The trouble is, most care providers are only familiar with the classic tongue-tie.  Lip-ties and posterior tongue-ties are similar structural obstacles to nursing that are typically overlooked by most of us midwives, pediatricians, even lactation consultants because we simply aren’t aware of them;  We were never taught to look for them.

A Class II maxillary frenum attachment, or lip tie.

Unlike my son who nursed voraciously (and hourly), my daughter had a loose and lazy latch, and only nursed for short spurts as a newborn.  I checked under her tongue to see if she was tongue-tied, and she wasn’t.  She did eventually learn to latch well enough to get enough milk to feel satisfied and gain weight — albeit slowly.  Looking back on those first six months, I was so sleep deprived and busy trying to stay connected to my three year-old that it hadn’t occurred to me that she might have some other structural or oral-motor problem contributing to her poor latch.

My familiarity with lip-ties and posterior tongue-ties came only after the subject was introduced in my allergy support group.  Through our own research,  many of us figured out we had babies and kids with these pronounced lip-ties who couldn’t latch or feed well,  had major tooth decay on the upper front teeth or had speech challenges.

Lip-ties occur when the upper lip is tightly attached to the gums or between the teeth.  The diagnosis of lip-tie is relatively new and we do not know how prevalent they are. A recent Greek study revealed a rate of nearly 50% for class 3 and 4 lip-ties among school children.  The incidence of tongue-tie is estimated between 4-12%  although that may be a low estimate considering the difficulty in diagnosing posterior ties.  It is not clear why tongue and lip ties are so prevalent. Some literature lumps them in with a handful of other midline defects which are associated with low folate levels (that’s a story for another post) but their origin appears to be largely unknown.

I’d like to share with you what I’ve learned, as well as some of our stories, to help mothers and midwives be on the lookout for any of these structural problems when you have a baby who is struggling to latch or gain weight. (This post is intended only as a primer.  I have included resources below for learning more).

Signs and Symptoms of lip and tongue ties:

Infants:
poor/weak latch, cannot stay latched; cannot empty the breast;  gums the breast/nipple; clicking while nursing or feeding; nurses for long periods; gassy, “colicy,” or reflux; back arching; always hungry/up all night nursing; poor weight gain; “failure to thrive;”  can’t use a pacifier; tooth decay on the upper front teeth (in cases of lip ties).

Children:
challenges chewing or swallowing; speech delays or difficulty with certain sounds; gap between the two front teeth; tooth decay on the upper front teeth (in cases of lip ties).

Moms:
flat, creased, misshapen or white nipples after nursing; nipple pain, discomfort with nursing;  cracked/bleeding nipples; plugged ducts/mastitis/full breasts that don’t empty.

Lip Ties

Upper lip-ties occur when the small flap of tissue connecting the upper lip to the gums, called the maxillary or labial frenum (or frenulum), is so short and tight that it restricts movement of the upper lip.  It may make it impossible to fully flange the upper lip upward toward the nose, or it may blanch white as it is extended.  Most people have a minimal maxillary frenum attachment that can be felt by running your tongue back and forth along the upper gum line.  Severe lip-ties can extend all the way down between the front teeth, forcing them apart and creating a gap.  The following photos illustrate the degrees of attachment classified by Dr. Lawrence A. Kotloff, a pediatric dentist and expert on lip-ties and their repair.  Class 1 (not shown) is a normal attachment where no significant skin can felt or seen along the upper gum line back and forth.

Class II frenum attachments
insert into the gums above the teeth.

Class III frenum attachments insert just at or between the front teeth, often creating a telltale gape between the teeth.

Class IV frenum attachments wrap all the way around to the palate behind the teeth. leaving the telltale gap between the two front teeth.

Lip-ties can impede a baby’s ability to latch onto the breast well by  1) restricting the upper lip from flanging out (like the bottom lip flanges out),  2) by causing it to tuck inward or  3) by preventing a tight seal from being formed around the areaola, leading to clicky, noisy nursing and swallowing air.  Some babies with lip-ties have no trouble nursing, no tooth decay issues, and no speech problems.  Tight lip-ties will often stretch and tear on their own during the course of normal childhood tumbles and falls.  After I discovered my daughter’s lip-tie I thoroughly checked out my son’s mouth and saw that his tie was more pronounced than hers but appeared to have naturally torn on its own.

Lip-ties can be revised surgically or by laser. Laser revision is preferable for a few reasons.  It can be performed in the office, does not require anesthesia, is over in about a minute, does not require sutures, and babies are immediately able to nurse following the procedure.  Unfortunately pediatric dentists specializing in laser repair are few and far between, and most dentists and physicians only have experience with surgical repairs (which are more traumatic to the tissues and require suture and usually anesthesia).  I’ve listed a few pediatric specialists below.  The procedure is termed interchangeably in the literature: frenectomy, frenotomy, and frenulotomy.

In evaluating whether or not an infant or child would benefit from a maxillary frenulum (lip-tie) revision, Dr. Kotlow considers the following questions:

1. Is the frenum creating a diastema (gap) between the maxillary central Incisors?

2. Will revision of the frenum prevent an orthodontic problem such as a gap or diastema from developing or remaining in when all the permanent teeth erupt into the mouth?

3. Does the frenum interfere with normal lip position? Does this effect eating [latching, or breastfeeding]? Does the lip get stuck between the front teeth?

4. Does the frenum make oral hygiene care difficult?  Is there bleeding?  Does the frenum contribute to caries formation or post treatment home care?

5. Has the frenum area been subject to repeated trauma?  [Has the frenulum already torn on its own?]

Tongue-ties (ankyloglossia)

A tongue is “tied” when the lingual frenum (the stretch of tissue that attaches the tongue to the floor of the mouth) is short and tight, restricting the movement of the tongue.  The tongue may not be able to extend out past the lower lip and usually the tip of the tongue cannot touch the roof of the mouth when the mouth is wide open.  Tongue-ties may cause many of the same problems as lip-ties: poor latch or feeding, challenges with speech and forming certain sounds, digestive troubles, etc.

Tongue-tie in an adult

There are different types of tongue-ties. the ‘classic’ or anterior tongue-tie is one most familiar to practitioners.  It is easily seen when the tongue is lifted and it can be felt with a finger swept underneath the tongue.  It has been referred to as feeling a speed bump, fence or ridge in the bottom of the mouth.  Classification of tongue-tie severity can be found on Dr. Kotlow’s site.  Another type, the ‘posterior tongue-tie’ (or PTT) is also called a ‘hidden’ tongue-tie because it is not easily seen or felt.  Posterior tongue ties attach towards the back of the mouth and under the mucosa, out of sight.  While the classic is perceived to be the more common type, one children’s hospital reports that more than half of the revisions they perform are on posterior ties.

A heart-shaped tongue tip is a common feature of tongue-ties.

Most infant and child healthcare providers are not trained to diagnose posterior tongue-ties.  Some may be aware of them, but only know to assess one sign — how far the tongue extends beyond the lips, which alone is not a sufficient for a diagnosis.  This is why, if you suspect a tongue-tie in your child, it is so important to take them to someone who really knows the ins and outs of detecting these ties. In the absence of a wise lactation consultant, a knowledgeable pediatric dentist may be best person to evaluate your baby for tongue and lip-ties, and then do the repair if necessary (resources below).

Tongue-ties can be easily be revised by a quick snip of the frenulum.  This procedure is referred to interchangeably in the literature as frenectomy, frenotomy and frenultomy.  Historically, snips were  performed after birth by the midwife or attendant.  Nowadays snipping at birth is uncommon;  Birth providers lack the skills and/or necessary tools (and may also fear excess bleeding/VKDB or infection).  Tongue-ties can be snipped at any time and often do not require anesthesia, although toddlers may be more difficult to repair on account of the wiggle/fear factor.

