You and your baby’s safety is of the greatest importance to us. Our goal in prenatal care is to provide education and wise counsel to keep you and your baby as healthy as possible and remain low-risk.
When you contact us to come to your labor we bring equipment that help us monitor and care for you and your baby during labor and after birth. We set this up in a discreet way so that it doesn’t interfere with the setting you have created. What do we bring? A doppler to monitor your baby’s heart tones while allowing you freedom of movement and the ability to be in water; IV fluids, oxygen, neonatal resuscitation equipment, and medications to use if we note excessive bleeding after birth.
Our primary tools are that of observation, assessing, and suggestions that will keep your labor and birth within the limits of normal. We are trained and experienced in doing just that. Allowing a birth to occur without unnecessary interventions is the best tool to achieve a positive outcome. Birth is a normal physiological event, we are present with you to keep it that way. You know your body (we work on helping you get in deeper touch and learning to listen to your body during prenatal care) and that knowledge you have and the skill in listening to your body helps you during labor to know how to move and what positions to take to facilitate birth. We’re there with you, serving you and helping you through the process.
We’re equipped to see, identify, and know what to do if a complication arises. Potential complications that worry parents are maternal exhaustion, concerning heart tones in the baby, cord prolapse, shoulder dystocia, excessive bleeding, neonatal resuscitation, and vaginal repairs. These are all topics we discuss in prenatal care going over the details of each and what we would do in each situation.
Most of America has the idea that birth is what they have seen on TV or the movies, and it’s dramatic. We also have the perspective of those who see it as dangerous and an emergency. There is also this recent trendy view of homebirth as an Instagram photo op with mom in a pool staring dreamily off into space in a dark room with candles and the perfect light. What is truth? The truth is that there is are all kinds of experiences and that 90% of women are low-risk. Low-risk women have low-risk births. Midwives are trained to facilitate normal low-risk births and identify red flags that indicate a labor is no longer low-risk and what to do in that situation. A Nurse-Midwife is board certified, that’s what the initials CNM stand for. A CNM is an Advanced Registered Nurse Practitioner. Kim is licensed by the Board of Nursing in Iowa to practice Nurse-Midwifery and practice independently within that scope. She carries with her everything a birth center would have on site which includes: equipment to monitor vital signs, medical instruments, medications, IV fluids, oxygen, and resuscitative equipment. What she does not have with her at births are: an operating room, blood products, and a NICU. We would always move to a higher level of care when we start to see red flags and anticipate that those resources may be necessary.
The best way to prevent complications is to provide holistic care. This is what we do in the prenatal period and why we provide prenatal care in the way we do with lots of time and education. Getting to know a mom well helps us understand her individual health picture, help her learn to listen to her body, address issues as they come up, and make recommendations for nutrition, movement, and other healthy lifestyle choices.
We can’t eliminate 100% of risk in childbirth, of course. That can’t happen anywhere. Midwifery care is about partnership between the client and the midwife. You take responsibility for your part in your care and weighing the risks and benefits for the choices that impact you and your baby’s health status. The midwife’s role is to assess and evaluate the care given and address the issues that would push a woman outside of the realm of normal. The goal is to keep the woman and her baby within the range of normal and aim for a normal physiological birth. This is shared responsibility and decision-making.
Complications may occur, that’s true. They are often foreseen through a series of red flags that may add up to a complication, or not. This is why we are present at a normal, physiological event, to assess, anticipate, and head off a potential complication through making a change that brings a labor back into the range of normal or brings a decision to proceed to a higher-level of care.
If the baby’s shoulder gets caught behind the pubic bone while being born, it’s called a shoulder dystocia. Avoiding a shoulder dystocia in the first place is the best way to manage it. Leaving birth undisturbed and encouraging the mom to listen to her body, how it wants to move, and what position her body is instinctively telling her to push in is important. If mom is in a position that allows all of her pelvic bones room to move, waiting for baby to immerge, and keeping our hands off during delivery allow the baby to make the necessary full rotation for the shoulders to be born. Rushing the rotation can cause a shoulder dystocia. If shoulder dystocia does occur, the first move is to change the position of the mother and we can do this at a homebirth because she hasn’t had an epidural which limits her mobility. With a position change, the baby is often freed to rotate and finish birthing. If a position change doesn’t occur then there are series of systematic positions that we assist the mom through to free the shoulder. If that doesn’t work then we enter with our hands to reduce the baby’s shoulders for rotation. If baby has had an extended time in the shoulder dystocia the baby may need resuscitation and the mom may bleed more than normally expected. This is a scenario in which we respond to quickly.
