“We’ve never heard such a ruckus”

That was the quote from the Senate Chairman when talking about the recent Mississippi legislation (that died in committee), that would have made all non-nurse midwives illegal in our state. With over 5,000 phone calls, the response was unprecedented. While that may not seem like a lot of phone calls, apparently, it was! Considering that our whole state population is somewhere around 2.5 million, that is 0.2% of the population calling (assuming that each phone call was by a different person, which we know was not the case, since many people called every Senator, or at least, every Senator on the committee).

What started the bill? I’m not sure, but apparently, there was a midwife (perhaps living in Louisiana, perhaps just down in that area of MS) who attended a birth in which the baby died. It’s possible that it was just one of those things, but it’s also possible that she was not as well-trained as she could have and should have been. Since I know no details, and have only a rough idea of what happened, I most certainly cannot pass judgment. Regardless of what happened or “what might have been,” this case led the Board of Nursing to get with a legislator to introduce a bill to make non-nurse midwives illegal. As far as I know, nobody knew about it until it had already passed the House and was in the Senate. Then we spread the word, and “raised a ruckus,” and got it defeated. Yay!

Now, to work.

Last Tuesday, I was part of a group that met in Jackson to begin work on crafting our own legislation to introduce next year that will make CPMs recognized and licensed, and will create a review board to oversee them. I’m not totally sure how that will work, because I’ve just never dealt with that aspect of things before. However, there were some TN CPMs at the meeting that talked about how it worked in their state. You can join the Yahoo group MSFriendsofMidwives to see the latest version of the bill and to stay informed on the process.

Currently in Mississippi, there is only one CPM, although there are several out-of-state CPMs who serve various parts of MS, and many other midwives who could become credentialed and licensed. With licensure and certification not having been required to practice in MS, it could easily be seen by midwives as being an unnecessary use of time and money to get that piece of paper, when there was no risk to not having it and very little if any benefit to getting it. I suppose that saying that you’re a CPM might get you a few extra clients, but it wouldn’t alter your legal status, and you probably couldn’t file for insurance repayment either (I suppose it might be possible, but I highly doubt that without the legal recognition that insurance companies would recognize you either). Under the legislation that will be proposed next year, CPMs would be legally recognized, and current non-certified midwives who can demonstrate that they meet the NARM criteria would be grandmothered in.

So, benefits of the legislation would be that midwives who are currently operating legally and safely in the state will continue to be legal birth attendants, and will also be recognized by the state. I asked about legislation that would make Medicaid be able to pay for such midwives, and was told that the legislation doesn’t specify that, but once CPMs are recognized, that such a step may come in the future — I don’t know if it would need to be a law, passed through the state legislature, or if it’s just one of those things that once they’re legal, they can get set up to file claims, or petition Medicaid to recognize CPMs. Another benefit would be that with credentialing perhaps comes a higher degree of respectability and also recognition. There is a certain something that comes with proof that others recognize the work you’ve done, whether that’s proving you can survive med school and get M.D. after your name, or that you’re a certified piano technician, and become a member of the PTG.

One downside of this particular legislation is that it would make non-certified and non-licensed midwives illegal. Those working on the legislation believe that any measure that allows non-CPMs to practice would be defeated. I can see that, based on the bill that was just defeated, that would have made all midwives (except CNMs) illegal. Yet, midwifery has been unregulated for so long in our state, that I can also see that enough legislators might support the bill, even if it did not criminalize non-licensed midwives. But, it seems prudent to take the safe track. I do wish that legislation such as what is in Oregon could pass, with licensure being optional but having benefits; however, those with much more experience and knowledge about midwifery and legislation are making the suggestions, so I’m going along.

“Why would anyone not want certification??” I can think of a few reasons. Some just don’t like government interfering in your business — it’s simply a libertarian issue. “Government is there to keep the peace, and that’s about it — everything else should be left free and open,” some might say. With certification comes regulation — in some states, non-nurse midwives have become legal, only to be basically legislated out of existence by the laws that made it practically impossible to operate. It’s sort of like the hospitals that have labor tubs, but women can’t use them if their water is broken based on a theoretical but totally unproven risk of infection; and they can’t use them if their water hasn’t broken, lest their water break in the tub, and nobody know it. As long as rules and regulations are sound, then there is minimal problem with them; but when they get to be stupid and over-reaching, they can cause more problems than they solve. In Arizona, the law says that home-birth midwives cannot attend VBACs. If you agree that VBACs should not take place at home, then you’d probably agree that this is good legislation. However, if you think that the risk of adverse events is so small that HBAC is a reasonable choice for women to make, then you’ll probably disagree with the legislation.