For babies, breastfeeding in positions where baby is on top or with the head hyper-extended, e.g. the ‘biological nurturing’ style may help them to latch better than in cradle or football holds.  Here is a helpful step-by-step guide to evaluating your baby for anterior and posterior tongue tie and a short video demonstrating one way to check for posterior tongue tie.

Mother’s Stories:

Mama Leigh and Rostick
When Rostik was born, he was fine, but over the next few days he got more and more agitated, and was resisting latching on. Then on the third day he had ZERO in his diapers. (Good thing I was keeping a record). So there we were around 8pm, with him screaming nonstop, and I said “I must be doing something wrong.” I had gotten a recommendation for a postpartum doula, so I called her. She said she thought he was tongue-tied and gave us the number for Dr. Coryllos. In the meantime she showed me how to hand express but there was almost nothing since I hadn’t had any stimulation from Rostick. My father drove around looking for somewhere to buy formula that was open in the middle of the night, and we cup-fed him. Every hour round the clock he woke up wanting to guzzle down a ton of formula. First thing in the morning we rented a pump to try to bring my milk in and to give him whatever I could get out so he would have less formula.

Mama Heidi and Lucas
A nurse pointed out Lucas’ tongue tie after his birth, but nobody mentioned that it might be a problem. I noticed Mike had an almost identical tie and they both have the same cleft chin. Lucas was in and out of the hospital his first 10 days for jaundice, and by the end of the first week nursing was very painful. I called the lactation consultant at the hospital and she gave me tips to increase my supply, but offered no advice on the tie. At his 2 week checkup he was still down quite a bit from his birth weight so I asked the pediatrician if his tongue tie could be the reason for the pain and the slow weight gain. The pedi told me his tie wasn’t severe and wasn’t the cause of either the nipple pain or the slow weight gain, but gave me a can of formula because he needed to gain weight. I didn’t feed him the formula. He nursed for 1.5 hrs, every 3 hrs, around the clock. The pain was intense. At one point in the middle of the night I told Mike to go to the store and buy a can of formula because I was just done. He refused (and I’m glad) and we persevered.At around 5 weeks I asked my sister if this pain was normal. She said no, of course not. I called a new pediatrician and made an appointment for later that week.  At the appointment, Lucas was around 7.5 lbs (his birth weight was 6lbs15oz) and the doctor immediately recognized his tie. We put him on his back on the table and the doctor clamped his frenulum then cut the tie while I held Lucas. This took maybe 30 seconds. I picked Lucas up and immediately nursed him, which stopped the bleeding. I could feel an immediate difference. It still hurt, but his latch was better.We scheduled a follow-up for 2 weeks later to coincide with his 2 month checkup. At that appointment, we found that he’d gained more in that 2 weeks than he had in the previous 4 weeks. The doctor took a look at his tongue and decided to clip just a bit more. Same procedure as before. I was still in a bit of pain – my nipples were very bruised and Lucas had developed a bad habit of nursing with his gums. About a week later – I remember Mike was taping up the windows for Hurricane Rita – I noticed that nursing didn’t hurt anymore. At all.

Mama Heather and Isabel
I’ve always had a lot of pain in the early days of nursing my babies.  It wasn’t until my fourth baby was 2 months old that I finally realized why: they were all tongue-tied.  None had a severe, anterior tie, but all four had significant posterior ties.  My daughter had a variety of nursing issues, including choking, gagging, apnea, and tiring out, at which point she would unlatch and let a mouthful of milk drain out of her mouth.  She had a shallow latch and my nipple would be “lipstick shaped” after every nursing.  Her tongue didn’t elevate when she cried and didn’t pass her lower gum line.  I pursued a variety of options for getting her tongue clipped but found difficulty because it was “only” posterior.  After seeing a doctor one morning who told me, cheerily, that she was, “Just fine!,” I drove an hour to a midwife who could clip it that afternoon.  An hour later, she stuck out her tongue for the first time!  Nursing improved with the dribbling, choking, and apnea ceasing.  Her latch was still fairly shallow and she still has a tendency to cause the “lipstick shape” on my nipples.  An experienced ENT has confirmed that she still has some tie that should be revised.  While we have yet to get a second clip, she is still nursing at 20-months-old and has a wide range of movement for her tongue.  She is highly verbal and can make sounds that her older, tongue-tied brother cannot.  I smile every time she sticks her tongue out!  It’s a reminder that the struggle to get her tongue revised was entirely worth it.

Mama Cori and Cady, Sadie, Maya
I emailed Dr. Kotlow to ask for a referral to someone local who could help me determine whether my girls had significant frenulums that would benefit from a revision.  He replied the next morning (a Sunday!) indicating there was no one here in Florida.  I emailed him photos of their mouths which he reviewed and responded with a ‘yes’ or a ‘maybe’ to each one. He was especially convinced when I mentioned that Maya, one of the ‘maybes’ for lingual tie, also had digestive and speech problems. He said to call his office on Monday to schedule appointments if we wanted to come up. The following thursday we left home at 4:00 AM and landed in Albany at noon.  A short cab ride later we were at Dr. Kotlow’s office. Each of the older girls had Novocaine, laughing gas, and Tylenol with their frenectomies. Cady, my 4 month old, had no medication whatsoever due to a corn allergy but was swaddled during the surgery. Since her repair a few days ago, Cady has been nursing more aggressively, less frequently, and hardly spitting up at all.  She is also vocalizing quite a bit more and seems to be enjoying her free moving tongue!  We are hoping to prevent further problems that can arise when these ties are overlooked, such as those experienced by her older sisters. Sadie was 7 at time of her repair. She was a colicky baby and in hindsight I believe her severe lip tie prevented her from sucking on a bottle or pacifier properly and caused her to wean over a year earlier than my other children. She now has a 3-4 mm gap between her two front teeth. We were told by a former dentist that she would need braces to bring them together. Since her repair, the extra tissue between her front teeth is now gone and her teeth are expected to move together naturally. She will still need orthodontic care for palate expansion, but we hope to avoid braces. Maya was 9 at the time of her repair. By age 2 she had severe dental decay and needed caps put on her teeth. The remaining nubs of her front teeth rotted away and she had an adorable, but unfortunate, toothless grin for years until the adult teeth grew in. Around age 2 we also noticed she was having speech problems and had her evaluated by a speech pathologist.  Deficits, yes, but for her age it was OK. Finally, in third grade, her teacher referred her to speech therapy again and this time they agreed she had a problem.  She worked hard but didn’t get very noticeable results. Since her frenectomy, her speech is nearly perfect.  Within seconds of the surgery it was better!  Speech therapy had taught her how to speak, but the surgery allowed her tongue to cooperate finally.  She also reports that eating is much easier now (we had lamb steak the other night and I didn’t hear one complaint out of her).  She has not had any reflux since surgery. In all, the 3 girls’ laser surgeries cost $1450 out-of-pocket, and I understand some insurance will cover it.  That’s pennies compared to all the dental work (past and future) it could prevent, the pain and suffering from poor digestion, the social cost of a speech impairment, and the risks associated with early weaning.

More Reading

Tongue Tie – a good general site with detailed information on types of revision
Articles from Lawrence A. Kotlow, D.D.S., P.C. on tongue-ties, lip-ties, and frenectomy
Brian Palmer’s extensive frenulum presentation with case histories (adults and children) More tongue-tie photos
Top 10 Tongue-tie Myths
The kindest Cut? The Emotional Impact of the Tongue-Tie Maze
Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial

Providers offering surgical and laser frenectomies (If you have a good reference to add, please let me know)
National Databank of Providers

Florida – Denise Punger MD

Missouri – Amy Grawey MD,  James Maxwell MD

New York – Lawrence Kotlow DDS

Utah – Branton Richter DDS

Virginia – Ashburn Children’s Denstisty

The concept is alluringly pseduo-natural. Maybe this is your body harmony with the four seasons?

