Already the World

I’ve loved Victoria Redel’s poetry since I stumbled across her first book of poems for a dollar in the basement of a Saint Paul discount book store. Look at her, coolly facing down the reader in a leather jacket on the back cover - how could I not take her home?

I bought this book in my early twenties, before the idea of becoming a midwife had implanted itself into my consciousness. How satisfying, then, to revisit these poems after years of walking with families through pregnancy, birth and the postpartum wonderment of suddenly cohabiting with an almost alien being.

VictoriaRedel

Redel captures those moments so well - the loss of sovereignty as the pregnancy takes root and can sometimes seem to take over, the bittersweet of the last few weeks as the first separation approaches, and the desperate patience parenting demands.

***

Third Month

At first you were in the mouth,
nausea uncalmable.
Or you were the hard stools of constipation.
At night rocked
over to sleep at a child’s hour,
I slept with pillows layered
to ease my swollen breasts.
In books they claimed you were
no bigger than a fingernail,
but I could feel you, gargantuan,
settling in my body, assuming
what you needed to live,
risking everything
even if it meant risking
mother love.

 

Ninth Month

Already you are moving down.

Already your floating head
engaged in the inlet
from where you will head out.

Already the world, the world.

And you are slipping
down, away from my heart.

 

Psalm

All night pacing.
The baby hanging off my tit.
He has been at it for hours.
Four to be exact.
My one with eyes open
cannot cast himself
out into his blue sleep.
In the darkness singing,
in the darkness singing,
my off-pitched voice
trying every note
to save us both.

Birth is like jazz

In honor of Black Maternal Health Week, here's a birth poem by Elizabeth Alexander. I delved into her poetry after reading her beautiful memoir about the death of her husband, The Light of the World.  

Neonatology

Giving birth is like jazz, something from silence,
then all of it. Long, elegant boats,
blood-boiling sunshine, human cargo,
a handmade kite —

                            Postpartum.
No longer a celebrity, pregnant lady, expectant.
It has happened; you are here,
each dram you drain a step away
from flushed and floating, lush and curled.
Now you are the pink one, the movie star.
It has happened. You are here,

and you sing, mewl, holler, peep,
swallow the light and bubble it back,
shine, contain multitudes, gleam. You

are the new one, the movie star,
and birth is like jazz,
from silence and blood, silence
then everything,

jazz.

Birth at Alta Bates: What you need to know

Although Alta Bates’ long term future is uncertain, it’s still a hub for East Bay maternity care and sees over 600 births a month. That’s down from 700, perhaps due to Kaiser being such a (relatively) attractive plan through Covered California.

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I recently took a tour of Alta Bates Labor and Delivery. I’ve been there dozens of times as a support person, but I was curious to see it through the eyes of an expectant family.

About 12 couples gathered on the first floor in a big room where the tour guide answered questions and walked us through what to do when labor starts. Always call your doctor or midwife first!

Every provider may make a different plan with an individual patient, but as a general rule of thumb, Alta Bates encourages first timers to come in when contractions are coming every four to five minutes, lasting a minute, and that pattern has been in place for two hours. This is colloquially known as 4-1-2, and is a change from the old 4-1-1, with the pattern only lasting for one hour.

As the tour guide explained, “you are better of staying at home for as long as you can” because “birth is not a medical event” and it’s more comfortable to labor at home.

For a second baby (or more), they want to see you when you have been having contractions four minutes apart, lasting one minute, for half an hour. (I am often set up and waiting at the house of a second baby earlier in labor than that - second babies can come quickly!)

Our guide recommended parking in the garage and walking to labor and delivery (third floor) if labor isn’t too advanced. Once you are through triage and admitted, someone can go back out and exchange the parking slip for a $20 flat rate ticket with which the car can come go for 72 hours.