Before birth a baby receives oxygen through the umbilical cord. At birth the baby goes through a significant transition when they take their first breath and begin receiving oxygen through their lungs instead of the umbilical cord. Babies are often born looking a little blue which quickly transition to pink as the baby takes the first breaths in the first minute. A normal newborn reaches 90% oxygen saturation at 10 minutes.
Some babies (as many as 1 in 10) need a little help in going through this transition. To start with, we don’t clamp the cord until it has stopped pulsating, as long as the cord is pulsating the baby is still getting oxygen through the blood pumping through it. Drying the baby, stimulating the baby’s back and feet through vigorous rubbing often does the trick for the baby to take that first breath. If that doesn’t do the trick, then 1 to 5 breaths to inflate the lungs helps over 90% of babies. This is done with a positive pressure ventilation neonatal bag and mask. Giving the baby a gentle breath forces air into the lungs which drives the surfactant out and stimulates the baby to breathe independently and continue the normal transition. We will do this while the baby is being held by mom or right at her side.
Babies that need more help than the first 1 to 5 breaths will continue to receive breaths through the bag and mask until he or she breathes independently. Very rarely does a baby require chest compressions to stimulate the heart to beat correctly and we are trained to do this and will also be calling for emergency transport. When transport is necessary, one of us will travel with the baby to continue neonatal resuscitation. Far less than 1% of babies require interventions and transport such as this.
It is not unusual for a mom to bleed after birth and many women lose a couple hundred ml. 500 ml is approximately 2 cups. A postpartum hemorrhage is defined as blood loss of 1000 ml or blood loss and the mom is hemodynamically unstable. We assess a mom’s vital signs and listen to how she is feeling. Some moms tolerate blood loss better than others. This is one reason why we assess hemoglobin in prenatal care and help moms elevate it through nutritional choices and supplements if she needs to.
If we observe bleeding that calls for intervention we will first determine the source. It could be that there is a laceration that needs repaired, a piece of the placenta or membranes is retained, or the uterus is lacking tone. About 80% of the time there is excess bleeding it is because the uterus is not staying contracted after birth.
After the baby is born, the uterus continues to contract and this what causes the placenta to then be born. The muscles of the uterus continue to clamp down and close off all the capillaries and bleeding slows and eventually stops as an internal “scab” forms at the placenta site. This “scab” will slough off about two weeks after birth and a mom may notice a small amount of extra bleeding when that occurs. If the uterus doesn’t clamp down and remains soft and boggy, bleeding will continue.
To get the uterus to clamp down and remain hard we use external pressure on the uterus which stimulates the uterus to contract. We may need to internally assess for retained tissue and/or remove clots. We carry herbal tinctures that are known to stop uterine bleeding. If these don’t work, we also carry medications to stop bleeding. The most widely known of these is pitocin.
If blood loss is excessive and more than what is reasonable to handle at home then we contact EMS, administer IV fluids, and oxygen if necessary. Approximately 1.5% of homebirths transfer to higher level care after birth because of retained placenta or restore blood volume.
Prevention is the best way to address postpartum hemorrhage. This is why we emphasize nutrient dense foods in pregnancy and why we check your hemoglobin and address ways to bring up iron stores. We don’t insist that you push at birth until you and baby are good and ready for it. We are patient with the uterus and the birth of the placenta. By keeping baby skin-to-skin with mom, hormones are released that contract the uterus and cause the placenta to release. We don’t do a lot of external touching or rubbing on the uterus while we wait for the placenta because we don’t want to overstimulate it. We don’t pull on the cord to deliver the placenta unless there are other signs that indicate traction is needed. We respect birth and the birth of the placenta, we expect that a mom will be able to birth the placenta without intervention just as she birthed the baby. We are present to assess, to be watchful, and to be prepared if an intervention becomes necessary.
If we see that more is needed, we will call EMS for transport to higher-level care. When we have the at-home prenatal visit at 36-37 weeks we talk about the possibility and how we would manage a complication and change of plans. We will bring our equipment to show you, practice position changes, talk about herbal tinctures and medications, and learn what to expect in the case of an intervention. This education relieves worry and tension, it allows birth to proceed normally with the knowledge that if it veers outside of normal, we have skills and knowledge to bring it back to normal. Talking through various scenarios allows the parents to think through and choose care that makes them comfortable. This helps when quick action is called for. Respect and trust for each other is part of the midwife-client relationship.