#260 | Triplets at Home! With Traditional Midwife Kristine Lauria @globalmidwife64

All three of the babies has sounded really great during the whole labor whenever we listened to so there was never a concern that one of the other midwives said to me at one point, do you think she's dilated? I said, Oh, yeah, she's, she's probably complete, we should check her. And I'm like, I'm not doing that. I'm not checking. And I said, I'm not going to stick my hands up. She hasn't asked, and she wanted her mother to receive the babies. Her husband didn't want to, and her mother had been at all of her births. And she's like, I want my mom. And she told me this prenatally, I said, Oh, that's fine. That's great. Because I don't like to receive the babies. I like the mom to do it, or the dad or somebody of their choosing, I don't want to be the first person to touch somebody else's baby.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Hi, I'm Kristine Lauria. And I've been a midwife for 35 years, I was community based for a very long time. And now I work for Doctors Without Borders, doing humanitarian aid, and very low resource settings, including refugee camps, and conflict zones, disasters, and so forth. And so I work with a very high risk population with very little resources as the name would imply. And so because of that, I've seen a wide variety of things beyond what one might see in a home birth, and things that we would ordinarily of course risk out in a place like the US where we have good resources, and are able to get more succinct medical care for mothers and babies. And so in light of that, I have a nice collection of wonderful stories, I've attended a lot of breaches, over 500 multiples, including triplets, and this is what I'm here to talk about today, a most recent triplet home birth here in the US.

I love this, because when you remove the institution of birth, when you remove the the medical influence, and especially the liability piece of it, when you go to these countries where they're just happy to have somebody there to attend their birth, who knows what they're doing. This is how we can build so much more trust and confidence and faith and birth, because we're removing all those elements. And we're just allowing it to be because that's the only choice. Absolutely.

And this is how I have seen what's possible in birth. Because here if we, for example, you know, people say, Oh, well, the doctor would not allow my twins to go past X amount of weeks, and they wanted to induce or do a cesarean because, you know, sometimes that's just what they do, especially if one of them is presenting breech. And so physicians don't really, they're not able to see what would happen if they allowed in little quotes, a woman to go to term with, you know, monitoring, I'm not saying just throw caution to the wind, but not, you know, just not inducing unless there's a clear indication. Other than just, you know, there was a study that came out 20 years ago that said, X, Y and Z. And so now we're all following suit with that, because if midwives came forth with information that was 20 years old, as to why they're doing a particular practice, we would get laughed at by the medical establishment, but they're doing the exact same thing. Nobody knows how long twins would go if we just allowed them to gestate? I do, because because I've attended twins at home. And I can see that most women that are healthy and well nourished will go to term if they don't develop certain complications earlier in their pregnancy, but the ones that do not risk out, absolutely can go to term safely with their babies, including triplets. I always wonder about the same thing when they share data on when first time moms give birth. And what those babies way. Because such a high number of women are induced that it lowers both of those numbers. And I think most of us are unsuspecting to that fact. For example, in Nancy winters population, just by being close to hands with her. It's it's truly staggering when you see how many women go past 42 weeks. Do you agree with that in your own personal experience?

Yes, absolutely.

Many physicians haven't even seen a physiologic birth of a singleton, I always talk about the circle of safety and midwives have a such a broader circle of safety and birth because they have seen so much more undisturbed birth and they have seen what is possible. And in the in the medical model. And in the physician OB scope, it's so narrow. So the second something seems to not be following the Friedman curve, the birth is a problem, and an intervention is needed. So we are very excited today to hear the story of an incredible triplet homebirth, which is pretty much unheard of in this country. And where did this take place?

This was in Tennessee. So I was contacted by Amber and she's fine with her story being told, obviously her her video has gone viral our birth videos. So if you haven't seen it, you can check it out. So she's fine with her. Her name being used, but I was contacted by her early in her pregnancy, she had also contacted an obstetrician friend of mine and asked if we would be able to one of us at least would be able to attend her her trip of birth and I had attended a triplet birth last year. And she got my number from that mother. And I said, Well, you know, I talked to her about all the things you know where her general history and so forth shoot, this was going to be her. She was a g7. So she had given birth six other times. She has five children. And then one was a surrogate pregnancy. So she has five children at home. And then one not at home. But she's given birth six times uneventfully, once was at home, and she had wanted another home birth. And then she realized she was having triplets. So she thought it wasn't possible. These were tried tried triplets, which means they were all in their own amnion and chorion. They were just three separate babies. So they're siblings, they're not identicals. And she had two girls and a boy. And so she was telling me about all of these things, all of her pregnancies had been uneventful. She never had any issues giving birth with postpartum hemorrhage, nothing, no blood pressure issues, no diabetes issues. So the chances of her getting through this pregnancy, she's 31 years old, we're actually pretty good getting to 36 weeks, which is what I told her would be my personal cut off time I did would not want to attend her any earlier than that. There can be too many issues with the with needing transfer, for one, at least one of the babies. And so. So she said, that was fine. And she knows she that eating was going to be a full time job, just to get enough in to be able to nourish herself and the babies. She was great the entire time. And she got to 23 weeks, I believe 23 or 24. And she started leaking fluid. And there was a little bit of blood as well. immediately went into the hospital and she messaged me, she sent me an email saying oh, this is what they're saying, if possible. I'm like, Oh, she's gonna risk out now. And everything was good with the babies. Clearly the bag sealed. They did diagnosis subchorionic hemorrhage, which is just a little bit of hemorrhage area at the placental at one of the placenta sites. And but it all just kind of healed up she kind of sat there for about two weeks at the hospital and they said, you know, we're just going to keep you here until you hit 32 to 34 weeks, and then we will do a C section and put your babies in the NICU until their due date. And she said, I don't think so. She was consulting that. So I was listening to her and hearing what she was saying. But I said, you know, I'm a midwife. This is the time in a pregnancy that I don't manage. These are the things that I don't take care of here in the US. So talk to my colleague who's a physician, and he will tell you, you know, what is possible what, what they're if what they're saying is true, and so forth. And he basically said, now you're fine. If you want to sign out ama you should because she's like, I'm just lying here the bed the food is terrible. And I can do this at home and have better food and be with my other children. Because it will be like stressful for me. And so that's good. She did. Right.