What is so disturbing about this new birth control pill is not that it is available, but that the pharmaceutical industry has positioned itself to convince physicians, nurse-practitioners and midwives that it ‘knows’ what women want.   Suddenly big pharma understands the needs and desires of fifth-wave feminists?

I’ve used the pill (also called OCPs, or “oral contraceptives”) a few times in my teens and twenties.  Back then, birth control pills seemed like the best fit for me. They weren’t messy, they weren’t scary in the way that IUDs or injections were, or freaky the way implants were.  And they worked.  The pill was commonly pushed by OB/GYNs as such a benign medication that women could essentially forget they were taking a daily dose of synthetic hormones every day — I did, until I recognized that some of my new symptoms were the result of the additional hormone load.  I remember feeling like some other entity had come in and taken up residence in my body.  In a sense, I lost connection with myself.

Despite my personal experiences with birth control pills, I am ALL for choices in contraception.  I do wish the trade-off for effective birth control was not exposure to more exogenous hormones and an increased risk of certain cancers.  Pills like Seasonique™  expose women to an additional 13 weeks of exogenous hormones over the regular combined OCPs.  As an American woman I have a 1 in 8 chance of developing breast cancer in my lifetime — much higher odds than developing ovarian or uterine cancer.  Birth control pills slightly decrease the risk of ovarian and uterine cancer, while potentially increasing the risk of breast and liver cancer in some women.

In 2006, the Mayo Clinic determined that women who used the pill before their first pregnancies had a 44% higher risk of breast cancer than women who had not used the pill.  Yet, in a MAYO article discussing the use of birth control pills, the only noteworthy side effect mentioned is spotting.  ”You may notice bleeding or spotting between periods (breakthrough bleeding) when you extend the number of days between periods.”

Beyond the cancer risk, decades of research on traditional OCPs is clear about the other major risks including heart disease, stroke, and blood clots.  There are NO  long-term studies (more than a few years) on birth control pills like Seasonique™ to alter our cycles and eradicate a portion of our menses.

What price are we willing to pay for “seasonal” periods,  now that they are an option? Are we willing to be guinea pigs?

Seasonique™ can limit our monthly menses to mere seasonal inconveniences — until Annuelle™ comes on the market.

While doing a quick search for background information on Seasonique™  I learned that in 2004 the pharmaceutical industry is estimated to have spent spend $57.5 BILLION dollars on advertising.  Yes, that’s almost 58 BILLION dollars on advertising.  (Did that register?)  Big pharma spends TWICE as much on advertising as it spends on research, quality and safety control, and development of existing and new medications.  I also learned that maker of Seasonique, Teva Pharmaceuticals, was sued for Medicaid fraud in 2003 by the state of Massachusetts along with 12 other drug makers.  These companies allegedly inflated the prices of their medications, causing Medicaid to waste tens of millions of dollars in inflated reimbursements.  Think about the grandparents who have to choose between eating and fulfilling their prescriptions while the folks at Teva Pharmaceuticals are raking in obscene profits.  All 13 companies in the Mass Medicaid fraud suit settled, returning roughly $23 million dollars back to the state’s Medicaid program.

It is no secret that drug companies have a major influence over which drugs physicians prescribe.  In 2000, drug companies spent over $20 BILLION dollars on private sales meetings between their drug reps and physicians.  Big pharma knows from experience that targeting susceptible physicians will ensure humongous profits. A former drug rep for Eli Lilly describes the nature of the drug rep/physician relationship:

It’s my job to figure out what a physician’s price is. For some it’s dinner at the finest restaurants, for others it’s enough convincing data to let them prescribe confidently and for others it’s my attention and friendship…but at the most basic level, everything is for sale and everything is an exchange.    —Shahram Ahari

Think about this the next time you are discussing birth control options with your OB/GYN — or any medications for that matter.  I would like to believe that ethics would prevail and providers would place true informed choice about the risks and benefits of medications above cozy perks from the drug reps.  But I recall my own experiences.  I fear for young women going in for well-woman exams and birth control.  They are likely to come home with free packs of pills, completely unaware of the money, advertising, and unethical schmoozing involved in getting those pills to the providers desk.

I want the pharmaceutical industry to adopt a shred of decency and stop inventing and selling made-up conditions to women, and start spending more money on making safer drugs than on advertising them to us.  I want honest discussion about the possible risks. I want safer choices.  What do you want?

I am stunned and saddened by Ms.Tuteur’s hate-filled critique. Rather than commenting directly on my blog, where I welcome sensible debate and where we could have engaged in a meaningful discussion, she deliberately exploited my statements out of context in what amounts to a personal assault on me and on the greater body of midwives in the US.

I use hemorrhage to illustrate the larger point that events in typical hospital births — and their outcomes — cannot automatically be extrapolated to out-of-hospital settings. Missing this point entirely, Ms.Tuteur cites maternal death from hemorrhage in impoverished nations where women are malnourished and do not have access to skilled prenatal or intrapartum care as evidence that I do not understand the gravity of hemorrhage, or the international causes of maternal death.

To be clear, I did not state nor imply that women do not hemorrhage at homebirths. Hemorrhage can occur in all settings and midwives are trained and equipped to manage them. However, for the record: published evidence from medical studies on homebirth in the US, Canada, UK, and Netherlands shows a 0% rate of maternal death from hemorrhage at home, and of the studies that compared hemorrhage rates between homebirth and hospital births, all showed a lower incidence of hemorrhage at home.

I welcome substantive discussion on my blog, that is how birth change is happening in this country — with open and honest discussion. Until now, I have not removed or censored any genuinely critical comments from readers. I will not, however, publish vindictive comments that reflect more of a personal attack than honest questioning or critical discourse. These kinds of comments do not serve me, my readers, or women seeking to learn more about their choices in childbirth.

I became a midwife before I birthed my own babies.  People often ask me how my practice changed after I became a mother and gave birth.  All midwives advocate for the needs of babies, but giving birth to my own baby afforded me a more direct and visceral connection to the baby’s birth experience than I had previously known (among other things!).   I am more deeply attuned to how the both mother and baby experience labor, birth and the hours after birth — physiologically and emotionally;  From their passage out of the pelvis (or abdomen) to their first moments touching, hearing and smelling each other, it is a sacred and biologically unique time.

Harmful cord clamping practices are one of the first interventions experienced by most babies born in the US.  (Sometimes they are also needlessly bulb-suctioned or removed from their mother).  Cutting the umbilical cord within seconds of the birth, also known as premature or early cord clamping, is a routine practice of hospital births attended by physicians.  It is another intervention that has become so second-nature to physicians, and has gone largely unchallenged in the delivery room.

Dr. Nicholas Fogelson is a minority advocate for  ”delayed” or normal cord clamping within the medical community .  While he aptly draws a parallel between premature cord clamping and blood-letting in his latest video series, he is candid about just how far he has come in his practice:

For the majority of my career, I routinely clamped and cut the umbilical cord as soon as it was reasonable.   Occasionally a patient would want me to wait to clamp and cut for some arbitrary amount of time, and I would wait, but in my mind this was just humoring the patient and keeping good relations.  After all, I had seen all my attendings and upper level residents clamp and cut right away, so it must be the right thing, right?…….

Here you can clearly see the red, oxygen rich blood still in the cord that is about to be severed. This baby did not receive that cord blood that nature intended her to have.

During pregnancy, the baby’s blood circulates in a constant loop in and out of her body.  It flows through the body, back into the cord to the placenta, then back through the cord into baby’s body.  This pattern of circulation continues until shortly after the birth when the placenta separates from the inside of the uterus.  By the time the placenta separates, virtually all the oxygen-rich blood in the placenta and cord (up to 40% of the baby’s total blood volume) has made its way back into the baby.

