Helping primips acheive out of hospital birth

[Alison Cole]

I'm presenting this question for my own midwifery education, and because I myself am a primip seeking homebirth. And, too, of the first three births I've attended so far as an apprentice, two have been first-time moms and both ended in transfers. : I know that these things do happen, and three is not very many births, so I imagine I'll get many chances to see lovely first births at home and birth center, but it just sucks for those families, and it makes me nervous about my own chances. So...

What are reasonable transfer rates for primips? Is there anything you as a MW (or doula or CBE, etc) would encourage a first-time mom to do to achieve the home birth they desire? What can you as a midwife do for a primip, prenatally and/or at the birth, to reduce the need for transfer? Any other words of wisdom on the subject? Your replies will be much appreciated.

Blessings.

[DoomaYula]

I'm not a midwife (I preface) but in my experience with primips, if I can be allowed to generalize here (preface #2), they just get so darn excited, and they're just wide awake and thrilled and the adrenaline is pumping from the very first ctx... so after 24h of very early labor, many of them haven't slept, and then at 48h, when they're in active labor, they're EXHAUSTED. I haven't attended many homebirths, but in hospital births I see them ask for epidurals after that long, or fentanyl, or if they're really not progressing and the provider suggests a c-s, they'll jump at it.

Sleep deprivation sucks.

Recently I had a primip client who planned to go med-free, and she is in the military and an ultramarathon runner so she was definitely up to the task. But in prenatals I really worked on emphasizing prodromal labor, sleeping/resting as long as possible, staying home until she absolutely couldn't talk between ctx (she wanted to stay home until the last minute). Anyway, she ended up with a great med-free birth but her labor was short, for a primip, 12h or so.

[courtenay_e]

Me too, I'm a doula as well...I also assist a home birth midwife. I see her spend a lot of time on diet and exercise. I also spend a lot of time talking to my clients who hire me early about the same stuff, and then also about prodromal labor. I really talk a lot about it, because I had prodromal labor for SIX WEEKS with both of my kids. With my first I went to the hospital three times before I was in active labor, because I was paying attention to how far apart the contractions were, not to whether or not I was able to do life around those contractions. By the time I hit the third time around I was exhausted, tired of timing contractions, and tired of walking out of the hospital still pregnant. So, for the last time, I asked my midwife and my mother how I'd know that I was in labor since none of the "X number of minutes apart" definitions seemed to work for me. They both just looked at me and said, "You'll know." Boy, did that make me mad! BUT they were right, and when I was in active labor I KNEW IT.

I try to help my clients realize that, no matter how long early labor lasts, to rest as much as they possibly can, take naps if they possibly can, and then just to go about regular life when they can. If you look at labor from the first contraction and get all worked up about the fact that you're "in labor--" by the time you are actually in ACTIVE labor and can't nap, walk, sleep, do life any more, you'll be exhausted. But if you have some reserves you'll be much better off. Then, having eaten well and exercised all through your pregnancy will also help you to get through that labor.

[Alison Cole]

Thanks for the replies--obviously I appreciate insight from ANYONE, MW or no.

[jerawo]

I'm not a professional, but I had my first at home and had a relatively easy, short birth.

Here is what I think contributed to that in order:

1. I never had a vaginal check until I was at 10 cm. Being in the dark kept me more relaxed about labor. I didn't ever think I was close to the beginning of labor, and when I was in labor I really didn't know how far along I was. It was far better to be surprised about how fast the baby was coming, than to think the baby was going to come soon and be disappointed.

2. I spent the first 5 of my 8 hour labor sleeping between contractions. It was night, so it made sense for me to sleep. I also had the mind set this was going to take a while, so I knew I needed to rest every moment I could. Once I got up for the day, it was only 3 hours until my baby was born.

3. Staying home obviously. I had no distractions to prolong or stop my labor.

4. I walked almost every day and did yoga throughout my pregnancy. I ate well, and drank plenty of water.

[durafemina]

I'm a student midwife who has been to 22 births in the last 4 months (home and hospital) and is also pregnant with #1 and planning a homebirth.

I too have noticed in practice and listening to birth stories of other students/midwives that primips tire out with the long latent phases of labour and end up transfering for exhaustion/because labour stalls (which, of course, is also related to exhaustion etc).

My thoughts on the subject are

- ignore labour for as long as possible! By that I mean, if there are things you need to setup, by all means do them, and then go focus on something else (napping, snuggling w/ your partner, going for a nice walk, watching a movie, having tea with a friend, getting a massage, etc) until the contractions *force* you to pay attention to them.