She was away from all those children all that time. Yeah, she has a one year old and a two year old. Okay, so now she has five under under to Holland diapers. But so yes, she was away from her one year old and her two year old.

And don't we have evidence, good evidence that suggests that bedrest is not helpful in preventing preterm labor.

I mean, yeah, pretty much and she wasn't, she wasn't contracting and the subchorionic hemorrhage had healed and she wasn't leaking any more fluid and she was all of her vitals were fine. The babies every time they listened to them, we're fine. Then she said, I can go in for four ultrasounds every few weeks and check. And that's what she did. She went home, she got home on Thanksgiving Day, I think. And she, she did it, she made it to 36 weeks, and she grew some nice, healthy babies. And so I joined her at 36 weeks, and met her for the first time. And we had a nice, nice talk and talked about all just I just wanted to hear about her pregnancy and, and everything and all the things that she hoped to accomplish with her birth, how she saw her birth happening and unfolding. And so that's what we did, we spent most of the time doing that. And I visited every few days. Because not because, you know, I was worried about anything. But just because a she didn't know me and I didn't know her. And we have the short amount of time to build up this trust, she had a wonderful midwife that had been following her her whole pregnancy to leave her. And so she knew to leave the well, but she had not attended any multiples. And so she did not want to do this birth without that kind of experience. And so we put together a team to lead I found another midwife who did have experience with twins. And so she joined us and then there were three students as well. So I was going every few days, because of course, we have three babies to check on and one mom, and anything can change at any point in time. And so in that last month, I really do like that more close of a check in so I can detect anything that might be rapidly changing overnight. Or if there's a blood pressure spike, or suddenly there's swelling, she had no swelling, her blood pressure was actually too low for my taste. It did end up going up a little bit more at the end, which was great. But everything was really quite good.

Let's just simply Where were you staying?

Logistically, I was staying at an Airbnb about 35 minutes from her because you live 12 hours from her because I live 12 hours away. Yeah. And did two Lifa get the privilege of witnessing this multiples births. And she didn't have experience with it. Yes, so so it was Shannon and to Lisa and me. And then there were three students. One of them was Shannon's who was happened to be an ICU nurse who was studying to be a midwife. And so she was actually very useful, because I knew she could do IVs I knew she wouldn't panic. And then the students were less experienced. And so they were doing the charting. And then of course, all of the things in between the clean up the Chuck's pads and all of that stuff. But the three of us as midwives, were checking the heart tones and doing all the more midwifery things during the actual birth.

I like people to appreciate the responsible approach to things like this, because when you see the headline triplets born at home, most of the nation would just see that and immediately feel like oh, they were so lucky. Everyone survived. And, and that was so risky. But when you hear about the staff that you put together, the team that you put together to surround this woman, she was in perhaps better hands than she might have been in any other setting. Yeah,

she knew that at any point in time, she could potentially risk out. It wasn't something that was thrown in her face all the time. Like okay, I'm gonna check you now you might risk out today, it wasn't like that. It was like we're gonna check and see how great everything is and how well the babies are, are growing and so forth. I really like to palpate the babies well, so I get to know them and their positions and, and all of that so that I'm better able to manage things at the birth. And so this is a you know, I'm a traditional midwife. I have certifications and things but my training 35 years ago, was as a traditional midwife, so I use my ears and my hands.

Let's touch on that for a second because of course in any other environment she would have been having weekly NSGs if not twice, weekly ultrasounds, and you just said that you are monitoring the babies very carefully with your hands. Can you just explain a little bit to them? Everybody listening how that works? Sure you trust that? Yeah.