Why do physicians cord the cut so soon after birth?  Most believe that babies if babies receive their full blood volume from the placenta they will have too many red blood cells (polycythemia) and become jaundice.   They aim to prevent this by clamping and cutting the cord immediately after birth which stops the flow of blood from the placenta into the baby.

Also, it happens to be extremely convenient for the Swiss clockwork *ideals* of a hospital. Cutting the cord right away allows staff to get on with two other routine postpartum practices: active management of third stage (which includes early cord clamping, pitocin and pulling on the cord to extract the placenta) and routine baby assessment.  While the doctor facilitates the birth of the placenta, nurses can move the unattached baby to the warmer to perform their standard newborn care and assessment.  On the warmer, babies are typically suctioned, dried, swaddled, perhaps given oxygen, etc.  Some mother-friendly hospitals have begun to perform newborn care on mom. (In homebirths, these things are almost always done on the mother’s abdomen, or just beside the mother, with the cord intact).

In hospital births, physicians typically clamp and cut the cord moments after birth, and often before giving the baby to the mother.

In premature cord clamping we have an intervention that has become almost universally embedded into hospital birth on account of convenience and a desire to avoid jaundice –  the only trade-off is a loss of up to 40% of baby’s blood!?  Despite popular medical opinion, research favors delayed cord clamping for both preterm and term babies and has not found a significant association with either polycythemia requiring treatment or jaundice requiring treatment.

Two meta-analysis addressed the subject in the last five years — the JAMA and Cochrane reviews.  While the Cochrane review did report a small increase in jaundice requiring phototherapy among late cord-clamped babies (5% as opposed to 3% in the early clamping group), these results were based on one particular study that has been criticized by experts and physicians for a number of good reasons.  It is an unpublished PhD paper written by one of the review authors, and since the study was not published or peer reviewed its design raises a number of questions: we don’t know whether the physicians referring to treatment were blinded, whether confounding factors were accounted for, or what threshold for treatment was used 12 years ago in Australia when the study was undertaken.  The JAMA review found no increase in jaundice requiring phototherapy.

I’ve seen a good number of jaundice babies in my years attending homebirths, so for argument’s sake let’s say babies who have delayed cord clamping do develop more jaundice.  Is really worth significantly reducing their blood volume in order to reduce their odds of becoming jaundice?   Jaundice is “physiologic,” meaning normal.  Many healthy babies will become jaundice regardless of when their cord was clamped.  The vast majority of newborns with jaundice are normal and healthy and do not require medical intervention.  Depriving infants their full blood volume is not a reasonable response to something as common as jaundice.

The placenta has been born and the parents are ready to clamp the umbilical cord. The baby has received her full blood volume.

Why should we leave the cords alone?
It would be senseless and highly dangerous and to remove a third of the baby’s blood from their body before they were born, but doing this immediately after birth has become the norm.  Reknown physician and author of Zoonomia, Erasmus Darwin, recognized the danger in premature cord clamping in the 1800s:

Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases.  As otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child. (Zoonomia)

A little more physiology can help us understand why that blood is vital: Immediately after birth, babies transition from breathing amniotic fluid to breathing air.  This change requires the heart to pump far more blood to the lungs than it had before.  All the blood from the placenta and cord is needed in this process. The blood from the placenta also sends more oxygen around the body.  This transition process can take longer and be more difficult if the cord is cut early, preventing the baby from receiving her or his full blood volume.  In these cases babies often require supplemental oxygen — oxygen that would have been supplied by the umbilical cord.  We know now too that keeping the cord intact during resuscitation actually helps babies who are having trouble transitioning and breathing.  (Check out this new innovative mobile warmer unit from the UK that allows babies to be resuscitated with their cords intact).

Preterm babies also benefit greatly from delayed or physiologic cord clamping.  The benefits of keeping their full blood volume extend beyond the newborn period into infancy as well.  Babies have greater hemoglobin (iron) levels in the months after birth and benefit from the stem cells, antibodies and other life-sustaining components of their blood.

This cord was still pumping blood from the placenta to the baby when it was clamped. You can see blood in the vessels; the blood pressure gives the cord its shape.

This cord has finished pumping blood from the placenta to the baby. You can see only a residual amount of blood through the cord. It is pale, flacid, thin and elongated.

How do you know when the cord is ready to be cut? If the cord is still fat, taught, and spiral-ey, it’s not time to cut yet.  If blood forcefully spurts out when it was cut, it was cut prematurely.  It is almost always just as easy to wait until the placenta is born to cut the cord.  At homebirths, midwives typically wait to clamp and cut the cord until it  has stopped pulsing or the placenta has been born.  Waiting for the placenta also ensures that mothers and babies remain undisturbed in those precious and finite moments after birth.

I encourage women whose care providers insist on premature cord clamping to familiarize themselves with the subject and ask their physicians if they are aware of the body of research supporting delayed cord clamping.  You are your baby’s best advocate!

Resources:

Leaving Well Alone: A Natural Approach to the Third Stage of labour  –  Sarah J Buckley, MD

Delayed Cord Clamping Should Be Standard Practice in Obstetrics  –  Nicholas Fogelson, MD

Cord clamping researcher Judith Mercer talks about her study of delayed cord clamping for preterm, very low birth weight babies

This exceptional short video features renown midwives and physicians discussing cord clamping practices and the effects on babies: We Can Be Much Kinder

I interviewed homebirth midwife Hilary Schlinger about the proposed name change and her vision for the future of midwifery in the US. Hilary is both a Certified Nurse-Midwife and a Certified Professional Midwife and has a long history in midwifery politics. She has served on the Midwives Alliance of North America board of directors and is the author of Circle of Midwives, a book about the history of the Midwives Alliance of North America and the resurgence of midwifery as a profession in the United States.

Sit tight, this is a long one but there is lots to chew on here.  For help with the acronyms, see the MANA glossary of terms here.


Erin: You have spoken out publicly against the proposed name change of the ACNM. Yet you have worked as both a CPM and CNM, and have previously spoken out for unification of the profession. Why would you be opposed to this move?

Hilary: I would only support this name change if the ACNM concurrently commits the organization to working in partnership with MANA, NARM and MEAC to create one unified midwifery profession in the US. Without this commitment, calling CNMs “midwives” will increase their potential for working in opposition to direct-entry midwives who are striving on the political front to have CPMs included in national health reform initiatives, and of their being at odds with legislative efforts in states where the CPM has not yet been recognized. If the ACNM is going to rename itself the American College of Midwives, is it going to wield this moniker for the betterment of ALL midwives, or is the organization going to promote only its own brand of midwifery? As a corollary, is it going to change the title of all its members to CM – Certified Midwife?

Here’s another way of looking at it: Let’s say that the pride of the membership of the ACNM was their position as APNs (Advance Practice Nurses), rather than their attachment to the title of midwife. And let’s say that a motion was put forward to change the name to “American College of Advanced Practice Nurses.” Members would still have to go to an ACME-accredited program and pass the AMCB exam – the educational path and certification exams of other types of Advanced Practice Nurses (FNPs, CNPs, and Nurse-Anesthetists) wouldn’t qualify. Would you expect the excluded nurse-practitioners to think the name change was a positive move? That it wouldn’t confuse the public, or legislators? That it wouldn’t have the potential to undermine the work by other nurse-practitioner groups on political and/or legislative levels?

Erin: But some ACNM members are saying that they need to be more inclusive of their CM members. Why is it important to understand the politics surrounding the creation of the CM credential?

Hilary: For those who joined the ranks of midwifery after the early 1990’s: The history of the CM credential is NOT one that the ACNM can be proud of. To understand why this is so, one must understand the context of the times.