Although our tour guide said that she has “never heard of it being full in 29 years”, I have twice been told when calling to bring in a home or birth center transport that they were too full and we really should go elsewhere.  They can’t refuse to see someone in labor but I have seen patients have to wait in triage for a very long time to get a room.

When we moved up to the third floor to check out the labor and postpartum rooms, a loud moan from triage sent a thrill through the group of mostly first-timers. Later on we heard a newborn’s cry, equally exciting.

(Once, when I was working at a birth center, a woman was birthing down the hall from a full prenatal class. She screamed many times, at high volume, “Pull it the *@$# out of me! Just pull it out of me!” She did a great job birthing her own baby and did not need anyone to pull it out of her, but the shocked faces filing out at the end of class were a sight!)

They have three telemetry units (portable monitoring so that you can have more freedom to move away from the bed), which doesn’t sound like very many, but most people are on continuous monitoring due to pitocin or epidurals. I’ve never seen anyone not be able to get a telemetry unit who wanted one. They will do intermittent monitoring for low risk pregnancies, which to them means 20 minutes out of every hour on the monitors. I will add that sometimes getting what they consider an adequate strip takes more than 20 minutes.

 Not so appetizing... but luckily there are many close food options nearby! 

Not so appetizing... but luckily there are many close food options nearby! 

There are some archaic policies in place. Once admitted, you are not allowed to have solid foods, only liquids. The guide did say that every doctor feels differently and perhaps yours would be willing to override hospital policy, so that is a good question to ask prenatally (keep in mind the whole group of doctors or midwives has to be on board, because you don’t know who you will get in labor). You could be admitted for all sorts of reasons long before active labor (rupture of your membranes, induction) and have to go literally days without eating.

You are only allowed to have four support people in the labor room (including a partner) and one support person in triage. I have seen this be a problem many times during home birth transports, when support people can add up fast. The person in labor usually wants their partner with them in addition to the midwife and maybe a student midwife, a doula, and other family members or friends. It’s especially problematic in triage, when a laboring person may have a partner and a doula or midwife, and important decisions and conversations are happening about the management plan and whether to stay in the hospital.

In comparison, John Muir allows five support people in the delivery room and two in triage and allows eating in labor. I don’t know what the official Kaiser Oakland, San Leandro, and Walnut Creek policies are but at those facilities I’ve seen at least four support people allowed in triage (where the rooms are private) and at least five in delivery rooms.

After about two hours, everyone is moved to a postpartum room, which all have pullout couches for the partner. Alta Bates practices routine rooming-in (meaning your baby doesn’t leave the room except for medical procedures). Most people stay two days after a vaginal birth and three days after a c-section. There is the potential to go home after 24 hours if you ask.

Lactation consultants are available every day from 8am-6pm but they can get busy so you may have to ask to be seen. I recommend that all parents breastfeeding for the first time ask for a lactation consultant to come to their room before they go home from the hospital.

With the exception of four larger rooms in the middle, all the rooms have windows and are small relative to the labor rooms at John Muir or Kaiser Oakland. Ultimately, room size and shininess has a lot less impact on patient satisfaction and outcomes than the nursing care and provider management of labor and delivery. Unfortunately, those are harder to judge from a one hour tour.

 It never hurts to give feedback to any hospital or care provider

It never hurts to give feedback to any hospital or care provider

Personally, I have had many great experiences at Alta Bates and some that left the family and myself wishing for better care.

To some degree, the hospital and provider are the biggest determinants of your mode of birth. No matter how educated or prepared or motivated you are to have a vaginal or natural birth, you are constrained by the policies and approaches of your providers.

For hard data on outcomes by hospital we can turn to Calhospitalcompare.org, which offers statistics on four key indicators of quality in maternity care, most importantly, the c-section rate for a population that should be largely low risk: first babies, at term, singletons, and head down. They also look at breastfeeding, episiotomy, and VBAC (vaginal birth after cesarean) rates.