John Stossel is in a series of articles discussing the downside of certification (not mentioning midwives at all, and only briefly mentioning doctors). Here are two articles, “The Right to Work,” and “Licensing Madness,” as examples. He makes a pretty good case that certification serves to protect established industries at the expense of those who are equally competent to provide certain services (braiding hair, yoga instructor, writing wills), but don’t have the money (or don’t want to spend thousands of dollars) to certify just for the right to do what they already can do, especially if they’re doing it on the side, or are starting to build up a business. He points out that market forces will serve to weed out incompetent florists at least as well as (if not better than) the lengthy and expensive certification process. When it comes to businesses such as these, I’d have a hard time coming up with a counter argument — the “risk” of a bad florist is that you waste $30 on an ugly flower arrangement, in which case, you’d go tell all your friends and family and neighbors and co-workers to avoid that flower shop, and the florist would soon go out of business. But an incompetent midwife may lead to dead or injured mothers and/or babies, so it’s easier to say that doctors and midwives and such should be regulated and certified.

Still, there are probably some very good healers that could not be certified because they are alternative practitioners. For example, Chris Gardner, who wrote the book The Pursuit of Happyness, which was also a movie by the same name with Will Smith playing him, has an interesting history. If you remember the movie, he became a stockbroker while being homeless much of the time, with his son in tow. That’s only part of the story. When he was in the Navy and for several years afterward, he worked for and with a doctor. While my memory of what all he did is a little fuzzy, he had “great hands,” meaning, he was proficient in the medical work he did. He never went to one class of med school, but he had what it took to do what he did, including operate on people, teach med students how to do the right things — he even had work published in medical journals! But, because he wasn’t a doctor and hadn’t gone to med school, what would have been a promising medical career was necessarily stopped. He didn’t have enough money to become a doctor, and the doctor who employed him couldn’t afford to pay him more. “So, big deal — that’s just what you’ve got to do to become a doctor! We can’t have just anybody calling himself a doctor!” Well, true, but this also kept him from applying his skills and healing a lot of people. Sure, it kept some quacks out of the business of medicine, but it probably keeps some who would be very good doctors from doctoring.

There are definite upsides and downsides to this. Regulation helps to keep bad practitioners from starting a business, although it does not entirely eliminate bad practitioners. However, nothing can. While capitalism is a strong influence in keeping bad practitioners out of business (because people will not willingly spend their money on bad goods or services), they can for a time prosper. And if they’re schmaltzy enough, may be able to keep people blind to their incompetence or poor products or services to stay in business for a while — Bernie Madoff was a master at this (of course, he also blinded them with greed, which is another tangent and topic entirely). We’ve all known people who were certified, licensed, bonded, insured, and/or regulated who were really bad practitioners of their craft or trade. It happens. There are bad apples in every barrel. Regulation can make it so that people don’t have to do their own work to make sure people are really competent, which can be a good thing, or a bad thing if they are lulled to sleep and think that everyone who produces a piece of paper is competent.

As you can see, I’m conflicted about this — mostly because if you’ve got a bad midwife, we’re not talking about losing a little bit of money by not being more conscientious, but perhaps losing your baby’s life. Given enough time, the truly bad will probably be eliminated simply by market forces, but what may happen during that time? How many babies may die? Not something to be talked about lightly. However, we cannot protect people from themselves. Some people are going to choose things that others may think are “woo” (acupuncture, acupressure, magnets, copper, feng shui, craniosacral therapy, chiropractic care, herbs, vitamins, supplements, etc.) — we can’t stop them from doing that. And if a woman thoughtfully considers the matter, and chooses a non-certified midwife, or even just has a few friends over to attend her birth, can we really stop her? Should we? At what point does “society” get to dictate who attends her birth? Recently, there has been a national conference on VBAC (which since you’re birth junkies, you’ve probably heard about, unless you’ve been living under a rock). A similar argument has emerged from the pro-VBAC community, namely, that women have the right to choose how to give birth, and should not be forced into a C-section, even if there is a risk of uterine rupture and perinatal mortality. Does someone else get to choose how women give birth, or is that something that each woman should be able to choose for herself?

I think highly enough of women and our intellect to say that if a woman understands that she is hiring as a midwife someone who has only attended ten births, hasn’t really read too much about birth complications, and has never handled a postpartum hemorrhage or a “slow to start” baby, or any other complication, that she should still be allowed to hire that midwife, knowing the risks. I would want someone more qualified than that, but some women are comfortable with that level of skill and knowledge. Unless the midwife misrepresents herself or her skills, then I just don’t see that “we” should try to save the woman from herself. Others may disagree — it comes down to where on the “libertarian” continuum you find yourself.