In 1989, the first Carnegie Foundation Seminar on Midwifery Education was held, with joint representation from ACNM and MANA board members to discuss the expansion of direct entry midwifery education. One year later, Carnegie offered funds to establish an inter-organizational task force so discussions between MANA and ACNM could continue. A result of these meetings was the creation of the (original) “Midwifery Certification in the United States” document, jointly endorsed by the boards of both organizations in 1993. The document affirmed ACNM as the appropriate organization to oversee education, certification and advocacy for nurse-midwives, and of MANA to respectively do so for direct-entry midwives.

ACNM acted in direct violation of the agreement when, less than a year later, the idea of the CM credential was “sold” to the membership. Leading the charge for creation of the CM at the ACNM convention was the NY ACNM chapter. In essence, New York was being used as the “testing ground” for an ACNM brand of direct-entry. While other states were concentrating on defining nurse-midwives as advanced practice nurses, the legislative push in NY was to separate midwifery out from nursing. When I say ‘midwifery’ here, I mean ‘nurse-midwifery,’ as their intention was never to include the voice of the existing (but unlicensed) DEMs. The New York CNMs saw themselves being held back by nursing issues, and felt that the creation of a Board of Midwifery was their best route to controlling the parameters of their own practice. Add to this the desire of some influential CNMs to design a European-style direct entry for the US – and NY became the perfect place to test this concept.

So, when the New York midwifery law passed, the CNMs from that state needed the ACNM to move quickly in acknowledging its own route to midwifery separate from nursing. Again, they saw this new law as a triumph, as the opportunity to design midwifery according to their own visions, and this included the opportunity to create direct-entry education. And the last thing they wanted was to muddy their dreams with concerns of those outside their ranks. They didn’t want to talk about place of birth, or about CPM-style education – they wanted to create a brand of direct entry that they perceived would be acceptable to the American public – Master’s Degree educated, prepared for hospital practice, just not entwined with nursing.

In “selling” the idea of the CM, the membership was told that creating the CM was “good for” the existing DEMs because it would create a legitimate route for their practice. This couldn’t have been further from the truth; there was no intention of creating a mechanism for us to achieve certification – it was, and has continued to be, a route in direct competition for legitimization with the CPM.

Although the move to create the CM was a politically motivated effort, with the subtext of undermining MANA, NARM and MEAC by creating a direct-entry pathway that could be touted as more legitimate, it is not one that has been successful. We need only look at how the CM has floundered while the credibility and acceptance of the CPM has grown to observe that this effort has failed. However, if the name change goes through, I am anticipating a re-doubling of ACNM’s legislative efforts to promote the CM as a more legitimate direct entry midwife, and to block inclusion of the CPM.

It is naïve to think of this current proposal as altruistic, or to think that actions of the ACNM won’t affect all midwives. It is always telling to know your own history.


Erin: Voices within ACNM are promoting the name change as a step toward unity within the profession. What do you think?

Hilary: The ACNM is an organization whose charge is to represent its membership, but when that organization has been built on excluding those whose voices don’t fit with its philosophy, how can I trust that the future will be different – that the “new and improved” American College of Midwives is interested in building bridges? With the creation of the CM, they were so willing to burn the bridge they had built with MANA the previous year, because of self-interest. Now, I would like to hope that times have radically changed, that any political currency the organization has gained over the years will be spent on the promotion of midwifery as a whole…but I would not go to the bank with this hope.


Erin: Many would argue that a similar oppressive/hierarchical dynamic is occurring between NARM/CPMs and DEMs who choose to remain uncertified and/or unlicensed.

Hilary: This is not a new dynamic. There has long been a rift between those midwives who perceive certification as limiting to midwifery practice and those who seek out certification, who want to find a way to be included as legitimate providers in the healthcare system.

NARM was born out of a desire for midwives to create their own standards regarding the parameters of midwifery scope of practice and education, rather than waiting for these to be imposed on midwives by the individual states. I happen to believe that staying out of “the system” keeps midwifery care limited to those elite (usually middle class white women) who can afford to pay out-of-pocket for care, as well as making individual midwives vulnerable to charges, whether real or spurious, from any of those in power who feel threatened.

In order for midwifery care to be readily available and for home birth to move beyond the one percent, I believe we need to find a mechanism that allows for our inclusion in the greater health care system. And of course the goal is for this to occur without destroying those qualities which make midwifery unique. I think the NARM/CPM approach holds more potential for achieving both these goals simultaneously than the ACNM one, which I perceive as being willing to dilute midwifery to a greater and greater degree as long as nurse-midwives gain a foothold in “the system.” Theirs is not the model I want to emulate. However, if we step carefully with certification and licensure, being very cognizant not to compromise away our principles in the process, then I think many of those midwives who currently choose to remain uncertified or unlicensed may look differently at the process.


Erin: You started out as a DEM turned CPM, but eventually became a CNM despite your criticisms of ACNMs political tactics and being exiled from New York. Why?

Hilary: I have alluded to my personal involvement in the events that occurred in New York.

When the law changed in 1993, I and twelve other DEMs applied for midwifery licensure. During the prior legislative fight to establish midwifery as an independent profession in the state, we had been assured by the CNMs that we would have at least one seat on the New York board, which was never their intent, and did not happen. Furthermore, we had been led to believe that our educations would be individually considered under a provision in the New York law which allowed licensure for those who could prove educational “equivalency” to CNMs. Instead, the information we provided in our applications was forwarded to the punitive arm of the department, and eight of us received cease-and-desist orders, with felony charges if we failed to comply.

I chose two things: to relocate to a state where I could legally practice, and to continue pressing the New York Department of Education to declare my education as “equivalent.” This fight took over seven years, but finally, after enormous effort, in 2001 my education was deemed “comparative.” I was given clearance to take the ACNM boards, which I did in November of that year, and thus became a CNM without ever attending a CNM program. By doing so I opened a door to licensure that approximately 15 other DEMs have since stepped through. It was a point of pride for me that I not attend an ACNM-created CM program, but instead have the state declare my existing education as equivalent.

Eight years later I chose to attend the only ACNM-accredited school where I could obtain a Masters of Midwifery rather than a Masters in Nursing, not because I needed this degree to practice, but to expand my ability to be involved in the future of midwifery education.


Erin: Is a perceived lack of education the primary reason ACNM fails to support NARM and the CPM credential?

Hilary: I’d like to tie that question to our history. During our discussion, I have been taken back, again and again, to the original convictions that kept me from becoming a CNM during the 1980′s and 90′s. During the time that I was working illegally in NY, I had more education than many of the CNM’s in my community (a bachelor’s from an Ivy League college plus midwifery training at The Maternity Center in El Paso plus licensure as a midwife in New Mexico, at a time when most CNMs were ADN’s who had gone to Newark for 9 months to obtain their midwifery certification), as did the women I worked with (3 of whom were British-trained direct entry midwives). I also had more birth experience than many of the CNM’s around me, and I certainly didn’t see the need to repeat my midwifery education. Yet my education wasn’t acknowledged as such by the CNMs in the state. Was this because the education was inferior, or because it incorporated a philosophy at odds with the CNM educational model?

When the New York legislative push came to the forefront, I spoke publicly about how the New York DEMs needed to be included in the process. And those of us involved weren’t just any DEMs – of the three primary DEMs involved in the legislative effort, two were founding members of NARM, and I was then the North Atlantic representative to the MANA board. In our naïvety, we believed that if we participated in the legislative effort, if we demonstrated the validity of our education and practice, then we would find a place at the table. But this didn’t happen – instead, our voices were forced out, and all three of us ultimately ended up leaving the state. In essence, it became clear that our having more experience with direct-entry (and, for some of us, higher educational degrees) than the CNMs in the state didn’t matter; the point was that our goals didn’t line up with theirs.

So now, when the ACNM has twice raised the educational bar, and can thus wave the flag of “education” as the primary difference between CPMs and CNMs I have to sit back and ponder, “Is this really the issue underlying it all?” And my answer is a resounding NO. If the ‘sticking point’ back then had been education, surely those of us with national experience in direct-entry education would have been welcomed at the table during the planning of CM programs, not barred from participation.