So, you know, we did, she was getting ultrasounds. And at the end, she had a couple of biophysical profiles, which were useful to just know that everything on, aside from just my judgment, a separate entity has said, here's the report, all three of these babies look good. But aside from that, their weight estimates weren't that great. And so for me, checking the babies with my hands and being able to palpate them and their positions, which, you know, were was actually quite easy to do. And I could tell just how big the babies were. And I could tell that they were growing, and I was measuring her uterus, her uterus, in the end, measured 52 centimeters, okay, so normally it term it would be 40. So it was a lot, it was a nice big belly, but I could palpate the amount of fluid that was in, and I, when I do these things, I talked to the mother and I tell her what I'm doing and what I'm feeling all along the way. That's what I do with with all of the mothers. It's like, okay, I can feel this here. And I feel that here and the baby feels to be about like this, and it's facing this way. And this is why I know this. And are you getting the word the movements here? Are they there? Yes, they're right over here. Okay, yep. Because that's where I'm feeling a little feet or whatever. And then I you know, it's my hands on either side of her belly. If I can kind of just push back and forth, and just see everything moving. i There's plenty of fluid, you can feel the fluid pockets there, when it feels like like babies encased in like cellophane and there's no movement, and they're not billable, there. I know that there's less fluid. And so cuz I learned this ages ago, because I practiced illegally for 17 years. And I didn't have access to ultrasound. So I had to learn what this feels like. And so this is how I know.

I want to talk about this a little bit. Yeah. One feeling I have is I'm just so sad that this is a dying art. There's a generation of midwives that are taking this skill with them. And they're just, they're they're practicing. And now that you know, now they've practiced for decades, and the new young midwives following them don't have this ability. They don't have the skill. They're learning how ultrasound machines are working, rather than how to use and trust as you trust your senses to and you said to get to know these babies, you know, I mean, that's what it feels like for you. It feels like you know, these children before they come this one likes to be like this. And this one likes to be like that. Can you talk a little bit about what it means to be a traditional midwife? And what you meant when you said you practice unlicensed for 17 years. Can you please talk a little bit about those two things, how we initially trained and what did you mean by all of that?

Yes, sure. So I had a traditional apprenticeship, I worked with a midwife and the Amish community. And I actually worked with another midwife, about an hour south. And this was in Ohio, who happened to be a CNM, who had been in homebirth, midwife prior to going into CNM school. So I got to work with a traditional midwife and a CNM, who practiced a lot like a traditional midwife, but just had all the CNM knowledge. And so I got to work with both of them, which was really very cool. And so I had kind of a dual apprenticeship. And so I was attending a lot of births every month, especially in the Amish community. So 1215 births a month. So I got a lot of experience quite quickly. And again, we couldn't just order labs, we couldn't just do an ultrasound or refer for an ultrasound, if they wanted an ultrasound, they'd have to go in to see a doctor and then the doctor would order the ultrasound, but we couldn't just order and then they would oftentimes have to lie and not say they were having a home birth, because they would get treated very poorly. And so this is this is kind of what it was like practicing back then. It was very, it was difficult. I didn't even use a Doppler for Oh, several years, like it was only a Betta scope. So I got very good with it. And I still am very good with it. And, and I do believe that that is a dying art as is palpation help patients skills and really understanding. You know exactly where everything they're taught Leopold's maneuvers, but it's really not enough, especially judging by the amount of quote unquote surprise breaches people say they're encountering, and I'm like, Well, are they a surprise or are they undiagnosed?

Right because Oh, baby just turned in labor. No, it didn't fit It was a it was a missed breach all along

- more exactly. And that's majority of them. Yeah, and everybody's using midwives. Now it's just ultrasound to detect the baby's position. And so nobody's putting their hands on a mother's belly anymore. And so you don't have that fine tuned sense of fluid levels that are actually going to detect too little or too much fluid better than an ultrasound, which has a very inaccurate, you know, assessment of size and fluid levels. Yeah.

Yeah, I just get a lot of information with my hands. And after all of these years, it's also a very intuitive thing, like, something's not right here. And in fact, you know, it was interesting, because when I was, you know, coming up through the, the traditional midwife route, there was no CPM credential at that time, or it was just non was just beginning to be in there were whispers of, oh, you can be certified this or that. But that also wasn't recognized in any states. It's not like it is now. And so, for me, it was like, well, we'll have to just don't just practice illegally, like all these midwives and all of these places. Was it illegal? Or was it practice? midwifery was illegal? Yeah, there are places where you can't practice midwifery unless you have a license. And then in a lot of the states, there hadn't been licensure.

So that was what I was asking. Okay, that was the reason that they were illegal, because they had to be licensed. And they didn't have a license, because there was before the CPM route. And now, you know, now many, I think there's 35 states that will have that have CPM recognition.

What does traditional midwife mean to you? We've had this conversation on the podcast before and the conversation was a little. It was unclear, I think, yeah. So what does it mean to you?

Yeah, it's pretty, it's pretty unclear, because there's no specific definition for it. It's somebody that is using their knowledge and skills to pretty much do nothing unless or until nothing needs to be done traditional midwives. They do, you know, the expectant approach in birth, and they view birth as a normal physiological process, that the great majority of the time intervention is not needed. It sounds like it means midwives, drawing upon generations of experience, and passing down those skills from one generation to the next. And they're learning it not in a classroom. I mean, it's so different from what Trisha Trisha went to an Ivy League school, sat in their classrooms did God knows how many hours of studying and exams before attending her births. And there you were, at births before you you were at birth, before you really learned much you learned on the job, it seems it's just such a different approach. Does that characterize it? Well?

