlier than the mid-1970's.  The smear campaign launched by the medical establishment at this time was voracious and effective.  To the left is an ad from the New England Journal of Medicine at the turn of the last century.  Another ad from the same era showed a flattering picture of a clean white male doctor next to a stereotypical image of a dirty female African-American midwife, with a caption describing her as a former slave.  Bold text under the photos asked women who they would prefer to deliver their baby, with the obvious right choice being the male doctor. [4]  In 1900, over 90 percent of all births occurred in the mother’s home. But by 1940, over half took place in hospitals and by 1950, the figure had reached 90 percent. [5]  There were huge areas of the country where midwifery became extinct and 20-70 years passed with no babies delivered by midwives.

Orphan Midwives 1960s - 1970s

In 1960, the world of American women was limited in almost every respect, from family life to the workplace. A woman was expected to follow one path: to marry in her early 20s, start a family quickly, and devote her life to homemaking. As one woman at the time put it, "The female doesn't really expect a lot from life. She's here as someone's keeper — her husband's or her children's." As such, wives bore the full load of housekeeping and child care, spending an average of 55 hours a week on domestic chores. They were legally subject to their husbands via "head and master laws," and they had no legal right to any of their husbands' earnings or property, aside from a limited right to "proper support"; husbands, however, would control their wives' property and earnings. If the marriage deteriorated, divorce was difficult to obtain, as "no-fault" divorce was not an option, forcing women to prove wrongdoing on the part of their husbands in order to get divorced.​
The 38 percent of American women who worked in 1960 were largely limited to jobs as a teacher, nurse, or secretary. Women were generally unwelcome in professional programs; as one medical school dean declared, "Hell yes, we have a quota...We do keep women out, when we can. We don't want them here — and they don't want them elsewhere, either, whether or not they'll admit it." As a result, in 1960, women accounted for six percent of American doctors, three percent of lawyers, and less than one percent of engineers. Working women were routinely paid lower salaries than men and denied opportunities to advance, as employers assumed they would soon become pregnant and quit their jobs, and that, unlike men, they did not have families to support. [6]  Although much of the public debate during the 'Women's Lib" movement about reproductive rights centered on bringing attention to the prevalence of rape and the choice of abortion, a small minority were advocating for birthing rights.  In pockets around the country a few women started having homebirths alone or with supportive friends.  ​
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Ina May Gaskin
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26 Midwives from around the country attended the 'work meeting' in Boulder, CO, in 1982, where the articles of incorporation to form MANA were reviewed and agreed upon.
The renaissance of non-nurse midwifery became known on a wider scale with the publication of Ina May Gaskin's book, Spiritual Midwifery on January 1st, 1975, chronicling her experience at "The Farm", a hippy commune in Summertown, TN. The Farm community, which originally consisted of a group of over a 100 people who caravanned by bus from California in 1971, chose to have homebirths. Eventually this led to the establishment of the Farm Midwifery Center, and their detailed record-keeping of outcomes appeared in the book.

​Other influential books to come out about this time were, The Birth Book by Raven Lang in 1972, Immaculate Deception: A New Look at Women and Childbirth in America, by Suzanne Arms appeared in 1975. It became a best-seller, and was a New York Times Best Book of the Year​. Special Delivery by Rahima Baldwin Dancy published in 1979, and then in 1983, Nancy Wainer Cohen published, 'Silent Knife' which the Wall Street Journal called, "The bible of cesarean prevention."


​
​However, at this same point in history, mostly in southern U.S. states, a long and important tradition was being destroyed. Many do not know that the art of midwifery owes much of its influence to black midwives, although there are very few written records of this time (Effland, 2017; Bachlakova, 2016). "Granny midwives" in the south performed all the deliveries for all the black women and for a large amount of the white women too from the slave era all the way until ‘Jim Crow era’ (Lee, 1996). Licensing laws prevented almost all of them from continuing to practice between the 1940s and 1950s (Birthwise, 2016).