What it boils down to for me is that the roots (and subsequent actions) of the ACNM are in the gaining of power and legitimacy by being presentable to the powers-that-be. Even though the ACNM was born from out-of-hospital midwifery (be it in Santa Fe, Hyden or NYC), the emphasis from the start has been on incorporating midwifery into the existing medical and educational systems. And if this meant that those midwives had to wear a nurse’s cap, so be it. And if it later meant that they had to obtain a higher degree (regardless of their own research showing that ADN/certificate midwives had superior performance on the job), then so be it. And if it meant that they had to present a more medicalized version of midwifery in order to gain entrance to hospitals, then so be it.

Thus the question isn’t about “educated” versus not, but about the acceptance of midwifery knowledge that is both applicable to and acquired outside of, versus inside of, institutions.

This comes back to your question of how CPMs are viewed by the CNM community. One of the largest misperceptions about CPMs is that they have no didactic education, because for many it has occurred outside of the walls of standardized institutions. CPMs are all educated; however, a substantial percentage have not opted for “traditional” institutionalized education, often for the same philosophical/political reasons that lead them to avoid birthwork in medical institutions.

For those who don’t know, the NARM credential was created in conjunction with the National Assessment Institute to be in line with accepted psychometric standards. To quote Ida Darragh of NARM, “NARM does have a required curriculum – over 800 topics – which must be mastered both in theory and in practice.  There is no requirement that it happen in a classroom, but it must happen and must be verified by a qualified preceptor through over 50 pages of documentation.  All candidates then must pass the exam. It is NARM’s job to evaluate the educational pathway. There IS education, and it IS evaluated.”

We are seeing a veritable revolution in “non-traditional” education within many fields. Programs such as Empire College within the State University of NY system grants credit for demonstrated life experience, and Harvard admits homeschoolers. Both ACNM and NARM recognize didactic education online (ACME via Philadelphia University, Frontier, and SUNY Downstate; MEAC via National College of Midwifery, Midwives College of Utah, to name a few). So if both CNMs and CPMs now mutually acknowledge that nursing is not a prerequisite to midwifery, and as a society we are increasingly acknowledging multiple routes of education, then why are CNMs reluctant to acknowledge NARM certification as valid?Is the issue really about education, or is it about the underlying philosophy?

To turn the scrutiny the other way, we need to look at CNM education, as well. Most CNM education is lacking in continuity of care, in large-volume birth experience, in non-technological birth, in hands-on labor care, in newborn care, and the majority of ACME-accredited programs are educating CNMs only for employment in hospital settings, not for out-of-hospital (or even for true full-scope midwifery) practice. As a dually-educated midwife, I see the practice and the educational scope of each branch as overlapping circles – neither has it all, but merged together they would encompass the full scope of midwifery.

Erin: You’ve mentioned a merging of nurse-midwifery with direct-entry midwifery. How would one midwifery credential better serve childbearing women? Wouldn’t it mean less choice for them?

Hilary: It would only mean less choice if we allow the current model of nurse-midwifery to subsume direct entry.

A true merger takes the best of both worlds, and in the process gives the participants a greater societal voice. As long as we continue to put our focus on creating hierarchies within the midwifery community, rather than really listening to each other and learning how to work together, we will not be successful in building midwifery as an independent and powerful profession. If we choose instead to have one unified profession, where all midwives are educated to work in all settings, where the goal is to increase the profession until all women throughout the US can have access to a midwife, then we are creating more, not less, choice.

I believe that there is great potential for merging the two branches of midwifery via education, specifically via educational opportunities that have evolved due to the internet, as well as by weaving innovative midwifery programs into state colleges. Imagine a system where each midwife is educated (and permitted) to practice in all settings, incorporating the best of both NARM and ACME educational elements. Imagine a system where women who want to be midwives do not, on the one hand, have to spend years studying nursing when their true goal is midwifery; or, on the other, spend years studying midwifery, yet have no college credits to show for it. Imagine that midwifery education is available in every state college system, thus increasing the diversity of the midwifery population while decreasing the educational costs. There are waiting lists for state nursing programs; but I would bet that a fair number of those standing in line would jump at the chance to become midwives instead (and I’d bet that, for some, this was already in their plans). Imagine that we build birth centers in rural communities which serve the dual purpose of providing needed care while providing training sites for midwifery students.

And, if you can, imagine that we channel all the energy we have been wasting on fighting each other, and instead make a concerted effort to grow the profession. Imagine that the word “midwife” is known to every pregnant woman, and we read “more women demand midwives” in our local papers. We could stop celebrating when the number of midwifery-attended births in a particular state have reached the double digits, and instead look forward to them becoming the majority.

I am privileged to work in the state with the highest percentage of midwife-attended births in the US. Not surprisingly, we also have the lowest percentage of cesareans in the nation. I have full prescriptive privileges, the ability to provide primary care, am an independent provider, can write my own practice guidelines, and am reimbursed by all health insurance plans, including Medicare, Medicaid and private insurance. I am not saying that everything is ideal here; for example, hospitals are not required to grant admitting privileges to midwives, there is still a rift between the majority of CNMs and CPMs, and I only know of one midwife in the state who attends both home and hospital births. Still, I have gotten a glimpse of the vast potential for midwifery by working in New Mexico over the past 15 years. I believe that expanding the scope of practice for CPMs to include more well-woman and primary care, while simultaneously expanding the education and practice of CNMs to include more of the “midwifery model” qualities that CPMs hold dear, would serve to broaden choices for all women. It is only our misperceptions and petty squabbles that keep us from achieving unity. We will never know what opportunities for midwifery expansion are available as long as we continue our in-fighting. The current system limits choices; joined together we would have a much stronger voice, and the potential to reach all American women.

Hilary Schlinger, CNM, CPM, MS, RN, is a Certified Nurse-Midwife (ACNM), a Registered Nurse and a Certified Professional Midwife (NARM). She holds midwifery and nursing licenses in both New York and New Mexico. She first became a Licensed Midwife in NM in 1982. Hilary has attended approximately 1000 births, with a focus on home birth practice, and has provided well woman care for hundreds of women. Hilary holds a Bachelor of Science degree from Cornell University, an Associate of Science in Nursing from Regents College, an Associate in Midwifery from the National College of Midwifery, and a Masters in Midwifery from Philadelphia University. She held a seat on the Board of Directors of the Midwives Alliance of North America for four years. Hilary is the author of the book Circle of Midwives, editor of four midwifery texts, and has been a guest lecturer and workshop presenter in settings from medical schools to midwifery conferences. She has served as preceptor for numerous midwifery students, and is currently a faculty preceptor for the National College of Midwifery as well as adjunct professor for the Department of Continuing and Professional Education at Philadelphia University, where she teaches the on-line course “Homebirth Practice Essentials.” She lives and works in Albuquerque.

When I hear statements like this I cringe on the inside.  Being a midwife, I hear it a lot.  Women love to talk about their birth stories, as they should;  Storytelling is a natural and beautiful part of our collective journey as women and mothers.  In the park, at mom’s groups, among new friends, anywhere women gather there are stories of births and babies being told.  When I hear a story being told from the “I would have died at home” perspective, I do my best to nod with genuine empathy.  I want to support each woman’s telling of her own story. It does, however, feel like a double bind…

In these moments, I strive to listen with deep gratitude, kindness and love.  Every woman’s story is inherently valid and it is her story to tell, her journey.  The reality however is that these emergencies women experience are very often caused by unnecessary interventions in their labor or birth.  A huge part of my journey in birth work has been to advocate for truth and justice in maternity care and to illuminate the myths and realities of the hospital birth industry.   The best I can do in these situations is honor the mother’s feelings and experiences while side-stepping all the nuts and bolts of the “I/we would have died” argument.