- holding out on the VEs for as long as possible. In my books, an attuned midwife won't need them to tell her anything in a lot of cases. Not having something to measure 'progess' against means that you aren't so focused on it and your body works better when your mind isn't worrying about what schedule it's on.

- keep things calm, private, relaxed, intimate. . . the best primip births I went to, the woman and her partner just had lots of space and minimal interference. I know I hate performing!

- eat and drink! I've heard miso soup especially is an excellent energy booster during labour.

- don't set yourself up with expectations. I know one woman (who had a long labour, but a lovely first birth at home) told herself beforehand that she could "withstand anything for two days" and when her labour ended up being 40 hours long, she was still alright with that mentally (which can go a long way in terms of what your body can physically handle).

- Have support people who are committed and believe in you. Nothing worse than a midwife (etc) who suggests a transfer because of some minor issue when really the underlying exhaustion and belief that you won't make it yourself is their thought process.

- Believe in yourself! Have a constant mantra of faith in your body/strength/stamina - your body can give birth and you need to make sure you know this!

I think about this a lot, and I try to surround myself with positive primip birthing stories so I have lots of solid evidence built up within me. Ultimately, one's birth experience (I believe) will bring them exactly what they need in order to cross over from maiden-to-mother. . . and approaching the journey with calm strength and peaceful acceptance is the most we can do to honour the process within ourselves.

[Alison Cole]

"Ultimately, one's birth experience (I believe) will bring them exactly what they need in order to cross over from maiden-to-mother. . . and approaching the journey with calm strength and peaceful acceptance is the most we can do to honour the process within ourselves." --durafemina


: Thank you for these wise and beautiful words. Many of the things so many of you have said are things I know I want to work towards for myself -- excellent nutrition, exercise, living life (including food and rest) until labor makes me stop and take note, minimal vaginal exams, etc. The tricky part comes as a provider of care to birthing women -- if our mamas have chosen OOH birth, how do we help them to come to this place of "calm strength and peaceful acceptance," of remembering to eat and rest in spite of the excitement, etc? I must believe that I can trust myself to learn and know these things in preparation for my labor, though I don't know what that moment will look like at such a far vantage. But I also want the magic words (or exercises or hand outs or other resources) to help mamas in my care have this understanding as well...

[pamamidwife]

for me, in my practice, nearly all of my transports are first time moms with posterior babies. these labors are long, excruciatingly painful and exhausting. that's not to say that without more time they wouldn't have turned - it's just that the point was reached where mom wanted pain relief.

still, I used to worry more about posterior labors. I don't worry as much as I used to. I also know that even though there's all these ideas about how to turn a posterior (or ROA) babe prior to labor, many times it doesn't work. sometimes it's just a matter of allowing the baby time to do its thing.

I think that resting as much as possible in early labor and keeping everything quiet/dark in active labor is good advice. Definitely.

[MsBlack]

Good question...all of my handful of transports have been primips! Very early on in my practice was when most of em happened...and I learned some things that I believe has helped to prevent many more primip transfers:

First is--Is this mom/couple REALLY suitable for homebirth? Does the Mom really want this more than anything else? Or is she doing it because her friends did, or her dp thinks it's best, or it's the coolest thing to do...KWIM? Really wanting it does not just mean she/they can say it over and over again--it means preparing, taking action towards a healthy birth, learning to view and speak of discomforts of pregnancy in a positive and pro-active light. In other words, taking responsibility for herself/themselves. Just as important as mom's true desire for hb, is whether or not she either has wholehearted partner/fam support for homebirth, or is strong enough not to let a lack of support from partner or fam members get in her way. I would have to say that of all my early transports, there was either lack of true desire for hb on mom's part, or lack of ability to withstand partner/fam pressure against it. Remember how psychologically sensitive pregnant women are--and in my experience, primips often don't get this--they may be aware (all too aware) of the opposition to hb in their space, but they are often not so aware of how much this is working against them, psychologically. And a primip is a woman in a profound rite of passage into adult womanhood; birth is always a rite of passage, but the first time is when you are most seriously individuating from your own mother/social milieu--hard work, made harder if there is opposition to your birth plan. All this said means that I really keep an eye on the primips psychologically...pay close attention to their words and actions and try to work with them if I sense ambivalence, family pressure, less-than-optimal personal responsibility....