Throughout the south prior to the 1940s, there was often not a doctor who was available or would even come to assist a black woman during birth, let alone during her pregnancy (Ehrenreich & English, 2010). “In that time of segregation, even if black women had money, local hospitals were not interested in having them as patients” (Alabama Women’s Hall of Fame, 2005). Many of the midwives were referred to as granny midwives; this was because most of the practicing midwives were elder women (Lee, 1996). Midwives were also called doctors and hands-on healers (Ehrenreich & English, 2010). Some even assisted in the death process (Smith, 1951). Sadly, the practice of the southern midwives began to dwindle to non-existence when licensing practices came into the picture (Davis-Floyd, 2006). Black midwives, like Margaret Charles Smith, who is featured in the documentary and the subject of the book, Miss Margaret played an important part in the health of the black family (Alabama Women’s Hall of Fame, 2005). White Eurocentric midwifery and black African American midwifery were on opposite pendulums; the destruction of black community midwifery came to its abrupt conclusion just as white midwifery was beginning its renaissance.
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Women who became midwives in this era had no real mentoring in their craft - they were orphans. They had to create, invent, imagine, make-up, and discover ways to attend birth on their own or with the council of medical doctors. Almost every midwife in practice today is a descendant of this renaissance. Naturally the age-old tradition of apprenticeship began again and slowly more and more women began to go to each other's homebirths and learned together how best to attend births. Many decades of medicalized birth, however, influenced even these anti-establishmentarianism pioneers, and at homebirths women would lay down to give birth and depend on their providers to guide the process.
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Organized Midwives 1980s - 1990s

Note to reader: During the formation and growth of the various midwifery organizations, mentioned below, the racialized context in the U.S. caused most of the leadership overwhelmingly to come from the dominant white Euro-American culture (Dawley & Walsh, 2016). And in fact today, less than 2% of midwives in the US identify as black.
The students of the 'Orphan Generation' are a very different breed of midwife.  In reaction to their laissez faire and largely unorganized learning experience as apprentices, these Midwives became organized.  This era could also be called the era of acronyms because the midwifery organizations formed across the country created a kind of alphabet soup.  Aside from our nurse-midwifery sister's organization of ACNM, the 'Organized Midwives' created MANA, MEAC, NACPM, CfM and NARM, as well as countless state organizations all including the letter M.

​The Midwives Alliance of North America (MANA) was formed in 1982, with the vision and  intention to create a national, inclusive, organizing alliance. They created the Certified Professional Midwife (CPM) certification process, and in 1986, launched The North American Registry of Midwives (NARM) to oversee this process. The Midwifery Education Accreditation Council (MEAC) was formed in 1991 by the National Coalition of Midwifery Educators as a not-for-profit organization.  Citizens for Midwifery (CfM) is a non-profit, volunteer, grassroots organization. Founded by several mothers in 1996, it is the only national consumer-based group promoting the Midwives Model of Care. And finally, The National Association of Certified Professional Midwives (NACPM) is the membership organization specifically representing Certified Professional Midwives (CPM) in the United States. NACPM, formed in 2000 directs its influence toward promoting, developing and strengthening the profession, improving outcomes for childbearing women and their infants, and informing public policy with the values inherent in CPM care.
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This era accomplished a tremendous amount of professionalization, but at a high cost.  There was a lot of burn-out, usually an unsustainable level of income and subtle and not-so-subtle territorialism.  Because of how hard the organized midwives worked to legitimize their work, they clung very tightly to their ideals of practice, and often had very high expectations for their students. 

​Simultaneously, many midwives and students alike, frustrated by the lack of organization in the beginning, and then the lack of recognition in the end, chose to hop careers over to nursing or nurse-midwifery.  Many an L&D nurse or CNM (especially on the west coast) will admit to being a traditional homebirth midwife in the 70's, or 80's.
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These midwives turned away from their grass-roots mentor-midwives, craving structure and systemic steps.  They were the originators of the curriculum for all the Direct Entry midwifery training, but found it hard to put all that they learned, often over many, many years into a succinct 3-year process.  Consequently, midwives from this generation are aggravated when students anxiously 'count their numbers' like eggs before they hatch.
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Ida Darragh, CPM, a midwife in Arkansas and Executive Director of NARM, reiterates, ' A good midwifery education can't just be about the numbers, its about the development of  intuition, and intuition takes time.  You can catch 10 babies in a week and that doesn't teach you as much as following 10 women through their whole pregnancy and postpartum experience."  The challenge, of course, is that we lack enough training sites in our nation.  As interest in the field of out-of-hospital midwifery grows we have far more students than we have preceptors.  Ida agrees: "One-on-one apprenticeship is a very valued way to learn, but its a very slow way to create more midwives.  We need more clinical sites in this country."  This generation of midwives and the next have had many conversations over the years about the balance between time and numbers in student training, and, as of yet, there doesn't seem to be an answer to the challenge of making more midwives quickly, while maintaining our standards of education.  'Right now, CNM's aren't required to have any out-of-hospital birth experience before graduating, and wouldn't it be great if they did, but there is no where for them to get it, and precious few for CPM's to get", adds Ida.