A typical hospital birth hook-up: pitocin to speed up labor, epidural medication, and an IV bag. Pitocin use in labor makes women more likely to hemorrhage after birth.

Since a larger audience of women is hearing such emotionally charged statements about homebirth in the media feeding frenzy lately, let’s take a closer look.  Why do women in the US die while giving birth?  No one knows for certain because our reporting methods for maternal mortality are so abysmal.  We think, based on fractured US statistics and older studies, that the primary causes of death to women during birth or shortly after are thromboembolism, preeclampsia/eclampsia, hemorrhage, infection, and anesthesia deaths.

Lets look at hemorrhage because it is the most likely of these unlikely complications to occur in low-risk women birthing at home.  Here are a few reasons why.  Homebirth and hospital birth are supported by two divergent models of care.  The homebirth model subscribes to the philosophy of don’t fix what isn’t broken: natural processes generally work best when they are not interfered with.  The medical model subscribes to the (more profitable) philosophy of action: pregnancy and birth are conditions that require fixing.   All actions and interventions have consequences.  Many of the interventions in a typical hospital birth cause complications, like hemorrhage.  These interventions are far less likely to occur during homebirths attended by midwives.

New research demonstrates that women whose labors are altered by prolonged exposure to pitocin are more likely to hemorrhage after their birth.  This is because oxytocin, our body’s own version of pitocin, helps the uterus to contract after birth and minimize blood loss.  Pitocin binds to oxytocin receptor sites, and over time the body becomes desenstitized to it, preventing the uterus from contracting normally and leading to hemorrhage.   Regrettably, we’ve gotten to a point now where most births in the US are started artificially with the help of pitocin (induction) or hurried along by it (augmentation). Homebirth midwives do not use pitocin to start or speed up labor.

Immediate postpartum interventions can also lead to hemorrhage.  The period just after birth is a unique and potent time biologically for the mother and baby.  A natural flood of hormones connects mother and baby physically and emotionally, and helps the mother safely birth her placenta.  The mother’s hormone levels will never be as high as this hour after birth; and when this flow is disrupted the mother is more likely to bleed excessively.

Interventions during this immediate postpartum time are routine in a hospital setting: failing to give the baby to the mother immediately, assessing the baby away from the mother, pulling on the umbilical cord, changing the mother’s position to suit the care provider, diverting the mother’s attention away from the baby, clamping and cutting the umbilical cord without any good reason to do so, etc.

Midwives honor the biological importance of the hormonal bubble after birth and do not intervene unless the mother or baby needs help.

In a typical homebirth, mother and baby are undisturbed after birth. The midwife does not unnecessarily poke, prod, clamp, or otherwise interfere with the mother and baby unit.

When you hear someone say “I would have died if I had a homebirth” or “my baby would have died,” please remember that these are very emotionally charged declarations.  And yes, they may be true statements.  Yet tragic outcomes DO occur in any setting despite the “best” possible care — hospital or home.  However, in many hospital births, it is unnecessary interventions that have caused the complications that women and babies suffer from.  The CDC has estimated that half of maternal deaths are preventable.

You cannot simply cut and paste all the circumstances surrounding a given hospital birth, superimpose them on a homebirth setting, and predict the same outcome — or vice versa.  The models of care are too divergent.  Women can die from birth complications in any setting, and our hospital death rate from birth-related causes is indefensibly high. We know that low-risk women are as safe, if not safer, birthing at home.

The United States ranks 41st in maternal mortality among nations. That means in 40 other countries, women are less likely to die from pregnancy and birth related causes. The CDC also states that half of the reported deaths were preventable and that death rates are underreported by almost a third. On April 9th the Healthy Mothers Healthy Birth Summit will convene in Washington D.C. to examine the clinical and political issues surrounding maternal death in the United States.

I started EC’ing my first born about three weeks after his birth.  One day I held him over the toilet, and he peed.  Boys can be hilarious to EC if you have a sense of humor.  Their pee can shoot unpredictably in just about any direction.  This can make night-time EC’ing trickier in the winter time if you’re not using diapers, but for us it was still worth the added effort.  My son did not poop in a diaper after he was three months old, and by eighteen months he was wearing underwear full-time and independently taking himself to the toilet.

EC’ing at two months. This is the basic position, essentially assisting them into a squat with your support.

The books tell you people do it for the “communication” aspect — that babies indicate when they need to go, parents respond, and there is an ongoing ‘dialogue’ around the baby’s cues.   My son however gave no clues that I recognized. As a tiny baby, yes, he would get show a little fuss before peeing, but as he grew out of the newborn phase, he never really “cued,” or gave clear signals.  It was all about timing.  If it had been 15 minutes since his last pee,  I would take him to go.  I would “pee him” after waking up from naps, and more frequently after nursing.  Easy.

One day when my son was five or six moths old, an hour had gone by and I realized hadn’t taken him to pee and he had not peed on his own. It was a milestone!  All the work of the first few months paid off.  From then on EC’ing required far less of my attention and became even peripherally second-nature.  He began to stay dry at night too which made the initial work doubly worth it.

My daughter is now six months old and our EC’ing experience has been even easier.  We started at birth, and her patterns are more predictable than my son’s.  Her only poopy diapers have occurred on a boat and on an airplane.  Both times I knew she had to go but I could not easily get us to a toilet. That’s not to say I’ve caught all her pees! Puddles on the tile floor are still a regular occurrence when I am not entirely attuned to her (which with two kids at home is often!), but for us it is all part of the process and I don’t sweat the “misses.” I much prefer to quickly wipe up a pee puddle on the tile than undress, change a diaper, re-dress, etc.

EC’ing my seven month old after the long winter inside. Warmer climates are great for EC’ing.

I am home mothering my kids so I am physically around to do this.  If you have work away from home EC’ing poses additional challenges, but is still very do-able. It is NOT an all-or-none process.  You can EC part-time, or whenever it works for you. It is a lot of work at first, but the payoff comes quickly and beautifully: less diaper changing, less money spent on diapers, less laundry, no drama (or virtually none) over “potty training” when they are older.

While not meant to be a how-to list, here are a few bits I’ve learned from my experiences thus far:

Let them be naked as much as possible.

Going diaper-free at home is the quickest way to get in tune with your child’s elimination patterns.  It is exponentially easier if you simply don’t put a diaper on them.  Without even being aware of it, you will begin to make associations between their behavior, i.e., their “cues” if they make any, and when they have to go.  When babies are wearing a diaper you don’t have to pay the same amount of attention; you subconscious awareness of their patterns is not as dialed in because a diaper is there to catch the pee or poop.  Keep them naked.  This is my #1 piece of advice.

Don’t be afraid to get peed on!

It’s only pee. (And it’s sterile).  If you are using cloth diapers you would have to wash a wet diaper, and washing wet pants is not any different.  If you are using disposables, you’ve saved yourself (and the landfill) a diaper.  Most babies will give some warning before they poop, particularly if they do not have any food sensitivities contributing to explosive bowel movements.  (Did you see in the movie “Babies” the Namibian mother effortlessly scrape her baby’s poop off her knee?)

Naked baby time while sitting on a pre-fold (cloth diaper).

Girls are easier to EC than boys (generally).

I have observed this in others children and have found it to be true for my own kids.  Part of this is anatomical — boy pees are harder to catch as babies.  With girls, everything more or less just dribbles downward. Diaper-free overnights are also easier with girls because you don’t have to worry about the sheets and blankets above getting wet in addition to the sheets underneath.  If you have a baby boy, know that it only gets easier should you have a girl in the future.

People will be suspicious. 

Or outright think you are nuts. They might not say it to you directly, but many will think it.  I was talking to my grandmother recently about EC’ing my daughter and she said “Remember when we all [the entire extended family] laughed and thought it was ridiculous when you took him to the toilet as a baby? Well I can see now that it was a sensible thing to do” referring to my son being toilet independent at age two.