In a comparison between Alta Bates, Highland, and John Muir, Highland clearly comes in ahead. If you strongly desire a vaginal birth, and given that Alta Bates has a 19.4 % c-section rate, John Muir’s is 23% and Highland’s is 13.3%, I would choose Highland any day. Likewise on the episiotomies, which Highland reports at less than half the rate (1.3%) of Alta Bates (2.8%) and John Muir (7.2%).

Alta Bates and Highland have almost identical VBAC success rates at 33.2 and 33.8%, respectively. John Muir is much lower at 20.8%. Interestingly, Highland’s breastfeeding rate is the worst. There isn’t any information given on the website about how that outcome is measured. Any initiation of breastfeeding? Exclusive breastfeeding at discharge or at six weeks?

Unfortunately, in our byzantine insurance system, you may not have much of a choice. I recommend calling your insurance company to find out which hospitals are in-network. If Alta Bates is your only option, rest assured that you are still likely to receive quality care.

Letter to Malakai

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Hi little one.  Its me your auntie Erin.  I am writing my perspective of your arrival here into this world.  

I had been on-call to fly down to Oakland from Orcas Island since the middle of November.  Your momma thought you would come early so by the time her due date of Thanksgiving came and went, we were all very eager for your birthday!  Your momma and I talked on the phone every day.  She was loving her last days of being pregnant with you, what she called "the in-between time".  On December 1st, the midwives checked her and her cervix was 3cm dilated,  almost fully "effaced" and she had had a few contractions that woke her in the night.  So we made the decision that I would fly down the next day.  December 2-5 were sweet, sunny days, long, full super-moon nights.   It was like being on vacation, enjoying this sweet time with my best friend before she would become a mom.

One day, we got kimchi, persimmons and mandarin oranges from an old hippie selling his goods from a trailer on the way to a beautiful hike in Tennessee Valley to an incredible black sand beach where we spent the afternoon laying in the sunshine, laughing, sharing memories and dreaming about the future.  Another day, we ate Burmese take out, hiked in the Berkeley Hills, walked to the Essex tub house where we lazed around naked under the redwoods. I gave your mom lots of massage with clary sage oil, we got acupuncture together, your mom knitted, your dad tried to work remotely and we all enjoyed a sense of timelessness and being in the mystery, knowing you would be born any day but not knowing when.

We were sure the full moon would pull you earthside so when that passed, your momma was ready to help nudge the birth process gently.  She had several periods of having mild contractions over the past week but nothing that progressed in time or intensity.  Tuesday she took a cocktail of lemon verbena and castor oil twice and used a breast pump to get things started and waves of contractions came but then left.  You were still not ready.  The next day, Wednesday, your momma took more castor oil and her midwife Ellen came over and swept her membranes, feeling the cervix was even more ready.  She said there was a 99.9% chance you'd be born that day or the next. 

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I went to a yoga class and came back to your parents sweet apartment around 2pm.  Your mamma was in the bedroom having mild but consistent contractions that were coming every 4 min. but would lessen if she interacted with anyone.  She wanted to be alone.  Your papa was quietly working on his computer in the living room.  Around 2:30 your mom and I left for a walk to see if things might progress.  They sure did!  We were walking around the neighborhood and contractions started coming on stronger and stronger.  Every few minutes your mom would lean into me, we embraced and swayed as I rubbed her low back and she moaned.  A man passed us walking his dog, another man got into his work truck, and life continued on in a dreamy, surreal way around us as it became clear we needed to make our way back to where your mom wanted to be to give birth to you.  Castor oil, however, does a number on the bowels and suddenly we needed a bathroom asap.  I saw a portapotty in a front yard of a house that was being remodeled.  I ran inside to ask the carpenters in Spanish if we could use the bathroom and barely waited for their nod before running outside to help your mom onto the toilet.  Inside that green plastic porta potty, there was a moment of truth (and some fear); this labor was really finally happening and happening fast and strong and there was a gush of fluids.  We needed to get back to apartment 2 blocks, 1 big intersection and 4 flights of stairs away.  One step at a time, stopping on the sidewalk for contractions, we finally made it back to the apartment building on Telegraph Ave and up the stairs to your parents home by around 3:15pm.