Absolutely. And I learned I had to actually unlearn a great deal of what I learned in midwifery school so that I could learn the true art of Midwifery, which I was fortunate enough to go into the homebirth arena after graduation and learn actually from more traditional midwives. How to fine tune those midwifery skills that I didn't actually get in midwifery school. So the traditional midwife to me is the midwife who has been trained through the art of midwifery through apprenticeship through just like Cynthia said, generations of women who have that deep wisdom of birth, not what's taught in Barney's textbook, although that's important to know some of that stuff. There's great information in there, but it's missing an element. And that's yes. And I think you're spot on there. And I'm fortunate that I was able to have that kind of experience. And then my mentor of 30 years, she she died a couple of years ago, she had been practicing for 54 years. And since she was 12 years old, with her Cherokee grandmother. And so that was just some very ancient ancestral knowledge. And so I think that there are, you know, there, there are different types of midwives and there's a place for all the different types of midwives and regardless of whatever certifications and licensure that I might have, ultimately, I consider myself a traditional midwife and less is more the greater majority of the time even with something like triplets.

So tell us are like we want to hear the story. When did when did the labor tell us the details? Yeah, so her biophysical profile was about, I think, six days before she went into labor. And it was eight out of eight for all three babies. But the person reading the BPP was like these babies need to come out and we're like, but why called the midwife to leave the to panic that because she was already 37 weeks and some change, and that's just unheard of. And that's just horrible things are gonna happen.

Lazy, they get it, they had a perfect biophysical profile. It's like they want to find something. They want to find something wrong. So they can say we got the baby's fine. Nothing wrong with three babies in there. And they say we still have to get the babies out. Like you can skip this step and gone straight to the argument if you want. Yeah. So what happened? She turned 38 weeks and I checked on her right at 38 weeks, everybody felt good. They you know, they were growing and moving. Baby A was cephalic. Baby baby was breech. Those were the girls. And then the little boy was up top transverse.

Oh, my goodness, they went in a perfect loop together. Yeah, down one is up and one as they made a little triangle was was that a comfortable position to find those babies in because there really is nothing much else that nature can do when there are three in there is that is that typical for triplets to be in that position? Um, I think the last ones I did was a phallic breach breach. So I think they find their own way. But it's it wouldn't be uncommon to have at least one of them in a breech position. But it's the transverse that gets my attention. Transverse is always of concern, Karen. But in this case, it isn't right. Because there's going to be so much space with one or both of those other babies born first. Yeah, I was gonna say that one just hasn't had a chance to move into a position that's going to be born in yet. Right? Exactly.

And I attend a lot of multiples. And I always tell the parents, as long as the first baby isn't a longitudinal lie, I don't care what it is breech, or are symbolic. I'm good. The second baby can be doing anything it wants, because it's going to change, there's a 20% chance that if it is in a longitudinal lie, that it's going to flip one way or another. And if it's transverse, it's easy, easily enough, either moved, or usually they'll just come and change on their own once the first baby is out. So I'm never worried about that second baby or that transfers, baby. But if there's a distress, then we have to, that we actually have to address that straightaway. And so I told her if there was any distress with that baby, at editing point that I might need to do an extraction. And, you know, would she consent to that? And she understood and she said, Yep, whatever you need to do to get my babies out safely said, hopefully, we won't need to, but just so you know, and I explained what that looked like. And so she consented at that point.

Can you explain to us what a homebirth extraction looks like? Typically, we're talking about, you know, forceps or something like that. Oh, it's a manual manual extraction. Yeah. Yep. So and I'm happy to I can explain it when I get into the birth story as well. Oh, great. To hear it. Yeah. So um, oh, I had one more question. I'm sorry. But I know that that listeners will want to hear what did the biophysical profiles reassure you of what exactly are they checking? How do you get to vet eight out of eight? Yeah, so they're, they're checking the, the fluid level and they're checking the the breathing of the bait there. There's their scores. It's two four for each category. Then they're checking all the different each baby for the different movement.

Grimace isn't grimace. That's Apgar.

it's great. Believe me now Trisha said it someone's gonna say we need to do that. We need to now do that without see the expression on the baby's faces. Before we can let you continue with this pregnancy. That's just hilarious. They do monitor breathing on the on the physical profile breathing movements but yeah, it's just it's a assessment of the well being of the baby.

Okay, so here so they tried to talk her into saying she didn't she went home spoke to you. Did you say she was at 38 weeks with triplets? Did you say 38?

Yeah, she called me at 38 and two and labor. And her last labor had been about eight hours. So I figured this one would be around the same, perhaps maybe a little bit shorter but she called me straight away. And I went over there I'm right away also, because she was already feeling like it was active labor. she vomits throughout active labor, and she was already vomiting. And so I said, I'm on my way. And so she labored the majority of the time, just lying on her side in bed. Because of all the vomiting, we offered to put in an IV and give her some fluids, just because because a uterus does not work well, if it is not well hydrated, she was not able to hydrate herself because she was vomiting. So so we gave her some fluids for that, because even a distended uterus that, you know, we always have concerns like how well is this uterus going to contract with multiples? Right? So there's, there's always that and it was contracting quite well. And I think it was probably complete for a while as well.

