26674 Meadow Ridge Drive, Elko New Market, MN 55020
101 E 5th St., Suite 208 Northfield MN. 55057
Treasured Birth has a long-term goal to uphold the Ethics of Professional Midwifery Practice that supports the International Confederation of Midwives Statements made in 2003, which is the formulation and maintenance of healthy relationships, and an effort for midwives and students to work, support and validate each other. This includes the encouragement and growth of new midwives to practice in our communities. I vow never to bully, or belittle any student, or colleague in our community in order to better or make myself look good. The change starts with me — and you.
“Professional Ethics in Midwifery Practice” by Illysa Foster, page 121:
“It is a great travesty to the profession when new, educated inspired midwives are discredited and undermined by those who are threatened by shifting ways and ideas. To overcome these dynamics, midwifery organizations must take a stand on professional behavior among midwives. The ethical principles of beneficience, nonmaleficence, autonomy, and justice must be applied when working with other professionals, including midwife colleagues and their students.”
“People who bully often feel threatened and are resistant to change (Marinah Farrell, 2007) Overt monitoring, humiliating, persistently criticizing, spreading malicious rumors, and excluding or ignoring are common bullying behaviors (Hadikin, 2001). Hierarchical structures may support bullying, much to the detriment of the quality of midwifery care.”
“To overcome these dynamics, midwifery organizations must take a stand on professional behavior among midwives. Midwifery organizations can explore the concept of the integrity of the healthcare professional and create codes of conduct that set parameters on the behavior of midwives regarding their relationships with others. Midwives must not tolerate bullying in their labor and delivery units or their community. To stop bullying behavior, an individual or group must confront the perpetrator, or perpetrators, explain the effects of their behavior, and ask them to stop. Bullying is damaging to the bully, the victim, the community, and the profession. Greater awareness of bullying and codes of professional conduct that focus on professional relationships are needed.”
There are several organizations that have created Codes of ethical conduct regarding collaboration, referral, or transfer of care. ICM’s International Code of Ethics for Midwives (2003) contains the most developed guidelines relating to working with other professionals. “It is important for midwives to seek and understand the reasons for disagreements with clients and colleagues. Midwives should not stop with just understanding, or respect however. They must work to also resolve those conflicts that need to be resolved in order for ethical care to continue. The emphasis is on the relationship, to go beyond quelling the disagreement and to actively seek resolution of conflict.”
I am currently exploring the idea of opening a new Licensed Birth Center in Southeastern Minnesota. In order to do so, I will be making several blog posts about the process. Not only do I need to find a suitable location, but there are many steps to becoming a licensed birth center. Here is the Minnesota law that addresses the legal requirements for a Minnesota Birth Center. If you have knowledge, suggestions, connections in response to this blog, please feel free to let me know. This is the law as published by the Minnesota Department of Health.
(a) For purposes of this section, the following definitions have the meanings given them.
(b) “Birth center” means a facility licensed for the primary purpose of performing low-risk deliveries that is not a hospital or licensed as part of a hospital and where births are planned to occur away from the mother’s usual residence following a low-risk pregnancy.
(c) “CABC” means the Commission for the Accreditation of Birth Centers.
(d) “Low-risk pregnancy” means a normal, uncomplicated prenatal course as determined by documentation of adequate prenatal care and the anticipation of a normal, uncomplicated labor and birth, as defined by reasonable and generally accepted criteria adopted by professional groups for maternal, fetal, and neonatal health care.
(a) Beginning January 1, 2011, no birth center shall be established, operated, or maintained in the state without first obtaining a license from the commissioner of health according to this section.
(b) A license issued under this section is not transferable or assignable and is subject to suspension or revocation at any time for failure to comply with this section.
(c) A birth center licensed under this section shall not assert, represent, offer, provide, or imply that the center is or may render care or services other than the services it is permitted to render within the scope of the license or the accreditation issued.
(d) The license must be conspicuously posted in an area where patients are admitted.
For new birth centers planning to begin operations after January 1, 2011, the commissioner may issue a temporary license to the birth center that is valid for a period of six months from the date of issuance. The birth center must submit to the commissioner an application and applicable fee for licensure as required under subdivision 4. The application must include the information required in subdivision 4, clauses (1) to (3) and (5) to (7), and documentation that the birth center has submitted an application for accreditation to the CABC. Upon receipt of accreditation from the CABC, the birth center must submit to the commissioner the information required in subdivision 4, clause (4), and the applicable fee under subdivision 8. The commissioner shall issue a new license.