​The major difference between this generation and the next? "The internet," says Ida​ "Communication can happen so efficiently now.  The are no walls, no boundaries, with email we can literally talk with anyone and everyone in the country and the world.  Midwives can Google things at birth.  This technological change and many others and more still coming out is the biggest difference between midwives who came up in midwifery in my generation compared to the next.  I remember when I would send the hand-written notes from my states meeting to the president of the Missouri group and she would send me her's.  Indeed, so much is possible now that wasn't possible in this era.

Modern Midwives 2000s - 2010s

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The Modern Midwives who managed to make it through their 'sink or swim' apprenticeship, are a dedicated lot.  They have rounded many of the sharp edges of midwifery and awakened to their own needs as well of those of mother and babe.

 They have embraced formal education and command an impressive knowledge of anatomy and physiology as well as a strong understanding of all manner of policy and procedures of their obstetric counter-parts.  This era of midwife places a strong emphasis on balance (although, we may not feel we have achieved the elusive work/life balance in our own lives yet).  When asked to comment, Krista Miracle, DEM, a new midwife serving northern Utah said, "the most challenging piece of midwifery, in my opinion today, is the lack of true leadership and positive role models in midwifery necessary to LEAD women to this profession and mentor them successfully. The midwifery model, one of apprenticeship, has led to abuse of power and lack of accountability. Rather than plant, nurture and grow midwives, we are holding hostage their ability to flourish and in turn decreasing the opportunities for them to serve their communities, and those in need, successfully."
​

This generation believes in equal access and inclusion, and has been the driving force behind many initiatives to increase access to the under-served and low-income; honor and research multi-cultural traditions and educate the profession on cultural competency; mainstream the profession in all states; legislate mandated Medicaid reimbursement of services; and increase the numbers of midwives who serve people of color.  The website, Blackmidwives.org was launched in 2002 from the International Center for Traditional Childbearing (ICTC) and has been instrumental in  education and advocacy of this severely under-represented segment of the birthing world.
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AS much as this generation of midwives wants to grow the profession, they seem to be caught in a vicious cycle.  Experienced midwife, Andi Raine, CPM, LM, IBCLC in NE Wisconsin has this to say about her experience practicing midwifery, "The biggest challenge that I've faced in midwifery is bullying. Midwives of this generation and before so often approach their profession with the energy of scarcity because I think they've had to fight so hard to have it. They've had to fight institutionalized birth, they've had to fight to find an apprenticeship, fight to be legal, fight for a good education, fight for legitimacy, fight for the breath and lives of their clients. And that feeling of lacking abundance, and not having sustainability in this work has caused a wary disposition towards our sisters. Bullying is rampant in midwifery, and it's devastating.  There are so few of us that there simply are not alternative peer groups where we can seek support when our local organization is corrupt or disenfranchising.  We have been tormented by witch hunts for generations but have also created our own amongst our tribe. Midwifery is a place where you can get shunned just for practicing someone else's area, or not looking the part. I'm a good midwife and I've had a career attending many hundreds of births over 16 years with excellent outcomes. It's everything I wanted to be when I grew up, and when I'm practicing, I'm fully working within all of my gifts. But I'm leaving midwifery because the hatred shown towards me by other midwives has broken my heart."