GOING TO THE HOSPITAL DOES NOT STOP THE PAIN OR THE WORK. Sure, you might get an epidural...but the baby will not magically appear and then Mom is painfree henceforward; with an epidural, the chances of forceps/vacuum or csec is high, meaning that the pain is simply DEFERRED until a later time....and usually lasts longer than labor does! Also, labor is only a day or 2 usually...parenting is every day from now on. Besides, apart from physical pain or possible complications from epi, there is the loss of autonomy, baby going to nursery, possibility of early BF going awry...a variety of difficulties are presented by taking what appears to some--especially if she is very tired--as 'the easy way out'. I try to help these moms see that if they want to and they try, they can find the strength and energy to go on, that it's worth the effort and this is something they will have to do every day of parenthood anyway--good practice!

Yes, I harp a lot ahead of time on approaching labor well-rested and hydrated/nourished, and trying to relax/sleep rather than getting carried away on the excitement in early stages. But when the mom can't manage her excitement and does indeed get exhausted from trying too hard, too early in labor, then I will always try to get them a nap. Basically, I use a hypnotic approach, which can indeed make ctx get lighter and more spaced out....soft suggested words, soft touch, low lighting or none, mom in fully supported (pillows) position that allows for complete relaxation. Once mom gets comfy (and usually dp gets sent off for a nap himself--and is always happy to comply by this time!), I will say, repetitively, softly, persuasively-- and sometimes for 2hrs or more: "you are relaxing, you are releasing all the tension from your body. It's ok to sleep now you are feeling so relaxed and tired...it's ok to let those waves just wash right over you, let it be light and easy, soooo easy, just breathe easy easy, you don't even have to move, just relax..." And so forth, usually stroking softly down the length of her body, over and over again. At first, ctx might disrupt her relaxation, but usually when a mom is this tired, ctx will ease up and space out without much ado. Can't say I've ever seen a labor stop entirely with this method, but it will indeed ease so much that the mom gets a nice nap. Works best with at least 90 min (the length of a normal sleep cycle)--some moms do drop right off to sleep and don't need continous help, some do need continuous hypnotic suggestion and stroking but they all get a rest. And this might not change her mind about transport (tho it most always does), but it always helps her feel more ready for whatever she decides is next.

Not to mention that the deep relaxation of this method can be pretty miraculous in helping cervix open, and/or baby to turn.....

hope this helps!

[bryonyvaughn]

Originally Posted by Alison Cole

"Ultimately, one's birth experience (I believe) will bring them exactly what they need in order to cross over from maiden-to-mother. . . and approaching the journey with calm strength and peaceful acceptance is the most we can do to honour the process within ourselves." --durafemina

Your posts come across as so sincere and helpful that I really hate to smash your warm sentiment with my viewpoint. (I'm sorry. )

I think this quote is a whoo-whoo la-la platitude that everything is beautiful and good if you just examine in closely enough that disregards the impact of evil as well as our own responsibility to act in a moral manner. (How's that for loaded?)

You need a baby to become a mother, not a labor, or birth of your own. Ideally the experience will be empowering; realistically it can be an obstacle to be over come. I don't consider the overcoming of an obstacle a "gift" from the obstacle placer; I consider it an accomplishment *despite* the obstacle giver.

I lived despite the actions of the MW at my first birth, another MDC first (and only) time mom was subjected to a medically baseless court-ordered cesarean and other abusive treatment from staff. I believe this experiences radically impacted our motherhood *BUT* was not neccessary or even beneficial for us to become mothers. Vent off.

Back to your original question my MW could have prevented my transfer by...
* dropping me as a client in the last month when she (I assume) realized she didn't want to attend my birth,
* not coming out until I was in established labor,
* describing established labor in concrete terms (5-1-1 or 4-1-1 contractions, or contractions through which you can do nothing else physically or mentally but get through, etc),
* being willing to leave if a mom isn't in established labor rather than inducing and augmenting,
* not attending births in a class with which you seem to have a proven unacceptable track record you cannot overcome.
everyone's part.

As a mother who has to leave in 15 minutes for a counseling appointment for PTSD related to her first birth (a MW attended HB w/ PP transfer), I appreciate your examining this issue before entering practice. I think it's good for attendants to examine the "why" of different outcomes for specific groups, be they first-time moms, VBACs, color, married/ single/ non-married partnered moms, sexual orientation/preference, education level, religious belief, etc.

~BV

[durafemina]

bryonyvaughn -
perhaps I should have been clearer that the sentiments I expressed in that statement applied to my own personal attitude towards my impending first birth (I'm 28 weeks pregnant). Having seen such a variance in beliefs, attitudes and perceptions of women entering or in the 'birthspace' has informed me very profoundly that this approach won't apply or be relevant to loads of women out there. However, in my opinion, for me, my life and my experience it's a really reassuring thought process to engage in as I approach an event of unknown challenges. I trust birth to give me an experience I need because any other approach would make me fearful and anxious (perhaps because I am too well acquainted with the darker side of birth as well). I was definitely not suggesting that this is the way all mothers should feel (after all, one need not even give birth to become a mother!).