I want to just make a comment on the IV because I think that most people think that that's not one we talk about it as being an unnecessary intervention in the hospital. Yet to most people think that that isn't something that is done at home. And it is and an actually can be one of the things that prevents a home birth from making a transfer. So it's a really important skill. Yeah, midwives to have because dehydration, in the case of vomiting, really can, you know, cause a labor to peter out. And also, it is helpful if a woman is hemorrhaging. So it's a great intervention when we need it. Yeah.

And sometime a few months ago, I was reading quite a bit of research on water and hydration and labor. And I was astonished at how important being sufficiently hydrated is, and I know how important in general I know we all tell women how much water to drink. But when you read the data on it, and how it affects amniotic fluid and how it affects the uterus, it's like I'm sold hand me the water, because it had a radical effect on the baby's health on how the birth went. So it is a real risk. If a woman has diarrhea or is vomiting excessively in labor, she really can get dehydrated. It's very interesting, though. I haven't heard that come up in a home birth story on this podcast.

Yeah. Not all, home birth midwives in all states can do it. Some states prohibit it, actually. But I have talked to her ahead of time about it, especially with the potential of excessive bleeding afterwards, because it's almost a given with triplets because the placenta is a placental area, and the uterus is so large, so not even. It's not even necessarily a hemorrhage. It's just an a lot of extra blood. So so she knew that an IV was a possibility, and it was fine. She was lying there, and they put the IV and we were able to get her hydrated. And then we unhooked it and we kept the access so that we could give her more fluids later if needed. And, and so that was good to go. She was and she was lying in bed anyway. So it wasn't like she was tethered to this thing, because she didn't want to walk around anyway. And so eventually, you know, I said, you're probably dilated, completely Asian. I think she probably had been for a while I said, if you want these babies to come, you're probably going to need to get up.

Let me ask you a question right there. Yeah. You know, Nancy Waner, we talked about that before we started recording. Nancy doesn't tend to practice giving vaginal exams to women in labor during the homebirths she attended and it sounds like you're the same type of practicing midwife. Did you just say that because you suspected she was fully dilated, but you didn't do a vaginal exam? Am I hearing that right?

So I didn't do a vaginal exam. I was not she was gonna. She did not need one. And the other midwife or one of the other midwives said to me at one point, she kind of whispered in my ears. Do you think she's dilated? And I said, Oh, yeah, she's, I'm, she's probably complete. We should check her. And I'm like, I'm not doing that. I'm not checking. And I said, I'm not going to stick my hands up. She hasn't asked for it to be done. And had she asked, I would have said, well, let's Why don't you get up and see what because I knew what she needed was gravity so that that baby went right down into that pelvis. And so she did get up. And she I think you just get up and go pee and then maybe try walking around just a little bit. She went up. She she got up, went into the bathroom, and she's like, I can feel her coming down and she comes back to the, to the bedroom. And then she just breathes kind of sounded kind of like a sigh or just kind of like that when the first baby just started to come. And she wanted her mother to receive the babies. Her husband didn't want to, and her mother had been at all of her births and she Like, I want my mom, and she told me this prenatally, I said, Oh, that's fine. That's great. Because I don't like to receive the babies, I like the mom to do it, or the dad, or somebody of their choosing, I don't want to be the first person to touch somebody else's baby, right? So. So I was thrilled that the grandma was there. So I was right next to her. And, you know, you can see it on the video and the baby's coming. And it's in the amniotic sac. And as the heads born, you know, the sack breaks, and that Head and Shoulders came at the same time, and just right out into grandma's hands. And she was standing, Amber was standing. And so she just put this was Ilana and put Alana through her legs and, and she grabbed her and then sat down and talk to her. And the court was quite short.

I hope women can hear the respect and reverence that you have for the mother and her babies mean, the fact that you don't, you didn't even dare ask to do a vaginal exam when you didn't feel one was necessary. And the fact that you didn't even want to be the first hands when you think about how doctors walk around saying, I delivered how many babies today, you know, just just that language that they delivered the baby and you didn't even want to place your hands on a baby you wanted a family member to do it just says so much about the love and respect that belongs in that birth space. Is that what it feels like for you? Does it Yeah, no, I feel very much like, you know, the birth is a very sacred thing. It's one of the most important events in a woman's life, if not like the most important and life defining and our birth experiences really shaped who we are as women and certainly as mothers. And I just have a real reverence for the process. And I just have a tremendous amount of respect for the families. And I understand that. Yes, while I might be hired and being paid, I'm still an invited guest into this moment in their lives. And my job is to help everybody get safely to the other side. And most of the time, that means just sitting back and watching. I can say I said this many times people who know me, have heard me say it, but I consider talking at a birth and intervention talking from the midwife. The family can say whatever they want, and if you listen to the birth video, you will hear the people talking are the dad, the grandma, the Son, the her 13 year old son was there. You can hear me say what is the grammar caught because the the grandma had never received a baby. And I said, you hear me say, reached down and get your baby honey, because I wanted to make but that's all they said, I wasn't coaching the pushing and cheering no one else was either of the team. Because legally they knew they'd be in trouble. Probably strict, but but I'm just very clear about that. Because that every word robs this family of a little bit of their story. And when you hear Amber tell her story, the greatest compliment to me was I was hardly a footnote in her. She hardly mentioned me she, uh, she said the team was great and listening. But she was she and her babies and her family was all about them. And I'm like, I did it right. Because like, I feel really good when somebody tells their story. And I'm not the big hero and I'm not in the spotlight. I know that I've done it right. So that's how I you know, that's that's how I feel about it. So thank you for recognizing that.