An application for a license to operate a birth center and the applicable fee under subdivision 8 must be submitted to the commissioner on a form provided by the commissioner and must contain:
(1) the name of the applicant;
(2) the site location of the birth center;
(3) the name of the person in charge of the center;
(4) documentation that the accreditation described under subdivision 6 has been issued, including the effective date and the expiration date of the accreditation, and the date of the last site visit by the CABC;
(5) the number of patients the birth center is capable of serving at a given time;
(6) the names and license numbers, if applicable, of the health care professionals on staff at the birth center; and
(7) any other information the commissioner deems necessary.
The commissioner may refuse to grant or renew, or may suspend or revoke, a license on any of the grounds described under section 144.55, subdivision 6, paragraph (a), clause (2), (3), or (4), or upon the loss of accreditation by the CABC. The applicant or licensee is entitled to notice and a hearing as described under section 144.55, subdivision 7, and a new license may be issued after proper inspection of the birth center has been conducted.
(a) To be eligible for licensure under this section, a birth center must be accredited by the CABC or must obtain accreditation within six months of the date of the application for licensure. If the birth center loses its accreditation, the birth center must immediately notify the commissioner.
(b) The center must have procedures in place specifying criteria by which risk status will be established and applied to each woman at admission and during labor.
(c) Upon request, the birth center shall provide the commissioner of health with any material submitted by the birth center to the CABC as part of the accreditation process, including the accreditation application, the self-evaluation report, the accreditation decision letter from the CABC, and any reports from the CABC following a site visit.
(a) The following limitations apply to the services performed at a birth center:
(1) surgical procedures must be limited to those normally accomplished during an uncomplicated birth, including episiotomy and repair;
(2) no abortions may be administered; and
(3) no general or regional anesthesia may be administered.
(b) Notwithstanding paragraph (a), local anesthesia may be administered at a birth center if the administration of the anesthetic is performed within the scope of practice of a health care professional.
(a) The biennial license fee for a birth center is $365.
(b) The temporary license fee is $365.
(c) Fees shall be collected and deposited according to section 144.122.
(a) Except as provided in paragraph (b), a license issued under this section expires two years from the date of issue.
(b) A temporary license issued under subdivision 3 expires six months from the date of issue and may be renewed for one additional six-month period.
(c) An application for renewal shall be submitted at least 60 days prior to expiration of the license on forms prescribed by the commissioner of health.
(a) The commissioner of health, in consultation with the commissioner of human services and representatives of the licensed birth centers, the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the Minnesota Hospital Association, and the Minnesota Ambulance Association, shall evaluate the quality of care and outcomes for services provided in licensed birth centers, including, but not limited to, the utilization of services provided at a birth center, the outcomes of care provided to both mothers and newborns, and the numbers of transfers to other health care facilities that are required and the reasons for the transfers. The commissioner shall work with the birth centers to establish a process to gather and analyze the data within protocols that protect the confidentiality of patient identification.
(b) The commissioner of health shall report the findings of the evaluation to the legislature by January 15, 2014.
MASSAGE TECHNIQUES FOR LABOR
Article Published in: “A Midwife’s Touch,” by Elaine Stillerman. © 2008 Midwifery Today, Inc. All rights reserved.
[Editor’s note: This article first appeared in Midwifery Today Issue 84, Winter 2008. Portions of this article were taken from Prenatal Massage: a textbook of pregnancy, labor and postpartum bodywork, by Elaine Stillerman.]
As labor progresses into the active phase, a noticeable shift occurs in contraction pattern and mother’s emotional response. The midwife’s goal is to keep her calm, comfortable and focused and to encourage the normal progress of labor. Another important task is to meet her emotional needs with understanding, nurturing and respect. This will give her a greater sense of control over labor, which can lead to heightened self-esteem and a more satisfying, empowered experience.(13)
The bodywork techniques must now be adapted to the mother’s emotional and physical needs and changes. Her breathing pattern will be different and should be encouraged by breathing (or intoning, moaning, etc.) with her.
Techniques for Active Labor
As labor progresses into the transition phase of stage one, most women are no longer comfortable with long, gliding strokes. Some women may actually pull away from touch altogether as they focus on the task at hand. Hot or cold packs, or ice chips (perhaps imbued with an herbal remedy such as black cohosh, if her blood pressure is low and stable) may be welcome. Holding, rocking or swaying with her may be all the support she needs. Placing your hand on an area of tension or firmly applying pressure on her sacrum during a contraction can relieve back pain. (Don’t forget to keep her face and jaw relaxed, since a lot of women in late labor grimace in pain and lock their jaws.)