As soon as we entered the door I told your papa to call the midwives and get the birth tub set up.  Daniel sprung to action.  Rebecca went straight to the bedroom and I followed.    The next moments felt hectic and wild as we all adjusted to what we'd all been waiting so many days for.  A text went out to close friends and family, the midwives and Laura, your moms therapist, were called and the tub was getting inflated in the living room.  I supported your momma as she surrendered to increasingly stronger waves of sensation in her body.  Intense waves of nausea pulsed through your momma and I was baptized with her purges.  Within a half hour Renee the midwife arrived and found us in the bedroom getting through one moment at a time.  We moved into the bathroom and the golden light of winter's sunset glowed through the window above your mamma's head as she sat on the toilet.  The day was turning to night.  More purging on the toilet thanks to the castor oil and we all become hypervigilent about hydrating your mom from here on out.  

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Your momma wanted to be in warm water but the birth tub wasn't filled yet so I filled up the bathtub in the bathroom.  She labored in the tub for quite awhile.  She moaned and surrendered through each intense wave.  In between waves, she shared her fears with us about how chaotic it all felt, how intense it was.  We reminded her to let her body go into total relaxation in between the contractions.  I sang to her, "You are opening up in sweet surrender to the luminous love light of the One, you are opening, you are opening..."

At some point Laura, your mom's therapist, arrived to provide a sweet, peaceful presence.  Your papa turned on beautiful music that felt timeless and sacred.  I lit candles around the apartment, burned white sage and we thawed soup in preparation for after the birth.  I could tell this labor was happening fast and that you would be born that night.  

Your mom, however, was feeling lost in the intensity of it all and we reminded her constantly of her strength and helped her stay in the moment.  We let her complain and curse, a few times she exclaimed, "oh heavens" which I thought was old fashioned and endearing.  Your papa reminded her of how much he loved her.  

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The next phase of labor was a moving constellation between trying the big birth tub in the living room for 10-15 minutes (which your mom didn't like), being on the toilet, and on the bed in the bedroom.  The midwife Ellen arrived.  At one point all 6 of us were crammed in the little bathroom while your momma labored on the toilet.  The midwives regularly checked your heartbeat and we could hear your strong heartbeat throughout the birth.  We kept your mom hydrated, we fanned her, we kissed her and we moaned with her.  Although she was the only feeling her body open to the universal energy of birth and it was the scariest and most painful thing she'd ever experienced, she was not alone.  She was naked except for the necklace of beads given to her by her dearest girlfriends at her Mother Blessing ceremony and at one moment she clutched the necklace saying, "help me".  She prayed to God, she remembered her ancestors and all the women who had given birth before her.  She was healing her own birth trauma.  She was connecting to you moving through her bones.  I believe because she was so fully surrendering, she dilated so quickly.  And it was scary for her.  She had moments of doubt and of feeling so out of control but each time she felt that, we brought her back and reminded her of her strength and her power.  

She asked Renee to check her dilation because if she wasn't very dilated she was threatening to go to the hospital.  I was sure this wasn't the case.  We moved from the bathroom to the bedroom where after checking Renee announced there was no more cervix, she was fully dilated and there was a bulging bag of waters still cushioning your head.  This was around 5:30pm.  Rebecca began to feel urges to bear down and we moved back to the bathroom where sitting on the toilet felt most comfortable and where opening up to bear down felt easiest.  Each contraction now was your mom pulling me into her arms, tapping her hand against my back and groaning like a momma bear.  I could feel her entire belly surge up and then down against my own belly which had done the same thing 2.5 years ago when I birthed my baby Matia.  I felt merged with your momma in these moments, allowing her all my loving power as another woman who had done this before.  I had total faith in her power and in her body and in you.  A few times between pushes, she said, "I cant believe how powerful my body is!" Everyone in the tiny bathroom was present to her primal power.  Your papa cheered her on with each push.  Between contractions, she would let go into a deep trance of exhaustion and altered consciousness.  She reached her fingers in to feel your head at one point, yes she could actually feel you coming down the birth canal.  At some point,  there was a "pop" as the bag of waters finally broke.  Because your birth was so fast, the order of what happened when is a blur to some degree.  