That's a really beautiful example of the difference between the midwifery model of care traditional midwifery model of care, and the medical management of birth like that right there just explains it. One is. I'm center stage. And the other one is, I'm in the corner. You the mother is center stage and I am only here when needed when something goes off course. There's a HypnoBirthing video of a woman giving birth in Florida a few years ago and everyone's speaking Spanish in the room. So she's there with that She's in the bed and the birth is totally calm. But it you just, when you have this other perspective, you see the light, you feel the longing for it to go a little differently. She's in the bed, she's in the hospital gown, she's totally beautiful, calm, gentle presence. Her husband is on an iPad on a couch on the other side of the room. And she's in the bed. As the baby starts coming out on her. She's on her back. As the baby's coming out. The doctor walks in, puts on gloves, grabs the baby by the head and starts pulling, and he's going Sokka Sokka Sokka, which is like, take your baby ticket ticket ticket ticket, he's screaming over and over with the baby's head out. He's saying to the woman like take your baby, take it take a ticket. And she's constructed to start like pulling her baby up and out. And the baby lands on the hospital gown. She's hugging the baby on the hospital gown. And this is the part I was getting at. The husband looks moved, as you would expect. And he starts hugging the doctor kind of from behind from the side. He's hugging the doctor and then he kisses the doctor on the cheek. He kisses the doctor and squeezes the doctor shoulders. And I point that out to my clients. And I say the only reason he kisses the doctor is because he bought the fallacy that the doctor just got the baby into the world safely. Yeah. Yeah. Yep. And then we hear a story from a woman like you and it just like it just makes me emotional hearing it because, again, it's your reverence. And that's why the the mother she probably loves you with all her heart and will the rest of her life. But you were not a key player in the story. No, no. And I'm very happy for that. I I knew her birth history, I knew she wouldn't need anything from me, I knew anything that might be needed would be something like yeah, and IV for hydration and maybe help with hemorrhage assessment of fetal positions, because the other midwives weren't 100% comfortable, you know, doing multiples like that. So I that's what she wanted me therefore, just to make sure everything was going okay. And so if I didn't need to do something I wasn't going to so when did baby to come. So about an hour later, so she went to lie down with them with baby a nurse, the cord was pretty short. So and it had pretty much stopped any kind of pulsing. And so we cut it because it was short, she couldn't bring it up to her breasts. And she would like there and nurse the baby. And then she started to feel some contractions and I said, You know what you're gonna have to do right, you're gonna have to get up again, and be in a vertical position in order for this next baby to come out. Because I would have been fine with her sideline or being in the bed but just wasn't going to come down into the pelvis. And I knew that. And so she did, she got up and did the same sort of thing where she just paced a little bit and then started that. You know, that big heavy sigh sort of breathing and and she was standing there with her back to us and grandma was right there and this big water balloon comes down and it just keeps coming down. And it was the baby coming breech Frank breech. So its legs were folded up with the feet by the ears. But it was in the amniotic sac. You could see there was you can see the umbilical cord in there, right next to the baby and the baby was coming out directly posterior breech, sacrum posterior, which is really quite fascinating and fairly rare. Not rare with multiples I'd found but just generally, and that would be something where some providers would want to intervene. But she was pushing she was getting the baby was coming down quite well. It rotated ever so slightly to an oblique and then just came out completely in the sack right into the grandma's hands. And that was IV. And she passed her through the legs as well. And Amber grabbed her and sat down and she was covered in vernix and looked very different from her sister who had a whole her sister have a lot of hair she didn't. So that was another just beautiful successful birth. And then we immediately when each baby was born, we immediately listen to the heart tones, the other midwives grabbed the Dopplers and were listening to the other babies. That's a very important part. You know, assessing the fetal well being in between. And so we immediately listened. Um, baby see was still in the transverse but I said if you lie down on your side and nurse IV, I'm pretty sure that he's not going to like that because you're going to be bothering either his butt or his head, regardless of what depending on what side you're on. And he's going to want to shift and he did he was starting to shift to a breech position which is, which is what we needed. We were listening to him. He sounded great. All three of the babies has sounded really great during the whole labor whenever we listened to so there was never a concern. And then she started to get some contraction. And then I said, Okay, well, let's get you up again, because we're going to have to get this baby into the pelvis. And as she was getting up, her membranes released, and so it was a lot because of course, this baby was on its way to the pelvis, but not deep down in right. So a lot of fluid and some blood in the midwife. I quickly grabbed some sterile gloves. The other midwife was listening to the baby. And I said, What do you have? And she's like, 70. And I said, Okay, Amber, and I had just discussed, after Baby B came out, I said, Now remember, if he doesn't change, or if there's any kind of distress, I will have to go in and get him. And we discussed that prenatally. Are you okay with that? And she said, Yep, that whatever you need to do, I said, hopefully, we won't have to. But then I said, Yeah, okay. So this is what we talked about, are you okay? And she said, yeah, and she just, she could have stood up or squatted, or whatever. But she decided to lie back. And so I have my glove on and I went in with with one hand, and my external hand goes on to the head of the baby, so that I can kind of direct it and my internal hand is looking for the feet. And I encountered them, I was hoping they would be right at the introit is, so I didn't have to put my whole hand in. And I could just say, go ahead and push us right here. That was not the case, he was higher up. And so high enough up that I'm in up to my wrist, you'll see on the video, and then I could feel the feet. And he was in really good condition still. So he was pulling his feet away from me. And so I was able to grab one and bring it all the way to the interest. And we all saw it. And then he pulled it back in. And I'm like, Well, this is embarrassing. So all I could think of was oh my gosh, these other midwives and students are are watching me and they're thinking she has any idea what she's doing. This is what I'm thinking. They're thinking, of course, we're no way that's what they were thinking something almost no one has the skill to do. Thinking it wasn't they were glad it wasn't them, you know, they had to do it. So the baby questions. Yeah, I'm like, I need to grab both of these feet clearly and really hold on to them well, and I grabbed them and he was biting me. And I told the other midwife I said, Forget about her tones, just because they had dropped to 50. But he was clearly not feeling that. And I said just hold on to him keep him in place so that as I bring him down, he doesn't, he can't go back up. And they're like, Okay, so I'm bringing him down. And once I got him down to the pelvis, I said keep pushing, and she was pushing and helping. And once his pelvis was out, then I was able to, to grab that because you have to grab the bony part of the baby, because you will injure them otherwise. And so I grabbed the pelvis and I didn't we call it a love sets maneuver. And, and just with her pushing, I rotated him to transfer Scott one arm down, then rotated him back to sacrum anterior. So I'm looking at his back. And then I was just scooping the other arm. I just needed to sweep and I lifted him up. And it's a Brock's maneuver. And he just came out easily. She was pushing and he was small, like like a siblings. And so he was going to come out just fine with no issues. And he did. And I set him right on her belly. And he was already spitting and sputtering and his app cars were eight nine, I believe. So he did quite well, we got him out in a timely manner. And they had already hooked up the IV. We had Pitocin happening. We had fluids going. It was it was very well done on the part of the team. They worked really well. And all three babies did did well. And we took them on and I think the placenta came about 45 or so minutes later, she needed to rest a bit before before she was ready for that.