Other organizations have also sprung up in support of birthing rights in this era:
  • The Elephant Circle, founded in 2009, with fiscal sponsorship from the Colorado Organization for Latina Opportunity and Reproductive Rights, brings the strength of advocacy, scientific inquiry, information, and education to issues of birth and reproductive justice, protecting mothers, their children, families, and health providers. 
  • The Foundation for the Advancement of Midwifery (FAM) was founded in 2003. Since its inception, FAM has granted funding to more than 40 organizations representing projects and programs across North America including the United States, Canada, Mexico, Indigenous Nations, and Guatemala. Projects have also been funded that benefit the international community in Haiti and Northern Uganda through MamaBaby Haiti and Mother Health International respectively. Programs and projects funded include critical research on the midwifery model of care, training programs for those serving vulnerable populations of birthing women, public education campaigns targeting consumers, students, and policy makers; and capacity building for midwifery education and licensing organizations.
  • The Home Birth Summits bring a cross-section of the maternity care system into one room to discuss improved integration of services for all women and families in the United States. In 2011, 2013, and 2014 the Home Birth Summits convened a multidisciplinary group of leaders, representing all stakeholder perspectives, to address their shared responsibility for care of women who plan home births in the United States.
  • Human Rights in Childbirth believes every woman has the right to be respected as the decision-maker about her own care and her baby’s care.  Every healthcare system should be equipped to meet women’s individual needs and personal decisions around childbirth.  HRiC is committed to supporting the efforts of individuals and organizations working all over the world to promote the fundamental human rights of pregnant people.
  • The Asian & Pacific Islander American Health Forum - Asian Americans (AA), Native Hawaiians and Pacific Islanders (NHPIs) are the fastest growing population in the US. Yet, many AAs and NHPIs still do not have access to high quality services, strong community infrastructure, or a recognized policy voice. The Asian & Pacific Islander American Health Forum (APIAHF) works with communities to mobilize in order to influence policy and to strengthen their community-based organizations to achieve health equity for AAs and NHPIs across the country.
  • National Latina Institute for Reproductive Health (NLIRH) builds Latina power to guarantee the fundamental human right to reproductive health, dignity and justice. NLIRH elevate Latina leaders, mobilize our families and communities, transform the cultural narrative and catalyze policy change.
  • Uzazi Village has been established to decrease the maternal and infant health disparities found in the urban core, particularly among African-American women, but also other at-risk populations residing there.
  • Changing Woman Initiative  seeks to draw on cultural strengths to renew indigenous birth knowledge and healing through holistic approaches and community empowerment. It is focused on developing a culturally centered reproductive wellness and birth center. 
  • Commonsense Childbirth's mission is to inspire change in maternal child healthcare systems worldwide. They believe that ALL women deserve a healthy pregnancy, birth and baby!
  • The Big Push for Midwives provides vital “labor” support to the courageous mothers and midwives nationwide, who sacrifice so much in pushing forward the national movement for out-of-hospital maternity care and birth options, provides public policy and public education experience, highlighting strategies and best practices that have worked, and discusses tactics to avoid that have proven ineffective and empower states to educate more efficiently and effectively for CPM regulation.

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Future Midwives 2020s - 2030s

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Future midwives are current students.  This next generation of midwives express much concern about discrimination and cultural appropriation.  In fact, a current National College of Midwifery student, Jessie Rhoads in California, adds that, "We're not just accepting the way things were, we're not doing things just because that's the way its usually done.  My generation is asking 'why' a lot and finding that the answers don't always amount to evidence-based practice."  

​Additionally, many students report significant hardship with apprenticeships citing: lack of access to preceptors of color; restrictive organizational rules that limit and dictate the order and location in which experience must be gained; a culture of abuse with many preceptors, including the hazing by requiring students to do personal errands, childcare, or menial work for their midwives, sometimes for years before being 'allowed' to participate in patient care; and the high cost associated with getting a midwifery education.

​Jessie goes on to add, "My generation is a lot less 'woo' than our teachers, we want a more clinically-based education - we want to bridge the gaps between the midwifery and obstetrical models."  It seems like this new generation of midwives is ideally poised to tackle the systemic problems in maternity care and co-create a truly integrated health care system.  These students are certainly more visible than any previous generation of students and they are asserting their need for respect.  So, too, are they being handed a much clearer picture of their career path with many more resources than previous generations.

​They have access to 11 MEAC accredited school in as many states, many offering distance education, US Dept of Education title IV funding, and scholarships.  They also have many independent schools that help a student complete the PEP process through NARM.  Additionally, a joint statement among the seven US MERA organizations in 2015 created support for licensure legislation nationally on the condition that it include a requirement for a graduation from a MEAC accredited program or the Midwifery Bridge Certificate.  NARM took up the mantel of creating and certifying already credentialed CPM's in the additional  required 50 accredited continuing education hours within the five-year period prior to application. The continuing education hours must be in specific subjects. More information on the approved courses.  This additional certification may be necessary as some of the last 17 states without a licensure program develop and legislate one and/or in moving us toward state uniformity allowing midwives to transfer licenses easily between states if they move.

​Nikki Helms a southern California student at Nizhoni Institute of Midwifery echo's this enthusiasm about becoming a midwife. "I'm excited to become a midwife because it is part of the extensive legacy of African women brought to this country. I am a Midwife of Color, and that, unfortunately, is a rare thing. I am very proud of returning attention to the work of the hands of my foremothers. I, however have a bit of an anxiety disorder, so all this "being on call" business is for the damned birds."