Quiet encouragement and reassurance are paramount during transition. Keeping her relaxed and calm lets her natural rhythm of labor proceed smoothly and on course.
After the short resting phase of stage two where she may enjoy a few gliding strokes on her back or belly, strong contractions resume and the urge to push becomes involuntary and compelling. Relaxation is vital to the conservation of her energy and smooth passage, particularly her pelvic floor and adductors, as any physical tension could increase pain and slow labor. Gently and quietly remind her to release tension and allow her body to open.
Helpful ways to support her include encouragement, staying calm and helping her follow patterned breathing and chosen relaxation strategies. Help her change positions and rub any tense areas—if she wants the touch. The strokes of abdominal effleurage during the active phase begin at the fundus and move toward the pubic bone in tandem with uterine contractions. Between contractions, try effleurage of the lower back, or she might prefer gentle pelvic rocking. Leg cramps or muscle spasms can be treated with active or passive stretching or appropriate light leg massage. She will most likely need assistance straightening her legs after squatting to either stand erect or sit down.
Most of the support during the baby’s birth helps to calmly remind mother to stay relaxed and conserve her energy. You can offer some physical support such as counter-pressure or perineal support and help her find a comfortable birthing position.
Expulsion of the Placenta
In the tribal world, placental birth was usually very fast because women were in good physical shape and they used efficient birthing positions. Standing and stretching can expedite placental delivery.(14) Massage was used almost exclusively to encourage expulsion of the placenta in tribal societies. Other procedures included contracting the abdominal muscle, having the woman sneeze, having the new mother bite on something very hard or having her blow into her hands or an empty bottle.(15) Heat applications were also used to effectively expel the afterbirth.
The women of Morocco soak the end of the severed umbilical cord in oil heated over hot coals. Within a few minutes of the treatment, the new mother stands and the placenta falls out.(16) The Filipinos warm the handle of a wooden rice ladle and press it against the woman’s navel. In certain regions of Mexico, a hot tortilla is placed against the mother’s right side.(17) In India, the birth attendant oils her head and rubs it against the standing mother’s belly until all the blood comes out.(18) In Tahiti, the afterbirth is expelled as mother kneads her own abdomen while bathing in the sea. Her husband presses his foot against her to stimulate further expulsion of fetal detritus.(19)
Abdominal massage from the fundus to the pubic bone, skin-to-skin contact between mother and baby (kangaroo care, nursing), nipple stimulation or oral stimulation (by the partner) promote the release of endogenous oxytocin that encourages the uterus to contract and expel the placenta. Midwives can stimulate acupuncture point Spleen 10 to release the placenta. Place the heel of your hand at the top border of the mother’s knee. Your thumb should reach the belly of the vastus medialis muscle where the point is found. Hold for a count of 10, repeating until the uterus starts to contract.(20)
If mom starts to shake, squeeze the arches of her feet to control the trembling and guide her through gentle breathing.
Many helpful bodywork and massage techniques, along with numerous comfort measures and coping strategies, can have a positive impact on the way a woman perceives and experiences her labor. These techniques also provide midwives with additional ways to keep their clients calm, comfortable and relaxed.
Elaine Stillerman, LMT, has been a New York State licensed massage therapist since 1978. She began her pioneering prenatal practice in 1980. She is the developer and instructor of the professional certification workshop “MotherMassage: Massage during Pregnancy” (www.MotherMassage.net) and the author of MotherMassage: a handbook for relieving the discomforts of pregnancy (Dell, 1992); The encyclopedia of bodywork (Facts On File, 1996); Prenatal massage: a textbook of pregnancy, labor, and postpartum bodywork (Mosby, 2008); Modalities for massage and bodywork (Mosby, publication date to be announced). She is the researcher and writer for the PBS-TV show “Real Moms, Real Stories, Real Savvy” and is proud to have helped organize the March 2008 Midwifery Today conference in Philadelphia, Pennsylvania.
For years the story of the Little Red Hen has been going on in this local birth community. I have asked many times for connection and support in helping to finish my midwifery education and clinical training, only to find it necessary to need to leave this great State of Minnesota to find the education and community in states other than Minnesota.
I want to publicly thank those midwives who have really been there for me– to teach and mentor me, those who didn’t haze, those that followed through with their promises, those who actually cared whether or not I succeeded, those midwives from other states, like Washington, Arizona, Missouri, Illinois, Utah, Wisconsin, Florida and California, who have mentored me, and encouraged me to keep walking with my education, even after pursuing it for 14 years.