This has been a great thread - thanks everyone else for the interesting viewpoints! Pam - based on my own observations and your musings on OP-presentation as cause for transport (on your blog) I did my 2nd year research inquiry on the subject and found quite solid evidence for assisting a malposition to turn with hands-and-knees position. Although clearly research doesn't translate perfectly into everyone's experiences. . . have you noticed any positioning that has helped (at all? ever?).

with peace -
durafemina

[BetsyS]

"Ultimately, one's birth experience (I believe) will bring them exactly what they need in order to cross over from maiden-to-mother. . . and approaching the journey with calm strength and peaceful acceptance is the most we can do to honour the process within ourselves." --durafemina

Now, see, I love this quote. Love it. I think that, for me and my experience, it acknowledges that everyone's experience is different. That our experiences make us who we are. That, in the end, when it's over, we don't have any choice but to embrace what our experience was and realize that it is now part of our history. And, to work towards using that history for good. Perhaps for some of us, the journey to motherhood, the "birth", involves many heartaches and tears and eventually adoption paperwork. For others, it involves a lovely homebirth. And, for others, perhaps a homebirth transfer that ended in a c-section, all the things that the mama didn't want.

I do not have nor do I have experience with some of the terrible, awful things that I have heard about on this site. For those mamas that have PTSD and other long lasting complications from their birth, my heart goes out.

I am only speaking from my own experience (as that's really all I know). I had a birth that didn't go the way I wanted it to. It was by accepting that that I was able to embrace motherhood.

[MidwifeErika]

I agree with the statement about first time moms becoming excited and not resting through early labor. I think it is good to stress that a mom should pay no mind to ctx until she can't ignore them anymore. Otherwise, it is good to go about the normal day of eating, drinking, resting, maybe running a few errands, etc. Not just sitting with a stop watch and timing each ctx to see if they get closer together. If it is labor, it isn't going to go anywhere, even if a mom isn't paying attention to it.

[bryonyvaughn]

Originally Posted by durafemina

bryonyvaughn -
perhaps I should have been clearer that the sentiments I expressed in that statement applied to my own personal attitude towards my impending first birth (I'm 28 weeks pregnant).

Oops! When I read Allison's post I didn't realize she was quoting someone on this thread. I *assumed* durafemina was someone published elsewhere. Buried within your post as you comment was, I would have considered it a personal spiritual belief and left it at that.

As it was I thought Allison was quoting a beloved author (maybe she was ) who encapsulated her world-view that everything is good if you just look close enough. IMO this Pollyanna thinking disregards and can even rationalize evil. It's like when Ike Turner when confronted with his abuse of Tina, rationalized it by saying Tina Turner wouldn't be where she was today if it weren't for everything she'd been through with him. While this is technically factual, it does NOT mean she wouldn't be in a better place without an abusive marriage. I think it's naive, arrogant, and twisted to believe people need abusive relationships for them to grow and mature into fully functioning well-balanced individuals.

Everyone who agreed with durafina's comment is free to whether they believe some women *need* to be medically raped to pass from maidenhood to motherhood. I'd personally find it reassuring if there are communities out there where women are so respected that folks could philosophize broadly on birth without abusive HCPs ever crossing their minds.

Originally Posted by durafemina

Having seen such a variance in beliefs, attitudes and perceptions of women entering or in the 'birthspace' has informed me very profoundly that this approach won't apply or be relevant to loads of women out there. However, in my opinion, for me, my life and my experience it's a really reassuring thought process to engage in as I approach an event of unknown challenges. I trust birth to give me an experience I need because any other approach would make me fearful and anxious (perhaps because I am too well acquainted with the darker side of birth as well). I was definitely not suggesting that this is the way all mothers should feel (after all, one need not even give birth to become a mother!).

Well here's Durafina's answer to my question before I posted it. I agree it can be a helpful thought going into a situation. Being observant, open to learning from many directions, and grateful IMO is a very positive mindset.

Originally Posted by BetsyS

Now, see, I love this quote. Love it. I think that, for me and my experience, it acknowledges that everyone's experience is different. That our experiences make us who we are. That, in the end, when it's over, we don't have any choice but to embrace what our experience was and realize that it is now part of our history.