​

In Conclusion 

Lest anyone take offence where it was not meant, let me state that these generational titles were not meant as another way to isolate or separate, but rather as a way to understand the many parts of the whole and give framework to the future generation who enter this profession frequently missing much of the her-story and the nuanced influences in this profession.  Additionally, it is my strong belief that, just as in society, each previous generation lives in many of the next generations, I believe this is true of midwifery.  We are all in a state of evolution and hopefully all growing toward our best selves in each new era of understanding and professional development.

​Midwifery is expanding at an exponential rate.  According to the American Association of Birth Centers, a new birth center open in the US almost every month.  Homebirth rates have seen as much as a 20% increase in the last decade and for many of the western states the homebirth rate is between 2-6% of the population.  But there is so much room for growth as the national homebirth rate sits just at 1.36%.  I envision an integrated US maternity system where homebirths are encouraged by all maternity providers for low risk women and a national midwifery usage rate is above 50%.  This obviously represents accelerated growth like we've never seen, but luckily we have many successful models of integrated midwifery to learn from in Europe.

​In order to meet the consumer demand and offer safe, competent, evidence-based care in every state, we still need to solve many issues as a profession.  But I believe it is possible.  Please speak up with your solutions and ideas and join me as we live the next era of midwifery!

​
9 Comments

Birth Songs

12/7/2019

1 Comment

 
by Augustine Colebrook

Sing your song

Any experienced midwife will tell you she can 'hear' a woman reach 'complete'.  The sound of birth is fairly ubiquitous - individual and unique for sure - but there's just this sound.  It rattles your jaw and tingles your spine - we midwives just KNOW it's time when we hear it.

Midwives also like to encourage women to be loose and mobile and SING THEIR SONG.

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But what does that mean?

What does it mean to sing your song?  

​This recommendation to pregnant women is akin to telling a nulliparous woman, "you know, how it feels when the baby kicks?"

​No, she doesn't know - she can imagine possibilities, but she has no actual reference for that magical feeling.  So too is it for primiparous women being told to just let go and make sound authentically.  She can imagine various ways that might sound/feel, but she really has no idea until she's in it.

​Singing your song is simply telling your truth.

The Unknown

And this is truly the magic of natural birth in this day and age.  How often are any of us really in 'beginners mind' anymore?  We can google, Wikihow, or YouTube how to do anything. Seriously, ANYTHING.  Except Birth.

​Birth must be felt and experienced. Birth must be lived.  

​No one can adequately prepare you to birth - except you, and your own willingness to walk into the unknown; the shadows.  For some women the unknown is entering the hospital and pondering the different options of pain medications.  For others it's wondering about the pain and how much they can take.  For others still, it's about who will be there and how they will help.

​As much as we'd like to, we can't plan birth anymore than we can plan life.​
"Did you really think you'd be HERE, 5 years ago?"
No matter what we plan, birth demands that we show up and see just what unfolds.  

All women need midwives

Women are stronger than they think, but the degree to which they will believe this or not is entirely dependent on the people that they surround themselves with. The music and books and media they consume are more impactful than some might realize.  An environment free of toxic exposure is just as important for the mother as it is for the baby.

​Here's the real reason all women need midwives - we're literal experts at walking/living without a plan; without a script.  We can't do it for them or even adequately communicate what it feels like.
Just try to explain what opening feels like...
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But we can demonstrate courage in the face of the unknown in our own lives.  We can say, "I too, will walk into the fire."
Courage is an old English word, meaning to speak your whole truth with your whole heart. ​​

With woman


We can sit in all the uncomfortable places in life and choose to smile with courage.  Midwives can model the way.  SO midwives, how are you modeling courage in the face of the unknown in your life?  How are you stepping into your own shadows/fire/underworld?  And who midwifes you?

​Are you singing your song?
1 Comment

"Braving the Wilderness"

11/23/2019

0 Comments

 
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Hey birthy-people – 

Brrrrr - its chilly, and I don’t mean the nights as the weather grows cooler. The national midwifery vibe is chilly as more and more situations of preceptor abuse and discrimination of midwives of color are brought to light.

Unity is what we preach; but rarely what we practice. As the polarization of factions within the midwifery community grows wider – we have an even bigger job ahead of us - bridging the gap in our words and actions.