My education has spanned far and wide and when it is completed, which will be very soon, I will be a caring, knowledgeable and empathetic midwife who knows what it is like to have both a caring, and an uncaring birth community behind her.
For those who are current midwives in Minnesota, I ask you for this — don’t say words like: “I think we need more midwives!”… and not take any personal action to make those words come true. If you are truly a midwife who wants to support the overall growth of midwifery, then follow through with what you say.
Don’t be like the Little Red Hen. The story of the Little Red Hen is one in which the hen does all of the work, getting the garden ready, planting the garden, weeding the garden, watering the garden, harvesting the garden, and then making bread to eat from the harvest. The Little Red Hen from beginning to end had no help, no support from her closest people. She remained dedicated to doing the project from beginning to end, overcoming all obstacles to keep going. Throughout her journey, she kept asking for help, support, friendship, invested time, but no one helped her. until she was ready to present the final product–that is when everyone comes to her and asks for a piece of her work.
Minnesota hear my words — if you are wondering why this nearly educated student midwife is not a part of your community, you should probably remember the story of the Little Red Hen. When she completed her project, she alone sat at her table and enjoyed the fruit of her labor. That will be Treasured Birth. This chick is getting ready to hatch! <3!
Women’s memories of childbirth and their perceptions of its personal impact have been the subject of a number of investigations, most of which indicate that women have vivid memories of the events and strong feelings about their birth experiences (Hodnett, 2002). Studies of long-term birth memories have found varying degrees of consistence (Bennett, 1985; Simkin, 1990; Simkin, 1991; Waldenstrom, 2003). The intensity of women’s positive or negative feelings often changes over time, especially when compared to their feelings a day or two after the birth.
The immediate relief felt by parents when labor is over and their enchantment with their baby lasts for a few weeks postpartum, and often temporarily overrides negative experiences. However, memories of unpleasant birth aspects, such as complications, frightening moments or decisions, or unexpected or coerced interventions can emerge later as this “halo effect” wears off (Bennett, 1985). Women’s impressions of the psychosocial care they received (i.e., sharing of information and decision making, respectful treatment, attentiveness and emotional support, a welcoming environment, an opportunity to process the birth afterwards) tend to remain consistent over time, and when these impressions are positive, they may be associated with overall satisfaction and positive impressions of their births (Simkin, 1991); Waldenstrom, 2004). When a high degree of attention is given to women’s psychosocial needs there is a long-term positive effect on women’s perceptions of their birth experience (Simkin, 1991).
During labor if a woman experiences unmanageable pain and emotional distress, her body produces hormones called catecholamines. High levels of this hormone can result in a physiological response known as the “fight or flight” response. Because the body cannot distinguish between physical danger and emotional distress, it reacts as if the distress could result in bodily harm. Blood flow to the uterus diverts to the skeletal muscles to aid in fighting or fleeing. This results in the slowing of contractions, and the stall of labor progress. The fetus’ movements and heart rate slow to conserve oxygen for the fetal brain, and in response to this reduction in blood flow the placenta receives less oxygen. This mechanism explains how maternal distress contributes to dysfunctional labor and fetal distress. From this it can be concluded that some labor complications are preventable if excessive pain and maternal distress are avoided (Taylor et al., 2000). If those caring for a laboring woman understand and respond appropriately to possible sources of distress, it may be possible to prevent the surge of catecholamines that interfere with normal labor progress. Doulas are trained to know this and make it a high priority to maintain a relaxed, non-stressful environment in which the woman feels empowered (Odent, 1999). When personal control and involvement in decision-making was present, a woman’s satisfaction with her birth experience was enhanced. Trials that examine this satisfaction level found increased levels of satisfaction among women who had doulas attend them during birth (Hodnett et al., 2004; Simkin & O’Hara, 2002).