Bandl’s Ring

I recently received the following comment:

This is a really great post. I had never heard of women having a VBAMC before…but now that I know about this I am curious. I have had 1 CS, after a 24 hr homebirth turned emergency. Our daughter was born still after Csec to save her life was performed…

Our miracle baby was born c-sec after more than 24hrs of VBAC-ing labor. His heart rate de-celled enough times that we decided to get him out, after I was stuck at 9/5 cm’s for many, many hrs with no progress!

As it turned out, i had an obstructed labor…and a Bandel’s Ring, so baby was never coming out vaginally. So, now I am concerned for the next baby (prob a yr from now). Should I attempt another VBAC? How do I find out if I have a true Bandels Ring? What are things I can do to prevent this from happening?

I’ve done some research into this topic, but it is frustrating.

What is “Bandl’s Ring”? There are two types of uterine muscles, one to help the cervix dilate and the other to help push the baby out. At their juncture, rarely (usually during a prolonged and/or obstructed labor) a ring develops around a “depression” in the fetus, usually over the neck. [Click here to see a picture of a woman’s abdomen, showing the stark outlines of the baby’s body, due to a Bandl’s Ring. Sometimes when this happens, even a birth by C-section is difficult, because the ring prevents the birth of the shoulders and the rest of the body. Usually, the uterus will greatly constrict, which disrupts placental blood flow, and therefore oxygen flow, to the fetus. Bandl’s Ring was named after the doctor who first identified it.

One source said that a T incision was indicated for Bandl’s Ring. Since a T incision is usually (if not always) a contraindication to a VBAC, it seems pretty certain that it is not always necessary. One mother said that she had a Bandl’s Ring but still had a vaginal birth, and someone else responding to the comment questioned whether she really had a “true” Bandl’s Ring, since she actually had a vaginal birth. In the old days, and currently in areas of the world without access to medical care, Bandl’s Ring frequently results in high perinatal mortality (many times the baby is stillborn, or dies of birth injuries soon after birth) and also maternal mortality and morbidity. Uterine rupture will likely occur after a Bandl’s Ring develops, because the lower uterine segment is just stretched so thin, and subsequent contractions stress it even more. In the old days, it was sometimes necessary to dismember the fetus (who was usually dead, due to lack of oxygen); and even then, sometimes the woman died or suffered debilitating injuries to her internal organs.

One of the frustrating elements in doing the search was a paucity of materials on Bandl’s Ring, especially recent materials — many of the Google Scholar results were case studies from the 1960s and before; including at least one from 1891 (yes, not 1981, but 1891, right before an article debating chloroform and ether). This article from 1961 (click on the pdf to read the article) included many alternate names: ring of Bandl, contraction of the ring of Bandl, contraction ring dystocia of White, retraction ring dystocia of Pride, simple contraction or retraction ring, uterine contraction ring, or constriction ring of Rudolph. Then it launches into a discussion of what different doctors have differentiated between the various names (and perhaps various types) of ring.

Johnson also commented that the terminology and assumptions used in reference to pathologic rings are bewildering, and he, too, emphasized the difference between the rings of obstructed and nonbstructed labor, although he referred to both as contraction rings.

“Bewildering” is correct. I tried to find information on Bandl’s Ring, Bandel’s Ring, and “uterine constriction ring,” and got precious little information. On one message board, someone identifying herself as a midwife said that once a woman develops a Bandl’s Ring, it will always happen again, and the woman will always need C-sections. But on another board, a doctor said that since the woman asking the question was being offered a VBAC, then that was proof that a vaginal birth was still a possibility.

The blogger at Abundant B’earth wrote the following for a “complications project,” which is a nice summary (and is more informative than Google Scholar turned out to be!):

Pathological Retraction Ring of Bandl

Definition and Etiology:

-Occurs in second stage labor (after dilation complete).

-Cause is 2nd stage obstructed labor due to CPD, malposition, uterine neoplasm/ abnormality, or fetal abnormality such as hydrocephalus.

-Uterus tries to compensate by increasing in tone and intensity & frequency of contractions.

-As a result, the lower uterine segment lengthens and thins, and becomes tender.

-Upper segment becomes hard and thick, and progressively retracts.

-The physiologic ring at the junction of upper and lower segments becomes extremely pronounced.   Ring rises in abdomen.