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We all moved into the bedroom since your mom didn't want to give birth to you on the toilet:)  The room was aglow in candlelight, that same ancient music floated through the apartment and there was a sacred stillness between each series of pushes.  Your momma could feel your head moving down and out, your papa watched in awe as your head began to be visible.  Your mom got onto all fours and I stayed by her head to cheer her on while everyone else watched your head slowly emerge.  Your head finally emerged, chubby cheeks and all and your whole body came into this world at 7:37pm on December 6, 2017.  Your papa was crying as he helped bring you onto your mamma's belly.  Your papa whispered a secret blessing into your ear.  The lights were turned on so the midwives could see.  You were perfect.  You sputtered a few squeaky cries as your momma held you and your parents welcomed you.  

The next 5 hours were spent taking care of you and your momma.  I made food for your parents; congee, black sesame paste, mung beans, kale, warms teas. You found your mommas nipples to suckle on.  You stayed skin to skin with your momma and your papa.  Your placenta came out and you got to stay attached to it for awhile.  Lots of photos were taken and your extended family was notified of the wonderful news of your arrival.  The midwives cared for your momma while the support team cleaned up.  Your parents were busy falling in love with every little part of you.  

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I hope one day you'll know how blessed your birth was.  To be born in the comfort of a home, to be welcomed in such a holy way by such loving parents who were so fully loved and supported by their intimate, chosen birth team.  Your mom fully empowered.  No interventions.  May this way you came into the world imprint upon you love, trust, safety, and life long bonding with your parents.  May you know in your cells that you entered this world in love.

I hope to know you and witness you and love you for a long, long time.  Your momma is like the sister I never had, so that makes you like a nephew to me.  I love you and your parents very much.

Kaiser Oakland's New Midwifery Care Offering

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Kaiser members have been flocking to Walnut Creek in search of less medicalized births, and Kaiser Oakland has finally taken notice. In an attempt to draw back birthing women to Oakland, and to improve the hospital’s poor maternity care rankings, they have brought in six midwives, and with them, some big changes. 

Head midwife Anne Galko sat down with a roomful of doulas last week to give them the skinny on the new structure. As a home birth midwife, I attended the meeting with my colleague Firen Jones, glad for a chance to scope out the hospital. Although we mostly attend planned home births, we accompany the occasional transport or monitrice client to the hospital, so we like to know what to expect. There is much to be glad about, although the structural integration of the midwifery team is unusual. And there are certainly some areas that still need improvement.

First, the fact that meeting took place at all and that Anne was willing to meet is encouraging. While many hospitals around the country are still openly or passively hostile to doulas, birthing women are better served when hospitals recognize that doulas have become important members of the care team. Anne’s commitments to welcoming doulas and maintaining dialogue and transparency are commendable. 

The new midwife team is atypical in that they are there to teach the residents about normal birth, not to give direct midwifery care to patients. Midwives will not be providing any prenatal or outpatient postpartum care. The six staff midwives supervise all first- and second-year residents for births, and will be available around the clock except for Saturday and Sunday from 8am to 8pm. Anne hopes that eventually they will be able to add those shifts. Any women designated as low-risk will be managed by the resident/midwife team — including vaginal births after cesareans (VBACs). Higher risk laboring women will be managed by third- and fourth-year residents and a supervising obstetrician. 