TRUST YOUR INTUITION. 

I can’t tell you how many times I knew my daughter needed to pee, but I turned my attention elsewhere, or second-guessed myself and got peed on thirty seconds later.  In a way EC’ing is an exercise in developing your instincts as well as your baby’s.  If you have the sense that they have to go, they probably do.

Clear potties allow you to see what is happening below.

In some high-risk labors these procedures may truly be necessary for the safety of moms and babies (or for women using epidural medications).  Most healthy low-risk women do not need to be hooked up to anything in order to safely birth a baby.  Imagine how different hospital birth would be if most women could move around as they pleased without any sensors or straps attached to them.  Imagine women moving instinctively, following their own inner rhythm and positioning themselves in ways that made their bodies feel powerful, relaxed, and productive.

Women typically spend spend a large portion of their labor hooked up to machines in bed while laboring in the hospital.

How might this freedom to be mobile affect their sense of privacy and autonomy?  How might nurses and doctors entering the room approach a woman who was walking around and moving instinctively rather than laying confined on the bed?  When women are mobile and moving with the rhythm of their labor they are less likely to accept the battery of routine procedures and vaginal checks than if they were lying in bed.  Women would have more self-confidence and a stronger connection to their primal birthing instincts if they could move how and where they pleased without being attached to fetal monitors, which effectively serves as an constant (if subconscious) reminder that their bodies or babies could fail at any moment.

Electronic fetal monitoring (EFM) surely has its place. It can help us observe what the heart is doing, how well oxygenated the baby is, and whether the baby appears to be struggling or happily trucking along.  EFM became routine in the 1980′s under the assumption that it was going to save babies lives and make birth safer.  It was believed that continuous monitoring would pick up the small number of babies who show signs of hypoxia or distress and allow them to be ‘saved’ by cesarean section.  Today we have decades of evidence showing that continuous EFM has no effect on neonatal mortality or morbidity — it does not help babies be born any healthier.  It does however increase the risk of cesarean birth by about three times.  As with many obstetrical interventions that become standard before adequately being studied to see if they do any good, EFM was studied after it became a routine part of hospital birth.

We now know that a baby’s heart rate in labor is not great indicator of how well the baby is going to do after s/he is born.  Regrettably, the technology has been applied in such an extreme manner — virtually all women in the US are attached to a fetal monitor during most or all of their labor — without consideration of whether there could be too much of a good thing.  Physicians know this, and many will freely discuss it.  Both the US Preventive Services Task Force and the Canadian Task Force on Preventive Health Care recommend against routine EFM for low-risk women and cannot even recommend it for high-risk women in labor.

Why then are healthy, low-risk, un-medicated women still being confined to fetal monitors when we know they don’t make birth any safer?

1) Electronic fetal monitoring produces a permanent written record of the baby’s heart rate.  It is believed that this record will help protect physicians against claims of malpractice or negligence should a patient decide to sue in the future.  One labor and delivery nurse on My OB Said What?!? shared the truth:

“We always do continuous fetal monitoring, not because we think it helps, but just for legal reasons.”

2) Nurses are overworked and maternity floors are often under-staffed.  It is easier for nurses to manage multiple patients when they are being monitored electronically.  Nurses already perform the majority of care given to women in labor and they have heaps of charting to keep up with on top of patient care.  A well-known physician and midwifery advocate confided to me that,  as with many aspects of maternity care,  EFM boils down to dollars and cents.  Keeping women strapped in and hooked up affords hospitals a higher nurse-to-patient ratio.

There is another way to monitor babies that does not require being strapped to a monitor: periodic monitoring with a hand-held doppler (or fetoscope if you are hoping to avoid ultrasound).   This kind of monitoring is called “intermittent auscultation.”  It is what midwives do at homebirths.  ACOG even acknowledges it is a safe and appropriate method of monitoring babies.  Physicians and nurses do not typically use intermittent monitoring because it requires one-on-one nursing care —  something hospital labor and delivery units do not provide.  It also requires that maternity floors keep a hand-held doppler readily available.  I have attended numerous births  where women have been told that yes, they could be monitored with a doppler if only they knew where one was. (I wanted to include a photo here of a hand-held doppler being used in the hospital. After about forty-five minutes of searching I gave up.)

Some women ask their physicians or midwives prenatally about how long they are required to be hooked up to the monitor.  They are commonly reassured that they will only have to be on the monitor periodically each hour, maybe twenty minutes.  Twenty minutes each hour adds up to a lot of time for mothers to be hooked up and immobilized if there is no wireless EFM. And it is a slippery slope.  When you add in pitocin and pain medication, or a “concern” about the baby’s well-being, periodic monitoring quickly turns into continuous monitoring (cEFM).  When one intervention leads to numerous others we call it the cascade of intervention.  EFM is a significant component of this cascade.

This is an area however where pregnant women CAN create change.  You can demand the freedom to be mobile in labor.  You can demand to labor without electrodes and sensors on your belly.  The science is on your side. Midwives are on your side.  ACOG even supports you (in theory).   So yes —  you CAN say no to the monitor, but you will need to bring your own doppler  … and your own nurse.

The press release begins with ACOG’s ostensible commitment to informed choice, at least it pertains to other types of care providers:

“As physicians, we have an obligation to provide families with information about the risks, benefits, limitations and advantages concerning the different maternity care providers and birth settings.”

Fair enough — sensible even. But mothers: how many of you were counseled by your physician during your prenatal visits on their cesarean and induction rates, or the risks of pitocin to start and stimulate labor? The rest of the release is more or less the same-old same-old  though it does acknowledge that the “absolute risk of planned homebirth is low.”

If the tables were reversed and midwives attended the majority of births, and had a large, powerful and politically divisive trade union, would we charge forward with an all out media attack on the obstetric industry, highlighting the dangers of hospital birth and deceptive physician practices? Probably not. As a profession, we do not desire to further the division between physicians and midwives. It’s not about attacking the competition. It’s about safeguarding women’s ability to determine where and how to bring their children into the world.

Certified Professional Midwives (CPMs) do have a trade union, so to speak, in the National Association of Certified Professional Midwives (NACPM), but it is a relatively new organization, and since not all midwives are registered as CPMs, the organization does not represent the entire body of US midwives.

As it is now, third-party journalists, researchers, activists, and physicians are increasingly illuminating the pitfalls of modern obstetrics and doing a fine job of critiquing that which needs to be critiqued in our maternity care system. But in order to really reach into the minds and hearts of American women we need more than rational analysis and deconstruction. We need to move beyond the political and the scientific debates. We need a large enough PR campaign aimed at reframing the debate in the public sphere, not a mud-slinging campaign. We need a campaign that promotes woman-centered midwifery care and out-of-hospital birth in a context that is complimentary to conventional obstetric care. There is room, and need, for both models to harmoniously coexist.

The nine months were not without challenge. My partner accepted a new job before I discovered I was pregnant, and we moved from New Mexico to Montana during my first trimester. I was extremely sick again with nausea and vomiting. Many months are a blur. I have no idea how I packed and unpacked a house and moving truck, drove three days with a toddler, and moved into a new house! I was dead tired and constantly falling asleep while my two year old climbed all over me. I think there were weeks, and maybe months, when all I ate were rice cereal and gluten-free waffles. But she grew quietly and sweetly and let me have the peace I needed when I was able to surrender to it.

I was able to move through my pregnancy and birth guided primarily by my own intuition and desires. How freeing it was!

My daughter remained quite a mystery all the way to the end. She was much smaller than my first, and was only a fraction as active. She stayed in one position the entire time, and kept herself nicely flexed and anterior thank heaven and earth! Her birth was glorious, painful, surprising, primal, divine. She sleeps. She laughs. She sits happily in my arms. Many of you know my journey through my son’s first years and you know I needed this!

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