“Birth trauma” is an event that can occur during the labor and delivery process that involves actual or perceived threatened serious injury, or death to the mother or her infant. The birthing mother experiences intense fear, helplessness, loss of control and horror (Beck, 2004a, 28). This definition of “birth trauma” is consistent with the definition of “trauma” that applies to any life event, as described in the authoritative Diagnostic and Statistical Manual of Mental Disorders (ADA, 1994). An extensive literature review reports that many studies have surveyed pregnant and/or postpartum women to determine the incidence and causes of birth trauma and Post Traumatic Stress Disorder (PTSD) (Beck, 2004a). Traumatic births are reported as occurring in 33% to 34% of births. Women suffering from these disorders will require time and effort of support to process and resolve their difficulties. Thankfully, most women with birth trauma do not go on to develop the full syndrome of PTSD, however 1.5% to 5.6% are affected (Creedy, Shochet, and Horsfall, 2000; Soet, Brack, & Diloria, 2003; Beck, 2004a). Numerous studies have identified a number of PTSD-associated factors that can occur during the birth process that are preventable. These would include a lack of support, a feeling of not being listened to, a perceived lack of communication or a feeling of being ignored, insensitive caregivers, negative comments from the medical staff, and a feeling of a lack of control by the mother (Beck, 2004b). PTSD can even occur when labor is normal. One study reported an incidence of 3% among 274 women who had normal births; that is they included no obvious physical trauma (Czarnocka, Slade, 2000).
There are no studies specifically investigating the impact of the doula on birth trauma and PTSD. The top priority of doula care, however, is to provide those elements that were almost always missing for women who have PTSD after childbirth – reassurance, expression of needs and feelings, continuing and undivided attention, and a sense of control. The doula supplies the kind of care that may prevent many traumatic births from progression to PTSD. Therefore, the doula plays an essential role in maintaining the psychological and physical well-being of laboring women. A doula can improve short and long-term birth outcomes by encouraging the reduction of catecholamine production in the first stage of labor through striving to maintain a consistent and relaxing environment during labor. A doula can empower the mother and encourage positive communication and information sharing between the parents and the caregivers. She can eliminate much of the fear by bringing her experience and knowledge into the birthing room, and support both parents by supporting a feeling of control in the labor room. A doula strives to nurture and protect a woman’s memories of her birth experience, and help her to process all that happens in a positive way.
In the United States, pregnant adolescent girls – particularly those living in poverty with an unintended pregnancy encounter overwhelming medical and psychosocial challenges. These challenges encompass not only their pregnancy but also their future (Corcoran, 1998). Adequate social support during pregnancy to disadvantaged and non-disadvantaged populations of women improves perinatal outcomes for the mother and her infant (Norbeck, DeJoseph & Smith, 1996; Schaffer & Hoagberg, 1997).
Teens from underserved communities can benefit from a connection to a doula. Goals of community doula programs include increasing knowledge of pregnancy physiology and nutrition; promoting the health benefit of breastfeeding; encouraging high school completion and further education; working toward higher cessation rates of smoking and lower rates of alcohol and illicit drug use; and connecting to community resources that lead to increased access to health care, as well as demonstrating a decreased rate of pregnancy-related illness and infant mortality and morbidity. It has been proven that with doula support teens experience similar benefits and positive birth outcomes with doula support. Teens have a significantly lower cesarean rates, as well as lower epidural rates in comparison to the general population. More than 80% initiate breastfeeding (Altfeld, 2003), and feel encouraged to hold and talk to their babies immediately following birth (Abramson, Altfeld, & Teibloom-Mishkin, 2000). This model of doula support is very personal, and rooted in and embraced by the communities that are being served. These doulas “hold” young families as they experience the challenges of pregnancy, birth and parenting, the value of this kind of support is being revealed through outcomes within the passage of time (Atfeld, 2003).
The program is currently meeting or exceeding its goals. With a cesarean section rate of 12.9%, it is far below the national level of non-doula attended births which is at 60%; low birth weight babies is at 4.8%, compared to the Oregon average of 6.1%; breastfeeding initiation rate is 99%. This is going to have a positive impact on the health of many children, saving future taxpayers and current insurance companies vast amounts of money.
The Chicago Health Connection (CHC) is a Federally-funded program held up as the model maternal-child health organization. They state that the measurable cost savings of community-based doula programs include the thousands of Medicaid dollars saved by an averted cesarean section ($10,000), or an epidural ($3,000), with an additional cost savings possible due to reduced length of hospital stay (24 hours for vaginal delivery, and four days for cesarean or complication birth). There is an additional cost savings to public health from increased breastfeeding, which can total anywhere from $300 to 1,400 per child per month, and $500 per family.
Promoting long-term health benefits such as breastfeeding and achieving personal educational success goals with help these teens to stand on their own two feet to be productive and health citizens. For many of these teen parents, this is the first time they have had a caring adult in their lives who listens to them, and provides useful suggestions and respects their individual choices. This model addresses the disparity of needs for teen parents as a result of diminishing resources, and shows that doulas can have a positive effect on birth outcomes for teens. Birth can be a transformative experience for a teenager. A positive birth experience can transform teens into parents and produce positive long-term benefit implications for their children and families.