There were the one placenta. Yes, so there were so babies A and C. The placenta was a little bit fused. And then babies B was separate. So there were three placentas, but A and C were kind of fused because as they as they grow, sometimes they they grow. If they're growing next to each other, they tend to sort of grow together. But I guess

my question is after babies A and B were born was their placenta born no baby see the so all the placenta came out later? Yeah, so there was the cord still attached to the other babies? Yeah, we there were two cord. Well, it wasn't attached to the other babies we cut both of they were quite short. And we cut both of them when they were done pulsating so that the mama could bring her bring them up and breastfeed them. So when BBC came out there were two cords also cords hanging down.

Two cords hanging down with little clips on them. Yeah.

You just touch on a couple things. The BBC. I'm curious about. One, I want to just comment on the heart rate. So you had mentioned that when the first two babies leave the uterus, there's a chance to the third baby's heart rate is going to decrease. What's the reason for that? If they're, if it's not related to?

Yeah, sometimes it's cord compression. Sometimes it's they're moving, and there is a cord compression. And that I mean, that's all that we can assume that it would be just a shift in the internal environment causing

Yeah, exactly. And things moving around. It could be that the placentas are starting to pull away, in which case, and I think that that was happening in this case that up just a little bit, because when we went to actually get the placentas, they there was still, you know, when we had her push, they did not come out easily right away, they were still attached, at least one of them was or part of the other. But I think the one had started to partially detach, I also want to comment on the heart rate dropping down to 50. And to acknowledge that in a hospital environment, even the 70 probably would have pushed a woman into the operating room. And you knew that that was a normal part of multiples delivery. And you knew because of how the baby was responding to you that the baby still had really good reserves. And so a baby who has strong reserves and has been doing really well throughout the whole labor can tolerate a heart rate in the 50s or 60s and 70s for a period of time. Whereas in the hospital, you know, oftentimes those those are the mothers who are given that emergency C section potentially unnecessarily and then of course, told that your baby's heart rate was terrible. And it's it's that that trust and that experience that you have as a midwife for so many years seeing this, that you knew that that would still be okay. And you knew how the baby was responding and showing you that the baby was still okay. Yeah, absolutely. It was very reassuring to me. And because we had been really monitoring see closely after a&b came out, you know, we knew he had been doing very well. And there have been a couple of comments online like, well, obviously, the extraction did not need to be done, because that baby was fine. That baby was fine, because the extraction was done. Quickly. Yes. And, you know, I didn't hesitate. I knew that we had maybe put, perhaps the heart rate might have gone back up, but it wasn't while we were listening, so I wasn't going to listen, I wasn't going to waste any time. And any, any experienced provider watching that would have said, yeah, no, you that needed to be done. I stand by it. 100% still. And I think that, you know, it was much faster to do that than to wheel somebody, if even if we had had a C section just down the hallway, it still would have been faster to do the extraction and much and make much more sense. It's to do an emergency cesarean is much riskier than just doing an extraction maneuver. As much as I didn't want to do it. I did it. And, you know, she said afterwards, she says, On Oh, on one interview that I heard, you know, this was my best birth experience. And it was my easiest. And I didn't expect that because it was three babies. And somebody said, Well, but what about the extraction, she said, Oh, it didn't hurt as much as as my second birth. And that baby was so phallic and he had a big head. You know, when when she gave birth nine years ago, she still remembers the pain from the symbolic birth. And that was worse than the extraction and that that was a hospital birth where she was probably on her back. Yes. Yep. So I just my final point on that is just for people to understand how important it is for midwives and obstetricians to have the skills which they are no longer learning. Because that your skill set in that situation prevented a C section. That could have been a much different outcome for the mother and the baby.