Si/sx: [“symptoms”]

-Hypertonic contractions

-presenting part driven/jammed

-mother experiences severe pain and excited or restless emotions

-maternal pulse, temperature rise

-palpable, taut round ligaments; may also be visible

-Baby entirely or almost entirely in lower uterine segment.

-ring felt as transverse ridge, as high up as umbilicus or potentially even higher

Differential Diagnosis: May appear to be constriction ring.  (see chart Frye p. 1043)

Complications/Sequelae:

-rupture of the lower segment, maternal hemorrhage

-placental abruption

-maternal exhaustion, inertia, and arrest of contractions

-uteroplacental insufficiency with resultant fetal hypoxia and distress.

-maternal fistula, lacerations more likely

South Carolina Regulation 61-24

Midwives shall obtain consultation for, or refer for care, any woman who:

(39.) develops pathological retraction ring.

Midwifery Management/Care Plan

Transport at once.

Medical Management

Tocolytic medications.

Holistic Midwifery Volume II p.241, 251, 376-7, 1038-45

Human Labor & Birth p.655-7, 662-3, 664-5, 671

11/2/2009

So, I don’t know how common it is. I don’t know what the rate of recurrence is. It seems that uterine fatigue is the chief cause of it (although there are other factors — for instance, fetal malposition may cause obstructed labor which may lead to uterine fatigue due to a lengthy labor), which makes me think that perhaps red raspberry leaf tea may help to prevent it. I don’t think there are any contraindications to this tea in the third trimester, although some people think it might increase the risk of miscarriage in the first trimester. This website says, “Red Raspberry leaf does not start labor or promote contractions. It is NOT an emmenagogue or oxytocic herb. What it does is help strengthen the pelvic and uterine muscles so that once labor does start the muscles will be more efficient.” So, this may help in general to prevent uterine fatigue. Chiropractic adjustments and optimal fetal positioning may help to prevent fetal malposition (along with the mother being upright and mobile during labor, if she desires). Cephalopelvic Disproportion (CPD) is over-diagnosed, but it may occasionally happen even in well-nourished mothers. [In developing countries, many women have malformed pelvises due to poor nutrition in childhood and adolescence, and many cultures have child-brides which leads to many still-developing adolescents giving birth to children, so the incidence of true CPD is higher there.]

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Great VBAC story

This one is a bit different, in that it’s told by the L&D nurse, instead of the mom, but it is wonderful, just the same. Enjoy!

[Yes, RR, I’m thinking of you, in posting these hospital stories! :-)]

Considering a VBAC

I like what NavelGazing Midwife has to say about the process of considering whether to have a vaginal birth after a previous cesarean, or whether to choose a c-section for a subsequent birth. She says in part,

I encourage you to start a list, even from the very beginning of research. A column for Risk of CBAC and then another for Benefit of CBAC. Then do the same for VBAC. As you learn, put your thoughts into those columns. I promise, as you read more and hear about more, your risks and benefits might flip flop several times. But, having the columns allows you to keep a somewhat logical head about the impending decision.

Then from VBACfacts, a post titled,

An OB you like or who makes you comfortable isn’t enough

It includes a letter from a woman who just had a repeat Cesarean after wanting a VBAC. She begins,

It is with great reluctance that I submit payment to you for services rendered.

I hired you for an intervention free VBAC.  Instead I had EVERY intervention I told you I did not want.  Under your care, I failed in the most basic way a woman can fail – I failed to birth my children.   You ignored each and every point on my birth plan.  I cannot help but wonder if you even read it, or if you ever had any intention of following it.

She did it! — What a birth story!

You’ve got to read Heather’s birth story, on The Unnecesarean. Wow.

Twin VBA2C

This was a cool birth story! And it happened in a hospital. I know some of you are going to cringe that she even attempted a vaginal birth after two cesareans; others may be worried about her having a vaginal birth of twins (with or without a C-section). But even leaving that aside, it was a great story.

On some nurse’s blog recently, I read that they had a surprise twin VBAC — the VBAC was planned, but two babies were a surprise — and the blogger said that twin pregnancy is a contraindication to VBAC. I’m assuming because the uterus is stretched larger to accommodate two babies, thus thinning the uterus more than usual, but I’ll have to look that up. Anybody have any research on that? It makes sense, but then some things that ought to make sense don’t always pan out. The doctor who attended the birth didn’t seem to think it was that big of a problem (or maybe that part was not included in the story).

All in all, I enjoyed reading the story. Very cool for her to discover (with the help of a great L&D nurse) that her body actually worked!