I can agree with you completely here BUT I don't think all our experiences are necessary to make us what we are. Corrie ten Boom was a loving, compassionate, righteous woman as shown by her taking in children beginning in the late 19teens, organizing girls clubs in the 20s & 30s, and hiding Jews from the SS in the 40s. She didn't *need* Hitler's concentration camps to become a compassionate, loving, righteous and forgiving woman. She already was that and her actions inside and outside after the concentration camps revealed to a much larger audience the kind of woman she was all along.

And, to work towards using that history for good. Perhaps for some of us, the journey to motherhood, the "birth", involves many heartaches and tears and eventually adoption paperwork. For others, it involves a lovely homebirth. And, for others, perhaps a homebirth transfer that ended in a c-section, all the things that the mama didn't want.

I'm reacting to the (apparently incorrectly interpreted by be as a broad and general statement) from the point of view of a woman who was lied to repeatedly during labor, had labor induced and augmented without my knowledge let alone consent, and had other life endangering procedures performed without my knowledge or consent. I'm not a stupid naive woman but I never in a million years would have suspected a HB MW would need to be watched continually to keep her from spiking my tea. My treatment was wrong, evil, and criminal and I did not *need* it to become a mother. I would have had a much easier and more joyful time entering motherhood if I weren't struggling adverse reactions to the drugs to which I'd never consented. I wouldn't have struggled with PTSD related to the medical profession. I would have had much more freedom in my life and had more freedom for my family.

More in accordance with other's beliefs, I can't change the past but can change what I do with it. I'm writing a grievance to submit to my former MW's credentialing organization in the hopes the MW will submit to peer review and get the help she needs to stop abusing women. I'm attending a discussion next week for MWs, doulas, and midwifery students, apprentices and assistants about attending women with a history of abuse. I think sharing my perspective could help birth professionals not contribute to the abuse and give abused women a safe option for attended birth. I think my actions are good considering the past circumstances I can't change BUT I don't think my making the best of a bad situation can ever justify a bad situation.

BV, who suspects we agree more than originally appeared.

[JunipersMom]

Talk about straying from the OP...
Primips need lots of education IMHO. This will help them to not get too exicited too fast, hopefully rest and relax until they cant anymore, and know that its all normal and just to let their body work.
I think other than that it's really hard to find what a mom will need in labor until your in it.

[momdzn]

For the mother-to-be, education the importance of nutrition, exercise, rest and balance in life.
For the birth team, love and patience because some women need us there for a long time, even though we may prefer to be elsewhere.

[SublimeBirthGirl]

I'm no midwife, but I believe it's more emotional/mental than physical. IMO it's very important for women to work through their fears, and to develop confidence in their bodies to do what they need to do.

[Earthy Birthy]

Originally Posted by MsBlack

...I will say, repetitively, softly, persuasively-- and sometimes for 2hrs or more: "you are relaxing, you are releasing all the tension from your body. It's ok to sleep now you are feeling so relaxed and tired...it's ok to let those waves just wash right over you, let it be light and easy, soooo easy, just breathe easy easy, you don't even have to move, just relax..." And so forth, usually stroking softly down the length of her body, over and over again.

You almost put me to sleep!

[veganf]

All 3 of mine were homebirths. With my first, I think what made a difference was the midwife's total confidence that she conveyed throughout my labor that I could do it. If she had any doubts she kept them to herself. Yes I pushed for 3.5 hours in various positions, but she only gave the gentlest encouragement when I needed it without getting excited. She was a quiet rock, just what I needed. I think most important is to get to know the mother and what she needs to be successful and keep her confidence up at all times.

[Mamabeakley]

This is probably not going to help the OP much in practical terms, but what I believe made a difference in my own primip homebirth was the fact that in a way, it wasn't my first homebirth. I was born at home. I was at my brothers' births at home. It wasn't DH's first homebirth, either, exactly - his sister was born at home although I believe he chose to be at his grandma's for the birth.

In other words, homebirth was normal to me. I was not afraid of it. I was very afraid of going to a hospital to give birth, and I knew I would only agree to transfer in a life-threatening emergency.

Labor was 22 hours of not being able to do something else during a contraction - well, of not being able to sleep during a contraction. I did hemorraghe, I think because I was really tired by the end. And I think DS1 was posterior for much of the labor.

DS2, however, was born posterior after 6.5 hours of labor.

Okay, I'm rambling now. But I do think that birth professionals may be able to help primips simply by knowing that homebirth is normal. This won't alleviate all problems or transfers, but I'm sure that birth professionals who do NOT know this on a deep level of total conviction will have more problems or transfers.