Yeah. Yeah. Absolutely. And, and, and probably prevented a demise if there had been somebody else that that didn't really know how to react to what was happening or decided to call 911. Instead, that baby probably would not have survived. But we were it's a very rural place where we were we were not in a big city. So there wasn't a hospital, you know, five minutes down the road. And even EMS probably there, they probably have about a 10 minute response time out there if you know, maybe even longer I'm not sure, but I knew that anything we encountered I would have to be able to deal with in the moment even if we were going to call 911 I still knew I had to deal with what I needed to do. And we didn't have to resuscitate any of the babies. The first two were at guards. 910. And then and then Israel has was eight, nine. So then they were all nursing. Well, and they all nurses to be even before I left. So yeah, what what percentage of your clients ended up having to have C sections? Avoided one here? Yes.

So when I was attending homebirths, I think my C section rate was about 3%. It wasn't a lot. And it wasn't for breach. It wasn't it was usually just a failure to progress with the prime IP. And maybe there was, you know, a syncretism and we tried everything, and we got to the hospital, and then they did Pitocin and an epidural. And it wasn't that many. And it was for just very rare and strange things. One of them was for a face presentation with a baby that had a contemplation, so dwarfism. So the head was quite large. So that face was not coming out. So for very good reasons, I would say. And when I'm in the field, actually, curiously enough, we don't have good access to, to cesarean. And when we do, we only use it for maternal indications. So I'm essentially required to get all babies out, regardless of what even the outcome for that baby is going to be. It's never to save the baby's life, it's for the sake of the mother, that will do a C section. So I have to get all babies out vaginally, then my my C section rate in, in South Sudan, in a refugee camp, after six months, was just over slightly over 4%. And that's because in November, we had we get transferred all it was a high risk maternity that I was in charge of. And we get sent high risk cases. And so I had like six was complete, previous in the month of November. And then so those went to C section being you and having your knowledge and living in your skin. I'm just wondering, what are your emotions around the reality that a third of American women and far more of other women and other populations like Brazil, I mean, vast majority are having C sections. How do you feel when you think about that?

Yeah, it's it makes me so sad. And it makes me an angry and frustrated Of course, too. And then, and not only that, but so many of them are coerced. And I you know, I read it all the time on threads, I'll post something. And then somebody will say, Oh, they told me that I needed to have a cesarean because of that. And now I know that they lied to me and, and women are really being damaged, and there's just so much obstetric trauma happening. And it's it, it just makes me very sad, but I teach for breech without borders. I'm one of their instructors. And we're teaching more and more in hospitals. And even when we're not in hospitals, we get obstetricians taking our class on their own. And so they are learning breech maneuvers, and they are, you know, slowly at least breach. Syrians for breaches might go down a little bit, at least in some of these places. There are some hospitals that are really committed to offering breach services so so I have a little bit of hope, and I try to focus on what we're doing right and what I can, what I can help do and if that's educate the next generation of obstetricians, I'm more than happy to do that. I love teaching.

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Someday, Kristine, I hope my children will be out of the house that I will have the opportunity to do Learn from you, I would be so be so amazing to get some of these skills. And so I hope that we can stay in touch and really, really impressed and respect the work that you're doing. No, thank you. Yeah, I would love that I love to, to work with other midwives and just I, I appreciate the collaboration, everybody has something to bring to the table. So and, you know, I, I said to another, somebody after the birth was nine we were talking about not the other midwives that were there. And, you know, I said, if you had walked into that room, you would not have been able to tell who was in charge because we were all just sitting there quietly, you know, and I don't consider myself in charge. I think the moms in charge but, but I who that I like to call myself like the team leader when something needed to be done, you see that I'm doing what I needed to do, and the rest of them are helping and then, you know, I called for the I said, Oh, really, you know, get ready to resuscitate like I'm leading the team. We didn't have to resuscitate but not until then would you have been able to tell who in this room was quote unquote, managing this birth because it wasn't managing anything. I was just observing.