Our struggle in midwifery is not unique, in fact, it’s just a microcosm of the challenges we face as a nation politically- albeit with less violence. My friend and community elder, Asha, an ally to the disenfranchised and a friend to midwives, an entrepreneur and philanthropist – owner of Pacific Domes, recently lost her son to racial and religious violence in Portland, Oregon. In witnessing her grief, I am reminded of our shared grief at the shocking injustice in our world. She has been a model on how to love in the face of devastating violence and loss. Her grace and her son’s brave actions have inspired me to persevere in finding the illuminated path through to a peaceful place in myself, in my community and in the world.

As a community Midwives have been victim to ‘moral exclusion’. We modern midwives exist with the genetic and soul wounds of generational abuse, marginalization, and delegitimization by our obstetric sisters and brothers and the medical establishment in general. We all have been and/or are currently being excluded from our sovereign rights to be part of the fundamental solution to women’s health care. With so much subtle and not so subtle violence directed at women and midwives (both now and in the recent and distant past), it's no wonder we fight with tooth and nail to establish our ‘place’ within our society. The challenge, of course, is that some of us have forgotten what we’re fighting and speaking for.
​
“Opting out of speaking out because we may get criticized is the definition of privilege” – Brene Brown

Let us all denounce our privilege and speak out for what is right both in our nation and in our profession. Inclusion and tolerance are needed in all areas of our life. Two of my mentors recently had a conversation about this very topic – Marie Forleo interviewed and discussed the profound content of the new book, “Braving the Wilderness” with Brene Brown. So much of this book and video can be applied to midwifery: 


Love & light,
Augustine + team
​​
0 Comments

What a Pain in the ... heartburn

11/9/2019

0 Comments

 
Oh that chest burn that just wouldn't go away; what a drag for pregnant moms...
I recommend some prevention,  a few easy remedies, and an AVOID.

Prevention: First try to avoid getting too full - so snack often, eating 6 meals not 3 every day. If you notice that spicy foods or foods that make you burp increase the heartburn, than obviously avoid them. Try not to eat right before laying down, as the sheer pressure of your growing belly on your squished stomach can increase the leakage of acids into your esophagus.  Also see your chiropractor to have your stomach checked for a diaphragmatic hernia because having part of your stomach caught in your diaphragm will definitely cause heartburn.
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Remedy: Try having raw almonds in your purse and snacking on them periodically, they contain an enzyme that is somewhat neutralizing to stomach acid, also many people find success with Papaya Enzyme pills or lozenges. Our favorite middle-of-the-night remedy is slippery elm bark powder mixed with a little honey. Mix about about a tablespoon of both in a small bowl until a paste is formed, then gum it down. This is especially helpful for middle of the night heartburn. Some people try a glass of milk, but we have heard that heartburn with acidy-milk burps are almost worse.  And the best immediate fix-on-the-go remedy is just chomping on some chia seeds.  Yes, thats right, the old cha-cha-chai pets of our youth have been re-purposed to eliminate heartburn (an make you laugh while singing the theme song in your head). Bonus:
A 1 ounce (28 grams) serving of chia seeds contains:
  • Fiber: 11 grams.
  • Protein: 4 grams.
  • Fat: 9 grams (5 of which are Omega-3s).
  • Calcium: 18% of the RDA.
  • Manganese: 30% of the RDA.
  • Magnesium: 30% of the RDA.
  • Phosphorus: 27% of the RDA.
  • They also contain a decent amount of Zinc, Vitamin B3 (Niacin), Potassium, Vitamin B1 (Thiamine) and Vitamin B2.
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Chia Seeds
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Slippery elm bark powder & honey
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Raw Almonds
Avoid: Tums or other ant-acids with added calcium. The calcium sounds like a good idea but actually is practically non-absorbable and in large doses (as in popping 2 tums every couple days the entire last trimester) forms calcium deposits in the placenta. These deposits of calcium can cause certain small parts of the placenta to die. The calcium deposits may cause some parts of the placenta to be replaced with fibrous tissue. The calcium deposits can also obstruct parts of the placenta with clots of maternal blood which can  harden or block the maternal blood vessels. Calcification can be caused by other factors as well, like just post mature pregnancy, or cigarette smoking.  In most cases, placental calcification does not affect the functioning of the placenta, and the fetus is generally not harmed. But I feel it wise to avoid adding that much of a substance that isn't helpful and can be harmful.
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