Anne was clear that residents are supposed to check in with the supervising midwife before they intervene in any way, such as breaking a bag of waters or performing a vaginal exam. You cannot request a midwife without the resident — they come as a package deal. Although this will frustrate many women who would prefer to have just a midwife, the silver lining is that the residents will get plenty of experience with midwifery care.

There are lots of positives about the new hospital and team:

  • There is routine delayed cord clamping of one minute for cesareans.
  • They are trying hard to increase skin to skin between mother and newborn.
  • They are getting a TENS unit and nitrous oxide for pain relief.
  • Every room has more bells and whistles than in the old building, such as showers, fridges, rocking chairs, mirrors, and screens that can play calming music and meditation videos.
  • Every room has portable monitoring units (telemetry), meaning that women don’t have to compete for one or two telemetry units.
  • Low risk women can have intermittent monitoring. The protocol is to listen through two contractions every 30 minutes, and then to have continuous monitoring for 20 minutes every two hours. 
  • Out-of-hospital midwives will be happy to know that clients who choose not to screen for Group B Step prenatally, and transport in labor to Kaiser Oakland, will be treated with antibiotics only with risk factors (greater than 18 hours of ruptured membranes, less than 37 weeks gestation, fever).
  • The hospital will not terminate care with people who refuse postdates inductions — although I imagine the pressure to induce from the staff will be extreme at 42 weeks.

Unfortunately, there are some major areas in which the built environment and protocols are far from the midwifery model of care. A huge drawback of the new facility is that it does not have a single water birth tub. Every room has a shower, but I am shocked — perhaps naively — that a new hospital could be built in this day and age without even a single tub in which to labor, let alone birth. With ample evidence of safety and benefits, I just don’t understand the deep-rooted fear the obstetric profession has of water birth.

Also defying current research, birthing women are not allowed to eat anything in active labor, although they may continue to drink fluids. Active labor is defined by Kaiser as six centimeters, instead of the more common four, but still, many women need some energy in the form of food to keep going through a long labor.

The ability for women to freely eat and drink in labor is part of the Ten Steps of the Mother-Friendly Childbirth Initiative, endorsed by the American College of Nurse Midwives and the Midwives Alliance of North America. A Cochrane review from 2013 concludes that “there is no justification for the restriction of fluids and food in labour for women at low risk of complications”. Kaiser has no evidence base to support this punishing policy. 

There are some other questionable protocols: 

  • Heavy use of Misoprostol inductions, despite a controversial risk profile.
  • Routine Pitocin shots after the birth of the baby.
  • Only three support people are allowed in the birth room. I’ve personally been to lots of births where the mother wanted more than three support people with her at some point. There’s definitely a place for clearing the room in certain circumstances, but having a blanket policy about something so personal and subjective is ridiculous.
  • The protocols around spontaneous rupture of membranes (SROM) don’t make much sense. Women are supposed to go to the hospital immediately upon SROM for evaluation. If they refuse induction, they are told to remain in the hospital, and can only go home to wait for labor Against Medical Advice, even though the risk of infection is higher in the hospital.
  • All women receive a routine ultrasound to check for breech at 36 weeks. We’re not sure if this means that there is no palpation being done prenatally or if the obstetricians don’t trust their palpation skills. Either way, it’s strange. 

The doulas also raised a number of issues that their clients have experienced at the old and new Oakland hospital, which Anne promised to investigate. The list includes availability of hot postpartum meals, mandatory ultrasounds in triage, doulas not being allowed in the operating room, and nurses placing towels between newborns and mothers immediately after birth instead of facilitating skin to skin. 

A Kaiser member myself, I will definitely switch to a different insurance company if I ever plan a pregnancy, because they are one of few companies that offer zero coverage for out-of-hospital birth. But all in all, the introduction of midwives at Kaiser Oakland can only benefit families planning a hospital birth. I believe Anne Galko and her team have every intent of bringing better care to the new Kaiser Oakland, despite some institutional barriers. I hope they succeed.